Prediction of response to bortezomib and dexamethasone resistance in myeloma (MM) by novel mutations in the NFKB pathway

8007

Background: We recently described mutations in multiple genes in MM patients that lead to the activation of the non- canonical NF-KB pathway. Among the mutated genes, TRAF3 is the most commonly affected, and is inactivated in about 20% of patients. In this study, we further defined the clinical significance of TRAF3 inactivation in MM. Methods: Deletion of TRAF3 was identified by array- based comparative genomic hybridization using Agilent Human Genome CGH 44k oligonucleotide array and confirmed by fluorescent in situ hybridization. Mutations were detected by sequencing. We use a TRAF3 gene expression cut-off (derived from 127 Mayo clinic patients) as a surrogate for TRAF3 inactivation to investigate its association with Translocations and Cyclin D genetic subtypes, response rates, and survival using 2 large gene expression dataset: UAMS dataset (559 newly diagnosed patients treated with Total therapy II and III) and Millenium datasets (213 relapsed patients entered into randomized study of bortezomib versus dexamethasone). Results: A normalized expression level of less than 0.6 identified all but three of the known TRAF3 inactivated cases in the Mayo dataset (p<0.0001). Using this cut-off, TRAF3 inactivated cases were enriched for t(4;14) (26%, p=0.00002) and rarely D1 (mostly hyperdiploid) (9%, p=9.6E-10) in all 3 datasets. TRAF3 inactivation did not affect survival of patients treated with transplant-based therapy (UAMS and Mayo dataset) but was strongly associated with bortezomib response (89% TRAF3 low versus 40% TRAF3 normal, p0.6 had similar PFS with the two treatment. Conclusion: Mutations resulting in TRAF3 inactivation are common, particularly in non-hyperdiploid MM, and predict for response to bortezomib and resistance to dexamethasone suggesting that inhibition of the non-canonical NF-KB pathway may be one of the principle mechanisms of action of proteasome inhibitors in MM.

No significant financial relationships to disclose.

Neuroprotective effect of adenoviral-mediated gene transfer of TIMP-1 and -2 in ischemic brain injury

Gene therapy may be a promising approach for treatment of brain ischemia. We and others previously demonstrated that increased activity of matrix metalloproteinases (MMPs) contributes to the tissue damage that results from ischemic injury. The proteolysis of MMPs is tightly controlled by tissue inhibitors of MMPs (TIMPs). In this study, we examined whether adenoviral-mediated gene transfer of TIMP-1 and TIMP-2 could protect against neuronal damage induced by global cerebral ischemia in mice. An adenovirus expressing TIMP-1 or TIMP-2 (AdTIMP-1 or AdTIMP-2) or a control adenovirus (RAd60) or vehicle was injected into the striatum 3 days before transient global cerebral ischemia. The extent of neuronal damage was quantified 3 days post-ischemia. There was no significant difference in the extent of neuronal damage in vehicle as compared to RAd60-treated mice. In contrast, neuronal damage was reduced, by approximately 50%, after gene transfer of AdTIMP-1 (P<0.001) and AdTIMP-2 (P< 0.01) as compared to controls. This study provides the first in vivo evidence of the protective effects of TIMP-1 and TIMP-2 via gene transfer in global ischemia.

The use of tissue inhibitors of matrix metalloproteinases to increase the efficacy of a tumor necrosis factor/interferonγ antitumor therapy

Owing to its impressive ability to kill tumor cells, especially in combination with interferon-gamma (IFNgamma), tumor necrosis factor (TNF) is widely appreciated as being a potential systemic therapeutic for the treatment of cancer. On the other hand, owing to its proinflammatory activities, administration of TNF leads to many systemic side effects and eventually to a potentially lethal systemic inflammatory response syndrome (SIRS). However, systemic treatment of tumor-bearing mice with TNF/IFNgamma in combination with BB-94 (a broad-spectrum metalloproteinase inhibitor) confers protection against TNF/IFNgamma-induced mortality, whereas preserving the antitumor activity. In this study, we investigated the effect of the adenoviral delivery of human tissue inhibitors of matrix metalloproteinase (hTIMP)-1 and hTIMP-2 genes on the outcome of TNF/IFNgamma antitumor therapy. The dose of adenovirus was limited to 10(8) PFU per mouse owing to the additive toxicity of combining it with TNF/IFNgamma therapy. Nevertheless, this dose was sufficient to achieve highly efficient adenoviral transfer and expression of hTIMP-1 and hTIMP-2 in the liver, but not the tumor. Treatment with this low dose of AdhTIMP-1 or AdhTIMP-2 was not enough to protect the host against the toxic effects of TNF/IFNgamma. However, it was sufficient to show a synergistic effect of hTIMPs with TNF/IFNgamma such that tumors regressed significantly faster. Interestingly, only AdTIMP-2 was able to prevent relapses after treatment.

