Dual inhibition of angiotensin converting enzyme and neutral endopeptidase by omapatrilat in rat in vivo

The pharmacological profile of a vasopeptidase inhibitor is dependent on the ratio of neutral endopeptidase (NEP)vs angiotensin converting enzyme (ACE) inhibition of the particular drug. We used in vitro autoradiography to determine the local renal and cardiac NEP and ACE inhibition after oral treatment with the dual NEP/ACE inhibitor omapatrilat in rat. Maximal inhibition of both renal NEP and ACE was achieved at the omapatrilat dose of 40 mg kg(-1)day(-1). Effective local ACE inhibition was detected also in the myocardium. The haemodynamic effects were similar to captopril, but omapatrilat treatment produced more favorable effect on natriuretic peptide levels. In conclusion, good tissue penetration of omapatrilat and balanced NEP/ACE inhibition may prove to be useful in the treatment of hypertension and heart failure.

Skateboarding injuries of today

BACKGROUND

Skateboarding injuries have increased with the rise in popularity of the sport, and the injury pattern can be expected to have changed with the development of both skateboard tricks and the materials used for skateboard construction.

OBJECTIVE

To describe the injury pattern of today.

METHODS

The pattern of injuries, circumstances, and severity were investigated in a study of all 139 people injured in skateboarding accidents during the period 1995-1998 inclusive and admitted to the University Hospital of Umeå. This is the only hospital in the area, serving a population of 135 000.

RESULTS

Three of the 139 injured were pedestrians hit by a skateboard rider; the rest were riders. The age range was 7-47 years (mean 16). The severity of the injuries was minor (AIS 1) to moderate (AIS 2); fractures were classified as moderate. The annual number of injuries increased during the study period. Fractures were found in 29% of the casualties, and four children had concussion. The most common fractures were of the ankle and wrist. Older patients had less severe injuries, mainly sprains and soft tissue injuries. Most children were injured while skateboarding on ramps and at arenas; only 12 (9%) were injured while skateboarding on roads. Some 37% of the injuries occurred because of a loss of balance, and 26% because of a failed trick attempt. Falls caused by surface irregularities resulted in the highest proportion of the moderate injuries.

CONCLUSIONS

Skateboarding should be restricted to supervised skateboard parks, and skateboarders should be required to wear protective gear. These measures would reduce the number of skateboarders injured in motor vehicle collisions, reduce the personal injuries among skateboarders, and reduce the number of pedestrians injured in collisions with skateboarders.

Inpatient care quality: analyzing Swedish hospitals with stroke as a tracer

Mortality statistics are an important source of information concerning variations in time and place, identification of risk factors and the evaluation of treatment programs. In this study, a new death certificate was completed "blind" on the basis of hospital records from the last episode of care, across a random sample of 1,376 cases. The results showed that the overlap between the official register's underlying cause of death and that of a panel was 72 per cent at the three-digit level. The official underlying cause of death from cerebrovascular diseases (CVD) was 72 cases in this sample, while 93 were deemed to have CVD by a panel. Additionally, of the 1,233 cases originally reported as non-CVD, the panel deemed non-CVD to be the true underlying cause in 1,176 cases. The paper concludes that CVD was most often correctly reported as the underlying cause of death in the investigated ages up to 75 years but plain differences were found between specialities and in different hospital size.

[GHB--dangerous, addictive and uncontrollable "party drug"]

This report reviews the pharmacology, toxicity and abuse pattern of gamma-hydroxybutyrate (GHB). The legislative changes pertaining to this substance are also addressed. Examples of abuse, driving under the influence and fatal intoxication are given. It is concluded that GHB is widely abused, particularly among the younger generation, and that further cases of severe intoxication are likely to occur as long as the substance is easily available from countless sources, including via the Internet. Despite the classification of GHB as a narcotic in Sweden and several other countries, continued problems are expected since the precursors gamma-butyrolactone (GBL) and 1,4-butanediol (BD) are widely--and legally--available.

Positron emission tomography (11)C-methionine and survival in patients with low-grade gliomas

BACKGROUND

Considerable numbers of patients with low-grade gliomas experience an early malignant course and may benefit from aggressive treatment. These patients are difficult to identify using established prognostic factors. A retrospective study was performed to determine whether the (11)C-methionine uptake in tumor is a survival factor in adult patients with supratentorial gliomas classified as World Health Organization Grade 2.

