Iron catalyzed oxidative damage, in spite of normal ferritin and transferrin saturation levels and its possible role in Werner's syndrome, Parkinson's disease, cancer, gout, rheumatoid arthritis, etc

Iron loading in hemochromatosis attains extremely high levels and is accompanied by many signs (ferritin >300 microg/l, hematocrit >50%, transferrin saturation >70%, etc.). Nevertheless, the disease is often overlooked by physicians, until several organs have been damaged permanently (heart, liver, brain, pancreas, kidneys, spleen, etc.). Therefore, severe oxidative damage catalyzed by Fe could occur, without the extremely high ferritin, hematocrit and transferrin saturation levels of hemochromatosis, and it is unlikely that it would ever be detected or even suspected. I postulate a mechanism, by which a cell can continue to express transferrin receptors, without producing ferritin, even when it is saturated with iron. Furthermore, I suggest that this silent iron loading, induced by cadmium and other metals, plays an important role in many degenerative diseases involving free radicals, DNA damage and peroxynitrite, all of which are intimately linked to iron.Moreover, since ferritin, transferrin saturation and hematocrit levels are not directly related to cellular iron levels, and since excess iron can wreak havoc in the cell, we can conclude that there is a need for a better way to evaluate intracellular iron levels and especially the intracellular free iron levels by a non-invasive technique.Finally, phlebotomy is suggested as the best way to reduce Fe and Mo stores, and chelation with succimer is recommended in order to eliminate Cd.

Postmenopausal hormone use following a 3-year randomized clinical trial

Postmenopausal women often discontinue estrogen therapy within the first year. No studies have examined reasons why women continue or discontinue hormone replacement therapy (HRT) after several years of use, when hormone side effects have subsided. We wanted to identify determinants of estrogen use after participation in a 3-year randomized placebo-controlled trial. The Postmenopausal Estrogen/Progestin Intervention (PEPI) study compared the effects of estrogen alone or in combination with one of three progestogens with placebo. Post-PEPI use of hormone therapy was ascertained 1-4 years after the trial in 775 (90%) of the originally enrolled women. Potential correlates of treatment decisions were identified from sociodemographic characteristics, medical histories, and clinical measures ascertained at baseline and during and after the trial. Among women who had been assigned to placebo during PEPI, post-PEPI hormone use was significantly less common in women who were adherent to placebo during PEPI, older, or of non-Caucasian ethnicity. Hormone use was positively associated with hysterectomy. Among women assigned to an active regimen during PEPI, post-PEPI hormone use was significantly more common in women who used hormones before PEPI and in women who were adherent to hormones during PEPI. Older age, less education, and being non-Caucasian predicted less hormone use. Post-PEPI hormone use was highest in San Diego and lowest in Iowa City. Women on placebo who lost more bone mineral density (BMD) were more likely to begin hormones than women with less bone loss. Lipids, blood pressure, and other cardiovascular risk factors had relatively little influence on hormone use. The main predictors of post-PEPI hormone use were those associated with use in the general population (education, ethnicity, geographical region, hysterectomy, and prior use/adherence).

Prevalence of SIDS risk factors: before and after the "Back to Sleep" campaign in North Dakota Caucasian and American Indian infants

The objective of this study was to compare rates of infant sleeping position and other risk factors for sudden infant death syndrome from 1991 before the "Back to Sleep" campaign to rates in 1998 after the campaign. We used a cross-sectional risk factor prevalence study of risk factors for the years 1991 and 1998. In North Dakota the prevalence rates of prone sleeping declined 72% for American Indian infants and 62% for Caucasian infants. We were unable to identify a corresponding decline in SIDS in North Dakota for this time period. The relationship between sleeping position and SIDS may be more complex in rural and frontier settings and in American Indian populations than in urban and majority populations. The generalizability of this study is limited by the rural setting and small sample size. Longer term surveillance and additional reports from sites with pre "Back to Sleep" data as a baseline for both SIDS rates and sleeping position will be important to clarify the rate of prone sleeping position and SIDS.