Neuodevelopmental Outcomes for Children Transplanted Under the Age of 3 Years

Our previous investigations on neurodevelopmental outcomes for intestinal transplanted infants revealed that while some children were able to achieve a normal developmental outcomes, most children suffered from significant motor delays and several experienced severe cognitive delays. In our current investigation, we were especially interested in children who are transplanted before the age of 3 years because the impact of the chronic illness and nutrition impairment on the infant's developing brain may be more severe than those children who receive a liver transplant.

METHODS

We evaluated 34 infants using the Bayley Scales of Infant Development. Twenty-seven children received a liver/intestine or multivisceral transplant and seven received a liver transplant.

RESULTS

Comparison of the two groups revealed that children receiving an intestine/multivisceral transplant have much poorer outcomes. Seventy-four percent of these children were significantly delayed mentally compared to only 57.14% of the liver transplant infants. Furthermore, 42.86% of the liver-transplanted infants were actually functioning in the normal range posttransplant. The intestinal/multivisceral transplant infants' motor development shows the most striking difference, with 96.3% being severely delayed as compared to liver transplant infants in whom only 71% experienced serious delays. The neurodevelopmental impact of organ failure and transplant before the age of 3 years may depending on the type of organ transplant. Our study found that it may be more likely to expect a good outcome for liver transplant patients than for intestinal and multivisceral transplanted infants. This difference maybe due to the overall severity of the disease and the possible impact of nutritional deficits early in infancy.

Neurodevelopmental Outcomes of Infant Multivisceral Transplant Recipients: A Longitudinal Study

This longitudinal investigation compares cognitive and physical capabilities of transplant recipients, both before and after receiving an intestinal transplant.

METHODS

Using the Bayley Scales of Infant Development, we conducted pretransplant and posttransplant assessments on nine children (4 males, 5 females) who received either an isolated intestine, combined intestine and liver, or multivisceral transplants, with a mean age at transplant of 18 months (range 8-29) and a mean time posttransplant of 2 months (range 1-4 months).

RESULTS

Scores on the Mental Developmental Index reflected that a majority (55.6%) of patients who scored in the significantly delayed range prior to transplant remained in the significantly delayed classification after receiving a transplant. In addition, 33.3% showed a decrease in their mental classification; either from "mildly delayed" to "significantly delayed" or from "within normal limits" to "mildly delayed". Results on the Motor Developmental Index demonstrated that 78% of recipients had significant delays both before and after receiving a transplant, while 11.1% fell one standard deviation after transplantation. We found that the majority of children who experience developmental delays prior to transplant are still experiencing delays when they are discharged from inpatient care. In addition, those children receiving multivisceral transplantations, as opposed to an isolated bowel, may be at a much greater risk of developing and retaining both cognitive and physical delays. Early neurodevelopmental evaluations of these patients is essential for early parental education and compliance with early intervention services to maximize potential recovery and ability to obtain normal development.

