Estimating diagnostic test accuracy for infectious salmon anaemia virus in Maine, USA

Infectious salmon anaemia virus (ISAV) is a pathogen of consequence to farmed Atlantic salmon, Salmo salar L. ISA control centres on active surveillance for early detection by reverse transcription polymerase chain reaction (RT-PCR), indirect fluorescent antibody assay (IFAT) and virus isolation. Because diagnostic test performance varies among populations and laboratories, the Office International des Epizooties (OIE) recommends an evaluation of test accuracy in each region of use. This is complicated in Maine, USA by the co-existence of ISAV genotypes homologous to North American (NA) and European (EU) isolates. While NA ISAV genotypes isolated in Maine are characterized by high morbidity and mortality, the single EU genotype in Maine has not yet been linked to disease or isolated by cell culture. Consequently, distinguishing among genotypes is critical to infection response. Accuracy in NA genotype detection was estimated from ISA surveillance data using latent class models. Results suggested that RT-PCR is an excellent screening test for NA ISAV genotypes in Maine, although probably with reduced specificity in the presence of EU genotypes. IFAT, in contrast, was a poor screening test for detection of ISAV in Maine, although it may be useful in confirmation of NA genotypes during disease outbreaks.

Profiling of membrane protein variants in a baculovirus system by coupling cell-surface detection with small-scale parallel expression

Production of structure-grade mammalian membrane proteins in substantial quantities has been hindered by a lack of methods for effectively profiling multiple constructs expression in higher eukaryotic systems such as insect or mammalian cells. To address this problem, a specialized small-scale eukaryotic expression platform by Thomson Instrument Company (Vertiga-IM) was developed and used in tandem with a Guava EasyCyte microcapillary 96-well cytometer to monitor cell density and health and evaluate membrane protein expression. Two proof of concept experiments were conducted using the human beta(2)-adrenergic receptor (beta(2)AR) and the gap junction protein connexin26 (Cx26) in a baculovirus expression system. First, cell surface expression was used to assess the expression levels of 14 beta(2)AR truncation variants expressed using the Vertiga-IM shaker. Three of these variants were then compared to wild-type beta(2)AR using three metrics: cell surface expression, saturation ligand binding and protein immunoblot analysis of dodecylmaltoside extracted material. Second, a series of systematic Cx26 truncation variants were evaluated for expression by protein immunoblot analysis. The cumulative results for these two systems show that the Vertiga-IM instrument can be used effectively in the parallel insect cell microexpression of membrane protein variants, and that the expression of cell surface molecules as monitored with the Guava EasyCyte instrument can be used to rapidly assess the production of properly folded proteins in the baculovirus expression system. This approach expedites the in vitro evaluation of a large number of mammalian membrane protein variants.

A strategy to develop advanced pharmacy practice experiences

OBJECTIVE

To establish statewide medication, disease management, and other clinical programs to serve as advanced pharmacy practice experience (APPE) training sites for the University of Colorado at Denver and Health Sciences Center School of Pharmacy, and to guarantee year-round support for the programs by providing pharmacy students with the necessary competencies to carry a significant proportion of each program's workload.

METHODS

Partnerships with pharmacies willing to use students to expand their scope of clinical practice or support existing programs were established. Partners were asked to choose the clinical program(s) they wished implemented or supported and were guaranteed that APPE students would contribute to carrying each program's clinical service workload for 48 week/year under the supervision of the partners' pharmacists. In addition, partners implementing new programs were offered other support, including equipment, supplies, and training and mentoring for their pharmacists.

EVALUATION

Twenty-two partnerships involving anticoagulation, diabetes, immunization, medication reconciliation, and other clinical programs were established with hospital, community, and community health center pharmacies. The partnerships provided 213 APPE placements in the 2006-2007 academic year.

CONCLUSION

This work demonstrates that by using innovative approaches, a pharmacy school can form new partnerships with hospital, community health center, and community pharmacies, as well as work with existing clinical programs, to create a variety of medication, disease management, and other APPEs to meet its increasing placement needs and evolving accreditation standards.

Low-dose oral tri-iodothyronine does not directly increase food intake in man

Previously, we have shown that low-dose tri-iodothyronine (T3) increases food intake in rodents. This randomised, double-blind, placebo-controlled study aimed to investigate the effects of low-dose T3 on food intake in normal body weight individuals. However, despite an elevation in fT3 comparable to our earlier studies, administration of low-dose T3 in the fasted state did not stimulate food intake in man.

Rheumatoid arthritis patients have elevated antibodies to cross-reactive and non cross-reactive antigens from Proteus microbes

BACKGROUND AND OBJECTIVE

Although a large number of independent studies have shown a paramount role for Proteus mirabilis in the aetiopathogenesis of rheumatoid arthritis (RA), this hypothesis is still controversial among rheumatologists. The main obstacle to its acceptance is the impression that increased Proteus antibodies in RA patients is a secondary phenomenon, occurring as the result of cross-reactivity between bacterial and self-antigens. To shed light on this problem, we examined the link between antibodies to various cross-reactive and non cross-reactive antigenic peptides from P. mirabilis and analysed the relationship between these antibodies and disease severity in patients with RA.

