The effect of chronic insulin delivery via the intraperitoneal versus the subcutaneous route on hepatic triglyceride secretion rate in streptozotocin diabetic rats

Chronic intraperitoneal or subcutaneous insulin administration increases triglyceride secretion rate (TGSR) in normal rats. We wished to determine the effect of this treatment on TGSR and the hepatic lipogenic enzymes acetyl-CoA carboxylase (ACC) and fatty acid synthase (FAS) in diabetic rats. Streptozotocin-diabetic rats, untreated (D), diabetic rats treated with insulin (3 U/day for 21 days) intraperitoneally (IP) or subcutaneously (SC) and non-diabetic rats (N) were studied. TGSR was determined using Triton WR-1339. Fasting glucose and triglyceride levels, high in D, were normalized by insulin treatment regardless of route. Peripheral insulin levels were lowest in D and highest in SC, portal insulin levels were lowest in D and highest in IP. Non-esterified fatty acid levels were not elevated in D, presumably due to adipose tissue depletion. TGSR was reduced in D (P<0.05) and was normalized following insulin administration, regardless of route. ACC activity was normal, but FAS was decreased in D (P<0.05). ACC and FAS were normal in both IP and SC. Thus, in streptozotocin-diabetic rats, chronic intraperitoneal or subcutaneous insulin treatment increases TGSR and FAS activity from their low levels in insulin-deficient rats to levels equal to but not higher than those in normal rats.

Identification of a novel receptor for B lymphocyte stimulator that is mutated in a mouse strain with severe B cell deficiency

BLyS (also called BAFF, TALL-1, THANK, and zTNF4), a TNF superfamily member, binds two receptors, TACI and BCMA, and regulates humoral immune responses [1-7]. These two receptors also bind APRIL [7-10], another TNF superfamily member. The results from TACI(-/-) and BCMA(-/-) mice suggest the existence of additional receptor(s) for BLyS. The TACI knockout gives the paradoxical result of B cells being hyperresponsive, suggesting an inhibitory role for this receptor [11, 12], while BCMA null mice have no discernable phenotype [13]. Here we report the identification of a third BLyS receptor (BR3; BLyS receptor 3). This receptor is unique in that, in contrast to TACI and BCMA, BR3 only binds BLyS. Treatment of antigen-challenged mice with BR3-Fc inhibited antibody production, indicating an essential role for BLyS, but not APRIL, in this response. A critical role for BR3 in B cell ontogeny is underscored by our data showing that the BR3 gene had been inactivated by a discrete, approximately 4.7 kb gene insertion event that disrupted the 3' end of the BR3 gene in A/WySnJ mice, which lack peripheral B cells.

A study of demographic changes under sustained below-replacement fertility in Hong Kong SAR

The total fertility in Hong Kong SAR fell continuously below replacement in the past two decades and reached a level of 0.98 in 1998. The rate in 1981 was close to replacement at 1.93. In this paper the theoretical outcomes of long-lasting below-replacement fertility are identified with a view to gaining some analytical insight into the situation, where the population is experiencing such a striking demographic trend. In the absence of migration, Hong Kong SAR will see its population start to decline between 2008 and 2038, if the future course of fertility falls within these 'bounds'. Concurrently, the aging of population will be reaching unprecedented proportions. Should fertility remain at the present below-replacement level, i.e. the worse-case scenario, the proportion of population aged 65 years or older would increase to 44 per cent, and those aged under 15 years would decrease to six per cent, by 2048. As a result, the potential labour supply (those aged 15-64 years) would dwindle to only 50 per cent of the population, suggesting that there would be less than one person potentially working to support one dependent (who is likely to be a person aged 65 years or older). The socio-economic consequences of population aging are discussed. By analysing net immigration in the demographic process in the past, the way in which replacement migration would help alleviate the problem of population decline and population aging is also discussed.

Activation and accumulation of B cells in TACI-deficient mice

The tumor necrosis factor (TNF)-related ligand B lymphocyte stimulator (BLyS) binds two TNF receptor family members, transmembrane activator and calcium-modulating and cyclophilin ligand interactor (TACI) and B cell maturation molecule (BCMA). Mice that are transgenic for BLyS show B cell accumulation, activation and autoimmune lupus-like nephritis. The existence of at least two distinct BLyS receptors raises the question of the relative contribution of each to B cell functions. We therefore generated mice that were deficient in TACI. TACI-/- mice showed increased B cell accumulation and marked splenomegaly. Isolated TACI-/- B cells hyperproliferated and produced increased amounts of immunoglobulins in vitro. In vivo antigen challenge resulted in enhanced antigen-specific antibody production. Thus, TACI may play an unexpected inhibitory role in B cell activation that helps maintain immunological homeostasis.

TACI-ligand interactions are required for T cell activation and collagen-induced arthritis in mice

Interactions of the tumor necrosis factor superfamily members B lymphocyte stimulator (BLyS) and a proliferation-inducing ligand (APRIL) with their receptors-transmembrane activator and CAML interactor (TACI) and B cell maturation molecule (BCMA)-on B cells play an important role in the humoral immune response. Whereas BCMA is restricted to B cells, TACI is also expressed on activated T cells; we show here that TACI-Fc blocks the activation of T cells in vitro and inhibits antigen-specific T cell activation and priming in vivo. In a mouse model for rheumatoid arthritis (RA), an autoimmune disease that involves both B and T cell components, TACI-Fc treatment substantially inhibited inflammation, bone and cartilage destruction and disease development. Thus, BLyS and/or APRIL are important not only for B cell function but for T cell-mediated immune responses. Inhibition of these ligands might have therapeutic benefits for autoimmune diseases, such as RA, that involve both B and T cells.

On-line detection of sleep-wake states and application to produce intermittent hypoxia only in sleep in rats

Sleep-disordered breathing is associated with adverse clinical consequences such as daytime sleepiness and hypertension. The mechanisms behind these associations have been studied in animal models, especially rats, but intermittent stimuli such as hypoxia have been applied without reference to sleep-wake states. To determine mechanisms underlying the adverse physiological consequences of stimuli associated with sleep-disordered breathing requires criteria for detection of sleep-wake states on-line to trigger stimuli only in sleep. This study aimed to develop such a system for freely behaving rats. Twelve rats with implanted electroencephalogram and neck electromyogram electrodes were studied in the light and dark phases. Electroencephalogram frequencies in the high (20–30 Hz) and low (2–4 Hz) frequency bands distinguished non-rapid eye movement (REM) sleep, whereas neck electromyogram distinguished REM. Using these parameters in a simple algorithm led to detection accuracies of 94.5 ± 1.0 (SE) % for wakefulness, 96.2 ± 0.8% for non-REM sleep, and 92.3 ± 1.6% for REM compared with blinded human judgment. The algorithm was then used to trigger hypoxic stimuli only in sleep. Because frequency and amplitude analysis is readily performed using a variety of commercial systems, incorporation of these parameters into such an algorithm will facilitate studies investigating mechanisms underlying the physiological consequences of sleep-related respiratory stimuli in a fashion that more effectively models clinical disorders.

Anti-IgE efficacy in murine asthma models is dependent on the method of allergen sensitization

BACKGROUND

Murine models used to delineate mechanisms and key mediators of asthma have yielded conflicting results and suggest that the dominant mechanism and mediators required for disease induction differ depending on the model and method of allergen sensitization used.

OBJECTIVE

The goal of this study was to determine whether the mode of allergen sensitization influenced the role that IgE had in allergen-induced pulmonary eosinophilic inflammation.