METHODS

The authors identified 89 patients with histologically confirmed low-grade gliomas in whom an (11)C-methionine positron emission tomography (PET) scan had been performed as part of the diagnostic tumor investigation from 1983 to 1998. Clinical data were collected, and the PET scans were re-evaluated according to a fixed protocol. The (11)C-methionine uptake in the tumor and relevant clinical parameters were entered into univariate and multivariate survival analyses.

RESULTS

At the end of the study, 49 patients (55.1%) had died. The median overall survival was 5.7 years. Low methionine uptake was significantly favorable in the multivariate survival analysis (P = 0.04) along with oligodendroglioma (P = 0.003). In the histologic subgroups, (11)C-methionine uptake was an important survival factor among patients with astrocytomas (P = 0.05) and oligodendrogliomas (P = 0.03). Tumor resection was a favorable prognostic factor in patients with high methionine uptake (P = 0.01) but not in patients with low uptake.

CONCLUSIONS

Baseline (11)C-methionine PET is a prognostic indicator in patients with low-grade gliomas. The results imply that PET is a valuable tool in the clinical management of these patients and may assist in the selection of patients for therapy.

Teenager injury panorama in northern Sweden

OBJECTIVES

To study non-fatal unintentional injuries among teenagers and to suggest preventive measures.

SETTING

The emergency care unit of the University Hospital, Umeå, Sweden.

METHODS

All injured teenagers (N = 1044) attending the emergency care unit during 1991 were asked to answer a questionnaire focusing on when, where and how the injury occurred. All available medical records were examined. Data were coded according to the Nordic Medico-Statistical Committees Classification for Accident Monitoring, NOMESCO, and to the Abbreviated Injury Scale, AIS.

RESULTS

1,043 teenagers were treated with sports and transportation related injuries as the most common ones. Most injuries were minor (AIS 1), transportation related injuries had the highest proportion of non-minor injuries (AIS > or = 2), 139 teenagers were admitted for in-patient care. Most injuries occurred during leisure/school time.

CONCLUSIONS

Sports and transportation related injuries were most frequent. Body weight and length differs among teenagers, we suggest that teenagers should exercise and play together, not only by age, but also to some extent, to height and weight. Curfew laws, a compulsory bicycle helmet law are other injury reducing measures suggested.

Preventability of vehicle-related fatalities

Several different methods have been used to evaluate the survivability of traffic injuries. Previously published methods were reviewed to develop a specific method for vehicle-related fatalities. All fatally injured victims (n = 474) of vehicle-related crashes in the four northern-most counties of Sweden during a 5-year period were studied. Almost half (48%) of the victims had non-survivable injuries. The remaining cases were classified into different injury groups according to the Injury Severity Score (ISS) including 56 (12%) with an ISS < 25, 150 (32%) with ISS 25-49 and 42 (9%) with ISS 50-74. The median distance from the scene to the nearest hospital was 49 km. In the cases with ISS < 50 the medical care was further analyzed. In close to half of these cases, the victim did not receive optimal care in time with transportation time being of major importance. The absence of first aid was judged to have contributed to the death in 4% of the cases.

Cardiomyocyte apoptosis and ventricular remodeling after myocardial infarction in rats

We investigated the role of cardiomyocyte apoptosis in the remodeling of the left ventricle from 24 h to 12 wk after myocardial infarction in the rat. Infarct size planimetry, quantification of cardiomyocyte apoptosis, terminal deoxynucleotide transferase-mediated dUTP nick-end labeling (TUNEL) methodology, and echocardiography (left ventricular diastolic diameter and ejection fraction) were performed. Sham-operated animals showed low rates of cardiomyocyte apoptosis (0.03%) and no change in diastolic diameter or ejection fraction during the study. Twenty-four hours after infarction, TUNEL positivity was high in the infarct areas (1.4%) and border zones (4.9%). It declined to 0.34% (P < 0.01 vs. sham) at 4 wk and 0.10% at 12 wk in the border zones. In the remote myocardium, cardiomyocyte apoptosis increased to 0.07% (P = 0.03 vs. sham) on day 1 and remained on the same level up to 4 wk. The increase in diastolic diameter 1-4 wk after infarction correlated (r = 0.60, P < 0.01) with cardiomyocyte apoptosis in the noninfarcted myocardium, which quantitatively contributed most (>50%) to the apoptotic cell loss by 4 wk.

