Patient empowerment in secondary prevention of coronary heart disease

Despite a large evidence base, the practice of secondary prevention in coronary artery disease is suboptimum and needs improvement. We have shown that although patient empowerment led to an increase in cholesterol checks, the action taken by health-care professionals as a result of these checks was poor.

Purification, crystallisation and preliminary X-ray study of haemoglobin from Crocodilis palustris and Crocodilis porosus

The unsolved three-dimensional structure of crocodile haemoglobin and its prospects as a blood substitute have led us to initiate the purification and crystallisation of haemoglobin molecules from crocodile species (Crocodilis palustris or mugger and Crocodilis porosus or salt water crocodile). The work has resulted in the prevention of polymerisation of naked haemoglobin molecules using N-ethylmaleimide or iodoacetamide. The purified monomeric haemoglobin molecule of C. porosus was crystallised in two different forms and X-ray diffraction data were collected up to 2 A resolution for both forms. Form I: a=53.62, b=53.55, c=103.77 A; beta=93.35 degrees, space group P2(1), Z=2. Form II: a=71.30, b=54.70, c=80.00 A; beta=106.4 degrees, space group P2(1), Z=2. Structure solution and rigid body refinement of form I data resulted in a model with R(free)=0.42 and R=0.35.

Syntheses and structures of heterobicyclic bis(tert-butylamido)cyclodiphosph(III)azane compounds having phosphorus(III) and arsenic(III) centers

Syntheses and single-crystal X-ray diffraction studies of heterobicyclic cyclodiphosphazanes having central phosphorus(III) and arsenic(III) atoms are described. Interaction of PCl3 or AsCl3 with cis-[(tBuNP)2(tBuNLixTHF)2] produced the isomorphous ([(tBuNP)2(tBuN)2]ECl); E = P(1), As(4), respectively. These Cs-symmetric molecules crystallize with two molecules in the monoclinic space group P2(1)/m. Unit cell dimensions of 1 are (293 K) a = 9.777(1) A, b = 11.745(1) A, c = 9.986(2) A, and beta = 97.44(1) degrees; those of 4 are (213 K) a = 9.688(3) A, b = 11.873(3) A, c = 9.975(3) A, and beta = 97.80(3) degrees. When ([(tBuNP)2(tBuN)2]PCl) was treated with NaN3 or LiN(SiMe3)2, ([(tBuNP)2(tBuN)2]PN3)(2) and ([(tBuNP)2(tBuN)2]PN(SiMe3)2)(3), respectively, were obtained. Compound 2 crystallizes in the monoclinic space group P2(1)/m and has until-cell dimensions (213 K) of a = 9496(7) A, b = 12455(7) A, c = 10043(6) A, and beta = 9723(4) degrees, Z = 2.

Telephone support for Canadian nurses in HIV/AIDS care

An assessment study was conducted with Canadian nurses (N = 177) in HIV/AIDS care to determine how social support influences the relationship between job stress and health (job satisfaction and burnout). The assessment study revealed that social support and coping both moderate the effects of these stressors on nurses' health and functioning outcomes (i.e., job satisfaction and burnout). Accordingly, the follow-up study tested the effectiveness of an intervention designed to enhance social support, promote the use of certain coping strategies for managing occupational stress, and prevent burnout in nurses. Telephone support groups, co-led by an expert facilitator and an expert AIDS nurse, were tested in a demonstration project for nurses in HIV/AIDS care (n = 30). The nurse participants reported that the intervention enhanced their coping, confidence, relationships, client care, and connections to the HIV/AIDS nursing community.

Brief report: relationship between HIV infection and WPPSI-R performance in preschool-age children

OBJECTIVE

To determine the neurodevelopmental effects of perinatally acquired HIV infection on children of preschool age.

METHODS

Participants included 40 children infected with HIV between the ages of three and five and an equal number of noninfected controls individually matched according to ethnicity, age, sex, and prenatal drug exposure. Participants were administered the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), upon which an analysis of subtest distribution was conducted.

RESULTS

Whereas both groups evidenced mean IQ and subtest scores significantly below published norms, an effect for HIV group status was not found when a factor combining Performance IQ (PIQ) and Verbal IQ (VIQ) was analyzed. However, the group infected with HIV scored significantly lower than controls on the Block Design subtest.

