Disinhibition in the gamma motoneuron circuitry: a neglected mechanism for understanding myofascial pain syndromes?

Dysregulation in the gamma motoneuron circuitry is proposed as one mechanism to explain the development of trigger point activity in myofascial pain syndrome. Dysregulation in this context is defined operationally as significantly (and functionally) different levels of electrical activity detected in the same muscle on the left and right sides of the body that is persistently present with movement of that muscle. Neurophysiological concepts as they pertain to muscles and motor control principles are reviewed. Research is integrated that ties together material from diverse fields of psychology and medicine. Dysregulation in the gamma motoneuron circuitry may lead to disinhibition of muscle that causes it to remain hyperactive after contraction, generate excessive electrical activity during movement, and/or inappropriately coactivate with other muscles during movement. Any or all of these phenomena may occur with dysregulation. Such dysregulation may be corrected by learning. Immediate clinical implications are discussed, including the addition of specifically targeted neuromuscular retraining procedures via surface electromyography, as well as some conceptual and research issues that require further clarification.

Thiols protect the inhibition of myocardial aconitase by peroxynitrite

Peroxynitrite (ONOO-) is a potent inhibitor of myocardial aconitase. Because ONOO- reacts with sulfhydryl moieties, we investigated whether thiols protect against ONOO(-)-mediated inhibition of aconitase. Aconitase activity was examined in ventricular homogenates prepared from freshly isolated rat hearts. Peroxynitrite, but not the nitric oxide donor S-nitroso-N-acetyl-d,l-penicillamine (0.03-300 microM), inhibited aconitase activity (IC50 = 47 +/- 6 microM). L-Cysteine (0.03-3 mM), glutathione (0.03-3 mM), and N-(2-mercaptoproprionyl)-glycine (MPG, 0.1-3 mM) protected against the inhibitory effect of ONOO- (100 microM) with the rank order of potency of MPG > glutathione > L-cysteine. D-Cysteine (3 mM) had a protective effect similar to L-cysteine, but L-cystine, the oxidized form of L-cysteine, offered no protection. Ferrous ammonium sulfate (1 mM) markedly enhanced the protection provided by L-cysteine, but not by glutathione or MPG. Thiols protect myocardial aconitase against inhibition by ONOO- in a manner which is sulfhydryl group dependent and not stereospecific. The protection is related to the maintenance of the redox state of the iron-sulfur cubane cluster and cysteine residues at the active site of the enzyme. Both naturally occurring thiols and thiol-based drugs may be useful to protect the heart during ischemia-reperfusion injury where there is an excessive production of ONOO-.

Prevention of ischemic preconditioning only by combined inhibition of protein kinase C and protein tyrosine kinase in pigs

In rabbits, inhibition of either protein kinase C or protein tyrosine kinase abolishes the infarct size reduction achieved by ischemic preconditioning. In pigs, however, inhibition of protein kinase C does not attenuate ischemic preconditioning. The present study tested whether inhibition of protein tyrosine kinase alone or in combination with inhibition of protein kinase C interferes with ischemic preconditioning in pigs. In 29 enflurane-anesthetized pigs, the LAD was cannulated and perfused from an extracorporeal circuit. Protein tyrosine kinase and protein kinase C were inhibited by continuous intracoronary infusion of genistein (5x10(-6) mol/l) and staurosporine (10(-7) mol/l), respectively. Subendocardial blood flow (ENDO) was measured with microspheres. Infarct size was analysed by TTC staining (% of LV area at risk) following 90 min low-flow ischemia and 120 min reperfusion. In the presence of genistein, 90 min ischemia at an ENDO of 0.06+/-0.01 (+/-s.e.m.) ml/min/g resulted in an infarct size of 16.7+/-4.2% (n=8). With genistein, ischemic preconditioning by 10 min ischemia and 15 min reperfusion still reduced infarct size to 6.5+/-2.7% (ENDO: 0.05+/-0. 01 ml/min/g, n=7, P<0.05). In the presence of both genistein and staurosporine, infarct size following 90 min ischemia was 14.1+/-3. 6% (ENDO: 0.06+/-0.01 ml/min/g, n=7). With genistein and staurosporine, ischemic preconditioning no longer reduced infarct size significantly (11.5+/-3.1%, ENDO: 0.06+/-0.01 ml/min/g, n=7). The effective attenuation of ischemic preconditioning only by simultaneous inhibition of both, protein kinase C and protein tyrosine kinase, suggests a complex signal cascade involving both protein kinases.