DNA-Dependent Protein Kinase Is Inhibited by Trifluoperazine

The DNA-dependent protein kinase (DNA-PK) is a serine/threonine nuclear kinase, important for the repair of DNA double strand breaks (DSB). Cells defective in DNA-PK show increased sensitivity to ionising radiation and different DNA-damaging drugs, such as cisplatinum. Increased sensitivity to cisplatinum has previously been noted in the presence of phenothiazines. We tested a panel of phenothiazines and one thioxanthen for any influence upon the activity and expression of DNA-PK in a nonsmall cell lung cancer cell line, U-1810. The activity of DNA-PK was completely inhibited in cell lysate and in purified enzyme by 200 microM TFP. DNA-PKcs and Ku86 cleavage were evident in U-1810 cells after 30 min incubation with 100 microM TFP, along with changes in the cells consistent with apoptosis. Our study suggests that phenothiazines and thioxanthens, acting through DNA-PK, have the potential to enhance the effects of DNA damaging agents.

A rural ambulance helicopter system in northern Sweden

INTRODUCTION

In Sweden, several ambulance helicopter programs have been used during the past 3 decades. This article describes one of these programs.

SETTING

The catchment area of the helicopter system under study was a typical rural setting with a population density of less than 5 people per square kilometer.

METHODS

We describe in detail, with special reference to medical aspects, the activities of an helicopter ambulance program in 1997.

RESULTS

A total of 288 missions, including 328 patients (204 men), were analyzed. Trauma cases (29%) and patients with cardiovascular (24%) and neurologic problems (13%) dominated the missions. One-sixth of the cases occurred at night. The median response time was 12 minutes, and the median on-scene time was 28 minutes. The medical interventions performed included intubations; central venous catheter, arterial needle, and duodenal tube insertions; and medication administered intravenously, orally, and intrabronchially.

CONCLUSION

We detected a higher rate of trauma cases than in previously published investigations, probably related to the outdoor activities of the area. We believe that the rapid institution of thrombolytic treatment in suspected acute myocardial infarction and a more rapid and flexible transport of trauma cases in a rural area are important. We estimate that, in most cases, the helicopter service could provide a quicker transport than a ground ambulance; however, for short distance transports, ground ambulance is faster than helicopter ambulance.

[All traffic related deaths are not "fatalities"--analysis of the official Swedish statistics of traffic accident fatalities in 1999]

In 1997 the Swedish Parliament decided, in accordance with the so-called Vision Zero, that one official goal for the national traffic safety effort is that the number of traffic fatalities in the year 2007 must not exceed 270. In order to monitor efforts toward this hard-won goal, it is of course of utmost importance that official statistics on traffic deaths are reliable. In a meticulous analysis of all 580 officially registered traffic deaths in Sweden in 1999, we found that 490 were true accidental deaths, while 18 were suicides, 12 were deaths due to indeterminate causes, 59 were natural deaths and 1 case was not possible to evaluate due to missing data. Thus, only 84% of the officially registered "accidental traffic deaths" were bona fide accidents. In order to enhance the reliability of the official statistics, we suggest that regulations concerning police investigation and medicolegal autopsy of all unnatural deaths be adhered to all deaths reported to the Swedish National Road Administration should be checked in the database of autopsied cases in the National Board of Forensic Medicine in order to exclude natural deaths the time delay (1.5 years) to complete the official Cause-of-Death Register be shortened criteria for the classification of manner of death in "borderline" cases be suggested for international acceptance.

Pedestrian fatalities and alcohol

Since the share of alcohol-positive victims has been reported not to show the same reduction in pedestrian fatalities as in other 'road users', this study analysed pedestrian fatalities with special emphasis on the presence of alcohol. Autopsied pedestrian fatalities (286 victims) in northern Sweden from 1977 to 1995 were investigated, using autopsy and police reports. Blood alcohol was detected in 19% of the fatalities, with a median concentration of 1.6 g/l. The proportion of test-positive victims did not change significantly during the period of study. Males more often tested positive for alcohol than females (24 vs. 11%). Further, the test-positive victims had a lower mean age (49 vs. 59 years) and the proportion of test-positive victims was higher during weekends and nights. Pedestrian fatalities testing positive for alcohol differ from those testing negative in several respects. The public should be enlightened of the fact that drinking is a risk not only among users of motor vehicles, but also among pedestrians. Separation of pedestrians from motor vehicles by, e.g. fences, is of greatest importance.