METHODS

Mice were exposed to dust mite extract in 2 models of allergic inflammation that differed in the method of sensitization. We compared sensitization by aerosol exposure with and without concomitant human respiratory syncytial virus infection with sensitization by means of systemic (intraperitoneal) exposure with adjuvant. After sensitization, animals were similarly challenged with aerosolized allergen. Animals were treated with anti-IgE mAb to deplete IgE and to determine its role in the induction of allergic inflammation and mucosa pathology in these models.

RESULTS

Concomitant respiratory syncytial virus infection significantly enhanced allergen sensitization by aerosol exposure and exacerbated eosinophilic inflammation and airway mucosa pathology. Depletion of IgE in this model significantly reduced lung eosinophilic inflammation and airway mucosa pathology. However, in the model in which animals were sensitized by means of systemic allergen exposure with adjuvant, depletion of IgE had no ameliorative effect on lung inflammation or pathology.

CONCLUSION

We demonstrated that the method of antigen sensitization can delineate the role of IgE in allergen-induced lung inflammation. In a murine model that more closely resembles ambient allergen exposure in human subjects, IgE had a critical role in the pathogenesis of allergic asthma and mucosa pathology. The results parallel the results reported with anti-IgE efficacy in allergic asthmatic human subjects.

A simple, rapid method for HPLC analysis of lycopene isomers

A rapid method for the extraction, separation and quantification of the geometric isomers of lycopene and beta-carotene from tomato fruit is described. Carotenoids in tomato were separated and eluted using a reversed-phase HPLC with a C30 column and a mobile phase consisting of methyl-t-butyl ether, methanol and ethyl acetate. The system provided sharp resolution of cis- and trans-isomers of lycopene within approximately 23 min in contrast to the longer and more complex gradient procedures required by previously described methods. Experiments indicate that the stability of extracts of fresh tomato may be improved if stored at -20 degrees C, and that the presence of the antioxidant BHA has no apparent effect on stability.

Myopia in Singapore kindergarten children

PURPOSE

The purpose of this study was to examine whether close-up work was related to myopia in Singapore kindergarten children.

METHODS

One hundred twenty-eight children, ages 3 to 7 years, from a kindergarten in Singapore were examined by cycloplegic autorefraction. The parents also completed a questionnaire on the different types of close-up work activities each child was engaged in, socioeconomic status, and parental history of myopia.

RESULTS

Myopic children spent 3.0 hours per day (median) on close-up work activity, while nonmyopic children spent 2.0 hours per day (median) on close-up work activity. The prevalence of myopia in the sample was 8.6%.

CONCLUSION

Close-up work activity was not related to myopia in pre-school children.

Cell surface glypicans are low-affinity endostatin receptors

Endostatin, a collagen XVIII fragment, is a potent anti-angiogenic protein. We sought to identify its endothelial cell surface receptor(s). Alkaline phosphatase- tagged endostatin bound endothelial cells revealing two binding affinities. Expression cloning identified glypican, a cell surface proteoglycan as the lower-affinity receptor. Biochemical and genetic studies indicated that glypicans' heparan sulfate glycosaminoglycans were critical for endostatin binding. Furthermore, endostatin selected a specific octasulfated hexasaccharide from a sequence in heparin. We have also demonstrated a role for endostatin in renal tubular cell branching morphogenesis and show that glypicans serve as low-affinity receptors for endostatin in these cells, as in endothelial cells. Finally, antisense experiments suggest the critical importance of glypicans in mediating endostatin activities.

Consistency analysis of similarity between multiple alignments: prediction of protein function and fold structure from analysis of local sequence motifs

A new method to analyze the similarity between multiply aligned protein motifs (blocks) was developed. It identifies sets of consistently aligned blocks. These are found to be protein regions of similar function and structure that appear in different contexts. For example, the Rossmann fold ligand-binding region is found similar to TIM barrel and methylase regions, various protein families are predicted to have a TIM-barrel fold and the structural relation between the ClpP protease and crotonase folds is identified from their sequence. Besides identifying local structure features, sequence similarity across short sequence-regions (less than 20 amino acid regions) also predicts structure similarity of whole domains (folds) a few hundred amino acid residues long. Most of these relations could not be identified by other advanced sequence-to-sequence or sequence-to-multiple alignments comparisons. We describe the method (termed CYRCA), present examples of our findings, and discuss their implications.

Increased cell proliferation and associated expression of PDGFRbeta causing hypercellularity in patellar tendinosis

OBJECTIVE

This study assessed cellularity in patellar tendinosis with respect to cell proliferation and the expression of platelet-derived growth factor receptor beta (PDGFRbeta).

METHODS

Surgical samples were taken from 11 patients fulfilling criteria of patellar tendinosis and from 12 matched controls. Standard immunohistochemistry methods were used to detect expression of PDGFRbeta and proliferation cell nuclear antigen (PCNA). Results were analysed by computer-assisted microscopy. Tendon cells were isolated from nine tendinosis and eight control tissues for cell culture.

RESULTS

Increased cellularity (P<0.001) was observed in tendinosis tissues compared with controls, and also a higher proliferative index (P:<0.001). Increased expression of PDGFRbeta was demonstrated (P<0.001). Cultured tendinosis cells showed a higher proliferation rate than controls (P<0.001). This was maintained when the cells were cultured under various conditions of serum supplementation (P<0.01). Tendinosis cells also showed a higher proliferation rate (P<0.01) in medium containing 10 ng/ml PDGF.

CONCLUSION

Hypercellularity in patellar tendinosis is caused by increased cell proliferation and is associated with increased expression of PDGFRbeta.

The financial performance of hospitals belonging to health networks and systems

The U.S. health industry is experiencing substantial restructuring through ownership consolidation and development of new forms of interorganizational relationships. Using an established taxonomy of health networks and systems, this paper develops and tests four hypotheses related to hospital financial performance. Consistent with our predictions, we find that hospitals in health systems that had unified ownership generally had better financial performance than hospitals in contractually based health networks. Among health network hospitals, those belonging to highly centralized networks had better financial performance than those belonging to more decentralized networks. However, health system hospitals in moderately centralized systems performed better than those in highly centralized systems. Finally, hospitals in networks or systems with little differentiation or centralization experienced the poorest financial performance. These results are consistent with resource dependence, transaction cost economics, and institutional theories of organizational behavior, and provide a conceptual and empirical baseline for future research.

Evolutionary coadaptation of the motif 2--acceptor stem interaction in the class II prolyl-tRNA synthetase system

Known crystal structures of class II aminoacyl-tRNA synthetases complexed to their cognate tRNAs reveal that critical acceptor stem contacts are made by the variable loop connecting the beta-strands of motif 2 located within the catalytic core of class II synthetases. To identify potential acceptor stem contacts made by Escherichia coli prolyl-tRNA synthetase (ProRS), an enzyme of unknown structure, we performed cysteine-scanning mutagenesis in the motif 2 loop. We identified an arginine residue (R144) that was essential for tRNA aminoacylation but played no role in amino acid activation. Cross-linking experiments confirmed that the end of the tRNA(Pro) acceptor stem is proximal to this motif 2 loop residue. Previous work had shown that the tRNA(Pro) acceptor stem elements A73 and G72 (both strictly conserved among bacteria) are important recognition elements for E. coli ProRS. We carried out atomic group "mutagenesis" studies at these two positions of E. coli tRNA(Pro) and determined that major groove functional groups at A73 and G72 are critical for recognition by ProRS. Human tRNA(Pro), which lacks these elements, is not aminoacylated by the bacterial enzyme. An analysis of chimeric tRNA(Pro) constructs showed that, in addition to A73 and G72, transplantation of the E. coli tRNA(Pro) D-domain was necessary and sufficient to convert the human tRNA into a substrate for the bacterial synthetase. In contrast to the bacterial system, base-specific acceptor stem recognition does not appear to be used by human ProRS. Alanine-scanning mutagenesis revealed that motif 2 loop residues are not critical for tRNA aminoacylation activity of the human enzyme. Taken together, our results illustrate how synthetases and tRNAs have coadapted to changes in protein-acceptor stem recognition through evolution.