Measurement choices in multi-site studies of outcomes in dementia

This paper summarizes the measurement choices made by selected current or recently completed multi-site projects with a common emphasis on measuring outcomes in dementia. Information on number of items and scoring, reason(s) for selecting the measure, and reliability and validity of the measure (either citations providing this information or a report of pertinent unpublished findings) is presented for eight domains: cognition, behavioral symptoms, physical health status, physical functioning and self-care abilities, quality of life, family/staff caregiver outcomes, service use, and cost. We found considerable reliance on the published literature as a guide to measurement choice, motivated largely by measures' superior psychometric properties, their ubiquity in the literature, and/or their brevity or ease of use. There is still evidence of "starting from scratch" in some domains, however. To the extent that these projects reflect the state of the art in dementia-relevant outcomes research, we conclude that comparison of outcomes across studies will continue to be problematic. However, as long as dissemination of methodological as well as substantive findings continues to characterize outcome studies in dementia, there is hope that a more congruent view of how to assess key outcomes in dementia will emerge.

The measurement of caregiver outcomes in Alzheimer disease research

The focus of this paper is on the measurement of outcomes for caregivers of patients with Alzheimer disease and related disorders. The discussion addresses theory-based and proven measures and seven major measurement domains: health effects, caregiver characteristics and contextual measures, service utilization, burden, positive aspects of caregiving, quality of care provided, and measures related to normative caregiver transitions such as institutionalization and death of the care recipient. Also provided are a brief summary of existing measurement approaches for assessing caregiver outcomes and general recommendations regarding the measurement of caregiver outcomes.

Rat beta-adrenergic receptor kinases 1 and 2 in mouse neuroblastoma X rat glioma NG 108-15 hybrid cells

Beta-adrenergic receptor kinase (betaARK, EC 2.7.1.-) has been implicated in the phosphorylation of G protein-coupled receptors, including opioid receptors. Since delta-opioid receptors of mouse neuroblastoma x rat glioma hybrid cells (NG 108-15) desensitize upon activation, this investigation was designed to find out whether NG 108-15 cells contain betaARK activity. Using the reverse transcription polymerase chain reaction technique, we identified two mRNAs, one coding for rat betaARK1 and the other for rat betaARK2. No hint was found for the presence of mouse betaARK. Examining the cytosolic betaARK activity in these hybrid cells using rhodopsin as substrate, we found a strict functional dependence on the presence of exogenous G protein subunit Gbetagamma. This relationship reflects a characteristic for betaARK1 and 2 out of the known G protein-coupled receptor kinases. Finally, highly purified recombinant betaARK1 proved active to phosphorylate enriched delta-opioid receptor preparations in an opioid agonist-dependent manner. The results reported here provide the basis to study more closely the molecular function of G protein-coupled receptor kinases in a cell line (NG 108-15) most frequently used to investigate acute and chronic opioid actions.

Enhanced stimulatory adenylyl cyclase signaling during opioid dependence is associated with a reduction in palmitoylated Gs alpha

Chronic opioid treatment of stably mu-opioid receptor transfected human mammary epidermoid A431 carcinoma cells (clone A431/mu 13) results in sensitization of adenylyl cyclase (AC), a cellular adaptation associated with drug dependence. Up-regulation of AC is characterized by significantly increased levels of both basal and post-receptor-stimulated effector activities, which develop without any apparent change in the quantity of stimulatory G proteins and the maximum catalytic activity of AC. Here, we report that detergent extracts from membranes of chronically morphine-treated (10 microM; 2 days) A431/mu 13 cells display higher stimulatory AC activities as assessed in the S49cyc- reconstitution assay. This finding is most likely due to an increased functional activity of Gs alpha because the addition of exogenous G beta gamma subunits, which per se stimulate AC in S49cyc- membranes, failed to affect the difference in reconstitutive AC activity. Moreover, both chemical depalmitoylation by hydroxylamine and inhibition of palmitoyl-CoA transferase in vivo by tunicamycin treatment incresed the reconstitutive activity of detergent extracts and eliminated the differences between native and opioid-dependent cells, indicating that the increase in stimulatory activity is due to depalmitoylation of Gs alpha. Indeed, metabolic labelling studies with [3H]palmitic acid revealed that chronic opioid treatment reduces considerably the fraction of palmitoylated Gs alpha in the plasma membrane. Furthermore, high affinity [3H]forskolin binding experiments demonstrated that depalmitoylated Gs alpha is able to associated directly with AC during the state of opioid dependence even without preceding receptor activation. These results suggest that post-translational palmitoylation of Gs alpha provides a potential regulator of transmembrane signaling. Moreover, accumulation of the depalmitoylated form of Gs alpha in the plasma membrane as reported herein may contribute to the increase in stimulatory AC signaling, as is characteristic for the state of opioid dependence.