[Inadequate management of unnatural deaths]

A death certificate was issued without a medicolegal autopsy in one third of all Swedish cases of unnatural death during 1991 through 1996. Out of 415 unnatural deaths in the northern part of Sweden, not subjected to a medicolegal autopsy but analyzed in this study, only 14% were reported to police authorities. Elderly, women and patients dying after a longer period of hospital care were more often not reported to the police. It is recommended that forensic pathologists be consulted in order to achieve better management of unnatural deaths.

Clinical outcome after successful coronary angioplasty: impact of intracoronary stent implantation

The clinical outcome after successful conventional coronary balloon angioplasty is compared with that of stent implantation after 30 days and 12 months. The study took place at the Divisions of Cardiology and Thoracic Radiology, Norrland University Hospital, Umeå, a referral centre for northern Sweden. The first 100 consecutive patients with stable or unstable angina undergoing successful percutaneous transluminal coronary angioplasty (PTCA) in 1994 and the first 100 consecutive patients undergoing successful coronary stent implantation in 1995 were included. The cardiac endpoints studied were death, myocardial infarction, need for repeat PTCA or coronary artery bypass grafting (CABG). Significantly more adverse cardiac events were observed in the PTCA group compared with the stent group. Event-free 12 months' follow-up (no deaths, myocardial infarction or re-intervention) was 64% in the PTCA group and 86% in the stent group (p < 0.005). The main explanation for the observed difference was a reduction in the need for a repeat PTCA (7 vs 18, p < 0.05) or CABG (4 vs 12, p < 0.05) in the stent group. Patients with stable or unstable angina who can be treated with a stent have a better clinical outcome than those treated with coronary balloon angioplasty only.

Protocol for using signal peptide differential display and representational difference analysis to isolate differentially expressed cDNAs from fetal mouse brain

Comparing female and male brain structures reveals a variety of sex differences in many vertebrates. Some of these differences are thought to be induced during the fetal period by the effect of steroid hormones produced in the gonads. Not much is known about molecular mechanisms involved in gender-specific development of the brain. We have taken a broad approach to isolate sex-specific genes from 18.5 days post coitum brain (A. Eriksson, C. Wahlestedt and K. Nordqvist. 1999. Isolation of sex-specific cDNAs from fetal mouse brain using mRNA differential display and representational difference analysis. Mol. Brain Res., 74, 91-97). Female and male mouse brains were screened with the signal peptide differential display, developed in our laboratory, and with a modified representational difference analysis of cDNA. The resulting sex-specific fragments were verified by semi-quantitative RT-PCR. Here we describe these methods in detail.

Quantification of alcohol-related mortality in Sweden

The main aim of the present study was to estimate total alcohol-related mortality in Sweden. For natural deaths, a meta-analysis carried out in Australia was updated to the end of March 1998, and pooled estimates of the relative risks were calculated for different diseases based on data from scientific studies that have been published in the international literature. The proportion of current alcohol drinkers from recent Swedish surveys, and the pooled relative risk estimates were used to estimate disease-specific alcohol-attributable fractions. Natural deaths 'caused' or 'prevented' by alcohol were estimated for the period 1992-1996. For unnatural deaths, all cases from 1992 through 1996 in Sweden were analysed (n = 23 132). Alcohol was regarded to attribute to the death: if the deceased was a 'known alcoholic'; if the underlying or contributing cause of death was alcohol-related; if the deceased had an alcohol-related in-patient diagnosis during a 3-year period prior to death; if the case tested positive for blood alcohol. Person years of life lost/gained (<70 years) due to alcohol were also assessed. The assumptions underlying the attributable risk methods used to analyse alcohol-related mortality due to natural causes need to be borne in mind when interpreting the results on natural deaths. Moreover, the preventive effect of alcohol on coronary heart disease and stroke is still controversial. The findings of alcohol-related mortality due to unnatural causes were much more reliable. About 3.5% of deaths were attributed to alcohol; alcohol involvement was more than twice as common in deaths of males (4.8%) than in those of females (2.0%). About one-quarter of the deaths in those aged below 50 years were attributed to alcohol. In those (</=69 years, alcohol had a net harmful effect in that it 'caused' more deaths than it 'prevented'; 7% of deaths were in net 'caused'. More person years of life were in net lost than were saved by alcohol, suggesting that alcohol has a negative effect on premature mortality. We conclude that alcohol accounted for about 3. 5% of deaths in all ages, and 25% of deaths in those aged below 50 years, and about 10% of person years of life lost in Sweden. The balance of harm and benefit does not weigh in favour of making a recommendation to the public to drink in order to prevent death.

