Treatment of seborrheic dermatitis

Seborrheic dermatitis is a chronic inflammatory disorder affecting areas of the head and trunk where sebaceous glands are most prominent. Lipophilic yeasts of the Malassezia genus, as well as genetic, environmental and general health factors, contribute to this disorder. Scalp seborrhea varies from mild dandruff to dense, diffuse, adherent scale. Facial and trunk seborrhea is characterized by powdery or greasy scale in skin folds and along hair margins. Treatment options include application of selenium sulfide, pyrithione zinc or ketoconazole-containing shampoos, topical ketoconazole cream or terbinafine solution, topical sodium sulfacetamide and topical corticosteroids.

Effects of isradipine, a dihydropyridine-class calcium channel antagonist, on D-methamphetamine-induced cognitive and physiological changes in humans

D-methamphetamine is abused for its euphoric effects and stimulatory action on cognitive function. Its abuse can, however, be associated with massive hypertension resulting in strokes, ruptured aneurysms, or myocardial infarction. We examined the utility of isradipine, a dihydropyridine-class calcium channel antagonist, in treating d-methamphetamine induced hypertension and evaluated its effects on cognitive function, both of which are mediated by dopaminergic mechanisms. D-methamphetamine dose-dependently increased all vital signs (systolic, diastolic, and mean arterial pressure, and pulse rate) parameters. Isradipine significantly reduced d-methamphetamine-induced increases in diastolic and mean arterial pressure; however, this potentially beneficial therapeutic effect was offset by a significant reflex rise in pulse rate. D-methamphetamine also improved attention, accuracy of reasoning ability, and performance on computerized cognitive function tasks. D-methamphetamine's cognitive improving effects were not altered significantly by isradipine. Isradipine increased the false responding rate but was without significant effect on any other attentional task, or on reasoning ability, or performance. Isradipine does not appear to enhance cognitive function in healthy humans.

Combining ondansetron and naltrexone effectively treats biologically predisposed alcoholics: from hypotheses to preliminary clinical evidence

BACKGROUND

Individuals considered to be early onset alcoholics (EOA) are characterized by an early onset age, a broad range of antisocial behaviors, high familial loading, and presumed biological disease predisposition. Ondansetron, a 5-HT3 antagonist, improves drinking outcomes and increases abstinence rates among EOA. Individuals with high familial loading for developing alcoholism have lower levels of beta-endorphin and demonstrate a more pronounced increase in beta-endorphin levels in response to alcohol administration compared with individuals who do not have alcoholic relatives. The propensity for naltrexone (a mu opioid antagonist) to reduce alcohol's rewarding effects and drinking in humans is greatest in individuals with high familial loading. Predicated on the added knowledge that 5-HT3 receptors may themselves mediate alcohol reward via activation of the endogenous opioid system, we hypothesized that the combination of ondansetron and naltrexone would act synergistically and would be an effective treatment in EOA.

METHODS

We conducted an 8-week double-blind placebo controlled clinical trial in which 20 EOA were randomized to receive ondansetron (4 microg/kg twice a day) + naltrexone (25 mg twice a day) or placebo as an adjunct to weekly standardized group Cognitive Behavioral Therapy.

RESULTS

At endpoint, subjects who received ondansetron + naltrexone (n = 10), compared with those who received placebo (n = 10), had fewer drinks/day (covariate adjusted mean 0.99 +/- 0.60 vs. 3.68 +/- 0.63; F1, 16 = 9.35,p = 0.008; effect size = 1.42), drinks/drinking day (covariate adjusted mean 3.14 +/- 0.87 vs. 6.76 +/- 0.71; F1, 13 = 10.45, p = 0.007; effect size = 1.71), and a trend toward increased percent days abstinent (covariate adjusted mean 69.76 +/- 8.64 vs. 48.24 +/- 9.12; F1, 16 = 3.58, p = 0.08; effect size = 0.88).

CONCLUSIONS

Ondansetron plus naltrexone seems to synergistically improve the drinking outcomes of EOA. Larger scale studies that test these medications, both alone and together, among various alcoholic subtypes are needed to establish and extend these promising findings.