CONCLUSIONS

Gross cognitive deficits are not evident among preschool children infected with HIV relative to matched controls. However, this study does provides some evidence for more focal deficits. Further investigation with older children should be conducted.

Effect of furnace type and ceramming heat treatment conditions on the biaxial flexural strength of a canasite glass-ceramic

OBJECTIVE

To assess the effect of different heat treatment conditions when using two different furnace types on the biaxial flexural strength (BFS) of a fluorcanasite castable glass-ceramic.

METHODS

Two furnace types, one a programmable furnace (PF), the other a dental laboratory burnout furnace (DLF), were used with various ceramming times to determine their effect on the BFS of a fluorcanasite castable glass-ceramic. The glass-ceramic material was cast to produce discs of 12 mm diameter and 2 mm thickness using the lost wax casting process (n = 80). After casting, both furnace types were used to ceram the discs. Half the discs were not de-vested from the casting ring before ceramming but cerammed in situ (DLF) and half were de-vested before ceramming (PF). All the discs were given a nucleation heat treatment at 520 degrees C for 1 h and then cerammed at 860 degrees C using four heat soak times (0.5, 1, 2 and 3 h). The DLF furnace had a rate of climb of 13 degrees C/min and the PF furnace had a rate of climb of 5 degrees C/min to 520 degrees C and 3 degrees C/min to 860 degrees C. After ceramming the discs were de-vested and the BFS determined using a Lloyd 2000R tester.

RESULTS

The maximum BFS values seen for both furnace types were almost identical (280 MPa), but were achieved at different heat soak times (1 h DLF, and 2 h PF). The only significant differences in BFS values for the two furnaces were between the 0.5 and 2 h heat soak times (p < or = 0.05). Individual differences were seen between results obtained from each furnace type/heat soak times evaluated (p < or = 0.05).

SIGNIFICANCE

Already available dental laboratory burnout furnaces can be used to ceram fluorcanasite glass-ceramic castings to the same BFS values as more expensive and slower specialist programmable furnaces.

Long-term impacts of the Exxon Valdez oil spill on sea otters, assessed through age-dependent mortality patterns

We use age distributions of sea otters (Enhydra lutris) found dead on beaches of western Prince William Sound, Alaska, between 1976 and 1998 in conjunction with time-varying demographic models to test for lingering effects from the 1989 Exxon Valdez oil spill. Our results show that sea otters in this area had decreased survival rates in the years following the spill and that the effects of the spill on annual survival increased rather than dissipated for older animals. Otters born after the 1989 spill were affected less than those alive in March 1989, but do show continuing negative effects through 1998. Population-wide effects of the spill appear to have slowly dissipated through time, due largely to the loss of cohorts alive during the spill. Our results demonstrate that the difficult-to-detect long-term impacts of environmental disasters may still be highly significant and can be rigorously analyzed by using a combination of population data, modeling techniques, and statistical analyses.

Protein kinase C-alpha mediates endothelial barrier dysfunction induced by TNF-alpha

We tested the hypothesis that protein kinase C-alpha (PKC-alpha) mediates tumor necrosis factor-alpha (TNF-alpha)-induced alterations in permeability of pulmonary microvessel endothelial monolayers (PEM). The permeability of PEM was assessed by the clearance rate of Evans blue-labeled albumin. PEM lysates were analyzed for PKC-alpha mRNA (Northern cDNA blot), protein (Western immunoblot), and activity (translocation and phosphorylation of myristoylated arginine-rich C kinase substrate). Incubation of PEM with TNF-alpha (1,000 U/ml) for 4 h resulted in increases in 1) PKC-alpha protein, 2) cytoskeletal-associated PKC-alpha, 3) PKC-alpha activity, and 4) permeability to albumin. The TNF-alpha-induced increase in PKC-alpha protein, PKC-alpha activity, and permeability was prevented by a 4-h pretreatment with PKC-alpha antisense oligonucleotide but not by the scrambled nonsense oligonucleotide. The TNF-alpha-induced increase in permeability to albumin was prevented by myristoylated protein kinase C inhibitor (an inhibitor of PKC-alpha/beta, 100 microM) and calphostin (an inhibitor of the classic and novel PKC isotypes, 200 nM). The treatment with calphostin from 0.5 to 3.0 h after TNF-alpha still prevented barrier dysfunction induced by 4 h of TNF-alpha treatment. The data indicate that prolonged activation of PKC-alpha, maintained by a translation-dependent pool of PKC-alpha protein, mediates TNF-alpha-induced increases in endothelial permeability in PEM.