Characterisation of the fluorescence from freshwater, planktonic bacteria

Amino acid-like fluorescence has been used as an indicator of biological activity in wastewater effluent and in natural waters, and can be detected using fluorescence spectroscopy. Little or no work has been able to state conclusively that these so called 'amino acid-like' fluorophores are associated with proteins present as a result of bacterial activity. This work aims to ascertain whether bacteria are one possible cause of these 'amino acid-like' peaks observed in natural waters. In addition, fluorescence derived solely from one bacterial source was determined as a function of the growth time and temperature. The bacterium Pseudomonas aeruginosa was isolated from the urban River Tame, Birmingham, UK, and planktonic bacteria were grown in sterile, sealed glass jars, in 100 ml growth media. Bacteria were grown at 11, 25 and 37 degrees C, over a maximum of 10 days. A 3D Excitation-Emission Matrix (EEM) plot was generated from fluorescence analysis of the samples. Both tryptophan and tyrosine-like fluorescence, resembling that observed in natural and waste waters, was observed in these samples, indicating that observed fluorescence signals from aquatic systems in the literature were of biotic origin. Significant differences in fluorescence signals were obtained from planktonic cells grown at different temperatures. At 25 and 37 degrees C, cells were found to produce predominantly tryptophan-like fluorescence, with some tyrosine-like fluorescence also detected. A further unknown fluorophore was also detected (emission wavelength of approximately 460 nm, with three excitation centres at 225, 260 and 390 nm), likely to be a bacterially produced metabolite. At 11 degrees C, a more environmentally realistic temperature in temperate environments, quantitative and qualitative differences were observed in fluorescence signals when compared with the higher temperatures, indicating that laboratory observations conducted at higher temperatures may not be easily used to interpret environmental processes.

Outbreak of low pathogenicity H7N3 avian influenza in UK, including associated case of human conjunctivitis

On 26 April 2006, the veterinary authorities in the United Kingdom reported that there had been an outbreak of avian influenza type A/H7 among a 35 000-bird housed poultry flock in eastern England, United Kingdom.

Fractionation of Freshwater Colloids and Particles by SPLITT: Analysis by Electron Microscopy and 3D Excitation−Emission Matrix Fluorescence

This paper reports the first application of a combined approach utilizing split-flow thin-cell (SPLITT) separation to size fractionate natural aquatic colloids and particles collected from freshwater samples. No sample preconcentration was performed although some samples were investigated after alteration of the ambient pH. The unfractionated and fractionated samples were analyzed by scanning electron microscopy (SEM), environmental SEM, and 3D excitation emission matrix fluorescence. Qualitative and quantitative results by microscopy indicated that SPLITT produces well-resolved fractionations at appropriate sizes but with some perturbation of the sample. In addition, tryptophan-like fluorescence was shown to be caused by different organic moieties compared with humic-like and fulvic-like fluorescence. Tryptophan-like fluorescence intensity is found mainly in the particulate material but is not pH dependent, while humic- and fulvic-like fluorescence intensities are dependent on pH but not on size. Fulvic-like fluorescence intensity normalized to absorbance, related to fluorescence efficiency and molar mass, varies with size.

Extraoral removal of a lower third molar tooth

This case report illustrates an example of when an extraoral approach was successfully used to remove a lower left third molar.

Development and application of functional assays for freshwater dissolved organic matter

A series of 11 standardised, reproducible, assays have been developed of physico-chemical functions of dissolved organic matter (DOM) in freshwaters. The assays provide quantitative information on light absorption, fluorescence, photochemical fading, pH buffering, copper binding, benzo(a)pyrene binding, hydrophilicity and adsorption to alumina. To obtain DOM for the assays, a 45 L sample of filtered freshwater was rotary-evaporated to reduce the volume to ca. 500 cm3. The concentrate was then passed through a strong cation exchanger, in the Na+ form, to remove alkaline-earth cations, and then through 0.7 and 0.2 microm filters. Eight samples, two each from a lake and three streamwaters, were processed. The yields of dissolved organic carbon (DOC) ranged from 70% to 107% (average 91%). The samples of DOM, stored in the dark at 4 degrees C, retained their functional assay characteristics for up to 7 months. When assaying the concentrates, parallel assays were performed with Suwannee River fulvic acid (SRFA), as a quality control standard. For most of the assays, the results for eight freshwater DOM samples are similar to those obtained with SRFA, the chief exception being the greater hydrophilicity of the DOM samples. For eight of the assays, variability among the DOM samples is significantly (p < 0.01) greater than can be explained by analytical error, i.e. by comparison with results for the SRFA quality standard; the three exceptional assays are photochemical fading, copper binding and benzo(a)pyrene binding. The two lakewater samples studied gave the most extreme assay results, probably because of the influence of phytoplankton-derived DOM. Significant correlations of hydrophilicity and adsorption with optical absorbance may mean that some DOM functional properties can be predicted from comparatively simple measurements.

Bayesian projections: what are the effects of excluding data from younger age groups?