Assessment of hemodynamic response during focal neural activity in human using bolus tracking, arterial spin labeling and BOLD techniques

In this study, the hemodynamic response and changes in oxidative metabolism during functional activation were measured using three functional magnetic resonance imaging (fMRI) techniques: the blood oxygenation level-dependent (BOLD) technique, flow-sensitive alternating inversion recovery (FAIR), and bolus tracking (BT) of an MR contrast agent. With these three techniques we independently determined changes in BOLD signal, relative cerebral blood flow (rCBF), and cerebral blood volume (rCBV) associated with brain activation in eight healthy volunteers. In the motor cortex, the BOLD signal increased by 1.8 +/- 0.5%, rCBF by 36.3 +/- 8.2% (FAIR), and 35.1 +/- 8.6% (BT), and rCBV by 19.4 +/- 4.1% (BT) in response to simultaneous bilateral finger tapping. In the visual cortex, BOLD signal increased by 2.6 +/- 0.5%, rCBF by 38.5% +/- 7.6 (FAIR), and 36.9 +/- 8.8% (BT), and rCBV by 18.8 +/- 2.8% (BT) during flickering checkerboard stimulation. Comparing the experimentally measured rCBV with the calculated rCBV using Grubb's power-law relation, we conclude that the use of power-law relationship results in systematic underestimate of rCBV.

Microvascular reconstruction and tracheotomy are significant determinants of resource utilization in head and neck surgery

BACKGROUND

Successful "critical pathway" design and implementation are dependent on appropriate patient stratification according to those factors that are primary determinants of resource utilization.

OBJECTIVES

To test the validity of our previously reported critical pathway design and to determine whether tracheotomy and microvascular reconstruction (MR) are primary determinants of resource utilization.

DESIGN

Cost-effectiveness analysis.

SETTING

Tertiary referral academic institution.

METHODS

Retrospective analysis of data from 133 head and neck surgery cases in which the treatment regimen was based on critical pathways over a 26-month period.

OUTCOME MEASURES

Length of stay and total patient charges were used as indices of resource utilization. One-way analysis of variance and t tests were used for statistical analysis of significance.

RESULTS

Ninety patients (67.7%) underwent MR; 43 (32. 3%) did not. Seventy-five patients (56.4%) underwent tracheotomy; 58 (43.6%) did not. Four patient groups were constructed in decreasing order of complexity as follows: group 1, patients who underwent both tracheotomy and MR (n = 58); group 2, patients who underwent MR alone (n = 32); group 3, patients who underwent tracheotomy alone (n = 17); and group 4, patients who did not undergo either procedure (n = 26). Both tracheotomy and MR were found to be independent determinants of resource utilization and were additive when both were present. The length of stay varied from 8.4 days (in patients who underwent both procedures) to 6.7 days (in patients who did not undergo either procedure), with intermediate values in cases in which only 1 procedure was performed. The total charges varied in a similar manner from a high of $33,371 to a low of $19,994. Subanalysis with respect to intensive care unit, ward, and operating room charges showed a similar stratification.

CONCLUSION

Tracheotomy and MR are both significant determinants of charges and length of stay in head and neck surgery cases and must be considered in the design of strategies to promote efficient resource utilization.

FIZZ1, a novel cysteine-rich secreted protein associated with pulmonary inflammation, defines a new gene family

Bronchoalveolar lavage fluid from mice with experimentally induced allergic pulmonary inflammation contains a novel 9.4 kDa cysteine-rich secreted protein, FIZZ1 (found in inflammatory zone). Murine (m) FIZZ1 is the founding member of a new gene family including two other murine genes expressed, respectively, in intestinal crypt epithelium and white adipose tissue, and two related human genes. In control mice, FIZZ1 mRNA and protein expression occur at low levels in a subset of bronchial epithelial cells and in non-neuronal cells adjacent to neurovascular bundles in the peribronchial stroma, and in the wall of the large and small bowel. During allergic pulmonary inflammation, mFIZZ1 expression markedly increases in hypertrophic, hyperplastic bronchial epithelium and appears in type II alveolar pneumocytes. In vitro, recombinant mFIZZ1 inhibits the nerve growth factor (NGF)-mediated survival of rat embryonic day 14 dorsal root ganglion (DRG) neurons and NGF-induced CGRP gene expression in adult rat DRG neurons. In vivo, FIZZ1 may modulate the function of neurons innervating the bronchial tree, thereby altering the local tissue response to allergic pulmonary inflammation.

A mixed-penalty biphasic finite element formulation incorporating viscous fluids and material interfaces

The fluid viscosity term of the fluid phase constitutive equation and the interface boundary conditions between biphasic, solid and fluid domains have been incorporated into a mixed-penalty finite element formulation of the linear biphasic theory for hydrated soft tissue. The finite element code can now model a single-phase viscous incompressible fluid, or a single-phase elastic solid, as limiting cases of a biphasic material. Interface boundary conditions allow the solution of problems involving combinations of biphasic, fluid and solid regions. To incorporate these conditions, the volume-weighted mixture velocity is introduced as a degree of freedom at interface nodes so that the kinematic continuity conditions are satisfied by conventional finite element assembly techniques. Results comparing our numerical method with an independent, analytic solution for the problem of Couette flow over rigid and deformable porous biphasic layers show that the finite element code accurately predicts the viscous fluid flows and deformation in the porous biphasic region. Thus, the analysis can be used to model the interface between synovial fluid and articular cartilage in diarthrodial joints. This is an important step toward modeling and understanding the mechanisms of joint lubrication and another step toward fully modeling the in vivo behavior of a diarthrodial joint.

Effects of humanized monoclonal antibody to rhesus CD11a in rhesus monkey cardiac allograft recipients

INTRODUCTION

Leukocyte function-associated antigen-1 (LFA-1, CD11a) monoclonal antibody (mAb) affects many leukocyte functions without cell depletion. We hypothesized that the use of a humanized, anti-rhesus modified LFA-1 mAb (H2C12) in rhesus monkeys would cause: (1) prolonged heart allograft survival, (2) inhibition of primary but not secondary antibody responses, and (3) minimal drug toxicity.

METHODS AND RESULTS

Control (n=5) and H2C12-treated (n=7) (8-20 mg/kg i.v. on day -1 followed by 10 mg/kg/day) adult male rhesus recipients were inoculated with GP120 protein antigen on day -28 and -1 and grafted with heterotopic abdominal hearts (day 0). Donor-recipient pairs were equally MLR mismatched (4329.8+/-1124.1 CPM controls vs. 7289.0+/-1926.5 treated, P=NS). Mean heart allograft survival as evaluated by daily abdominal palpation was significantly prolonged in high dose recipients (23.0+/-2.6, n=4) vesus controls (8.2+/-1.3, n=5, P<0.02, Mann-Whitney U test). H2C12 treatment did not produce signs of cytokine release or toxicity, was nondepleting, but down-modulated PBL CD11a expression to 43.4+/-3.6% (n=4) of control levels (n=5) at day 7 as demonstrated by flow cytometry. It had no effect on postoperative Con A or MLR and did not prevent mAb clearance due to the rhesus-antihuman antibody response. The addition of mycophenolate mofitil prevented rhesus-antihuman antibody response with therapeutic H2C12 levels seen for >35 days.