[Cortisol levels in blood and urine of trotting horses]

Statistical analysis of normally occurring cortisol levels in serum and urine of horses served to recommend thresholds for this corticosteroid in these body fluids, as application of exogenous cortisol as well as ACTH may elevate the cortisol concentrations above the proposed threshold. The present study contributes to the general issue of how to establish thresholds for trotting horses upon sportive examination. 100 randomly selected post competition serum and urine samples, respectively, were submitted to cortisol analysis by means of HPLC. Concentrations of the endogenous corticosteroid in serum and urine followed a log-normal distribution with mean values of 61 and 49 ng/ml, respectively. The probability was 1: 100,000 to exceed concentration limits of 230 (serum) and 394 ng/ml (urine). Designation of thresholds for cortisol has proven problematic and is discussed here.

Localization of epileptic auras induced on stimulation by subdural electrodes

PURPOSE

This study evaluates the localization of stimulation-induced auras (SIA) and tries to determine whether the SIA can help to define the boundaries of resection in epilepsy surgery.

METHODS

Using subdural grid electrodes, 31 patients with drug resistant focal epilepsy were examined in a retrospective and prospective study lasting 2 years.

RESULTS

On stimulation by subdural electrodes, we elicited habitual auras in 16 patients (52%). The zone of SIA overlapped the epileptogenic lesion in 12 patients (75%), the EEG seizure onset zone in 12 patients (75%), and the irritative zone of interictal spikes in eight patients (50%). Postoperative results showed a significant correlation with the complete removal of the epileptogenic lesion (p < 0.001). Because the number of patients in the study was small, we could not find a significant correlation with the complete removal of the SIA zone, EEG seizure onset zone, and irritative zone.

CONCLUSIONS

Our study confirms previous analyses which indicate that complete resection of the epileptogenic lesion is essential to achieve a good outcome. Frequent overlap of the SIA zone with the epileptogenic lesion and the EEG seizure onset zone indicates proximity of the SIA with the epileptogenic zone. Nevertheless, this study does not support the concept that the SIA zone and the EEG seizure onset zone have additional value in defining the boundaries of resection in epilepsy surgery. Three case presentations suggest that SIA result from facilitated pathways between the stimulated cortex, the epileptogenic zone around the lesion, and the symptomatogenic zone. Functional reorganization in the vicinity of the cortical lesion cannot be ruled out but was not seen in our patients. Thus, SIA often do not reflect the normal function of the stimulated underlying cortex.

[Biomechanical stress studies with a new Y-nail]

The current success of the treatment of trochanteric fractures of the femur still depends on the type of fracture involved. A number of surgical procedures have proved successful in the treatment of stable fractures (e.g. dynamic hip screw, gamma nail). However, the treatment of unstable fractures remains a problem. With this type of fracture the implant is exposed to very unfavourable biomechanical loading that often leads to failure of the osteosynthesis, and makes removal of the implant necessary. In extensive tests, the biomechanical loading capacity of a new Y-nail has been investigated as a function of the stability and location of the fracture. The results show that this form of intramedullary fixing is suitable for both stable and unstable fractures. Unstable, far distal subtrochanteric fractures of the femur remain borderline indications.