Bayesian age-period-cohort models are used increasingly to project cancer incidence and mortality rates. Data for younger age groups for which rates are low are often discarded from the analysis. The authors explored the effect of excluding these data, in terms of the precision and accuracy of projections, for selected cancer mortality data sets. Projections were made by using a generalized Bayesian age-period-cohort model. Smoothing was applied to each time scale to reduce random variation between adjacent parameter estimates. The sum of squared standardized residuals was used to assess the accuracy of projections, and 90% credible intervals were calculated to assess precision. For the data sets considered, inclusion of all age groups in the analysis provided more precise age-standardized and age-specific projections as well as more accurate age-specific projections for younger age groups. An overall improvement in the accuracy of age-standardized rates was demonstrated for males but not females, which may suggest that analysis of the full data set is beneficial when projecting cancer rates with strong cohort effects.

Hypotension and Eosinophilia with Atorvastatin

A case report of a 67-year-old man who suffered a hypersensitivity reaction to atorvastatin is described. He suffered collapse and was in shock characterised by marked hypotension, facial oedema and eosinophilia. His initial condition led the surgeons to think he might have had an abdominal sepsis. The reaction with angio-oedema reoccurred on rechallenge. The literature on statin hypersensitivity reactions which can occur several months after commencing therapy is reviewed. Although the estimated prevalence is rare (0.1%), prescribers and pharmacists should be aware of this important reaction which can be quite debilitating.

Is a large-scale DNA-based inventory of ancient life possible?

A complete DNA-based inventory of the Earth's present biota using large-scale high-throughput DNA sequencing of signature region(s) (DNA barcoding) is an ambitious proposal rivaling the Human Genome Project. We examine whether this approach will also enable us to assess the past diversity of the earth's biota. To test this, we sequenced the 5' terminus of the mitochondrial cytochrome c oxidase I (COI) gene of individuals belonging to a group of extinct ratite birds, the moa of New Zealand. Moa comprised a large number of taxa that radiated in isolation on this oceanic landmass. Using a phylogenetic approach based on a large data set including protein coding and 12S DNA sequences as well as morphology, we now have precise information about the number of moa species that once existed. We show that each of the moa species detected using this extensive data set has a unique COI barcode(s) and that they all show low levels of within-species COI variation. Consequently, we conclude that COI sequences accurately identify the species discovered using the larger data set. Hence, more generally, this study suggests that DNA barcoding might also help us detect other extinct animal species and that a large-scale inventory of ancient life is possible.

Catchment-scale fluorescence water quality determination

Chemical water quality determinants and river water fluorescence were determined on the River Tyne, northeast England. Statistically significant relationships between nitrate (r = 0.87), phosphate (r = 0.80), ammonia (r = 0.70), biochemical oxygen demand (BOD) (r = 0.85) and dissolved oxygen (r = -0.65) and tryptophan-like fluorescence intensity were observed. The strongest correlations are between tryptophan-like intensity and nitrate and phosphate, which in the Tyne catchment derive predominantly from point and diffuse source sewage inputs. The correlation between BOD and the tryptophan-like fluorescence intensity suggests that this fluorescence centre is related to the bioavailable or fluorescence intensity and ammonia concentration and dissolved oxygen. The weaker correlation with ammonia is due to good ammonia treatment within the wastewater treatment plants within the catchment, and that with dissolved oxygen due to the natural aeration of the river such that this is not a good indicator of water quality. Mean annual tryptophan-like fluorescence intensity, measured by both bench and portable spectrometers, agrees well with the General Water Quality Assessment as determined by the England and Wales environmental regulators, the Environment Agency.

Perioperative cytokines during orthotopic liver transplantation without venovenous bypass

Since most of studies investigating cytokine levels during human orthotopic liver transplantation used venovenous bypass (VVB), it may be difficult to distinguish between the increase in proinflammatory mediators induced by VVB, by ischemia-reperfusion injury or by splanchnic venous congestion in the anhepatic phase. The goal of this investigation was to assess the levels of interleukin-6 (IL-6) and soluble interleukin-2 receptors (sIL-2r) during OLT procedures routinely performed without VVB.