CONCLUSIONS

The use of this mAb to block CD11a had the benefit of being a well tolerated, highly targeted therapy. These are the first results showing that monotherapy with anti-leukocyte function-associated antigen-1 mAb prolonged survival of MLR mismatched allogenic cardiac grafts in primates.

A multi-mutant herpes simplex virus vector has minimal cytotoxic effects on the distribution of filamentous actin, alpha-actinin 2 and a glutamate receptor in differentiated PC12 cells

To develop effective gene therapy techniques that target populations of neurons in the spinal cord, suitable vectors must be developed that will undergo efficient, retrograde transport from an appropriate peripheral site and will not be cytotoxic. Our previous work (LeVatte et al, 1998a) has demonstrated that a replication defective herpes simplex virus vector 14Hdelta3vhsZ, that has been substantially detoxified, is retrogradely transported from peripheral sites and can infect large numbers of the targeted spinal neurons. We plan to develop targeted gene therapy approaches designed to modulate the excitatory glutamatergic methyl-D-aspartate (NMDA) receptor in spinal cord neurons as a means of ameliorating a form of episodic high blood pressure that occurs after spinal cord injury. In this report, we demonstrate that, in differentiated PC12 cells, a neuronal-like cell line, the virus vector does not appear to alter aspects of the cytoskeletal architecture important to the proper distribution of the NMDA receptor. In turn, the distribution of endogenous NMDA receptor 1 subunit protein (NMDAR1) or a transfected NMDAR1-green fluorescent fusion protein was also found to be unaltered after vector infection. However, whereas endogenous NMDAR1 distribution was maintained, vector infection did tend to reduce the level of its expression. This drop in endogenous NMDAR1 expression coincided with the expression of the HSV immediate early genes ICP0 and ICP27 over the first 24-48 h. These results indicate that the 14Hdelta3vhsZ herpes simplex virus vector is suitable to use in future strategies to alter the level of gene expression in targeted populations of spinal cord neurons.

Cloning of mouse prostaglandin transporter PGT cDNA: species-specific substrate affinities

We recently identified and/or cloned the PG transporter PGT in the rat (rPGT) (Kanai, N., R. Lu, J. A. Satriano, Y. Bao, A. W. Wolkoff, and V. L. Schuster, Science 268: 866-869, 1995) and the human (hPGT) (Lu, R., and V. L. Schuster, J. Clin. Invest. 98: 1142-1149, 1996). Here we have cloned and expressed the mouse PGT (mPGT) cDNA. The tissue distribution of mPGT mRNA expression is significantly more restricted than that of rPGT and hPGT mRNA. Although the deduced amino acid sequence of mPGT is similar to the rat (91% identity) and human (82% identity) homologues, it has three regions of dissimilarity: amino acids 128-163 and 283-298, and valine 610 and isoleucine 611 (predicted to lie within putative transmembrane span 12). Affinities of hPGT, rPGT, and mPGT for several PG substrates differed, with hPGT having the highest [low Michaelis constant (K(m))] and mPGT the lowest affinity. A chimeric protein, linking the N-terminal domain of mPGT with the C-terminal domain of hPGT, had affinity for PGE2 indistinguishable from that of hPGT, indicating that the C-terminal domain dictates K(m). We mutagenized mouse valine 610 and isoleucine 611 to their corresponding human residues (methionine and glycine, respectively); however, these changes did not convert the inhibition constant of mPGT to that of hPGT. The mouse gene was localized to chromosome 9 in a region syntenic with the region of human chromosome 3 containing the hPGT gene. These studies highlight the species-dependence of tissue expression and function of PGT and lay the groundwork for the use of the mouse as a model system for the study of PGT function.

American Society for Microbiology--99th general meeting. 30 May-3 June 1999, Chicago, IL, USA

The American Society for Microbiology (ASM) celebrated its centenary at this meeting, which aimed to appeal to an audience with diverse microbiological interests. The program comprised six colloquia, division lectures and award sessions, division sessions, poster and special interest sessions, as well as pre-meeting workshops. The colloquia topics, selected by the ASM members advisory committee, were: pathogenesis; microbes and public health; microbial diversity; beyond the recombinant RNA revolution; molecular dissection of complex biological processes; and, host defenses. The divisional groups were: diagnostic microbiology and epidemiology; pathogenesis and host response mechanisms; general microbiology; and, molecular microbiology, physiology and virology. Each group highlighted a topic of importance to scientists from all divisions within that group and the divisional lecture was given by a distinguished scientist within one of the division's sessions.

Organizational and administrative factors influencing the adoption of consortia programs by rural hospitals

This study was designed to assess the effects of various hospital and environmental characteristics on the involvement of rural hospitals in forming and governing consortia and adopting consortia programs. The study focused on the 127 hospitals that are members of the nine rural consortia developed by grants from the Robert Wood Johnson Foundation during 1989 under its Hospital-Based Rural Hospital Consortia Program. Hospital involvement in the formation and governance of the consortia was found to be far less than expected for these grass-roots organizations. Only 38 percent of the administrators said that their hospitals were involved in developing the consortia, and 44 percent said that they played a role in determining the program menu. Governing board and medical staff involvement was even more limited. Program adoption rates were found to be related to both the types of programs offered by the consortia and the characteristics of the hospitals. In general, greater involvement of physicians and governing board members in hospital decisions was found to enhance program adoption rates, but the influence varied by type of involvement in the hospital and program content.

The effects of group size and group economic factors on collaboration: a study of the financial performance of rural hospitals in consortia

STUDY QUESTIONS

To determine factors that distinguish effective rural hospital consortia from ineffective ones in terms of their ability to improve members' financial performance. Two questions in particular were addressed: (1) Do large consortia have a greater collective impact on their members? (2) Does a consortium's economic environment determine the degree of collective impact on members?

DATA SOURCES AND STUDY SETTING

Based on the hospital survey conducted during February 1992 by the Robert Wood Johnson Hospital-Based Rural Health Care project of rural hospital consortia. The survey data were augmented with data from Medicare Cost Reports (1985-1991), AHA Annual Surveys (1985-1991), and other secondary data.

STUDY DESIGN

Dependent variables were total operating profit, cost per adjusted admission, and revenue per adjusted admission. Control variables included degree of group formalization, degree of inequality of resources among members (group asymmetry), affiliation with other consortium group(s), individual economic environment, common hospital characteristics (bed size, ownership type, system affiliation, case mix, etc.), year (1985-1991), and census region dummies.

PRINCIPAL FINDINGS

All dependent variables have a curvilinear association with group size. The optimum group size is somewhere in the neighborhood of 45. This reveals the benefits of collective action (i.e., scale economies and/or synergy effects) and the issue of complexity as group size increases. Across analyses, no strong evidence exists of group economic environment impacts, and the environmental influences come mainly from the local economy rather than from the group economy.

CONCLUSION

There may be some success stories of collaboration among hospitals in consortia, and consortium effects vary across different collaborations.

RELEVANCE/IMPACT

When studying consortia, it makes sense to develop a typology of groups based on some performance indicators. The results of this study imply that government, rural communities, and consortium staff and steering committees should forge the consortium concept by expanding membership in order to gain greater financial benefits for individual hospitals.