Interaction between insulin sensitivity and muscle perfusion on glucose uptake in human skeletal muscle: evidence for capillary recruitment

Insulin and glucose delivery (muscle perfusion) can modulate insulin-mediated glucose uptake. This study was undertaken to determine 1) to what extent insulin sensitivity modulates the effect of perfusion on glucose uptake and 2) whether this effect is achieved via capillary recruitment. We measured glucose disposal rates (GDRs) and leg muscle glucose uptake (LGU) in subjects exhibiting a wide range of insulin sensitivity, after 4 h of steady-state (SS) euglycemic hyperinsulinemia (>6,000 pmol/l) and subsequently after raising the rate of leg blood flow (LBF) 2-fold with a superimposed intrafemoral artery infusion of methacholine chloride (Mch), an endothelium-dependent vasodilator. LBF was determined by thermodilution: LGU = arteriovenous glucose difference (AVGdelta) x LBF. As a result of the 114+/-12% increase in LBF induced by Mch, the AVGdelta decreased 32+/-4%, and overall rates of LGU increased 40+/-5% (P < 0.05). We found a positive relationship between the Mch-modulated increase in LGU and insulin sensitivity (GDR) (r = 0.60, P < 0.02), suggesting that the most insulin-sensitive subjects had the greatest enhancement of LGU in response to augmentation of muscle perfusion. In separate groups of subjects, we also examined the relationship between muscle perfusion rate and glucose extraction (AVGdelta). Perfusion was either pharmacologically enhanced with Mch or reduced by intra-arterial infusion of the nitric oxide inhibitor N(G)-monomethyl-L-arginine during SS euglycemic hyperinsulinemia. Over the range of LBF, changes in AVGdelta were smaller than expected based on the noncapillary recruitment model of Renkin. Together, the data indicate that 1) muscle perfusion becomes more rate limiting to glucose uptake as insulin sensitivity increases and 2) insulin-mediated increments in muscle perfusion are accompanied by capillary recruitment. Thus, insulin-stimulated glucose uptake displays both permeability- and perfusion-limited glucose exchange properties.

The timing of treatment in breast cancer: gaps and delays in treatment can be harmful

'Timing' of treatment in breast cancer may refer to intervals within a single management or between different managements. Rates of shrinkage of breast cancers in response to treatment are related to histological grade and may be used as surrogates for growth rates. Histological grade should predict appropriate timing of treatment. Four cases of locally advanced breast cancer that illustrate a number of different types of interval are presented. Two tumours of differing histological grade (II and III) had been managed by historical 'split-course' radiotherapy and two similar grade III tumours were managed by primary medical treatment, followed at different intervals by radiotherapy. In the grade III tumours different radiotherapy fractionation régimes and effects of varying intervals between mangements are compared. The theoretical advantage of shrinkage (leading to reoxygenation) during the gap in 'split-course' radiotherapy is realized only in relatively slowly growing and shrinking tumours. Grade III tumours grow rapidly. They have the potential to shrink rapidly in response to appropriate treatment, namely intensive chemotherapy or radiotherapy but not hormones. Inadequate treatment leads to growth in intervals between individual doses, whether of drugs or radiation, and to failure of local control. The advantage of surgery or primary medical treatment will be lost if the interval between managements is too long in relation to the volume doubling time. Histological grade is a good guide of this parameter; the grade III tumours are particularly vulnerable to gaps in treatment.