PATIENTS AND METHODS

Twenty-one consecutive patients underwent OLT with cross clamping of the inferior caval vein without VVB. Soluble IL-2r concentrations were measured by means of luminescence enzyme immunometric assay and IL-6 by means of a sequential immunometric assay. Time points (TP) of sampling were before induction of anesthesia (TP1), after cross-clamping of the inferior vena cava (TP2), 15 minutes after reperfusion (TP3), and 24 hours after the transplant procedure (TP4).

RESULTS

Soluble IL-2r increased significantly 24 hours after transplantation (P =.02) compared to TP1, TP2, and TP3. IL-6 increased significantly during the anhepatic period (TP2 vs TP1, P =.003) and again in the reperfusion period (TP2 vs TP3, P =.002). Twenty-four hours after surgery IL-6 declined significantly (TP3 vs TP4, P =.001), but remained significantly higher (P = 0.04) compared to TP1. Furthermore, we examined the relative changes (DeltaTP %) in perioperative levels of cytokines compared with those previously published in studies using VVB. We observed higher values of DeltaTP % of IL-6 in TP2 and TP4 among our group of patient without VVB. The data on sIL-2r were similar, suggesting no major effects of the operative technique on sIL-2r levels.

CONCLUSION

The two interleukins showed different perioperative trends. Our data suggest that cross clamping contributes more to cell activation, namely, increased release of IL-6 in the anhepatic phase than the use of VVB. However, no major differences were observed during the reperfusion period. The extent of clinical effect on graft function of higher IL-6 levels in the anhepatic period among recipients not supported with VVB remains to be clarified.

Portal Vein Thrombosis and Pancreatic Failure

We report a case of a child with portal vein thrombosis presenting with protein losing enteropathy. Helater developed exocrine and endocrine pancreatic failure. This association has not been reported before.

Epstein-Barr virus-related post-transplant lymphoproliferative disorder with t(9;14)(p11-12;q32)

The immunoglobulin heavy chain gene locus on 14q32 is known to be involved in translocations that are associated with B-lymphoproliferative disorders, typically Burkitt lymphoma and B-cell acute lymphoblastic leukemia. Several cytogenetic abnormalities have been described in post-transplant lymphoproliferatve disease (PTLD), some of which include this locus. To our knowledge, we report the first case of translocation t(9;14)(p11-12;q32) in a PTLD that developed after orthoptic liver transplantation.

Precise dating of Dansgaard-Oeschger climate oscillations in western Europe from stalagmite data

The signature of Dansgaard-Oeschger events--millennial-scale abrupt climate oscillations during the last glacial period--is well established in ice cores and marine records. But the effects of such events in continental settings are not as clear, and their absolute chronology is uncertain beyond the limit of (14)C dating and annual layer counting for marine records and ice cores, respectively. Here we present carbon and oxygen isotope records from a stalagmite collected in southwest France which have been precisely dated using 234U/230Th ratios. We find rapid climate oscillations coincident with the established Dansgaard-Oeschger events between 83,000 and 32,000 years ago in both isotope records. The oxygen isotope signature is similar to a record from Soreq cave, Israel, and deep-sea records, indicating the large spatial scale of the climate oscillations. The signal in the carbon isotopes gives evidence of drastic and rapid vegetation changes in western Europe, an important site in human cultural evolution. We also find evidence for a long phase of extremely cold climate in southwest France between 61.2 +/- 0.6 and 67.4 +/- 0.9 kyr ago.

The impact of roster changes on absenteeism and incident frequency in an Australian coal mine

BACKGROUND

The occupational health and safety implications associated with compressed and extended work periods have not been fully explored in the mining sector.

AIMS

To examine the impact on employee health and safety of changes to the roster system in an Australian coal mine.

METHODS

Absenteeism and incident frequency rate data were collected over a 33 month period that covered three different roster schedules. Period 1 covered the original 8-hour/7-day roster. Period 2 covered a 12-month period under a 12-hour/7-day schedule, and period 3 covered a 12-month period during which a roster that scheduled shifts only on weekdays, with uncapped overtime on weekends and days off (12-hour/5-day) was in place. Data were collected and analysed from the maintenance, mining, and coal preparation plant (CPP) sectors.