Increased dependence of glucose production on peripheral insulin in diabetic depancreatized dogs

We have recently found that in nondiabetic dogs and humans, suppression of glucose production (GP) is mediated by both peripheral and hepatic effects of insulin. We have also found that both nonesterified fatty acids (NEFA) and glucagon are important determinants of the peripheral effect of insulin on GP. However, in moderately hyperglycemic depancreatized dogs, suppression of GP appeared to be mediated by peripheral but not hepatic insulin. In this latter study, insulin concentrations were in the high postprandial range (approximately 300 pmol/L) and suppression of GP may have been close to maximum. The aim of the present study was to determine whether GP can be regulated by hepatic insulin in depancreatized dogs at low insulin concentrations in the postabsorptive range. Depancreatized dogs were maintained at moderately hyperglycemic levels (approximately 10 mmol/L) by subbasal insulin infusions. In paired experiments, additional low-dose equimolar insulin infusions (0.75 pmol/kg x min) were administered peripherally (PER, n = 6) or portally (POR, n = 6) during glucose clamps. This resulted in a minimal increase in peripheral insulin levels, which was greater in PER versus POR, 29.0 +/- 3.7 versus 11.7 +/- 2.2 pmol/L. Also, we infused insulin peripherally at half this rate (1/2 PER, n = 6) to match the increase in peripheral insulin levels in POR (1/2 PER, 14.6 +/- 2.2) and thus obtain a selective POR versus 1/2 PER difference in hepatic sinusoidal insulin levels. PER suppressed GP more than POR (45.4% +/- 4.0% v 35.3% +/- 6.8%, P < .001), whereas POR did not suppress GP more than 1/2 PER (35.6% +/- 6.3%). Therefore, suppression of GP was proportional to peripheral rather than hepatic sinusoidal insulin levels, as in our previous study at higher insulin concentrations. In conclusion, during glucose clamps in moderately hyperglycemic depancreatized dogs, (1) suppression of GP was dominated by insulin's peripheral effects not only at postprandial but also postabsorptive insulin levels, and (2) we found no evidence for a hepatic effect of insulin in suppressing GP. We hypothesize that this effect is reduced in the depancreatized dog model of diabetes due to hepatic insulin resistance and/or hyperglycemia.

Intra-tRNA distance measurements for nucleocapsid proteindependent tRNA unwinding during priming of HIV reverse transcription

We report here the direct measurement of intra-tRNA distances during annealing of the tRNA primer to the HIV RNA genome. This key step in the initiation of retroviral reverse transcription involves hybridization of one strand of the acceptor arm of a specific lysine tRNA to the primer binding site on the RNA genome. Although the mechanism of tRNA unwinding and annealing is not known, previous studies have shown that HIV nucleocapsid protein (NC) greatly accelerates primer/template binary complex formation in vitro. An open question is whether NC alone unwinds the primer or whether unwinding by NC requires the RNA genome. We monitored the annealing process in solution by using fluorescence resonance energy transfer (FRET). Distance measurements demonstrate unequivocally that the tRNA acceptor stem is not substantially unwound by NC in the absence of the RNA genome, that is, unwinding is not separable from hybridization. Moreover, FRET measurements show that both heat- and NC-mediated annealing result in an approximately 40-A increase in the separation of the two ends of the tRNA acceptor arm on binding to the template. This large increase in separation of the two ends suggests a complete displacement of the nonhybridized strand of the acceptor stem in the initiation complex.

Human Immunodeficiency Virus Reverse Transcriptase and Protease Sequence Database

The HIV RT and Protease Sequence Database is an on-line relational database that catalogues evolutionary and drug-related human immunodeficiency virus reverse transcriptase (RT) and protease sequence variation (http://hivdb.stanford.edu). The database contains a compilation of nearly all published HIV RT and protease sequences including International Collaboration database submissions (e.g., GenBank) and sequences published in journal articles. Sequences are linked to data about the source of the sequence sample and the anti-HIV drug treatment history of the individual from whom the isolate was obtained. The database is curated and sequences are annotated with data from 180 literature references. Users can retrieve additional data and view alignments of sequences sets meeting specific criteria (e.g., treatment history, subtype, presence of a particular mutation).

Medicaid TEFRA option in Minnesota: implications for patient rights

This research studied a special-needs population under age 18 who had both private insurance and Medicaid coverage through the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) option. We found that children with managed care plans, particularly health maintenance organizations (HMOs), tended to incur higher total expenses to TEFRA than children with indemnity plans. Our findings also show that managed care in Minnesota tends to provide the same or marginally better coverage as indemnity plans do for core medical items but much less coverage for ancillary items such as home care, therapies, and durable medical equipment.

Effect of population-based interventions on laboratory utilization: a time-series analysis

CONTEXT

Previous studies have identified methods of decreasing laboratory utilization. However, most were hospital-based, relatively small, single-centered, or of limited duration.

OBJECTIVE

To determine the effect of 3 population-based interventions (physician guidelines, laboratory requisition form modification, and changes to funding policy) on laboratory utilization in Ontario.

DESIGN

Interventional time-series analysis in which data analysis was based on all claims made to the Ontario Health Insurance Program between July 1, 1991, and April 1997 for laboratory tests affected by the interventions.

SETTING

All clinical laboratories (not based in hospitals) in Ontario.

INTERVENTIONS

Physician guidelines, modification of laboratory requisition form, and changes in funding policy for the use of the erythrocyte sedimentation rate test (ESR), microscopic urinalysis, tests for renal function, iron stores, serum urea, and serum iron determinations, and tests for thyroid dysfunction (total thyroxine and thyroid-stimulating hormone [TSH]).

MAIN OUTCOME MEASURES

Change from 1991 to 1997 in utilization rates of ESR, microscopic urinalysis, serum urea and iron determinations, and tests for total thyroxine and TSH.

RESULTS

Age- and sex-standardized rates for laboratory tests unaffected by the interventions were stable during the study period. Utilization of ESR and urea determination decreased by 58% (P<.001) and 57% (P<.001), respectively, after they were removed from the requisition form and guidelines discouraging their use were disseminated. Rates for urinalyses without microscopy increased by 1700% (P<.001), while microscopic urinalysis decreased by 14% (P<.001), after a policy change eliminated microscopic urinalysis from routine urinalysis. Rates of iron determination declined by 80% (P<.001) and ferritin rates increased by 34% (P= .05) when policy changes eliminated iron testing when ordered with ferritin and guidelines advocating ferritin alone for investigating iron deficiency were disseminated. Utilization of total thyroxine testing declined by 96% (P = .02) when the provincial health plan stopped its funding. When TSH was removed from the laboratory requisition form, a 12% decline (P= .03) in its use was observed. Through April 1997, these interventions saved more than 625000 tests or $210400.

CONCLUSIONS

The combination of guideline dissemination, laboratory requisition form modification, and changes to funding policy was associated with significant reductions in laboratory utilization.

Patterns of practice among older physicians in Ontario

BACKGROUND

Policy-makers interested in the supply of doctors in Canada have recently begun focusing attention on older physicians. This study informs the policy debate by analysing the practice patterns of Ontario physicians aged 65 years and over.

METHODS

A cross-sectional and longitudinal analysis of physician claims data for fiscal years 1989/90 through 1995/96 was conducted. The number of full-time equivalent (FTE) physicians by age category, urban or rural status, and specialty was calculated by means of an established method, and differences between older physicians, established physicians and recent graduates (in practice for 5 years or less), in terms of the types of services provided and patients seen, were examined.

RESULTS

The proportion of FTE physicians aged 65 or more increased from 5.3% to 7.0% during the study period, whereas the proportion of recent graduates decreased from 19.6% to 16.3%. Of the older physicians, 61.4% practised part time (less than 1 FTE). Half of the physicians aged 75 in 1989/90 were still in practice 6 years later. Older physicians were less likely than those under age 65 to practice obstetrics (4.6% v. 16.9%), provide emergency department services (1.1% v. 14.8%) or house calls (38.7% v. 60.4%), or perform many minor procedures (38.7% v. 62.3%) (p < or = 0.001 for all comparisons). Older physicians tended to be male and had older patients in their practices than did younger physicians. Rural regions had higher proportions of older specialists.