[Embolic complications in bacterial endocarditis]

Embolic complications are a major prognostic determinant in the clinical course of infective endocarditis (IE) with an incidence of about 30-50%. In order to analyze risk factors leading to embolism in native (NVE) and prosthetic valve endocarditis (PVE), we reviewed 177 consecutive patients; 43% were female, 57% male, PVE occurred in 24% of all patients all left-sided, among the NVE were 11% right-sided IE. Major embolic complications occurred in 40% of all patients. In NVE, a higher rate of embolic events (45% vs. 26%; p < 0.05), and a larger vegetation size compared to PVE was observed (14 +/- 6 mm vs. 11 +/- 5 mm; p < 0.05). The most important risk factor for embolic complications in NVE was Staphylococcus aureus (odds ratio 6.4). Furthermore, double valve endocarditis, fever, and mitral valve endocarditis were associated with the risk for embolism. In case of severe regurgitation the rate of embolic complications was reduced (54% vs. 77%; p < 0.05). In PVE, fever was a risk factor for embolic events. Staphylococcus aureus was also a frequent microorganism in embolism (45% vs. 22%). The in-hospital mortality was significantly increased in case of embolism (NVE 40% vs. 11%; p < 0.001; PVE 36% vs. 9% p < 0.05). About 50% of all embolic events occurred before admission. In NVE, due to high in-hospital mortality, the rate of patients with embolism undergoing surgery was lower (57% vs. 72%; p < 0.05); whereas in PVE no significant difference was observed. In patients with NVE, aspirin therapy because of coronary artery disease appeared to reduce the rate of embolic complications (11% vs. 47%). However, the low number of patients on aspirin (9%) does not allow recommendations regarding a potential benefit. In conclusion, identification of risk factors leading to embolism in IE may be useful in considering early surgical therapy. However, the high rate of embolic complications before hospital admission indicates a need for improving the diagnostic delay in the prehospital phase.

Purification and characterization of cytochrome c6 from the unicellular green alga Scenedesmus obliquus

Purification of a soluble cytochrome c6 from the unicellular green alga Scenedesmus obliquus by a simple and rapid method is described. The purification procedure includes ammonium sulfate precipitation and non-denaturating PAGE. The N-terminal sequence of the first 20 amino acids was determined and shows 85% similarity and 75% identity to the sequence of cytochrome c6 from the green alga Monoraphidium braunii. The ferrocytochrome shows typical UV/VIS absorption peaks at 552.9, 521.9 and 415.7 nm. The apparent molecular mass was estimated to be 12 kDa by SDS-PAGE. EPR-spectroscopy at 20 K shows resonances indicative for two distinct low-spin heme forms.

Nitric oxide and platelet function: implications for neonatology

Nitric oxide (NO) is a mediator that modulates vessel wall tone and hemostatic-thrombotic balance. Platelet function is regulated by NO generated from platelets, endothelial cells and leukocytes. Nitric oxide has been shown to inhibit platelet adhesion, aggregation, and stimulate disaggregation of preformed platelet aggregates. Many of the effects of NO are mediated by its stimulation of guanylate cyclase and the formation of cyclic GMP and its subsequent transduction mechanism. In vivo, NO is likely to interact with prostacyclin, metabolites of ecto-nucleotidase, and lipoxygenase to modulate platelet function in a synergistic manner. An imbalance of NO production (deficiency or overproduction) has been implicated in the pathogenesis of various vascular disorders including thrombosis, atherosclerosis, septicemia, and ischemia-reperfusion injury. It is likely that some of detrimental effects of NO are mediated through its reaction with superoxide anion to form the potent oxidant, peroxynitrite. Nitric oxide gas and NO donors are used for the pharmacological treatment of various vascular disorders. Because inhaled NO has been documented to improve systemic oxygenation and reduce the need for extracorporeal membrane oxygenation, it has been widely used in neonates with severe hypoxemia. An inhibition of platelet function, resulting in a prolonged bleeding time, has been shown in adults receiving inhaled NO. Because bleeding complications may occur in high-risk infants, it is important to evaluate the effect of inhaled NO on platelet function and its correlation with clinical consequences such as intracranial hemorrhage. For these reasons, hemostasis should be carefully monitored during the administration of inhaled NO to critically ill neonates.

Changing nature of physician satisfaction with health maintenance organization and fee-for-service practices

BACKGROUND

Managed care practice arrangements, or health maintenance organizations (HMOs), are sufficiently mature to examine whether physicians' level of satisfaction has changed as managed care has developed. This study compares Dane County, Wisconsin, physicians' satisfaction with HMO and fee-for-service (FFS) practices in 1986 with that of 1993 and examines factors that contribute to satisfaction in an HMO-dominated environment.