Interaction of HLA and age on levels of antibody to Plasmodium falciparum rhoptry-associated proteins 1 and 2

The Plasmodium falciparum rhoptry-associated proteins 1 and 2 (RAP1 and RAP2) are candidate antigens for a subunit malaria vaccine. The design of the study, which looks at the acquisition of immunity to malaria from childhood to old age, has allowed us to document the interaction of HLA and age on levels of antibody to specific malarial antigens. Antibodies reach maximum levels to RAP1 after the age of 15 but to RAP2 only after the age of 30. The effect of HLA-DRB1 and -DQB1 and age on levels of antibody to rRAP1 and rRAP2 was analyzed with a multiple regression model in which all HLA alleles and age were independent variables. DQB1*0301 and -*03032 showed an age-dependent association with levels of antibody to rRAP1, being significant in children 5 to 15 years (P < 0.001) but not in individuals over 15 years of age. DRB1*03011 showed an age-dependent association with antibody levels to rRAP2; however, this association was in adults over the age of 30 years (P < 0.01) but not in individuals under the age of 30 years. No associations were detected between DRB1 alleles and RAP1 antibody levels or between DQB1 alleles and RAP2 antibody levels. Thus, not only the HLA allele but also the age at which an interaction is manifested varies for different malarial antigens. The interaction may influence either the rate of acquisition of antibody or the final level of antibody acquired by adults.

Lipoproteins and low-dose estradiol replacement therapy in post-menopausal Type 2 diabetic patients: the effect of addition of norethisterone acetate

AIMS

Low-dose continuous oestrogen/progestogen may increase patient compliance long-term but the cardioprotective effects in diabetes are unknown. The aim of this study was to compare the effect of low-dose oral oestrogen (1 mg, 17-beta-estradiol) treatment with oestrogen (1 mg 17-beta-estradiol) in combination with low-dose (0.5 mg) continuous norethisterone acetate (NETA) on lipoproteins in Type 2 diabetic patients.

METHODS

Thirty-four post-menopausal Type 2 diabetic patients in moderate control (mean haemoglobin A1c 7.7%) who had a serum oestradiol level of < 50 pg/ml were examined over a 6-month period. Serum lipids, and lipoprotein composition of very low density lipoprotein (VLDL), low density lipoprotein (LDL) and high density lipoprotein (HDL) were measured. Serum lipoprotein(a) was determined by an ELISA method, LDL fatty acids by gas-liquid chromatography and LDL oxidizability by thiobarbituric acid reactive substances (TBARS assay). Cholesteryl ester transfer protein (CETP), and cell cholesterol were measured.

RESULTS

There was a reduction in serum cholesterol on both treatments but no significant difference between treatment groups. LDL cholesterol decreased by 17% in each group. There was a no significant difference between the groups in serum VLDL or HDL cholesterol or serum triglycerides during the study. The change in lipoprotein(a) during the study was not significantly different between the groups. There was no significant difference in 4 h LDL oxidizability between groups. Although CETP increased with time in both groups there was no significant difference in the change between the groups.

CONCLUSION

In this small study, the addition of continuous low-dose NETA did not reduce the potentially beneficial effects of low-dose 17-beta-estradiol on the progression of atherosclerosis in diabetes.

Association of inverted sinonasal papilloma with non-sinonasal head-and-neck carcinoma

The nature and pathogenesis of inverted papilloma of the nose and paranasal sinuses are debated. Evidence suggesting a viral association is controversial, and epidemiological evidence has pointed to tobacco smoking as a potential etiologic factor. A retrospective regional cohort of 197 patients with sinonasal papilloma was compared with a cohort of 1583 patients with nasal polyps showing a similar distribution by age and sex. All instances of head-and-neck carcinoma diagnosed in both cohorts during a 38-year calendar period were culled from the regional cancer registry, the incidence rate ratio was computed (papilloma:polyp, on tumors detected at the time of or prior to the index diagnosis), and the clinical details were obtained. Nine instances of oral or laryngeal squamous-cell carcinoma, all in men, were identified in the papilloma cohort, and 7 labial, oral or laryngeal carcinomas (2 in women) in patients with polyps. In addition, 5% of the papillomas progressed to sinonasal carcinoma, including 2 cases among those with other primary head-and-neck carcinomas. The incidence-rate ratio for non-sinonasal head-and-neck carcinoma was 12.8 (95% CI, 3. 7 to 50; p < 0.0001). Among the papilloma patients with oral/laryngeal carcinoma, 8 smoked tobacco. Inverted sinonasal papilloma is associated with an increase in non-sinonasal head-and-neck carcinoma, and tobacco may be a causative link.