METHODS

Using the ELISA method, serum samples from 70 RA patients and 20 healthy controls were screened for total and class-specific antibodies against three human cross-reactive and non-crossreactive synthetic peptides from P. mirabilis haemolysin, urease C and urease F enzymes. An antibody index, which comprised the total concentration of antibodies against these peptides in each sample, was correlated with the biochemical parameters of disease activity and/or severity, such as the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and rheumatoid factors (RF). Furthermore, anti-peptide antibody indices were evaluated among RA patients with different levels of disease activity as defined by ESR and CRP.

RESULTS

Significantly elevated levels of total and class-specific IgG antibodies against the 3 Proteus peptides were observed among RA patients compared to healthy controls (p < 0.001). Active RA patients had elevated IgM antibodies against all peptides compared to healthy subjects (p < 0.001). However, no such elevation was observed in IgA anti-peptide antibodies in RA patients. A positive correlation was observed between the antibody indices and ESR (p < 0.001) and CRP (p < 0.01) concentrations, but not the RF status or disease duration. Furthermore, more than 90% of active RA patients showed positive values for the Proteus anti-peptide indices.

CONCLUSION

The elevated levels of antibodies against Proteus antigenic epitopes (which are cross-reactive or non cross-reactive with human tissue antigens) observed indicates that this enhanced bacterial immune response in RA patients is specifically triggered by Proteus microbes. Furthermore, the correlation of anti-peptide antibody indices with the biochemical markers of disease activity indicates that these antibodies exert damaging cytotoxic effects on joint tissues during the course of the disease.

An introductory pharmacy practice experience emphasizing student-administered vaccinations

OBJECTIVE

To introduce a requirement for second-professional year (P2) and third-professional year (P3) students to administer vaccinations to adults in community pharmacy-based immunization clinics.

DESIGN

Second-professional year students were trained to administer influenza, pneumococcal, and other vaccinations to adults following the American Pharmacists Association's standards. All P2 students in fall 2004 and all P2 and P3 students in fall 2005 were assigned to 2 community pharmacy-based immunization clinics in the metropolitan Denver area under the supervision of immunization-certified staff pharmacists. An evaluation of the experience was conducted using retrospective preceptor and student-based survey data.

ASSESSMENT

In 2004 and 2005, the students administered approximately 5,000 (30-50 immunizations per student) and 15,000 (60-70 per student) immunizations, respectively. Students and preceptors agreed that the requirement to administer vaccinations was an appropriate activity for students and that it increased the students' self-confidence. When asked to rate the value of the students' work administering adult immunizations in the fall 2004 semester, the mean score given by the P2 students' immunization-certified preceptors was 9.2 on a 10-point Likert scale (1 = no value and 10 = great value).

CONCLUSION

Consistent with accreditation standards for students to have direct patient care responsibilities in introductory pharmacy practice experience courses, a requirement for P2 and P3 students to administer vaccines to adult patients in community pharmacies was successfully introduced.

Spatial and non-spatial risk factors associated with cage-level distribution of infectious salmon anaemia at three Atlantic salmon, Salmo salar L., farms in Maine, USA

The distribution of infectious salmon anaemia (ISA) was examined among 80 cages from three Atlantic salmon grow-out farms in Maine, USA that were stocked with smolts from a single hatchery. Cage-level disease was broadly defined as one or more moribund fish testing positive for infectious salmon anaemia virus (ISAV) by RT-PCR and a second confirmatory test (IFAT, culture or genotype sequence). Spatio-temporal and cage-level risks were explored using logistic regression and survival analysis. Non-spatial risk factors associated with ISA, or shortened survival time to disease, included increased predation, trucking company choice for smolt transfers, a finely-sedimented benthic substrate, and smaller average size of smolts at stocking. Univariable analysis identified the time-dependent spatial factor 'adjacency to newly infected cages' to be predictive of new infection in neighbouring cages 11-12 weeks later. However, none of the spatial factors, or their lags retained relevance in multiple-variable models. The results suggest a diffuse distribution of virus exposure throughout infected sites, with host-susceptibility factors probably influencing disease manifestation in individual cages. The narrow focus of the current study may limit application of the findings to other sites and year-classes. However, these data support the relevance of husbandry efforts to optimize fish health in regions affected by ISAV.