INTERPRETATION

Ontario's physician corps is aging. This may result in decreasing availability of obstetrics and emergency department coverage in the future. Encouraging retirement may create more openings for recent graduates, but if such policies are enacted, special attention should be paid to ensure that rural communities and older patients continue to be served.

Variations in mental health needs and fee-for-service reimbursement for physicians in Ontario

OBJECTIVES

The study examined the match between mental health needs and physician fee-for-service reimbursements for mental health care within age and gender groups and health planning regions in Ontario, Canada.

METHODS

Indicators of need (mental disorder, reported disability, and self-rated mental health) from an epidemiologic survey of 9,953 Ontario household residents were compared with per capita reimbursement rates derived from an administrative data set containing all fee-for-service expenditures for mental health care paid by the provincial health plan.

RESULTS

Few gender differences were found in overall need, but need varied significantly by age. Those in greatest need were adolescent males and females, who had rates of need from two to four times higher than older respondents. Regional variations in need were less evident. By contrast, per capita reimbursement showed marked gender differences, with rates for women generally twice the rates for men. Considerable variations in reimbursement were also found across age groups; these variations did not match variations in need. Highly urbanized areas had per capita reimbursement rates between two and four times the rates for less populated areas.

CONCLUSIONS

Despite Ontario's universal-access health care system, notable discrepancies between need and resource use are evident for males, adolescents, and residents of less urbanized areas. Solutions require a combination of public education, provider training, attention to physician availability and practice patterns, and continuous monitoring of how resources are allocated relative to need.

Idiopathic progressive hyalinizing and calcifying CNS vasculopathy

We present a female adolescent with intermittently progressive neurologic deficits over a period of 7 years. Serial imaging studies showed a calcifying lesion with increasing enhancement, signal abnormalities from the subcortex to the medulla, and hemispheric volume loss. Stereotactic biopsies disclosed a hyalinizing and calcifying vasculopathy involving the penetrating vessels. The vasculopathy may result in ischemic lesions responsible for the severe deficits.

The economic cost of musculoskeletal disorders in Canada

OBJECTIVE

This study estimated the total cost of musculoskeletal disorders for Canadians in 1994 and assessed the sensitivity of these cost estimates to variations in the definition of musculoskeletal disorders.

METHODS

Disease-related costs, from a societal perspective, were measured using a prevalence-based analysis. First, direct treatment costs, including expenditures on hospitals and other institutions, physicians and other health professionals, drugs, research, and other items were assessed. Second, indirect costs associated with lost (or foregone) productivity due to disability and premature mortality were evaluated using the human capital approach.

RESULTS

The total cost of musculoskeletal disorders in Canada was $25.6 billion (in 1994 Canadian dollars, $1.00 CDN approximately $0.75 US) or 3.4% of the gross domestic product. Direct and indirect costs were estimated at $7.5 billion and $18.1 billion, respectively. Lower and upper bound estimates of the total cost of musculoskeletal disorders, derived from the sensitivity analysis, were $19.9 billion and $30.8 billion, respectively. Wide variations were reported in the total cost of various musculoskeletal disorder subcategories, with the highest costs reported for injuries ($10.7 billion), back and spine disorders ($8.1 billion), and arthritis and rheumatism ($5.9 billion).

CONCLUSIONS

The economic cost of musculoskeletal disorders was substantial and was sensitive to the definition of musculoskeletal disorders and other underlying assumptions. The hallmark of this study was the variation between subcategories in their cost, pattern of health resource use, and sequelae. The cost estimates may provide guidance in setting priorities for research and prevention activities.

Treatment of the serotonin syndrome with cyproheptadine

The serotonin syndrome is the result of excess stimulation of central nervous 5-hydroxytryptamine (5HT)-1a and 5HT-2 receptors. The diagnosis requires a history of exposure to agents active at serotonin receptors and the presence of alterations in mental status, autonomic instability, and neuromuscular abnormalities such as tremor, hyperreflexia, or myoclonus. In this descriptive case series, five cases of serotonin syndrome are reported. All patients gave a history of recent exposure to one or more serotonergic medications, including moclobemide, paroxetine, sertraline, and venlafaxine, with clinical evidence of serotonin syndrome. All patients were administered cyproheptadine (4-8 mg orally) for serotonergic signs. Three had complete resolution of signs within 2 h of administration. Another two had a residual tremor or hyperreflexia following the first dose, which resolved following a repeat dose. There were no adverse outcomes from cyproheptadine use. The role of specific serotonin receptor antagonists such as cyproheptadine in the treatment of the serotonin syndrome remains to be delineated. Its use should be considered an adjunct to supportive care. Currently, it is unknown whether cyproheptadine modifies patient outcome.

Fee code creep among general practitioners and family physicians in Ontario: why does the ratio of intermediate to minor assessments keep climbing?

BACKGROUND

"Fee code creep" is the increasing tendency of primary care physicians in Ontario to bill for more intermediate than minor assessments over time. The authors examine the extent and nature of fee code creep and describe physician characteristics associated with the changes.

METHODS

A cross-sectional and longitudinal analysis of Ontario Health Insurance Plan billing and physician characteristic data was conducted for fee-for-service general practitioners and family physicians (GP/FPs) in Ontario. The ratio of intermediate to minor assessments (I-M ratio) was determined for the period 1978-79 to 1994-95, and the relation of various physician characteristics to high ratios was tested with bivariate and multivariate analysis.

RESULTS

The I-M ratio rose 10-fold, from 0.3 in 1978-79 to 2.9 in 1994-95. Although the I-M ratio was higher for older patients and young children, changes in population age profile over time did not account for any of the increase. The median ratio varied widely among groups of physicians: urban physicians had higher ratios than rural ones (3.9 v. 3.0, p < 0.05), and recent graduates had higher ratios than physicians 60 years of age or older (5.1 v. 2.9, p < 0.05). The I-M ratio was inversely related to number of visits; physicians billing for fewer than 5000 visits had a median ratio of 4.2, whereas those billing for 20,000 visits or more had a median ratio of 1.6.

INTERPRETATION

Fee code creep has contributed to expenditure growth in Ontario. This phenomenon was related to both an increase in I-M ratio over time among physicians practising throughout the study period and an influx of new physicians billing at a higher ratio. Creep was not the result of aging of the population.

High-billing general practitioners and family physicians in Ontario: how do they do it? An analysis of practice patterns of GP/FPs with annual billings over $400,000

BACKGROUND

To better understand the reasons why some fee-for-service physicians have high billing levels, the authors compared the practice and demographic characteristics of general practitioners and family physicians (GP/FPs) who submitted over $400,000 in annual Ontario Health Insurance Plan (OHIP) fee-for-service claims in 1994-95 with those of GP/FPs who billed between $35,000 and $400,000.

METHODS

The authors describe the OHIP billing and physician characteristic data for fiscal year 1994-95. They used multivariate logistic regression to determine factors independently associated with high billing status.

RESULTS

A total of 219 GP/FPs (2.5% of the GP/FPs in Ontario) billed over $400,000 in 1994-95. Of these, 14 had billing patterns similar to those of specialists, and 27 billed predominantly for diagnostic and therapeutic procedures (particularly physiotherapy). The remaining 178 (81.3%) billed for a mix of services similar to that of other GP/FPs but on average had 2.6 times the volume of patient assessments and a greater share of their total billings derived from diagnostic and therapeutic procedures (9.1% v. 5.6%). Multivariate analysis indicated that these high-volume GP/FPs were less likely than GP/FPs who billed between $35,000 and $400,000 to be 60 years of age or older (odds ratio [OR] 0.09, p < 0.05) and female (OR 0.21) and were more likely to be foreign graduates (OR 1.85) and practising in a region with low physician supply (OR 0.45 for each increase of 1 physician per 1000 population). Metropolitan Toronto was an outlier to the latter relation and was more likely to have high-volume GP/FPs (OR 16.89).