METHODS

Cross-sectional surveys were mailed to all Dane County physicians in active practice in 1986 and 1993. Physician overall support for HMO development and satisfaction with work situation was measured with single items. Overall satisfaction and clinical freedom within HMO and FFS practices were measured using statistically reliable scales.

RESULTS

Significantly more physicians were supportive of the development of HMOs in 1993 than in 1986, and more than two thirds of physicians in 1993 were satisfied in their current work situation. Primary care physicians were significantly more satisfied than subspecialists across most dimensions of satisfaction. Perceived clinical freedom and satisfaction with income continued to be major predictors of satisfaction in 1993 as in 1986. While physicians' satisfaction with HMO practice remained stable, their satisfaction with FFS practice was significantly lower in 1993 than in 1986. Satisfaction with Medicare practice, which was not measured in 1986, was significantly less than with HMO or FFS practice in 1993.

CONCLUSIONS

Analyses suggest that primary care physicians are more satisfied than subspecialists with their HMO practice because of their greater satisfaction with HMO-generated income and the expanded clinical freedom they have in HMO practice. An across-the-board decline in satisfaction with FFS practice may be attributable to diminishing clinical freedom resulting from indemnity carriers' increasing micromanagement of patient care.

Glutathione causes coronary vasodilation via a nitric oxide- and soluble guanylate cyclase-dependent mechanism

The actions of thiols on coronary vascular tone in the intact heart are unknown. Glutathione (GSH), glutathione disulfide (GSSG), and L-cysteine (10-1,000 microM each) and GSH ethyl ester (3-300 microM) were infused into isolated rat hearts perfused with Krebs buffer at a constant pressure by the Langendorff method. GSH, GSSG, and GSH ethyl ester, but not L-cysteine, caused a concentration-dependent increase in coronary flow with the following order of potency: GSH ethyl ester > GSH = GSSG. The nitric oxide synthase inhibitor NG-monomethyl-L-arginine (300 microM), prevented the increase in coronary flow with GSH and attenuated that with GSSG (300 microM each). The vasodilation with GSH or GSSG and the associated increase in myocardial guanosine 3',5'-cyclic monophosphate were abolished by 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (a specific inhibitor of soluble guanylate cyclase) at 1 and 3 microM, respectively. The vasodilator action of GSH was abolished by superoxide dismutase (50 U/ml). Inhibition of GSH reductase abolished GSSG-induced vasodilation. Neither glibenclamide (1 microM) nor indomethacin (4 microM) affected the vasodilator action of GSH and GSSG. We conclude that GSH and GSSG cause coronary vasodilation that is mediated by a nitric oxide- and guanylate cyclase-dependent mechanism, possibly mediated by the reaction between GSH and peroxynitrite to form S-nitrosoglutathione, a nitric oxide donor.

Assessment of depression in patients with brain pathology: the case of stroke

The assessment of depression in patients with brain pathologies--a topic of considerable clinical and research interest--is complicated by a variety of factors. Among the most problematic are cognitive consequences of brain injury that can diminish the reliability and validity of information used to diagnose depression, determine its severity, ascertain its predictors, and evaluate its impact. In this article, the authors examine the challenges to depression assessment in patients who have had a stroke, the neurologically impaired population in which it has been most frequently studied. Focusing on poststroke depression research, they describe methodological limitations that may contribute to conflicting outcomes and conclusions and offer suggestions for improving the specificity, consistency, validity, and reliability of assessment methods and procedures when investigating depression in patients with brain pathologies.

Sonographic evaluation of interdigital neuromas

The purpose of this study is to evaluate the effectiveness of sonography to accurately identify interdigital neuromas. Twenty patients, all complaining of interdigital neuroma type pain, underwent sonographic evaluation of the symptomatic intermetatarsal space and adjacent interspaces. Each patient subsequently had surgical exploration of the symptomatic site. Fourteen patients had sonographic evidence of neuromas which were confirmed surgically; one patient had sonographic evidence of a neuroma that was not confirmed surgically. The remaining five patients did not have sonographic or surgical evidence of neuroma in spite of clinical signs and symptoms. No adjacent neuromas were appreciated. The correlation of sonography and clinical measurements was determined using Pearson's product moment correlation coefficient (r = 0.804, p < 0.001). Measurements performed with ultrasound were highly correlated with surgical findings. The mean size (standard deviation) of neuromas identified with ultrasound and during surgical inspection was 5.35 mm. (1.36) and 5.43 mm. (1.04). Ultrasound demonstrated a sensitivity of 100% and a specificity of 83.3%. Ultrasound was able to accurately predict the presence, size, and location of Morton's neuromas.