28 EXPRESSION OF MHC CLASS I IN THE PLACENTA AND THE LYMPHOCYTES OF BOVINE SOMATIC CLONES

A major limitation for the development of somatic cloning in cattle is the low efficiency for producing live offspring because only 5 to 25% of the reconstructed embryos reach full-term development, with variation between the genotypes. Hill et al. (2002 Biol. Reprod. 67, 55–63) reported that early fetal losses were due to inappropriate expression of trophoblast major histocompatibility complex Class 1 (MHC1) antigens on the placenta of bovine somatic clones. This abnormal expression was present in all clones, with more cells expressing MHC1 in those with growth retardation. These clones, however, originated from only one genotype, and only one antibody recognizing a monomorphic determinant of bovine MHCI was used. In the present study, MHC1 expression was examined throughout gestation in bovine clone placentas originating from 3 different genotypes. Placentas were collected at Days 32, 62, 180, 260, and 280 (term) in clones (n = 8) and in controls obtained by artificial insemination (n = 6). Four different monoclonal antibodies that recognize different determinants of MHC1 molecules (ILA-A88, IL-A19, H58A, and the β2-microglobulin, i.e. the MHC1 light chain) were used. Results showed MHC1 expression in the maternal tissue but not on the fetal side, regardless of group, gestational age, or fetal growth, although patchy expression of β2-microglobulin could be found in both clones and controls in the fetal mesenchyme in some but not all samples. In conclusion, MHC1 protein expression appears normally down-regulated in the placenta of clones, but the antibodies used do not discriminate between classical and non-classical expression. The mRNA expression of classical and non-classical MHC1 genes is currently being explored. These results cast doubt on the hypothesis that the observed fetal losses would be the result of an immunologic rejection due to inappropriate expression of some placental MHC1 genes. Although early observations suggest that immune functions appear normal (Lanza et al. 2001 Science 294, 1893–1894; Chavatte-Palmer et al. 2006 Reprod. Fert. Dev. 18, 121 abst), immunological deficiencies have been reported in some bovine somatic clones after birth (Renard et al. 1999 The Lancet 353, 1489–1491), and they may be related to an abnormal expression of MHC1 genes. We therefore determined the MHC1 haplotype of cell donors from 4 genotypes and 3 of their healthy clones using the Reference Strand Conformation Analysis method with DNA extracted from lymphocytes. Results showed that the MHC1 type was identical, as could be expected in clones. Animals that died of immune deficiencies, however, may have had abnormal MHC1 expression. Further work is therefore being performed on tissues obtained postmortem from cloned animals having been diagnosed with thymic atrophy.

BALF-derived fibroblasts differ from biopsy-derived fibroblasts in systemic sclerosis

Growth of fibroblasts from bronchoalveolar lavage fluid (BALF) in patients with systemic sclerosis (SSc) has previously been described. The purpose of the present study was to characterise fibroblasts from BALF and bronchial biopsies from SSc patients with alveolitis and from controls, to analyse fibroblast proliferation, migration, stress fibres and proteoglycan production. BALF and bronchial biopsies were collected from 10 patients with SSc and alveolitis and from 15 controls. Outgrowth of fibroblasts was observed from the BALF of four patients, particularly in those with a markedly increased percentage of eosinophils in BALF, but not in any member of the control group. Increased levels of granulocyte-macrophage colony-stimulating factor, correlating with the percentage of eosinophils in BALF, were found in patients when compared with controls. Fibroblasts from BALF showed an elongated, mobile phenotype and increased proteoglycan production compared to the corresponding biopsy fibroblasts. In conclusion, outgrowth of fibroblasts with an altered phenotype is reported from bronchoalveolar lavage fluid in systemic sclerosis patients with alveolitis and an increased percentage of eosinophils in the bronchoalveolar lavage fluid. These findings indicate a possible role for eosinophil-fibroblast interaction in pulmonary fibrosis in systemic sclerosis.

Efficacy of emamectin benzoate against sea lice infestations of Atlantic salmon, Salmo salar L.: evaluation in the absence of an untreated contemporary control

The efficacy of emamectin benzoate (SLICE) against sea lice infestations of Atlantic salmon, Salmo salar L., is typically assessed using untreated fish, or fish treated with alternative therapeutants, as controls. The State of Maine, USA, is currently under active management for the OIE-notifiable pathogen, infectious salmon anaemia virus (ISAV); consequently, neither control group is feasible in this region. Untreated salmon risk extensive damage from the ectoparasites, and threaten to increase vector-borne exposure or susceptibility of farms to ISAV; and the only treatment presently available in Maine is SLICE. However, because sea lice infestations are unlikely to resolve spontaneously, and response to treatment occurs within weeks, use of a pretreatment baseline is a reasonable alternative for confirmatory studies. We evaluated SLICE efficacy on Atlantic salmon farms in Cobscook Bay 2002-2005, in the absence of untreated controls, using pretreatment lice loads as a reference for calculation. Maximum efficacy ranged from 68% to 100% reduction from initial levels. Time-to-maximum efficacy ranged from 1 to 8 weeks after treatment initiation. Efficacy duration, measured between first reduction and first progressive rise in counts, ranged from 4 to 16 weeks.

Breath condensate ammonium is lower in children with chronic asthma

Exhaled breath condensate pH and ammonium reflect asthmatic status and acute exacerbations in adults. The aim of this study was to assess whether pH and ammonium could reflect asthma and its severity in children. The current study comprised two parts: 1) a cross-section of 74 children with asthma (median age 10.5 yrs) compared with 47 healthy controls (median age 10 yrs); and 2) longitudinal assessment of eight children (mean age 8.5 yrs) admitted with asthma exacerbation. Condensate pH and ammonium were compared with clinical observations. In the cross-sectional part of the study, lower per cent forced expiratory volume in one second was associated with more symptoms and treatment. There was no significant difference between median pH in children with stable asthma (6.05) compared with controls (5.90). Ammonium was significantly lower in children with asthma (median 258 microM) compared with controls (median 428 microM). No association was found between ammonium or pH and lung function or symptom-free days. In the longitudinal study, significant improvements in oxygen saturation and respiratory rate with treatment of an acute exacerbation were not reflected by changes in pH or ammonium. In conclusion, pH does not appear to reflect disease or severity in children with asthma. Ammonium was significantly lower in children with asthma when compared with controls.