Diabetes and the Mediterranean diet: a beneficial effect of oleic acid on insulin sensitivity, adipocyte glucose transport and endothelium-dependent vasoreactivity

Abnormalities in endothelial function may be associated with increased cardiovascular risk in diabetic patients. We examined the effect of an oleic-acid-rich diet on insulin resistance and endothelium-dependent vasoreactivity in type 2 diabetes. Eleven type 2 diabetic patients were changed from their usual linoleic-acid-rich diet and treated for 2 months with an oleic-acid-rich diet. Insulin-mediated glucose transport was measured in isolated adipocytes. Fatty acid composition of the adipocyte membranes was determined by gas-liquid chromatography and flow-mediated endothelium-dependent and -independent vasodilatation were measured in the superficial femoral artery at the end of each dietary period. There was a significant increase in oleic acid and a decrease in linoleic acid on the oleic-acid-rich diet (p<0.0001). Diabetic control was not different between the diets, but there was a small but significant decrease in fasting glucose/insulin on the oleic-acid-rich diet. Insulin-stimulated (1 ng/ml) glucose transport was significantly greater on the oleic- acid-rich diet (0.56+/-0.17 vs. 0.29+/-0.14 nmol/10(5) cells/3 min, p<0.0001). Endothelium-dependent flow-mediated vasodilatation (FMD) was significantly greater on the oleic-acid-rich diet (3.90+/-0.97% vs. 6.12+/-1.36% p<0.0001). There was a significant correlation between adipocyte membrane oleic/linoleic acid and insulin-mediated glucose transport (p<0.001) but no relationship between insulin-stimulated glucose transport and change in endothelium-dependent FMD. There was a significant positive correlation between adipocyte membrane oleic/linoleic acid and endothelium-dependent FMD (r=0.61, p<0.001). Change from polyunsaturated to monounsaturated diet in type 2 diabetes reduced insulin resistance and restored endothelium-dependent vasodilatation, suggesting an explanation for the anti-atherogenic benefits of a Mediterranean-type diet.

Improved metabolic control reduces the number of postprandial apolipoprotein B-48-containing particles in type 2 diabetes

Postprandial lipoproteins are raised in diabetes and there is increasing evidence for the atherogenicity of the chylomicron remnant. Increased postprandial cholesteryl ester transfer has also been demonstrated in diabetes and may contribute to the atherogenic lipoprotein profile. The present study examined the effect of improving metabolic control on postprandial lipoproteins in 13 Type 2 diabetic patients. Blood was taken fasting and at 2-h intervals following a high fat, 1100 kcal meal. Patients were brought into good control by intensified dietary advice and oral hyperglycaemic agents or insulin if blood glucose failed to respond. Fasting and postprandial cholesteryl ester transfer protein (CETP) and lecithin:cholesteryl acyltransferase (LCAT) were determined in six patients. Lipoproteins were isolated by sequential ultracentrifugation. Chylomicron and very low density lipoprotein (VLDL) apolipoprotein B-48 and apolipoprotein B-100 were isolated by polyacrylamide gradient gel electrophoresis and quantified by densitometric scanning. CETP and LCAT were determined by an endogenous method which determined cholesterol esterification and transfer between the patients' lipoproteins. There was a significant reduction in postprandial chylomicron apo B-48 (P<0.005), apo B-100 (P<0.0005) and chylomicron cholesterol (P<0.001) following improved diabetic control. The chylomicron lipid/apo B ratio increased with improved control (P<0.01). Postprandial CETP and LCAT were significantly reduced in good control (P<0.01 and P<0.05, respectively) and there were significant changes in HDL composition. The study shows that improvement in metabolic control in Type 2 diabetic patients leads to a reduction in postprandial chylomicron particles and less transfer of cholesterol to apo B-containing lipoproteins.