Reduction mammaplasty provides long-term improvement in health status and quality of life

The objective of this study was to assess health status and quality of life in macromastia patients undergoing reduction mammaplasty. From January of 1997 to June of 1997, the Department of Reconstructive Plastic Surgery, at Stockholm Söder Hospital/Karolinska Hospital, conducted a prospective questionnaire study with preoperative and postoperative (6 and 12 months) assessments in 49 women who were 20 years or older. The questionnaire included four parts: Part I assessed pain (scale 1 to 10) in the neck, shoulders, back, breast, bra strap indention, and head. Part II assessed effects of breast size and weight on body posture, sleep, choice of clothing, sexual relations, and working capacity (scale 1 to 10). Part III assessed preoperative expectations for the operation in comparison with postoperative result (scale 1 to 6). Part TV included SF-36, an international health-related quality-of-life questionnaire, which has been standardized for Swedish women. As a result, reduction mammaplasty (mean resection weight, 1052 g) provided significant reduction of pain in all locations (p < 0.001). The improvements continued up to 12 months postoperatively. The patients' main subjective problems related to the size and weight of the breast were body posture and choice of clothing. The patients scored significant improvements of all subjective problems (p < 0.001), except sleep. The patients' expectations were met to a high extent. In some areas such as intimate situations, femininity, and social contacts, the results exceeded the preoperative expectations. Preoperatively, the mammaplasty patients scored significantly lower (p < 0.05 to p < 0.001, depending on area) in SF-36, i.e., the patients had lower quality of life compared with women in the same age group. Reduction mammaplasty resulted in significantly improved quality of life; furthermore, the results were similar after 6 and 12 months, indicating long-term improvement. In fact, after 1 year, there was no statistically significant difference between the patients who had been operated on and the age-matched women, i.e., the women were normalized in health-related quality of life as judged by the SF-36.

[Low malignancy grade glioma in the Uppsala++/Orebro region. Prognostic factors and survival among 119 patients]

The benefit of surgery and radiotherapy for patients with low-grade gliomas is controversial. We studied case records of 119 patients diagnosed with low-grade glioma during 1987-1993 at our hospital. Statistical analysis was made on overall survival and on survival related to histological diagnosis and treatment modality. A large variation in survival of patients with similar histological diagnosis was seen. No correlation was found between survival and treatment modality. This clinical diversity probably reflects variations in tumor biological characteristics of low-grade gliomas. Greater understanding of the biology of these tumors will thus be needed for more effective therapies.

Expression and activity of DNA-dependent protein kinase in normal human leukocytes

BACKGROUND

DNA-PK is a serine/threonine protein kinase that has been shown to play an important role in V(D)J recombination, Ig switching and DNA double strand break (DSB) repair. We have investigated DNA-PK in whole cell extracts from B and T lymphocytes, monocytes and granulocytes and the effects of phorbolmyristate acetate (PMA) and Concanavalin A (Con A) on DNA-PK in B and T lymphocytes.

MATERIALS AND METHODS

Lymphocytes were separated from human peripheral blood using the E-rosette technique and DNA-PK was analysed using Western blot, DNA-PK kinase activity assay and flow cytometry.

RESULTS

The levels of DNA-PK activity and content varied among the leukocytes. PMA and Con A stimulation consistently increased both DNA-PK activity and content in B lymphocytes as cells entered the S phase. Up-regulation could normally not be seen in T lymphocytes, although cells entered the S phase following PMA and Con A stimulation.

CONCLUSION

Mitogenic stimulation up-regulates DNA-PK activity and protein expression in B lymphocytes. T lymphocytes show interindividual differences in DNA-PK. Regulation of DNA-PK is not strictly cell cycle dependent for all cell types.

Role of alcohol in unnatural deaths: a study of all deaths in Sweden

BACKGROUND

Most previous research has concentrated on the role of alcohol in one type of unnatural death in a selected population, but the present objective was to investigate the role of alcohol in all unnatural deaths (autopsied and not autopsied).