Unusual lung tumours: an illustrated review of CT features suggestive of this diagnosis

This review presents an imaging-centred approach to the diagnostic challenge of uncommon lung tumours in adults. Emphasis is placed on features that may be used to differentiate these tumours including fat content, tumour site, multifocality, calcification and predominant pattern of involvement.

Report of the equine herpesvirus-1 Havermeyer Workshop, San Gimignano, Tuscany, June 2004

Amongst the infectious diseases that threaten equine health, herpesviral infections remain a world wide cause of serious morbidity and mortality. Equine herpesvirus-1 infection is the most important pathogen, causing an array of disorders including epidemic respiratory disease abortion, neonatal foal death, myeloencephalopathy and chorioretinopathy. Despite intense scientific investigation, extensive use of vaccination, and established codes of practice for control of disease outbreaks, infection and disease remain common. While equine herpesvirus-1 infection remains a daunting challenge for immunoprophylaxis, many critical advances in equine immunology have resulted in studies of this virus, particularly related to MHC-restricted cytotoxicity in the horse. A workshop was convened in San Gimignano, Tuscany, Italy in June 2004, to bring together clinical and basic researchers in the field of equine herpesvirus-1 study to discuss the latest advances and future prospects for improving our understanding of these diseases, and equine immunity to herpesviral infection. This report highlights the new information that was the focus of this workshop, and is intended to summarize this material and identify the critical questions in the field.

Human Vero cytotoxigenic Escherichia coli (VTEC) O157 infection linked to birds

Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) infections are a threat to public health. VTEC O157 has been isolated from gulls but evidence of transmission to humans from birds has not been reported. We recount an incident of VTEC O157 infection affecting two sibling children who had no direct contact with farm animals. An outbreak control team was convened to investigate the source of infection, its likely mode of transmission, and to advise on control measures. Human and veterinary samples were examined and the human isolates were found to be identical to an isolate from a sample of bird (rook) faeces. Cattle, rabbit and environmental samples were negative. This report provides evidence that birds may act as intermediaries for human infection with VTEC O157.

Relation of interlobar collaterals to radiological heterogeneity in severe emphysema

BACKGROUND

A study was undertaken to assess the prevalence of interlobar collateral ventilation in patients with severe emphysema to identify factors that may help to predict patients with significant collateral ventilation.

METHODS

Between April 2002 and August 2003, ex vivo assessment of the lungs 17 consecutive patients with smoking related severe emphysema was performed. To assess collateral flow, all lobes of explanted specimens were selectively intubated using a wedged cuffed microlaryngeal intubation tube and then manually ventilated using a bagging circuit. Interlobar collateral ventilation was defined as the ability to easily inflate a non-intubated lobe at physiological pressures. Pre-transplant demographic characteristics, physiological data, radiological results, and explant histology were assessed for retrospective relationships with the degree of interlobar collateral ventilation in the explanted lung.

RESULTS

A total of 23 lungs were evaluated, 15 of which (66%) had significant collateral interlobar airflow. There were no significant differences in any demographic, physiological, or pathological variables between patients with collateral ventilation and those with no collateral ventilation. However, there was a significant relationship between the presence of interlobar collateral ventilation and radiological scores (p<0.05).

CONCLUSIONS

Interlobar collateral ventilation occurs to a much greater extent in patients with radiologically homogeneous emphysema than in those with heterogeneous emphysema. Heterogeneity of emphysema may predict patients with a significantly reduced risk of interlobar collateral ventilation.

Crustal flow modes in large hot orogens

Crustal-scale channel flow numerical models support recent interpretations of Himalayan—Tibetan tectonics proposing that gravitationally driven channel flows of low-viscosity, melt-weakened, middle crust can explain both outward growth of the Tibetan Plateau and ductile extrusion of the Greater Himalayan Sequence. We broaden the numerical model investigation to explore three flow modes: homogeneous channel flow (involving laterally homogeneous crust); heterogeneous channel flow (involving laterally heterogeneous lower crust that is expelled and incorporated into the mid-crustal channel flow); and the hot fold nappes style of flow (in which mid-/lower crust is forcibly expelled outward over a lower crustal indentor to create fold nappes that are inserted into the mid-crust). The three flow modes are members of a continuum in which the homogeneous mode is driven by gravitational forces but requires very weak channel material. The hot fold nappe mode is driven tectonically by, for example, collision with a strong crustal indentor and can occur in crust that is subcritical for homogeneous flows. The heterogeneous mode combines tectonic and gravitationally driven flows. Preliminary results also demonstrate the existence and behaviour of mid-crustal channels during advancing and retreating dynamical mantle lithosphere subduction. An orogen temperature—magnitude (T-M) diagram is proposed and the positions of orogens in T-M space that may exhibit the flow modes are described, together with the characteristic positions of a range of other orogen types.