Neuropharmacological treatments for alcoholism: scientific basis and clinical findings

Preclinical studies have exploded our knowledge about the behavioral and biological underpinnings of alcoholism. These studies suggest that certain neurotransmitters, particularly those interacting with the opioid, N-methyl-D-aspartate, and monoamine systems, may play a critical role in the expression of alcohol-drinking and other behaviors associated with its abuse liability. Built upon this foundation, important advances have been made in the development of therapeutic medications for the treatment of alcoholism. Of the medications reviewed, acamprosate's potential appears to be the most widely established. In the USA, naltrexone was approved by the Food and Drug Administration in 1995 for the treatment of alcoholism; however, the results of some studies have been less encouraging. Naltrexone's reliance on high compliance rates for efficacy may, eventually, limit its potential in clinical settings offering generic treatment for alcoholism. The relative paucity of dose-response studies on naltrexone's effects in treating alcoholics is an important gap in the literature. Recent data from a large clinical trial suggests that ondansetron, a serotonin3 antagonist, offers new hope for the treatment of early onset alcoholics; a type of alcoholism most difficult to manage with psychosocial measures alone. Different subtypes of alcoholic may, therefore, have varying treatment responses to serotonergic agents. Matching subtypes of alcoholic to effective treatment medications based upon their different biologies remains an important therapeutic goal. Combinations of effective pharmacological agents need exploration as they may prove to be synergistic, and could shepherd in a new era of treatments aimed at multiple neurotransmitter targets associated with the alcoholism disease. The coming decade promises more powerful tools for characterizing drug effects on alcohol drinking, thereby closing the gap between animal models of addiction and the human condition.

Ligand-induced stabilization of PPARgamma monitored by NMR spectroscopy: implications for nuclear receptor activation

Nuclear receptors are ligand-dependent transcription factors that are mediators of the action of lipophilic hormones and other endogenous ligands and are the targets of drugs useful in a variety of therapeutic areas. Peroxisome proliferator-activated receptor (PPAR)gamma is a nuclear receptor that, acting as a heterodimer with RXR, mediates a variety of cellular effects including adipocyte-differentiation. Due to its role in modulating insulin sensitivity, it is the target of therapeutically active anti-diabetic agents such as rosiglitazone. We have assigned the chemical shifts of the backbone atoms of the 32 kDa ligand-binding domain of PPARgamma in the presence of bound rosiglitazone. Three-dimensional HNCO spectra of the apo ligand-binding domain (LBD) have less than half the expected number of cross-peaks. The missing cross-peaks are restored upon binding strong agonists such as rosiglitazone. The NMR results indicate that the apo-LBD of PPARgamma is in a conformationally mobile state, and that agonist binding is associated with a marked stabilization of the conformation. Mapping the missing peaks to the 3D X-ray crystallographic structure indicates the region of mobility is extensive and includes the ligand-binding region and the cofactor-binding site. This leads to the conclusion that activation of this nuclear receptor is a result of a population shift of a dynamic ensemble of conformations, rather than a two-state switch from an inactive to an active conformation. Our results have important implications for the mechanisms by which antagonists, partial agonists, and agonists of nuclear receptor function operate.

Similar but distinct effects of the tristetraprolin/TIS11 immediate-early proteins on cell survival

The immediate early protein tristetraprolin (TTP) is required to prevent inappropriate production of the cytokine TNF-alpha, and is a member of a zinc finger protein family that is associated with RNA binding. TTP expression is induced by TNF-alpha, and evidence indicates that TTP can bind and destabilize the TNF-alpha mRNA. TTP and the closely related TIS11b and TIS11d proteins are evolutionarily conserved, however, and induced transiently in various cell types by numerous diverse stimuli, suggesting that they have additional functions. Supporting this idea, continuous expression of each TTP/TIS11 protein at physiological levels causes apoptotic cell death. By various criteria, this cell death appears analogous to apoptosis induced by certain oncoproteins. It is also dependent upon the zinc fingers, suggesting that it involves action on appropriate cellular targets. TTP but not TIS11b or TIS11d also sensitizes cells to induction of apoptosis by TNF-alpha. The data suggest that the TTP and TIS11 immediate early proteins have similar but distinct effects on growth or survival pathways, and that TTP might influence TNF-alpha regulation at multiple levels.

The accreditation status of student health services at academic medical centers

BACKGROUND

Student health services (SHSs) on campuses with academic medical centers (AMCs; schools affiliated with teaching hospitals) often provide clinical services (including occupational health services) for students and staff. There are few aggregate data about the accreditation status of these health services.

METHOD

A cross-sectional survey of SHSs at the 124 medical schools in the United States was conducted in spring 1999. SHSs were questioned about their accreditation status.

