Service use by elderly patients after psychiatric hospitalization

The extent and source of services used by older adults discharged to a community setting after a psychiatric hospitalization were examined in a prospective follow-up study. Patients were asked about service use in structured telephone interviews one month after hospital discharge. Subjects had comorbid medical conditions and high levels of functional impairment. Service use was low, highly skewed, and spread across three sectors of care-mental health specialty care (38 percent of the services), general medical care (35 percent), and social services and formal aging services (27 percent). Most service episodes were related to mental disorder.

Protein 4.1R-deficient mice are viable but have erythroid membrane skeleton abnormalities

A diverse family of protein 4.1R isoforms is encoded by a complex gene on human chromosome 1. Although the prototypical 80-kDa 4.1R in mature erythrocytes is a key component of the erythroid membrane skeleton that regulates erythrocyte morphology and mechanical stability, little is known about 4.1R function in nucleated cells. Using gene knockout technology, we have generated mice with complete deficiency of all 4.1R protein isoforms. These 4.1R-null mice were viable, with moderate hemolytic anemia but no gross abnormalities. Erythrocytes from these mice exhibited abnormal morphology, lowered membrane stability, and reduced expression of other skeletal proteins including spectrin and ankyrin, suggesting that loss of 4. 1R compromises membrane skeleton assembly in erythroid progenitors. Platelet morphology and function were essentially normal, indicating that 4.1R deficiency may have less impact on other hematopoietic lineages. Nonerythroid 4.1R expression patterns, viewed using histochemical staining for lacZ reporter activity incorporated into the targeted gene, revealed focal expression in specific neurons in the brain and in select cells of other major organs, challenging the view that 4.1R expression is widespread among nonerythroid cells. The 4.1R knockout mice represent a valuable animal model for exploring 4.1R function in nonerythroid cells and for determining pathophysiological sequelae to 4.1R deficiency.

Topoisomerase-I inhibitors in gynecologic tumors

The first section of this article reviews recent studies that have clarified both the cellular role of topoisomerase I and the mechanisms of cytotoxicity of the topoisomerase inhibitors, the camptothecins. Different analogs of this new class of antitumor drug have been studied using various dose schedules in the treatment of refractory or recurrent gynecologic cancer. Response rates are between 13% and 25%. The main toxic effects are hematologic and gastrointestinal, the latter remains problematic. Radiotherapy, alkylate, platinum analogues, and topoisomerase II inhibitors are currently being studied in combination with camptothecins.

Sonographic evaluation of infiltrating lobular carcinoma

OBJECTIVE

Infiltrating lobular carcinoma (ILC), which accounts for 7-10% of all breast malignancies, often poses diagnostic difficulties. The purpose of our study was to correlate the clinical, mammographic, and sonographic findings in each histologic subtype of ILC and to evaluate the sensitivity of sonography in its diagnosis.

MATERIALS AND METHODS

We reviewed 208 cases of invasive lobular carcinoma. In 81 of these tumors, sonography was performed to further examine a mammographically invisible palpable abnormality or a mammographically subtle lesion. A dedicated breast pathologist classified each of these tumors as pure invasive lobular carcinoma or mixed invasive lobular and ductal carcinoma. Pure ILC tumors were further subclassified as one of five histologic subtypes. We retrospectively studied the clinical, mammographic, and sonographic findings in each histologic tumor subtype.

RESULTS

The most common sonographic appearance of ILC was a heterogeneous, hypoechoic mass with angular or ill-defined margins and posterior acoustic shadowing, which was seen in 60.5% (49/81) of tumors. Of the remaining 32 tumors, 15% (12/81) showed focal shadowing without a discrete mass, 12% (10/81) appeared as a lobulated, well-circumscribed mass, and 12% (10/81) were sonographically invisible. Although considerable overlap occurred among histologic subtypes, classic ILC tended to present as focal shadowing without a discrete mass; pleomorphic ILC typically was seen as a shadowing mass; and, of all the tumor subtypes, signet, alveolar, and solid ILC were most likely to be revealed on sonography as a lobulated, well-circumscribed mass. In the 81 mammographically subtle or invisible lesions, sonography detected the tumor in 87.7% (71/81). The sensitivity of sonography in tumors smaller than 1 cm was 85.7% (12/14).

CONCLUSION

High-resolution sonography of the breast is a useful adjunct in the evaluation of ILC, a neoplasm that frequently presents a clinical and mammographic diagnostic challenge.

Communication and its disorders

This article defines communication and describes its various disorders. Some of these disorders are associated with other DSM-IV conditions, such as mental retardation or pervasive developmental disorder. Others are specific to the language-learning process. The interactions between communication and psychiatric disorders are discussed. Suggestions for integrating treating approaches among communication disorders and mental health professionals are presented.