Age-dependent augmentation of cardiac endothelial NOS in a genetic rat model of heart failure

Alterations in nitric oxide (NO) biosynthesis in the heart have been implicated in the pathophysiology of heart failure. We compared changes in cardiac nitric oxide synthase (NOS) activity and expression in genetically heart failure-prone (SHHF) rats at 6, 12, and 18 mo of age with those in age-matched spontaneously hypertensive (SHR) and Sprague-Dawley (SD) rats. Systolic blood pressure was significantly higher in SHHF and SHR rats compared with SD rats; however, it declined with age in SHHF rats only. Left ventricular mass increased with age in SHR and SHHF, but not in SD rats. Plasma nitrate and nitrite level was elevated in SHHF and SHR rats at 18 mo only. In left ventricular homogenates from SHHF rats, Ca(2+)-dependent NOS activity increased markedly with age and was accompanied by enhanced expression of endothelial NOS (eNOS). In contrast, SHR rats showed a much smaller increase in Ca(2+)-dependent NOS activity over time without changes in eNOS expression; neither parameter was altered with age in SD rats. Ca(2+)-independent NOS activity was not detected in any heart. This is the first report of a unique alteration in myocardial NOS activity in hypertensive rats genetically prone to heart failure.

Endogenous protective mechanisms in myocardial ischemia: hibernation and ischemic preconditioning

Myocardial ischemia, even if it persists for a prolonged period of time, does not inevitably induce irreversible damage. Recent studies have identified 2 phenomena that are characterized by endogenous cardioprotective features, i.e., myocardial hibernation and ischemic preconditioning. Myocardial hibernation is characterized by chronic contractile dysfunction during persistent ischemia. The myocardium remains viable, and function is restored upon reperfusion. Ischemic preconditioning is characterized by delayed development of infarct size when prolonged and severe myocardial ischemia is preceded > or = 1 short-lasting episodes of ischemia and reperfusion. While ischemic preconditioning involves the activation of the adenosine A1 receptor, the bradykinin receptor, and activation of adenosine triphosphate (ATP)-dependent potassium channels, the mechanisms underlying myocardial hibernation are still unclear.

Individual prediction of change in delayed recall of prose passages after left-sided anterior temporal lobectomy

Prognostic variables for individual memory outcome after left anterior temporal lobectomy (ATL) were studied in 27 patients with refractory temporal lobe epilepsy. The difference between pre- and postoperative performance in the delayed recall of two prose passages (Story A and B) from the Wechsler Memory Scale served as measure of postoperative memory change. Fifteen independent clinical, neuropsychological, and electrophysiological variables were submitted to a multiple linear regression analysis. Preoperative immediate and delayed recall of story content and right hemisphere Wada memory performance for pictorial and verbal items explained very well postoperative memory changes in recall of Story B. Delayed recall of Story B, but not of Story A, had high concurrent validity to other measures of memory. Patients who became seizure-free did not differ in memory change from patients who continued to have seizures after ATL. The variables age at epilepsy onset and probable age at temporal lobe damage provided complementary information for individual prediction but with less effectiveness than Wada test data. Our model confirmed that good preoperative memory functioning and impaired right hemispheric Wada memory performance for pictorial items predict a high risk of memory loss after left ATL. The analyses demonstrate that the combination of independent measures delivers more information than Wada test performance or any other variable alone. The suggested function can be used routinely to estimate the individual severity of verbal episodic memory impairment that might occur after left-sided ATL and offers a rational basis for the counseling of patients.