RESULTS

The only significant change in absenteeism rates was an increase in the maintenance sector in the third data collection period. Absenteeism rates in the mining and CPP sectors were not different between data collection periods. The increase in the maintenance sector may be owing to: (1) a greater requirement for maintenance employees to perform overtime as a result of the roster change compared to other employee groups; or (2) greater monotony associated with extended work periods for maintenance employees compared to others. After the first roster change, accident incident frequency decreased in the CPP sector but not in the other sectors. There was no effect on incident frequency after the second roster change in any sector.

CONCLUSIONS

The current study did not find significant negative effects of a 12-hour pattern, when compared to an 8-hour system. However, when unregulated and excessive overtime was introduced as part of the 12-hour/5-day roster, absenteeism rates were increased in the maintenance sector. The combination of excessive work hours and lack of consultation with employees regarding the second change may have contributed to the overall negative effects.

Portal vein thrombosis and pancreatic failure

We report a case of a child with portal vein thrombosis presenting with protein losing enteropathy. He later developed exocrine and endocrine pancreatic failure. This association has not been reported before.

Inhibition of retinal neovascularisation by gene transfer of soluble VEGF receptor sFlt-1

Retinal angiogenesis is a central feature of the leading causes of blindness. Current treatments for these conditions are of limited efficacy and cause significant adverse effects. In this study, we evaluated the angiostatic effect of gene transfer of the soluble VEGF receptor sFlt-1 in a mouse model of ischaemia-induced retinal neovascularisation using adenovirus and adeno-associated virus (AAV) vectors. We induced proliferative retinopathy in mice by exposure to 75% oxygen from postnatal day 7 (p7) to p12 and injected intravitreally recombinant viral vectors expressing the reporter green fluorescent protein (GFP) or vectors expressing the VEGF inhibitor sFlt-1. Efficient adenovirus-mediated GFP expression was evident in cells of the corneal endothelium and iris pigment epithelium. AAV-mediated GFP expression was evident in ganglion cells and cells of the inner nuclear layer of the retina. Vector-mediated sFlt-1 expression was confirmed by ELISA of pooled homogenised whole eyes. Injection of either vector expressing sFlt-1 resulted in a reduction in the number of neovascular endothelial cells by 56% and 52% for adenovirus and AAV vectors, respectively (P < 0.05). Local gene transfer of sFlt-1 consistently inhibits experimental retinal neovascularisation by approximately 50% and offers a powerful novel approach to the clinical management of retinal neovascular disorders.

The effects of a roster schedule change from 8- to 12-hour shifts on health and safety in a mining operation

The current study examined the impact on employee health and safety of changes to the roster system of an Australian coal mine. Absenteeism and incident frequency rate data were collected over a 33-month period that covered three different roster schedules, an 8-hour system, a 12-hour system and a 12-hour system incorporating unregulated overtime. The first change was implemented after consultation with the employee population, whereas the second was not. There were no significant negative effects of the 12-hour pattern, when compared to the 8-hour system. However, when unregulated and excessive overtime was introduced as part of the second round of changes, absenteeism rates were increased in one sector of the mine. The maintenance sector was subject to a significant increase in absenteeism rates, which may have been attributable to the excessive overtime required of the workers in that area. It is important that overtime be strictly monitored and that the employee population are involved in the process of roster change.

Catalytic oligodeoxynucleotides define a key regulatory role for early growth response factor-1 in the porcine model of coronary in-stent restenosis

Early growth response factor-1 (Egr-1) controls the expression of a growing number of genes involved in the pathogenesis of atherosclerosis and postangioplasty restenosis. Egr-1 is activated by diverse proatherogenic stimuli. As such, this transcription factor represents a key molecular target in efforts to control vascular lesion formation in humans. In this study, we have generated DNAzymes targeting specific sequences in human EGR-1 mRNA. These molecules cleave in vitro transcribed EGR-1 mRNA efficiently at preselected sites, inhibit EGR-1 protein expression in human aortic smooth muscle cells, block serum-inducible cell proliferation, and abrogate cellular regrowth after mechanical injury in vitro. These DNAzymes also selectively inhibit EGR-1 expression and proliferation of porcine arterial smooth muscle cells and reduce intimal thickening after stenting pig coronary arteries in vivo. These findings demonstrate that endoluminally delivered DNAzymes targeting EGR-1 may serve as inhibitors of in-stent restenosis.