INTERPRETATION

High-billing GP/FPs attained their high billing levels by maintaining large numbers of patient visits and by performing procedures. Further research is needed to determine the time spent per patient and the quality of care delivered by these physicians as well as the appropriateness of the procedures that they perform.

The nucleocapsid protein specifically anneals tRNALys-3 onto a noncomplementary primer binding site within the HIV-1 RNA genome in vitro

HIV type 1 (HIV-1) specifically uses host cell tRNALys-3 as a primer for reverse transcription. The 3' 18 nucleotides of this tRNA are complementary to a region on the HIV RNA genome known as the primer binding site (PBS). HIV-1 has a strong preference for maintaining a lysine-specific PBS in vivo, and viral genomes with mutated PBS sequences quickly revert to be complementary to tRNALys-3. To investigate the mechanism for the observed PBS reversion events in vitro, we examined the capability of the nucleocapsid protein (NC) to anneal various tRNA primer sequences onto either complementary or noncomplementary PBSs. We show that NC can anneal different full-length tRNAs onto viral RNA transcripts derived from the HIV-1 MAL or HXB2 isolates, provided that the PBS is complementary to the tRNA used. In contrast, NC promotes specific annealing of only tRNALys-3 onto an RNA template (HXB2) whose PBS sequence has been mutated to be complementary to the 3' 18 nt of human tRNAPro. Moreover, HIV-1 reverse transcriptase extends this binary complex from the proline-specific PBS. The formation of the noncomplementary binary complex does not occur when a chimeric tRNALys/Pro containing proline-specific D and anticodon domains is used as the primer. Thus, elements outside the acceptor-TPsiC domains of tRNALys-3 play an important role in preferential primer use in vitro. Our results support the hypothesis that mutant PBS reversion is a result of tRNALys-3 annealing onto and extension from a PBS that specifies an alternate host cell tRNA.

Murine CTLA4-IgG treatment inhibits airway eosinophilia and hyperresponsiveness and attenuates IgE upregulation in a murine model of allergic asthma

Antigen-specific T-cell activation requires the engagement of the T-cell receptor (TCR) with antigen as well as the engagement of appropriate costimulatory molecules. One of the most important pathways of costimulation is the interaction of CD28 on the T cell with B7-1/B7-2 on antigen-presenting cells. In the present study, we have examined the in vivo effects of blocking the CD28:B7 T-cell costimulatory pathway by administration of mCTLA4-IgG in a murine model of allergic asthma. Mice were sensitized with ovalbumin and exposed to repeated ovalbumin inhalation challenges. In mice treated with a control antibody at the time of ovalbumin challenge a significant increase in the number of eosinophils (12.8 +/- 4.3 x 10(3) cells, P < 0.05) in the bronchoalveolar lavage (BAL) fluid and airway hyperresponsiveness to methacholine (49 +/- 15%, P < 0.05) was observed. In addition, serum levels of ovalbumin-specific IgE were significantly (P < 0.01) increased after ovalbumin challenge compared with saline challenge (1,133 +/- 261 experimental units [EU]/ml and 220 +/- 63 EU/ml, respectively). In mice treated with mCTLA4-IgG at the time of ovalbumin challenge, the infiltration of eosinophils into BAL fluid and the development of airway hyperresponsiveness to methacholine were completely inhibited. The upregulation of ovalbumin-specific IgE levels in serum was attenuated by mCTLA4-IgG treatment. Furthermore, addition of mCTLA4-IgG to cultures of parabronchial lymph node cells from sensitized mice inhibited the ovalbumin-induced interleukin-4 production. These data indicate the therapeutic potential of blocking T-lymphocyte costimulation by CTLA4-IgG as a possible immunosuppressive treatment for patients with allergic asthma.

Economic consequences of multiple sclerosis for Canadians

OBJECTIVES

To estimate the total costs of multiple sclerosis (MS) for all Canadians in 1994.

METHODS

Prevalence-based study estimating disease-related societal costs for Canadians with MS in 1994. The human capital approach was used to estimate the value of lost productivity due to illness. Two components were revealed: first, direct costs, in terms of expenditures on hospital care, other institutions, physician services, other health professionals, drugs, and other expenditures; and second, indirect costs, in terms of lost productivity due to premature mortality and disability.

RESULTS

The total costs of MS for Canadians were $502.3 million in 1994, with direct and indirect cost components at $188.6 million and $313.7 million, respectively.

CONCLUSIONS

This study highlights the scope and magnitude of the economic consequences of MS for Canadians. The costs calculated may be used to provide guidance in the setting of national priorities for research and prevention activities.

The role of integrins and extracellular matrix in anchorage-independent growth of a mammary carcinoma cell line

Anchorage-independent growth is a property of malignant cells. Extracellular matrix proteins are present in tumor spheroids but their function is not clearly defined. In this paper we show that a murine mammary carcinoma cell line, SP1, which expresses the fibronectin receptor alpha 5 beta 1 requires fibronectin for anchorage-independent growth in soft agar. Growth factors (hepatocyte growth factor and transforming growth factor-beta) also promote SP1 colony growth. In contrast, collagen types I and IV have an inhibitory effect on SP1 colony growth. A clone isolated from SP1 cells which expresses the collagen/laminin receptor alpha 2 beta 1 as well as the fibronectin receptor alpha 5 beta 1, demonstrates increased colony formation in the presence of fibronectin and collagen. These data suggest a role for both the alpha 5 beta 1 and alpha 2 beta 1 integrin receptors in the regulation of anchorage-independent growth of mammary carcinoma cells.

Is colour flow imaging needed to exclude clinically significant valvular regurgitation in adult patients undergoing transthoracic echocardiography?

OBJECTIVE

To establish whether clinically significant aortic and mitral valvular regurgitation can be excluded in adult patients undergoing transthoracic echocardiography without using colour flow imaging.

SETTING

Sunnybrook Health Science Centre, a tertiary referral centre with full cardiovascular services affiliated with the University of Toronto, Toronto, Ontario.

DESIGN

Logistic regression models were developed from a retrospective review of 14,051 unselected consecutive echocardiograms from 1991 through 1994. The dependent variable was more than mild aortic or mitral valvular regurgitation. Independent variables included age, sex and various functional and structural measures obtained during routine two-dimensional echocardiography. The negative predictive values and sensitivity of the models were estimated.

INTERVENTION

The number of patients correctly classified by these models, as well as the proportion for whom the colour flow imaging did not add to the baseline echocardiogram, was determined. Nonparametric bootsrapping was used to obtain confidence intervals for these statistics.

MAIN RESULTS

Ten models were developed, with negative predictive values ranging from 96.2% to 100%. Incorporation of such decision aids into the software of echocardiographic machinery would help echocardiographers to rule out significant aortic or mitral regurgitant lesions. In practices where colour flow imaging is routinely employed, 40% fewer procedures could be performed.

CONCLUSIONS

Models based on simple demographic and two-dimensional echocardiographic variables can reliably exclude significant valvular regurgitation and could potentially reduce the volumes and costs of colour flow imaging. Given the widespread diffusion of colour Doppler imaging, the models may also be helpful to avoid misinterpretation of flow imaging results, by defining subgroups in whom the prior probability of significant aortic or mitral regurgitation is extremely low.

Spirometry utilization in Ontario: practice patterns and policy implications

OBJECTIVE

To describe growth and regional variation in the use of spirometry (flow studies) in Ontario.