METHODS

All cases of unnatural death from 1992 through 1996 in Sweden were analyzed (n = 23,132). Death was attributed at least in part to alcohol if the deceased was a "known alcoholic"; if the underlying or contributing cause of death was alcohol-related; if the deceased had an alcohol-related inpatient diagnosis during the 3-year period prior to death; or if the deceased tested positive for blood alcohol.

RESULTS

Just over 28% of the unnatural deaths could be associated with alcohol; the association with alcohol was more than twice as common in deaths of males (35%) as in females (16%). When only autopsied cases or only blood-tested cases were taken as the denominators, 38% and 44%, respectively, of the deaths were associated with alcohol. Alcohol involvement also was twice as common in intentional deaths (36%) as in unintentional deaths (18%). The intoxication group (78%) had the highest fraction of deaths that could be associated with alcohol, followed by the undetermined group (62%), homicide (49%), fire (41%), suicide (35%), asphyxia (29%), traffic (18%) and fall (9%) groups. In the 20- to 59-year age group, alcohol involvement was found in 51% of the males and 35% of the females (47% for males and females combined).

CONCLUSIONS

The present estimates are conservative; alcohol involvement in unnatural deaths probably is even higher, up to 44% of the total. The present estimation is an important step in policy-making to lower the number of alcohol-related deaths in Sweden.

Work-place homicide by bow and arrow

Arrow wounds represent an unusual class of wounds rarely seen by most forensic pathologists. In this paper we present a case of homicide by bow and arrow and the characteristics of such injuries. The essential characteristics of the lesions obtained from conically-tapered field points and from hunting broadhead tips are described and discussed in relation to injuries caused by firearm bullets. In the present case, three arrows struck the victim, and the order in which the injuries were sustained are analyzed. We also discuss the possibilities of localizing the shooter relative to the victim by analysis of the trajectories.

Alcohol and unnatural deaths in Sweden: a medico-legal autopsy study

OBJECTIVE

To investigate alcohol involvement in all types of unnatural deaths in Sweden.

METHOD

All cases of unnatural death that underwent medico-legal autopsies (1992-1996) in Sweden were analyzed (N = 15,630; i.e., 68% of all unnatural deaths). Alcohol was regarded as contributing to the death if: (1) there was any indication that the deceased was a "known alcoholic"; (2) the underlying or contributing causes of death were alcohol-related; (3) the deceased had alcohol-related inpatient diagnosis during a period of 3 years prior to death; or (4) the case tested positive for blood alcohol.

RESULTS

Thirty-nine percent of the blood-tested cases (n = 13,099) were positive for alcohol. Almost 40% of the unnatural deaths were associated with alcohol. Alcohol involvement was most common in the intoxication group (84%), followed by the "undetermined" (65%), homicide (55%), fall (48%), fire (44%), asphyxia (41%), suicide (35%) and traffic (22%) groups. More than half (52%) of the deaths in the age group 30-60 years, 35% of those aged 0-29 years and 25% of those aged 60 and over were associated with alcohol.

CONCLUSIONS

In Sweden, two of five unnatural deaths are associated with alcohol; this is a conservative estimate. Alcohol-associated mortality varies considerably between different groups of external causes of death, between men and women, and with age.

Acoustic effects of variation in vocal effort by men, women, and children

The acoustic effects of the adjustment in vocal effort that is required when the distance between speaker and addressee is varied over a large range (0.3-187.5 m) were investigated in phonated and, at shorter distances, also in whispered speech. Several characteristics were studied in the same sentence produced by men, women, and 7-year-old boys and girls: duration of vowels and consonants, pausing and occurrence of creaky voice, mean and range of F0, certain formant frequencies (F1 in [a] and F3), sound-pressure level (SPL) of voiced segments and [s], and spectral emphasis. In addition to levels and emphasis, vowel duration, F0, and F1 were substantially affected. "Vocal effort" was defined as the communication distance estimated by a group of listeners for each utterance. Most of the observed effects correlated better with this measure than with the actual distance, since some additional factors affected the speakers' choice. Differences between speaker groups emerged in segment durations, pausing behavior, and in the extent to which the SPL of [s] was affected. The whispered versions are compared with the phonated versions produced by the same speakers at the same distance. Several effects of whispering are found to be similar to those of increasing vocal effort.