Deaths from antidepressants in England and Wales 1993-1997: analysis of a new national database

BACKGROUND

The prescription of antidepressants has increased substantially over the last 10 years. It is therefore timely to examine trends in mortality associated with overdoses of antidepressants and to compare the relative mortality associated with different antidepressants.

METHODS

Data were derived from a newly developed national database of deaths from overdose and poisoning in England and Wales between 1993 and 1997. Age and sex specific death rates associated with overdose and poisoning with antidepressants were calculated together with numbers of deaths per 100,000 prescriptions of individual antidepressants.

RESULTS

Twenty per cent (2,503) of all deaths from overdose or poisoning were antidepressant related. The number of deaths increased by 18% between 1993 and 1997. Ninety-five per cent of deaths from antidepressants were associated with tricyclic antidepressants, particularly dothiepin and amitriptyline. Tricyclic antidepressants were associated with 5.3 deaths per 100,000 prescriptions, 4.4 for monoamine oxidase inhibitors and 0.4 for selective serotonin reuptake inhibitors. Annual death rates were highest in men aged 30-44 years (18.2 per million) and women aged 45-59 years (14.8). Death rates from antidepressants were 2.5 times higher in the most deprived fifth than in the least deprived fifth of enumeration districts.

CONCLUSIONS

Antidepressants are an important cause of death from poisoning and overdose. SSRIs and newer antidepressants are associated with <10% of the risk of death than the older antidepressants. There is a strong association between area deprivation and deaths from antidepressants.

Hemodynamic response to continuous infusion of dobutamine in Alagille's syndrome

BACKGROUND

Alagille's syndrome is a rare condition that is characterized by paucity of interlobular bile ducts and peripheral pulmonary artery stenosis. Liver transplantation in the setting of peripheral pulmonary stenosis and right ventricular hypertension seems to be associated with a higher mortality, which raises the concern that these patients are unable to increase their cardiac output in the immediate posttransplantation period to meet the demands of reperfusion and early graft dysfunction and cope with further increases in pulmonary vascular resistance.

METHOD

Cardiac catheterization was performed in 15 children with Alagille's syndrome and peripheral pulmonary artery stenosis to measure the cardiac output response to dobutamine infusion. The cardiac output was measured before and during each increment of infusion of dobutamine at 10 microg/kg/min and 20 microg/kg/min by using a thermodilution catheter placed in the pulmonary artery.

RESULTS

There was a significant change in the baseline cardiac index (P<0.001) with an infusion of 20 microg/kg/min of dobutamine with an increase from 4.4(1.0) L/min/m2 to 6.4(1.5) L/min/m2. There was, however, a wide variation between individuals in the increase in cardiac index, ranging from 7.3-95%. There was no correlation between the baseline systolic right ventricular/aortic pressure ratios and the increase in cardiac index (r=0.1086).

CONCLUSION

The increase in cardiac index, in response to dobutamine in patients with Alagille's syndrome, is independent of the more conventional measurement of the right ventricular pressure. This method of producing a hemodynamic response is closer to the response that results after liver transplantation, and thus, it may be a better way of predicting the outcome of liver transplantation in these patients.

Predictor index of mortality in dementia patients upon entry into long-term care

BACKGROUND

The purpose of this study was to develop an algorithm that predicts survival in patients with dementia upon entry into long-term care. There are, as yet, no predictive equations developed for those in the late stages of Alzheimer's disease (AD).

METHODS

This was a prospective, observational study of 132 patients with dementia (61% with AD) followed for up to 5.0 years (median of 41.0 months) after admission to a long-term care facility for dementia patients. Information on demographic characteristics, physical health, and cognitive, emotional, and behavioral characteristics was collected shortly after admission and entered as predictors of time until death in Cox regressions. Findings were used to derive an index predicting mortality.

RESULTS

There were 60 deaths among the 132 patients (45.4% mortality), with an average survival of 22.4 months in those who died. Better physical health and the presence of delusions were associated with longer survival. These two variables were aggregated into the Copper Ridge Index (CRI). Each one-point increase on the CRI was associated with a four-fold greater likelihood of death over 5 years.

CONCLUSIONS

A predictive equation incorporating measures of general physical health and delusions accurately predicted time to death in dementia patients in long-term care.