RESULTS

One-hundred three SHSs were included in the survey. Forty-seven (46%) of the SHSs were accredited, 30 (64%) through the Joint Commission on Accreditation of Healthcare Organizations, and the remainder through the Accreditation Association of Ambulatory Health Care (AAAHC). The Joint Commission predominated among private SHSs (13/15 [87%]), but public institutions were more evenly divided. Most of the SHSs accredited as freestanding ambulatory care centers were AAAHC accredited (16/27 [59%]). Nearly all the SHSs accredited as satellites of the AMCs were Joint Commission accredited.

CONCLUSION

Although fewer than one-half of SHSs at AMCs are accredited either through the Joint Commission or AAAHC, this is a far higher percentage than of accredited SHSs in general (134/1,500 [9%]). The Joint Commission dominates as the accrediting body for SHSs at AMCs largely because of the high-proportion of services accredited as satellites of the AMCs. Although the accreditation process is costly and time-consuming and may appear daunting, SHSs at AMCs should pursue accreditation to ensure quality in health care processes.

Pulmonary arterial smooth muscle cells modulate cytokine- and LPS-induced cytotoxicity in endothelial cells

Cytokines and lipopolysaccharide (LPS) are known to be injurious to vascular endothelial cells (ECs), but the influence of adjacent vascular smooth muscle cells (SMCs) on this injury is unknown. Exposure of cultured rat (RPMECs) or human (HPMECs) pulmonary microvascular ECs on tissue culture plastic to a mixture of cytokines (interleukin-1beta, tumor necrosis factor-alpha, and interferon-gamma) and LPS (cytomix) resulted in a significant increase in (51)Cr release to 35-40%. When unstimulated RPMECs were cocultured with cytomix-pretreated rat pulmonary microvascular SMCs (RPMSMCs) there was an increase in (51)Cr release to 8.4%, which was nitric oxide dependent. However, when RPMECs or HPMECs were stimulated in direct contact with their respective SMCs, rather than a further increase in cytomix-induced injury (e.g., >35-40%), (51)Cr release decreased to <10%. This cytoprotection was fully reproduced with fixed RPMSMCs, and partially reproduced by plating HPMECs on gelatin. These data show that the direct toxicity of a cytokine and endotoxin mixture on cultured ECs can be reduced by contact with vascular smooth muscle.

Topical therapy for acne vulgaris. How do you choose the best drug for each patient?

Although management of acne is sometimes difficult, primary care physicians can offer a number of treatment plans to patients with this skin condition. Comedonal acne usually responds to topical keratolytics, such as salicylic acid, benzoyl peroxide, adapalene, and tretinoin. Inflammatory acne is usually treated with topical therapy plus a systemic antibiotic. Nodulocystic acne generally requires an 8-week course of systemic antibiotics. If the nodulocystic acne does not improve, minocycline or isotretinoin may be needed. Topical therapy is often helpful in the long-term management of nodulocystic acne. New products are available that deliver topical agents in novel ways that decrease skin irritation. With the proper tools and instructions in use, most patients have significant improvement in their acne.

Both coactivator LXXLL motif-dependent and -independent interactions are required for peroxisome proliferator-activated receptor gamma (PPARgamma) function

Nuclear receptor activation is dependent on recruitment of coactivators, including CREB-binding protein (CBP/p300) and steroid receptor coactivator-1 (SRC-1). A three-dimensional NMR approach was used to probe the coactivator binding interface in the peroxisome proliferator-activated receptor gamma (PPARgamma) ligand binding domain (LBD). In the presence of a CBP peptide, peaks corresponding to 20 residues in helices 3, 4, 5, and 12 of the LBD were attenuated. Alanine mutants revealed that K301A, V315A, Y320A, L468A, and E471A were required for binding of both CBP and SRC-1 and for cell-based transcription. Several additional amino acids in helix 4 of the PPARgammaLBD were defective with respect to CBP recruitment, but retained relatively normal SRC-1 recruitment. Thus these amino acid residues may be important determinants of specificity for nuclear receptor LBD interactions with discrete coactivator molecules.

Cervical diskography: analysis of provoked responses at C2-C3, C3-C4, and C4-C5

BACKGROUND AND PURPOSE

Previous authors have described the locations of provoked responses to cervical diskography from C3-C4 to C6-C7, but we have found no description of the findings at C2-C3. This study was undertaken to analyze the sensations provoked during cervical diskography at C2-C3 and to compare the results with those provoked at C3-C4 and C4-C5.