Regulation of stimulatory adenylyl cyclase signaling during forskolin-induced differentiation of mouse neuroblastoma x rat glioma (NG108-15) cells

Chronic exposure of neuroblastoma x glioma (NG108-15) cells to substances that elevate intracellular cAMP levels results in morphological differentiation into a more neuronal-like phenotype. Here we report that forskolin-induced differentiation is accompanied by a biphasic regulation of stimulatory adenylyl cyclase (AC) signaling. While 1 day of forskolin exposure produces an initial increase in basal, [AIF4](-)-, and prostaglandin E1 (PGE1)-stimulated AC activities, stimulatory signal transduction is substantially reduced after complete differentiation of the cells (6 days). Western blot analysis revealed that these functional changes correlate well with changes in the quantity of G(s)alpha, the stimulatory component of AC. Additional forskolin-induced adaptations were found for PGE1 receptors, inhibitory G proteins and AC. These data demonstrate that neuronal differentiation of NG108-15 cells is associated with complex regulatory changes within the stimulatory PGE1 receptor system.

Influence of age on symptoms at presentation in patients with community-acquired pneumonia

BACKGROUND

Advanced age has become a well-recognized risk factor for death in patients with pneumonia. It may also be associated with reduced symptom reporting, raising the possibility that diagnosis and treatment may be delayed in older patients.

OBJECTIVE

To evaluate the association between age and the presenting symptoms in patients with community-acquired pneumonia.

METHODS

This study was conducted at inpatient and outpatient facilities at 3 university hospitals, 1 community hospital, and 1 staff-model health maintenance organization. Patients included adults (age > or = 18 years) with clinical and radiographic evidence of pneumonia, who were able to complete a baseline interview. The presence of 5 respiratory symptoms and 13 nonrespiratory symptoms were recorded during a baseline patient interview. A summary symptom score was computed as the total number of symptoms at presentation.

RESULTS

The 1812 eligible study patients were categorized into 4 age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 symptoms, there were significant decreases in reported prevalence with increasing age (P < .01). In a linear regression analysis, controlling for patient demographics, comorbidity, and severity of illness at presentation, older age remained associated with lower symptom scores (P < .001).

CONCLUSIONS

Respiratory and nonrespiratory symptoms are less commonly reported by older patients with pneumonia, even after controlling for the increased comorbidity and illness severity in these older patients. Recognition of this phenomenon by clinicians and patients is essential given the increased mortality in elderly patients with pneumonia.

Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia

CONTEXT

The American Thoracic Society (ATS) published guidelines based on expert opinion and published data--but not clinically derived or validated--for treating adult outpatients with community-acquired pneumonia.

OBJECTIVE

To compare medical outcomes and antimicrobial costs for patients whose antimicrobial therapy was consistent or inconsistent with ATS guidelines.

DESIGN

Multicenter, prospective cohort study.

SETTING

Emergency departments, medical clinics, and practitioner offices affiliated with 3 university hospitals, 1 community teaching hospital, and 1 health maintenance organization.

PARTICIPANTS

A total of 864 immunocompetent, adult outpatients with community-acquired pneumonia: 546 aged 60 years or younger with no comorbidity and 318 older than 60 years or with 1 comorbidity or more.

MAIN OUTCOME MEASURES

Patients' antimicrobial therapy was classified as being consistent or inconsistent with the ATS guidelines. Mortality, subsequent hospitalization, medical complications, symptom resolution, return to work and usual activities, health-related quality of life, and antimicrobial costs were compared among those treated consistently or inconsistently with the guidelines.

RESULTS

Outpatients aged 60 years or younger with no comorbidity who were prescribed therapy consistent with ATS guidelines (ie, erythromycin with some exceptions) had 3-fold lower antimicrobial costs ($5.43 vs $18.51; P<.001) and no significant differences in medical outcomes. Outpatients older than 60 years or with 1 comorbidity or more who were prescribed therapy consistent with ATS guidelines (ie, second-generation cephalosporin, sulfamethoxazole-trimethoprim, or beta-lactam and beta-lactamase inhibitor with or without a macrolide) had 10-fold higher antimicrobial costs ($73.50 vs $7.50; P<.001); despite trends toward higher mortality and subsequent hospitalization, no significant differences in medical outcomes were observed.

CONCLUSION

Our findings support the use of erythromycin as recommended by the ATS guidelines for outpatients aged 60 years or younger with no comorbidity. Although the antimicrobial therapy recommended in outpatients older than 60 years or with 1 comorbidity or more is more costly, this observational study provides no evidence of improved medical outcomes in the small subgroup who received ATS guideline-recommended therapy.