Effect of fatty acids and oils on photodegradation of azadirachtin-A

Azadirachtin-A on exposure to UV-light (254 nm) as a thin film on glass surface gave a isomerised (Z)-2-methylbut-2-enoate product. Half-life of azadirachtin-A as thin film under UV light was found to be 48 min. Azadirachtin-A was irradiated along with saturated and unsaturated fatty acids, and fatty oils under ultra-violet light as thin film. Saturated fatty acid increased the rate of photodegradation of azadirachtin-A, whereas unsaturated fatty acids such as oleic, linoleic and elaidic acid reduced the rate of degradation. Castor, linseed and olive oil accelerated the rate of degradation, whereas neem oil showed no or little change in the rate of degradation of azadirachtin-A. None of these fatty acids and fatty oils were effective in controlling the rate of degradation of azadirachtin-A under UV-light as thin film.

In vitro chemo-sensitivity of B-chronic lymphocytic leukaemia to ara-G

In vitro sensitivity to ara-G of peripheral blood B-CLL lymphocytes from 23 patients was assessed using the flow cytometric TdT assay. All patients had typical B-CLL, according to immunophenotype and morphology, and none had received treatment within 1 year of testing. A wide range of spontaneous apoptosis was recorded. Exposure of the cells to a concentration of ara-G, comparable to plasma levels achieved in a phase I trial, produced significant increases in the rate of apoptosis in 21 out of 23 patients. Prior treatment, stage or lymphocyte doubling time did not influence the effect of ara-G. Ten patients' samples tested, in parallel, for sensitivity to fludarabine demonstrated a good correlation of response to both drugs. This in vitro evidence of activity against B-CLL suggests that the spectrum of clinically useful action may be broader than previously demonstrated.

Setting standards using integrated care pathways

An integrated care pathway is a tool that can help to deliver clinical governance objectives if implemented well. Key factors of successful implementation are: effective project management; communication and training; and top-down and bottom-up support for the process.

Comparison of Florida Hispanic and non-Hispanic Caucasian women in their health beliefs related to breast cancer and health locus of control

PURPOSE/OBJECTIVES

To compare Florida Hispanic and non-Hispanic Caucasian women in their health beliefs about breast cancer and health locus of control (LOC).

DESIGN

Exploratory, comparative.

SETTING

A variety of healthcare settings in an urban area in Florida.

SAMPLE

Hispanic (n = 113) and non-Hispanic (n = 197) Caucasian women who could read and understand either English or Spanish.

METHODS

The Health Screening Questionnaire, which assesses health beliefs and health LOC, was administered in either Spanish or English, and the results were analyzed.

MAIN RESEARCH VARIABLES

Attitudes about health in general, perceptions about susceptibility to cancer, beliefs about benefits of early diagnosis, and perceptions about the seriousness of cancer; LOC.

FINDINGS

Florida Hispanic women are better educated than the Mexican American Hispanic women described in the literature. Hispanic and non-Hispanic women were significantly different in their health beliefs and LOC. With age and education controlled statistically, these differences remained. Hispanic women who preferred to speak/read English were more like the non-Hispanic women in their responses than were the women who preferred Spanish.

CONCLUSIONS

Cultural differences exist between Hispanic and non-Hispanic women; however, differences also exist between groups of Hispanic women in Florida versus Hispanics in the southwestern United States.

IMPLICATIONS FOR NURSING PRACTICE

Outreach programs for cancer screening should be culturally relevant and may need to be different for subgroups of Hispanics in the United States.

Properties of adenosine deaminase from Candida albicans

Adenosine deaminase (ADA; adenosine aminohydrolase, E.C. 3.5.4.4), a purine catabolic enzyme, was studied in Candida albicans, an opportunistic yeast that causes diseases ranging from superficial infections to the deep systemic disease, candidiasis, in immunosuppressed humans. The fungus was grown as a yeast form in LEE's synthetic medium, pH 4.5, at room temperature for various growth periods. Adenosine deaminase (ADA) activity was determined from the cell free extract by measuring the change in absorbance 265 nm resulting from the deamination of adenosine. In yeast form, maximum growth and ADA activity were found at 72 and 24 hours, respectively, whereas in the mycelial form both the growth and ADA activity were maximum after 48 hours. Among the three media tested, tryptic soy broth supported maximum growth and enzyme production, compared to LEE synthetic medium or SABOURAUD dextrose broth. The enzyme was active over the pH range 4-8 and the optimum temperature for ADA activity was found to be 37 degrees C.