DESIGN

Retrospective analysis of Ontario Health Insurance Plan (OHIP) fee-for-service billing data for spirometry from the 1989-90 to 1994-95 fiscal years.

SETTING

Physicians' office practices in Ontario.

OUTCOME MEASURES

Number of flow studies and associated expenditures, number and specialty of physicians performing flow studies and the distribution of their billings, number of studies per capita by age group of patients, expenditures by region and measures of variation among regions.

RESULTS

In 1994-95, $14.13 million was spent on flow studies in Ontario. This expenditure increased by 36.9% from 1989-90 to 1994-95, exceeding the overall growth rate of 20.8% for all expenditures under OHIP. Expenditure growth was driven by an increase in the number of physicians performing spirometry rather than a higher volume of services performed per physician. The substitution of flow-volume loops, for which the fee is higher, for simple spirograms also contributed to expenditure growth. There were wide regional variations in spirometry utilization. A small number of general practitioners and family physicians accounted for much of the regional variation.

CONCLUSIONS

The rapid growth in spirometry utilization may stem from the diffusion of inexpensive spirometers in physicians' offices and from increased awareness of guidelines promoting the use of flow measurements. However, the wide regional variation in utilization may indicate either incomplete implementation of spirometry guidelines or lack of direction on the appropriate frequency of spirometry use. Clearer, evidence-based guidelines and an implementation strategy are needed. Also required is further study of possible inadequate access to spirometry in low-use regions and inappropriate use in high-use regions, where spirometry use is concentrated among a small number of physicians.

Humanization of an anti-lymphocyte function-associated antigen (LFA)-1 monoclonal antibody and reengineering of the humanized antibody for binding to rhesus LFA-1

Lymphocyte function-associated antigen 1 (LFA-1; CD11a/CD18) is involved in leukocyte adhesion during cellular interactions essential for immunologic responses and inflammation. mAbs against LFA-1 have been shown to inhibit several T cell-dependent immune functions in vitro and prevent graft failure after bone marrow transplantation in vivo. A murine anti-human CD11a mAb, MHM24, has been humanized and shown to prevent adhesion of human T cells to human keratinocytes and the proliferation of T cells in response to nonautologous leukocytes in the mixed lymphocyte response assay. However, of the nonhuman primate CD11a that we tested, the murine and humanized mAbs cross-reacted only with chimpanzee CD11a. To have a mAb available for preclinical studies in rhesus monkeys, the humanized mAb was reengineered to bind to rhesus CD11a by changing four residues in one of the complementarity-determining regions, CDR-H2, in the variable heavy domain. Cloning and molecular modeling of rhesus CD11a I-domain suggested that the changes from Lys197 and/or Arg189 in human CD11a I-domain to Glu197 and Gln189 in rhesus CD11a I-domain may be the reason that rhesus CD11a does not bind to the murine and humanized mAbs.

Humanization of an anti-lymphocyte function-associated antigen (LFA)-1 monoclonal antibody and reengineering of the humanized antibody for binding to rhesus LFA-1

Lymphocyte function-associated antigen 1 (LFA-1; CD11a/CD18) is involved in leukocyte adhesion during cellular interactions essential for immunologic responses and inflammation. mAbs against LFA-1 have been shown to inhibit several T cell-dependent immune functions in vitro and prevent graft failure after bone marrow transplantation in vivo. A murine anti-human CD11a mAb, MHM24, has been humanized and shown to prevent adhesion of human T cells to human keratinocytes and the proliferation of T cells in response to nonautologous leukocytes in the mixed lymphocyte response assay. However, of the nonhuman primate CD11a that we tested, the murine and humanized mAbs cross-reacted only with chimpanzee CD11a. To have a mAb available for preclinical studies in rhesus monkeys, the humanized mAb was reengineered to bind to rhesus CD11a by changing four residues in one of the complementarity-determining regions, CDR-H2, in the variable heavy domain. Cloning and molecular modeling of rhesus CD11a I-domain suggested that the changes from Lys197 and/or Arg189 in human CD11a I-domain to Glu197 and Gln189 in rhesus CD11a I-domain may be the reason that rhesus CD11a does not bind to the murine and humanized mAbs.

Economic impact of cardiovascular disease in Canada

OBJECTIVE

To estimate the total cost of cardiovascular disease in Canada.

DESIGN

Prevalence-based study estimating disease-related costs generated by individuals with cardiovascular disease in 1994, from a societal viewpoint. The human capital approach was used to estimate the value of lost productivity due to illness.

SETTING

Canada.

OUTCOME MEASURES

First, direct costs, in terms of expenditures on hospital care, other institutions, physician services, other health professionals, drugs, research and other items; and second, indirect costs, in terms of lost productivity due to premature mortality or disability.

MAIN RESULTS

The total cost of cardiovascular disease was $18.0 billion in 1994, with direct and indirect cost components at $10.4 and $7.6 billion, respectively. Based on the sensitivity analysis, the lower and upper bounds were $14.1 and $20.4 billion, respectively.

CONCLUSIONS

This study highlights the scope and magnitude of cardiovascular disease through its economic consequences. While the figures calculated herein do not give an indication of the appropriateness of current health expenditures on cardiovascular disease, they provide guidance in the setting of national priorities for research and prevention activities.

Appropriateness of primary total hip and knee replacements in regions of Ontario with high and low utilization rates

OBJECTIVE

To compare the appropriateness of case selection for primary hip and knee replacements between two regions in Ontario: one with a high population-based utilization rate and one with a low rate.

DESIGN

Random audit of medical records sampled from hospital discharge abstracts, with subsequent implicit and explicit criteria-based assessments of the appropriateness of surgery.

STUDY POPULATION

People aged 60 years or over who underwent elective, single-joint, non-fracture-related, primary hip or knee replacement between Apr. 1, 1992, and Mar. 31, 1993, at one of seven hospitals in a high-rate region (comprising Brant, Huron and Oxford countries) or one of eight hospitals in a low-rate region (comprising the cities of Scarborough and Toronto).

INTERVENTIONS

Structured review of hospital medical records, with additional review of information from surgeons and family physicians' office charts if necessary. Three physicians reviewed patient data and rated the preoperative pain level and functional status of patients, with agreement among at least two reviewers. The proportion of inappropriate cases was then assessed according to explicit criteria defined by a multidisciplinary panel using the delphi process. Profiles of each case were also subjected to independent implicit review by two rheumatologists and two orthopedic surgeons.

OUTCOME MEASURES

Proportion of joint replacements deemed inappropriate in the high- and low-rate regions according to either the explicit criteria or the implicit review, as well as preoperative pain levels and functional status of patients in the high- and low-rate regions.

RESULTS

Hip replacements were more common among patients sampled in the low-rate region than among those in the high-rate region (57.3% v. 39.3%; p < 0.002), although the patients' baseline characteristics, including severity of preoperative pain and dysfunction, were otherwise similar between the regions. Inappropriate surgery, determined by explicit criteria, was equally uncommon in the two regions (6.4% and 6.1%). On implicit review, the two rheumatologists rated fewer cases as appropriate than did the two orthopedic surgeons (63.0% v. 80.0%; p < 0.001); however, the proportion of cases rated as inappropriate by the subspecialists was similar in the high- and low-rate regions (11.4% and 11.0%, respectively, by the rheumatologists, and 6.3% and 10.4%, respectively, by the orthopedic surgeons).

CONCLUSIONS

Patients selected for primary hip or knee replacement are similar in the high- and low-rate regions of Ontario. Inappropriate use of this procedure does not account for the high rate of surgery in some areas. Further studies will be required to determine which other factors account for the regional variations in the utilization rates and whether there is underservicing in low-rate areas.