Efficacy and tolerability of budesonide Clickhaler and Turbuhaler in adult asthma

New dry powder inhalers should be clinically comparable with established devices to ensure the continuity of effective therapy for asthma patients. This randomized, open, parallel group study compared the clinical efficacy and tolerability of budesonide delivered via Clickhaler or Turbuhaler dry powder inhalers in adults with mild to moderate stable asthma. Following a 4-week stabilizing period using budesonide Turbuhaler adults aged 18 years or older, who had been treated with inhaled corticosteroids for at least the previous 12 weeks, were randomized to receive budesonide twice daily (<or=1600 microg/day) via either Clickhaler (n=110) or Turbuhaler (n=112) for 12 weeks. Morning peak expiratory flow (PEF), evening PEF, asthma symptoms, and use of inhaled short-acting beta2-agonist were recorded daily by the patients on diary cards. Lung function and tolerability data were recorded at clinic visits following 4, 8, and 12 weeks' treatment. Efficacy was measured primarily by mean change from the run-in baseline in weekly morning PEF. Of the 222 patients randomized to treatment, 167 completed the study according to the protocol. Repeated-measures analysis of covariance indicated that the devices were clinically equivalent; a treatment difference of--2.3 L/min separated the group mean changes in weekly morning PEF (95% confidence interval--7.9 to 3.3). Secondary analyses also supported clinical comparability. This study demonstrates the comparable clinical efficacy and tolerability of budesonide Clickhaler and Turbuhaler devices in adult patients with stable asthma.

Fever suppression in near-term pregnant rats is dissociated from LPS-activated signaling pathways

Near-term pregnant rats show a suppressed fever response to LPS that is associated with reduced induction of cyclooxygenase (COX)-2 in the hypothalamus. The objective of this study is to explore whether the LPS-activated signaling pathways in the fever-controlling region of the hypothalamus are specifically altered at near term. Three rat groups consisting of 15-day pregnant rats, near-term 21- to 22-day pregnant rats, and day 5 lactating rats were injected with a febrile dose of LPS (50 μg/kg ip). The hypothalamic preoptic area and the organum vasculosum of the lamina terminalis (OVLT) were collected 2 h after LPS injection. The activation of three transcription modulators, nuclear factor-κB (NF-κB), extracellular signal-regulated kinase 1/2 (ERK1/2), and signal transducer and activator of transcription 5 (STAT5), was assessed using semiquantitative Western blot analysis. LPS activated the NF-κB pathway in all rat groups, and this response was not altered at near term. ERK1/2 and STAT5 were constitutively activated during all reproductive stages, and their levels were not significantly affected by LPS injection. Plasma levels of the proinflammatory cytokines (IL-1β, IL-6, TNF-α, and IFN-γ), anti-inflammatory cytokines (IL-4, IL-10, and IL-1 receptor antagonist), and corticosterone were unaffected during the three reproductive stages after LPS challenge. We observed a sharp decrease in the expression of a prostaglandin-producing enzyme called lipocalin-prostaglandin D2 synthase in near-term pregnant and lactating rats. Thus fever suppression at near term is not due to an alteration in either LPS-activated intracellular signaling pathways or LPS-induced pro- and anti-inflammatory cytokine production.

Bovine mammary progenitor cells: current concepts and future directions

Although cell number is positively correlated with milk production, much remains to be learned about the bovine mammary stem cell and progenitor cells. Bovine mammary development is driven by many of the same classic mammogenic hormones studied in murine models, yet histologic features of bovine mammary development differ from that of rodent models. Most notably, terminal end buds, as they have been described for murine models, do not exist in the bovine mammary gland. However, among the most important common features of mammary development in disparate species is the involvement of histologically distinct, lightly staining epithelial cells as putative stem and progenitor cells. Although stem cell research has often focused on mammary development, mammary stem cells seemingly provide the basis for mammary growth and cell turnover in the mature animal. These cells provide an obvious focus for research aimed at increasing the efficiency of milk production. This review addresses recent findings concerning the histology and molecular physiology of putative bovine mammary stem and progenitor cell populations, areas where more study is critically needed, and areas where studies of bovine mammary physiology may present a unique opportunity to better understand mammary physiology in many species.