METHODS

The locations of diskographically provoked responses from 40 consecutive patients who had undergone C2-C3, C3-C4, and C4-C5 diskography were analyzed. Only intensely painful (> or = 7/10) and concordant responses were considered. Disk morphology on MR images and diskograms was also compared with the provoked responses.

RESULTS

Eighteen subjects described either unilateral (n = 10) or bilateral (usually asymmetric) (n = 8) concordant pain at the craniovertebral junction in response to C2-C3 diskography. Nine subjects described either unilateral (n = 5) or bilateral (n = 4) neck pain during injection. Cephalalgia or head pain was provoked in 19 subjects, seven bilaterally. Four subjects described either unilateral (n = 3) or bilateral (n = 1) trapezius muscle and/or shoulder pain. Preliminary MR studies were not helpful, as most C2-C3 disks either appeared normal or exhibited nonspecific signs of degeneration. All disks exhibited either fissuring or extradiskal leakage of contrast material at diskography, regardless of the response provoked.

CONCLUSION

Diskography at C2-C3 and C3-C4 frequently produces pain sensations in the head, craniovertebral junction, and neck. There is no correlation between C2-C3 disk morphology and the diskographically provoked response.

Preclinical mobility disability predicts incident mobility disability in older women

BACKGROUND

Physical disability and dependency are serious, and frequent, adverse health outcomes associated with aging and resulting from chronic disease. Reasoning has suggested that there might be a preclinical, intermediate phase of disablement which might develop in parallel with progression of underlying disease and precede and predict disability. Definition of this stage could provide a basis for screening and early intervention to prevent disability. The objective of this study was to determine preclinical functional predictors of incident mobility difficulty and provide evidence for a preclinical stage of disability.

METHODS

A prospective, population-based cohort study was carried out in Baltimore, Maryland, with two evaluations 18 months apart. The participants were 436 community-dwelling women, 70-80 years of age at baseline, not cognitively impaired, and reporting difficulty in no areas, or only one area, of physical function (primarily mobility), who were participating in the Women's Health and Aging Study II. Participants were recruited from a population-based, age-stratified random sample. Incident mobility disability was studied in the subset without such disability at baseline. The main outcome measure was self-reported incident difficulty walking 1/2 mile or climbing up 10 steps.

RESULTS

At baseline, 69.3% of the cohort reported no difficulty with mobility. After 18 months, 16.0 and 11.7% of this group reported incident difficulty walking 1/2 mile or climbing up 10 steps, respectively. Those reporting baseline task modification due to underlying health problems, our measure of preclinical disability, were at three- to fourfold higher odds of progressing to difficulty than were those without such modification. In multivariate logistic regression analyses, this self-report measure, task modification without difficulty, and objective measures of performance were independently and jointly predictive of incident mobility difficulty. Specifically, for incident difficulty walking 1/2 mile, self-reported task modification odds ratio (OR) = 3.67, walking speed (.5 m/s difference) OR = 2.16; for incident difficulty climbing up 10 stairs, OR for task modification = 3.84, for stair climb speed (1/3 step/s difference) = 2.08 (95% CI did not include 1 for any). Covariates, age, living alone, number of chronic diseases, depression score, knee strength, and balance by functional reach, were not significant predictors in either model.

CONCLUSIONS

Two indicators of functional changes in older women without mobility difficulty, self-report of modification of method of doing a task in the absence of difficulty and performance measures, are independent and strong predictors of risk of incident mobility disability. The self-report measure provides substantial strength in predicting risk of incident disability across the full range of performance, and may identify a vulnerable point at which other risk factors act to cause transitions to disability. Together, the preclinical indicators identify a subset of high-functioning older women who are at high risk of mobility disability, and provide a potential basis for screening for disability risk and targeting interventions to prevent mobility disability.

Biphasic stimulation of prostacyclin by endogenous nitric oxide (NO) in endothelial cells transfected with inducible NO synthase

Nitric oxide (NO) regulates prostaglandin H synthase (PGHS) activity in various cell types, but reports conflict in regard to its stimulatory versus inhibitory role. Murine lung endothelial cells infected with a retroviral vector expressing the human inducible NO synthase gene were used to prevent ambiguous effects of NO from either exogenous chemical donors or cytokine-stimulated cells. Low concentrations of endogenous NO led to a dose-dependent increase in 6-keto PGF1alpha production (p < 0.05), whereas the highest production of NO resulted in lower 6-keto PGF1alpha production. These data demonstrate a complex regulation of PGHS activity by NO that needs to be considered when proposing a physiological or pathophysiological role for NO.