The relationship between fertility potential measurements on cryobanked semen and fecundity of sperm donors

Sperm penetration assay (SPA) scores obtained from cryobanked semen were correlated with therapeutic insemination (TI) fecundity in a group of established sperm donors, thereby evaluating the efficacy of the SPA in screening donors for sperm banking. While the SPA has been used to separate fertile from infertile males, we altered assay conditions to use frozen semen and to distinguish performance among fertile donors. Three frozen ejaculates from 11 pregnancy-proven donors were analysed. Of 905 TI cycles, 275 recipients achieved 95 pregnancies. There were no significant relationships between fecundity and donor semen, washed sperm parameters, sperm recoveries or recipient age. A significant relationship was revealed between mean SPA scores (range 8.7-66.6 penetrations/ovum) and donor fecundity (range 0.04-0.16, P < 0.03). Sperm concentration was varied in an effort to establish the most sensitive test condition. Using 0.25x10(6) motile spermatozoa/ml, a highly significant relationship was observed (P < 0.002). The four donors with the lowest SPA scores achieved the four lowest fecundities. It is concluded that a modified SPA can be used on frozen donor semen to estimate donor fertility potential. If applied routinely in donor semen banking, poor quality applicants could be excluded, thereby increasing pregnancy rates while decreasing donor screening costs.

Routine prenatal diagnosis of aneuploidy by FISH studies in high-risk pregnancies

This study is a prospective clinical trial with fluorescent in situ hybridization (FISH) as a "routine" test for prenatal detection of the most common aneuploidies in high-risk pregnancies. Since April 1996, FISH studies with multicolor, commercially available, specific probes for chromosomes 13, 18, 21, X, and Y have been routinely performed in our cytogenetic laboratory on uncultured chorionic villous samplings (CVS), amniotic fluid samples, or fetal blood obtained by cordocentesis from patients with major or minor fetal anomalies detected by ultrasonography. Among the 4,193 prenatal samples analyzed between April 1996 and June 1998, routine FISH studies were ordered by the referring physicians on 301 (7.2%) cases. Aneuploidies were detected in 32 (10.6%) samples. Fourteen trisomy-21, 10 trisomy-18, 3 trisomy-13, 4 monosomies of X, and 1 case of triploidy were diagnosed by FISH. All 1,505 hybridizations were informative, and all 301 results were available and reported to the referring physicians in 24-48 hr. All relevant FISH results were confirmed by subsequent cytogenetic analysis. In 10 (3.8%) cases with normal FISH results, the final cytogenetic analysis revealed abnormal chromosomal rearrangements that could not be detected by the routine FISH studies. We conclude that rapid FISH analysis of interphase, uncultured fetal cells is an accurate and very sensitive method for routine prenatal diagnosis of the most common aneuploidies in high-risk pregnancies.

The pharmacokinetics of ziprasidone in subjects with normal and impaired hepatic function

AIMS

To assess whether hepatic impairment influences the pharmacokinetics of ziprasidone.

METHODS

Thirty subjects with normal hepatic function or a primary diagnosis of clinically significant cirrhosis (Child-Pugh A or B) were enrolled into an open-label, multicentre, multiple-dose study. The subjects with chronic, stable hepatic impairment and the matched control subjects received ziprasidone 40 mg day(-1), given orally with food, as two divided daily doses for 4 days and a single 20 mg dose on the morning of day 5. Pharmacokinetic variables were determined from multiple venous blood samples collected on days 1 and 5. Liver function was evaluated quantitatively using antipyrine.

RESULTS

On day 1 there were no statistically significant differences in the pharmacokinetics (AUC(0,12 h), Cmax, tmax) of ziprasidone between the two groups. On day 5 there were no statistically significant differences in the Cmax or tmax for ziprasidone between the two groups. The mean AUC(0,12 h) for ziprasidone was statistically significantly greater in the hepatically impaired subjects compared with the normal subjects (590 ng ml(-1) h vs. 467 ng ml(-1) h, P = 0. 042). However, the AUC(0,12 h) increased by only 26% in the cirrhotic group compared with the matched control group. The ziprasidone lambda(z) in the subjects with normal hepatic function was statistically significantly greater than that in the hepatically impaired subjects (P<0.001). There was no correlation between antipyrine lambda(z) and ziprasidone lambda(z) in the subjects with normal hepatic function or in those with hepatic impairment.

CONCLUSIONS

The findings of this study indicate that mild to moderate hepatic impairment does not result in clinically significant alteration of ziprasidone pharmacokinetics.