Assessment of adrenal suppression from two new dry powder inhaler formulations of budesonide delivered by Clickhaler compared with the Pulmicort Turbuhaler

Assessment of adrenal suppression via systemic cortisol levels provides an indirect measure of the lung delivery of inhaled corticosteroids. This randomized, placebo-controlled, double-blind, double-dummy crossover study compared urinary and plasma cortisol levels in healthy adult volunteers following single 1,000-microg doses of budesonide from two multiple dose dry powder inhalers (DPIs). Two new formulations of budesonide (lactose and PassCal) delivered from the Clickhaler were compared with Pulmicort from the Turbuhaler. An open dose (2,000 microg) of Pulmicort Turbuhaler was included to validate the experimental model. Overnight (22:00-07:00 h) and early morning (07:00-08:00 h) urine and 08:00 h plasma samples were collected after each treatment and cortisol levels analyzed by radioimmunoassay. Combined overnight and early morning urinary cortisol values for PassCal Clickhaler and Pulmicort Turbuhaler (1,000 microg) were statistically significantly lower than placebo (p < 0.05). The lactose budesonide Clickhaler showed a non-significant urinary cortisol reduction compared with placebo. Differences between the three 1,000-microg budesonide treatments were not significant. The Pulmicort Turbuhaler 2,000 microg showed significant urinary cortisol suppression compared with placebo. Plasma cortisol showed similar effects, with significance between the two Pulmicort doses. These results suggest that adrenal suppression can be used to assess the pulmonary bioavailability of different formulation.

Retrospective analysis of outcome in a cohort of patients with lupus nephritis treated between 1977 and 1999

OBJECTIVE

To review the development, histological type and outcome of a cohort of patients with lupus nephritis who were managed and followed up by the specialist Bloomsbury Rheumatology Unit between 1977 and 1999.

PATIENTS AND METHODS

Seventy-eight of the 280 (28%) patients with systemic lupus erythematosus (SLE) developed nephritis. Occurrence of end stage renal disease (ESRD) according to World Health Organization (WHO) class was analysed, and patients were subdivided according to whether treatment included at least six pulses of intravenous (i.v.) cyclophosphamide (CYC) once a month.

RESULTS

For patients with WHO class III nephritis, three out of five treated with i.v. CYC developed ESRD compared with none out of 10 not treated with i.v. CYC (P < 0.02). There was no significant difference between these subgroups in terms of a variety of parameters with good prognostic value, except anti-dsDNA titre at time of biopsy (which was greater in the former). For patients with WHO class IV nephritis, three out of 16 treated with i.v. CYC developed ESRD, compared with five out of 20 not treated with i.v. CYC (no significant difference).

CONCLUSION

These data suggest that there may be a subgroup of patients with lupus nephritis (WHO class III) whose long-term outcome is not adversely affected by the omission of i.v. CYC.

Cell proliferation in bovine mammary epithelium: identification of the primary proliferative cell population

Histologic analyses indicate that a lightly staining cell population present in mammary parenchyma may function as mammary stem cells. We performed an analysis of mammary epithelial cell proliferation in prepubertal bromodeoxyuridine (BrdU)-injected Holstein heifers to investigate this hypothesis. We observed light, dark, and intermediate staining cells in histologic sections stained with basic fuschin and azure II. Light cells comprised 10% of the total parenchymal cell population but accounted for 50% of the cell proliferation. Intermediate cells comprised 60% of the cell population and 43% of proliferating cells. Dark cells comprised 30% of the parenchymal cell population but only 7% of proliferating cells. The distribution of BrdU+ cells across basal, embedded, and lumenal parenchymal cell layers was correlated with the fraction of total parenchymal cells present in each layer (r=0.99). However, the proportion of mitotic cells observed in the basal cell layer was only half of what would be predicted by the BrdU-labeling data. This observation suggests that some basal cells either arrest in G(2) or migrate into the suprabasal epithelial layers before undergoing mitosis. These results strongly support the concept that lightly staining mammary parenchymal cells are the primary proliferative cell population.

Postnatal mammary ductal growth: three-dimensional imaging of cell proliferation, effects of estrogen treatment, and expression of steroid receptors in prepubertal calves

Cows may provide insights into mammary development that are not easily obtained using mouse models. Mammary growth in control and estrogen-treated calves was investigated to evaluate general patterns of proliferation and relationship to estrogen receptor (ER) expression. After in vivo labeling with bromodeoxyuridine (BrdU), serial histological sections of mammary tissue were used to generate three-dimensional reconstructions. BrdU-labeled cells were present throughout the highly branched terminal ducts. ER and progesterone receptors (PR) were colocalized in nuclei of ductal epithelial cells. However, basal cells and epithelial cells that were located in the central region of epithelial cords and those that lined the lumen of patent ducts were ER- and PR-negative, as were stromal cells. Cells along the basal portion of the epithelium were not myoepithelial. ER in mammary epithelial cells but not stromal cells is analogous to patterns in human breast but contrasts with localization in murine mammary gland. After estrogen stimulation, 99% of BrdU-labeled (and Ki67-labeled) epithelial cells were ER-negative. Data suggest that proliferation in response to estrogen treatment was initiated within ER-positive epithelial cells of the developing mammary gland and the signal was propagated in paracrine fashion to stromal elements and ER-negative epithelial cells.

Clinical characteristics and outcome of patients with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction

AIMS

We examined the clinical characteristics and outcome of patients with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction.