Continuity of care and clinical outcome: a prospective cohort study

BACKGROUND

Continuity of care is a central objective of community psychiatric services, but there is no consensus about its measurement.

AIMS

We developed measures of continuity of care suitable for routine use, and measured continuity and individual patient outcome over a period in which community services were developing.

METHOD

One hundred patients with severe mental illness receiving continuing care from two sectorised services were sampled and interviewed. Data were collected concerning their care over 20 months prior to interview. After 20 months prospective follow-up, they were re-interviewed. Continuity was defined as: perceived accessibility of services and knowledge about them, the number of keyworkers in a defined period of time, and the proportion of time out of contact with services.

RESULTS

Continuity of care improved significantly on all measures over the period of the study. Individual patient outcome also improved, but in multiple regression models including clinical and demographic variables, measures of continuity were not significant predictors of outcome. Continuity was similar for white and non-white patients.

CONCLUSION

Simple measures of continuity are useful in evaluating changes in the process of care, but they are not straightforwardly related to individual outcome.

New challenge for states: Indian health care

Devolution has given states a role in making sure Indian tribes have adequate health care. Along with these new opportunities comes greater responsibility--for both states and tribes.

Service use and costs of people with dual diagnosis in South London

OBJECTIVE

To compare the service use and costs of individuals who have a dual diagnosis of psychosis and substance abuse with those who have a diagnosis of psychosis but no substance abuse.

METHOD

Patients with psychosis were identified and a representative sample were interviewed. Six-month service use was measured and costs calculated. Regression models were developed to predict costs from background characteristics and dual diagnosis status.

RESULTS

A greater proportion of the patients with dual diagnosis used community psychiatric nurses, in-patient care and the emergency clinic. The regression analysis revealed that dual diagnosis patients had significantly higher 'core' psychiatric service costs (a difference of pound sterling 1362) and non-accommodation service costs (pound sterling 1360) than non-dual-diagnosis patients. The difference when all services were analysed was pound sterling 1046, but this was not statistically significant.

CONCLUSION

Specific interventions for dual diagnosis patients should be introduced and assessed in terms of individual outcomes, service use and costs.

Fine specificity of autoantibodies to calreticulin: epitope mapping and characterization

Extracellular calreticulin (CRT) as well as anti-CRT antibodies have been reported in patients with various autoimmune disorders and CRT has been implicated in 'epitope spreading' to other autoantigens such as the Ro/SS-A complex. In addition, antibodies against parasite forms of the endoplasmic reticulum chaperone, CRT, have been found in patients suffering from onchocerciasis and schistosomiasis. In this study, we screened sera for anti-CRT antibodies from patients with active and inactive systemic lupus ertythematosus (SLE) and primary or secondary Sjögren's syndrome. Approximately 40% of all SLE patients were positive for anti-CRT antibodies. The antigenic regions of CRT were determined using full length CRT and fragments of CRT prepared in yeast and Escherichia coli, respectively. Synthetic 15mer peptides corresponding to the major autoantigenic region of CRT (amino acids 1-289), each one overlapping by 12 amino acids, were used to map the B cell epitopes on the CRT protein recognized by autoimmune sera. Major antigenic epitopes were found to be associated with the N-terminal half of the protein in 69% of the SLE sera from active disease patients, while the C-domain was not antigenic. Major epitopes were found to be reactive with antibodies in sera from SLE patients with both active and inactive disease, spanning different regions of the N and P-domains. Sera from both healthy and disease controls and primary Sjögren's syndrome patients were non-reactive to these sequences. Limited proteolysis of CRT with two major leucocyte serine proteases, elastase and cathepsin G, demonstrated that an N-terminal region of CRT is resistant to digestion. Interestingly, some of the epitopes with the highest reactivity belong to the fragments of the protein which bind to C1q and inhibit complement activation. Whether C1q association with CRT is a pathological or protective interaction between these two proteins is currently under investigation.

A comparison of teaching strategies for integrating information technology into clinical nursing education

As health care becomes more information-intensive and diverse, there is a need to integrate information technology (IT) into clinical education. Little is known, however, about how to design instructional strategies for integrating information technology into clinical nursing education. This article outlines the instructional strategies used by faculty in five nursing programs who taught students to use a point-of-care information technology system. The article also reports students' computer acceptance and summarizes IT clinical teaching recommendations.