METHODS AND RESULTS

We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n=1302) vs thrombolytic therapy (n=1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories: early presentation (<2 h), intermediate presentation (2-4 h), and late presentation (>or=4 h). At 30 days the combined rate of death, non-fatal reinfarction and stroke in patients presenting early was 5.8% in the angioplasty group vs 12.5% in the thrombolysis group, in patients with intermediate presentation, 8.6% vs 14.2%, respectively, and in patients presenting late 7.7% vs 19.4%, respectively. With increasing time from symptom onset to presentation, all major adverse cardiac event rates show a trend to a larger increase in the thrombolysis group compared to the angioplasty group, both at 30 days and at 6 months after the acute event.

CONCLUSIONS

Major adverse cardiac event rates are lower after angioplasty compared to thrombolysis, irrespective of time to presentation. With increasing time to presentation major adverse cardiac event rates increase after thrombolysis but appear to remain relatively stable after angioplasty.

Linkage of reproductive sciences: from 'quick fix' to 'integrated' conservation

Our laboratory has experienced four phases in understanding how the reproductive sciences contribute to genuine conservation of biodiversity. The first is the 'quick fix phase' in which the erroneous assumption is made that extant knowledge and techniques are readily adaptable to an unstudied wild animal to produce offspring rapidly. The second is the 'species-specificity phase' in which it is recognized that every species has evolved unique reproductive mechanisms that must be mastered before propagation can be enhanced. The third is the 'applicability phase' in which one grasps that all the new knowledge and technology are of minimal relevance without the cooperation of wildlife managers. The final phase is 'integration', the realization that reproduction is only one component in an abundantly complex conservation puzzle that requires interweaving many scientific disciplines with elaborate biopolitical, economic and habitat variables. These phases are illustrated using 20 years of experience with wildlife species, including the cheetah, black-footed ferret and giant panda. We conclude that the foremost value of the reproductive sciences for conserving endangered species is the discipline's powerful laboratory tools for understanding species-specific reproductive mechanisms. Such scholarly information, when applied holistically, can be used to improve management by natural or, occasionally, assisted breeding. Genuine conservation is achieved only when the reproductive knowledge and technologies are integrated into multidisciplinary programmes that preserve species integrity ex situ and preferably in situ.

Impact of the Duett sealing device on quality of life and hospitalization costs for coronary diagnostic and interventional procedures: Results from the Study of Economic and Quality of Life substudy of the SEAL trial

BACKGROUND

The Simple and Effective Arterial Closure (SEAL) trial examined the safety and effectiveness of the Duett vascular sealing device (Vascular Solutions, Minneapolis, Minn) versus manual compression after diagnostic and interventional coronary procedures. We compared quality of life and initial hospitalization costs among patients treated with the Duett device versus manual compression.

METHODS

Functional status was assessed with the Duke Activity Status Index (DASI) at 7 and 30 days after intervention. General health status was assessed with the Short Form (SF-36) at 30 days after intervention. Hospitalization costs were derived from the UB92 formulation of the hospital bill.

RESULTS

There was a strong trend toward higher functional status in patients receiving treatment with the Duett device at 7 days both before (P =.04) and after (P =.08) adjustment for significant covariates. This difference was significant in the diagnostic group but not in the interventional group. No significant differences in quality of life between the Duett device and manual compression at 30 days were found. There was no significant difference in total hospitalization costs between treatment arms (P =.91). For interventional patients, mean total in-hospital costs were $10,167 in the Duett group and $10,225 in the manual compression group (P =.82). For diagnostic patients, mean hospitalization costs were $7784 and $7996 for the Duett device and manual compression groups, respectively (P =.72). Trends toward reduced recovery/observation room costs with the Duett device (P =.06) were found; this difference was significant in the diagnostic group ($198 vs $279, P =.02).

CONCLUSIONS

The Duett sealing device was associated with significantly higher functional status at 7 days after the procedure in addition to shortened time to hemostasis and ambulation, with no associated increase in cost.

HLA-G remains a mystery

In this brief summary, we argue that many widely held beliefs about HLA-G are questionable. Recent research has led to a re-evaluation of many of the characteristics that were thought to make HLA-G unusual among the MHC class I molecules. First, contrary to reports suggesting that the gene encoding HLA-G exhibits marked polymorphism in some human populations, recent data have shown that the HLA-G gene has comparatively little polymorphism - a feature that might allow it to be expressed in the placenta without causing rejection by the maternal immune system. Second, although truncated forms of HLA-G are generated in the placenta, most of them are unlikely to have significant biological effects as they do not reach the cell surface. Third, the hypothesis that a major role of HLA-G is to prevent attack of the placenta by maternal natural killer cells is now the subject of renewed scrutiny. Finally, there is little evidence that the induction of expression of HLA-G is a major mechanism by which tumor cells avoid immune attack. HLA-G has once again become as mysterious as when it was discovered: an MHC class I molecule expressed at a challengingly extraordinary site--the immunologically uneasy interface between mother and fetus.

Activity of calcium activated protease in skeletal muscles and its changes in atrophy and stretch

The reduction of protein content in skeletal muscle undergoing disuse-induced atrophy is correlated with accelerated rates of protein degradation and reduced rates of protein synthesis. It is not known in what manner myofibers are partially disassembled during disuse atrophy to fibers of smaller diameter; nor is it known which proteases are responsible for this morphological change in contractile protein mass. Dayton and colleagues have suggested that the Ca(2+)-activated protease (CaP) may initiate myofibril degradation. The discovery of a form of CaP that is activatable by nanomolar concentrations of Ca2+ indicates that CaP activity may be regulated by physiological concentrations of Ca2+. The enhancement of proteolysis by the Ca2+ ionophore A23187, reported by Etlinger, is consistent with a significant role for CaP in protein degradation. It was of interest, therefore, to measure the levels of CaP activity and the CaP inhibitor in extracts obtained from skeletal muscles of rat and chicken limbs undergoing disuse atrophy or stretch hypertrophy, respectively.

The non-peptidyl fungal metabolite L-783,281 activates TRK neurotrophin receptors

Neurotrophin binding to the extracellular surface of the Trk family of tyrosine kinase receptors leads to the activation of multiple signalling cascades, culminating in neuroregenerative effects, including neuronal survival and neurite outgrowth. Since neurotrophins themselves are not ideal drug candidates due to their poor pharmacokinetic behaviour and bioavailability, small molecule neurotrophin mimetics may be beneficial in treating a number of neurodegenerative disorders. The present study demonstrates that L-783,281, a non-peptidyl fungal metabolite, is capable of stimulating TrkA, B and C phosphorylation to various extents in CHO cells stably expressing human Trk receptors. L-783,281 also stimulated Trk phosphorylation in a number of rat and human primary neuronal cultures, whereas the highly similar compound, L-767,827, was without effect. Mechanistic studies utilizing transiently transfected PDGF/TrkA and TrkA/PDGF chimeras, demonstrated that L-783,281 is likely to interact with the intracellular domain of the TrkA receptor. Further investigations suggested that L-783,281 was nevertheless able to instigate receptor dimerization by binding in a non-covalent manner. Although the cytotoxicity of the compound was shown to preclude its effects in neuronal survival and neurite outgrowth assays, it is a prototype for a small molecule neurotrophin mimetic that activates Trk by interacting at a site different from the neurotrophin-binding site.

Hoxa3 and pax1 regulate epithelial cell death and proliferation during thymus and parathyroid organogenesis

The thymus and parathyroid glands in mice develop from a thymus/parathyroid primordium that forms from the endoderm of the third pharyngeal pouch. We investigated the molecular mechanisms that promote this unique process in which two distinct organs form from a single primordium, using mice mutant for Hoxa3 and Pax1. Thymic ectopia in Hoxa3(+/-)Pax1(-/-) compound mutants is due to delayed separation of the thymus/parathyroid primordium from the pharynx. The primordium is hypoplastic at its formation, and has increased levels of apoptosis. The developing third pouch in Hoxa3(+/-)Pax1(-/-) compound mutants initiates normal expression of the parathyroid-specific Gcm2 and thymus-specific Foxn1 genes. However, Gcm2 expression is reduced at E11.5 in Pax1(-/-) single mutants, and further reduced or absent in Hoxa3(+/-)Pax1(-/-) compound mutants. Subsequent to organ-specific differentiation from the shared primordium, both the parathyroids and thymus developed defects. Parathyroids in compound mutants were smaller at their formation, and absent at later stages. Parathyroids were also reduced in Pax1(-/-) mutants, revealing a new function for Pax1 in parathyroid organogenesis. Thymic hypoplasia at later fetal stages in compound mutants was associated with increased death and decreased proliferation of thymic epithelial cells. Our results suggest that a Hoxa3-Pax1 genetic pathway is required for both epithelial cell growth and differentiation throughout thymus and parathyroid organogenesis.

Interpreting the findings of the IMPROVE study

Various findings of the Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers (IMPROVE) study are reviewed. Suggestions for future methodologies that will enhance this study are discussed. The IMPROVE study is one of the largest pharmaceutical care studies conducted. Although it was an intervention study that examined global outcomes following management by pharmacists, it was designed as an effectiveness study. Several new practice and research methods were developed, including a method to identify patients at high risk for drug-related problems utilizing pharmacy databases, a method to identify chronic diseases using pharmacy databases, a method to evaluate the structure and process for delivering pharmaceutical care in Veterans Affairs medical centers (VAMCs), and guidelines for providing care to patients in the IMPROVE study. Nine VAMCs participated in the study, and 1054 patients were randomized to either an intervention group (n = 523) or a control group (n = 531). Pharmacists documented a total of 1855 contacts with the intervention group patients and made 3048 therapy-specific interventions over the 12-month study period. There was no meaningful difference in patient satisfaction or quality of life in the two groups. Selected disease-specific indicators found an improved rate of measurement of hemoglobin A1c tests and better control of total and low-density-lipoprotein (LDL) cholesterol levels in the intervention group compared with the control group. Total health care costs increased in both groups over the 12-month period. The mean increase in costs in the intervention group was $1020, which was lower than the control group's value of $1313. The lessons learned from the IMPROVE study suggest to future investigators how to study and measure the effects of clinical pharmacy services on patient outcome.