Identification of secreted proteins of Mycobacterium tuberculosis by a bioinformatic approach

Proteins secreted by Mycobacterium tuberculosis are usually targets of immune responses in the infected host. Here we describe a search for secreted proteins that combined the use of bioinformatics and phoA' fusion technology. The 3,924 proteins deduced from the M. tuberculosis genome were analyzed with several computer programs. We identified 52 proteins carrying an NH(2)-terminal secretory signal peptide but lacking additional membrane-anchoring moieties. Of these 52 proteins-the TM1 subgroup-only 7 had been previously reported to be secreted proteins. Our predictions were confirmed in 9 of 10 TM1 genes that were fused to Escherichia coli phoA', a marker of subcellular localization. These findings demonstrate that the systematic computer search described in this work identified secreted proteins of M. tuberculosis with high efficiency and 90% accuracy.

Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine

Chronic insomnia is the most common sleep complaint which health care practitioners must confront. Most insomnia patients are not, however, seen by sleep physicians but rather by a variety of primary care physicians. There is little agreement concerning methods for effective assessment and subsequent differential diagnosis of this pervasive problem. The most common basis for diagnosis and subsequent treatment has been the practitioner's clinical impression from an unstructured interview. No systematic, evidence-based guidelines for diagnosis exist for chronic insomnia. This practice parameter paper presents recommendations for the evaluation of chronic insomnia based on the evidence in the accompanying review paper. We recommend use of these parameters by the sleep community, but even more importantly, hope the large number of primary care physicians providing this care can benefit from their use. Conclusions reached in these practice parameters include the following recommendations for the evaluation of chronic insomnia. Since the complaint of insomnia is so widespread and since patients may overlook the impact of poor sleep quality on daily functioning, the health care practitioner should screen for a history of sleep difficulty. This evaluation should include a sleep history focused on common sleep disorders to identify primary and secondary insomnias. Polysomnography, and the Multiple Sleep Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints. However, the complaint of insomnia does not preclude the appropriate use of these tests for diagnosis of specific sleep disorders such as obstructive sleep apnea, periodic limb movement disorder, and narcolepsy that may be present in patients with insomnia. There is insufficient evidence to suggest whether portable sleep studies, actigraphy, or other alternative assessment measures including static charge beds are effective in the evaluation of insomnia complaints. Instruments such as sleep logs, self-administered questionnaires, symptom checklist, or psychological screening tests may be of benefit to discriminate insomnia patients from normals, but these instruments have not been shown to differentiate subtypes of insomnia complaints.

Investigation and control of aspergillosis and other filamentous fungal infections in solid organ transplant recipients

Filamentous fungal infections are associated with high morbidity and mortality in solid organ transplant patients, and prevention is warranted whenever possible. An increase in invasive aspergillosis was detected among solid organ transplant recipients in our institution during 1991-92. Rates of Aspergillus infection (18.2%) and infection or colonization (42%) were particularly high among lung transplant recipients. Epidemiologic investigation revealed cases to be both nosocomial and community-acquired, and preventative efforts were directed at both sources. Environmental controls were implemented in the hospital, and itraconazole prophylaxis was given in the early period after lung transplantation. The rate of Aspergillus infection in solid organ transplant recipients decreased from 9.4% to 1.5%, and mortality associated with this disease decreased from 8.2% to 1.8%. The rate of Aspergillus infection or colonization among lung transplant recipients decreased from 42% to 22.5%; nosocomial Aspergillus infection decreased from 9% to 3.2%. Cases of aspergillosis in lung transplant recipients were more likely to be early infections in the pre-intervention period. Early mortality in lung transplant recipients decreased from 15% to 3.2%. Two cases of dematiaceous fungal infection were detected, and no further cases occurred after environmental controls. The use of environmental measures that resulted in a decrease in airborne fungal spores, as well as antifungal prophylaxis, was associated with a decrease in aspergillosis and associated mortality in these patients. Ongoing surveillance and continuing intervention is needed for prevention of infection in high-risk solid organ transplant patients.