Natural history of alcoholic myopathy: a 5-year study

Chronic myopathy is a common complication of alcoholism, but its natural history has not been well described. We, therefore, studied muscle structure and function in a 5-year study of 30 chronic alcoholics who became abstinent and 20 who relapsed, and 40 control subjects. The mean strength of the abstaining alcoholics increased from 18.6 to 23.2 kg; but, after 5 years, they were still substantially weaker than controls. In a subset who showed histological myopathy, the strength of half of the patients remained two standard deviations below that of controls. Alcoholics who relapsed tended to become progressively weaker (21.7 kg vs. 18.2 kg) and develop histological evidence of myopathy. Thus, continued alcohol abuse was generally reflected in deterioration of muscle strength and the appearance of histological injury to muscle. Importantly, almost half of the sober patients did not recover to normal levels, indicating that alcoholic myopathy is only partially reversible. We also unexpectedly found that, in some alcoholics, a substantial reduction in the amount of alcohol consumed may be as effective as complete abstinence in improving muscle strength or preventing its deterioration.

Protein phosphatase type 1, the product of the retinoblastoma susceptibility gene, and cell cycle control

Cell cycle regulation--three words which conjure in the minds of those conducting research in this area a myriad of proteins and biochemical pathways. In this examination, an overview of the mammalian cell cycle is presented with emphasis on the function of the negative growth regulatory protein, the product of the retinoblastoma susceptibility gene, pRb. Since the activity of this protein itself is regulated by phosphorylation on serine and threonine residues, more elaborate discussions on the enzymes involved in placing the phosphates on, and taking them off, are provided. The focus here is on the activity of the members of the type 1 class of serine/threonine phosphatases. More specifically, the role of PP1 in regulating cell cycle progression by dephosphorylating pRb during mitosis, thereby activating the growth suppressing function of pRb, is presented. Suggested avenues for further investigation regarding the functional significance, and ultimately the effect on cell cycle progression, of the complex between pRb and the type 1 phosphatases are also discussed.

The human integrin beta3 gene is 63 kb and contains a 5'-UTR sequence regulating expression

The human blood platelet fibrinogen receptor, integrin alphaIIbbeta3 (glycoprotein IIb-IIIa) is an archetypal member of the integrin family of adhesive molecules and is the only integrin encoded by genes physically linked in the genome. Because studies on the normal and abnormal expression of any gene require a thorough understanding of its organization, the initial goals of the current study were to determine the size and complete the genomic organization for the beta3 gene. We now report the isolation of the entire beta3 gene in a single P1 plasmid and for the first time have linked the first and second exons on a contiguous fragment of DNA. Using pulsed-field gel analysis, we determined the full size of the beta3 gene to be 63 kb and show a large (16.7 kb) first intron; based on this information, we propose a uniform numbering system for the beta3 exons. We have completed the 5' genomic structure and generated a long-range restriction map. The promoter and the 5' end of the first intron were found to have approximately 50% sequence identity with a region of the avian beta3 gene known to possess functional transcriptional activity. Analysis of three different homologous regions led to the identification of a sequence in the 5'-UTR of the human gene, CCGCGGGAGG, which shares 90% identity with the avian gene and which bound nuclear proteins in DNaseI and electrophoretic mobility shift assay studies. Mutating this sequence caused a 2.6-fold reduction in reporter gene activity. In these studies we have (1) determined the full length and 5' organization of the beta3 gene, (2) identified a large region of homology between the 5' regions of the avian and human genes, and (3) identified a sequence in the 5'-UTR that augments gene expression. Knowing the genomic structure of beta3 has permitted the uncovering of new mechanisms of mutagenesis causing Glanzmann thrombasthenia (Jin et al, J Clin Invest 98:1745, 1996), and our findings will be valuable for such genetic analyses as well as for studies on the transcriptional regulation of beta3 and other integrin genes.

Abortive gap repair: underlying mechanism for Ds element formation

The mechanism by which the maize autonomous Ac transposable element gives rise to nonautonomous Ds elements is largely unknown. Sequence analysis of native maize Ds elements indicates a complex chimeric structure formed through deletions of Ac sequences with or without insertions of Ac-unrelated sequence blocks. These blocks are often flanked by short stretches of reshuffled and duplicated Ac sequences. To better understand the mechanism leading to Ds formation, we designed an assay for detecting alterations in Ac using transgenic tobacco plants carrying a single copy of Ac. We found frequent de novo alterations in Ac which were excision rather than sequence dependent, occurring within Ac but not within an almost identical Ds element and not within a stable transposase-producing gene. The de novo DNA rearrangements consisted of internal deletions with breakpoints usually occurring at short repeats and, in some cases, of duplication of Ac sequences or insertion of Ac-unrelated fragments. The ancient maize Ds elements and the young Ds elements in transgenic tobacco showed similar rearrangements, suggesting that Ac-Ds elements evolve rapidly, more so than stable genes, through deletions, duplications, and reshuffling of their own sequences and through capturing of unrelated sequences. The data presented here suggest that abortive Ac-induced gap repair, through the synthesis-dependent strand-annealing pathway, is the underlying mechanism for Ds element formation.

Mammography of breasts in which catheter cuffs have been retained: normal, infected, and postoperative appearances

OBJECTIVE

The purpose of this report is to show that Dacron (DuPont, Wilmington, DE) cuffs retained in breasts after the removal of Hickman catheters may result in complications requiring radiographic evaluation for subsequent management. We also describe potential complications, including infection, associated with a retained cuff and changes after the removal of a retained cuff.

CONCLUSION

Because of the increased use of Hickman catheters for central vein access, Dacron cuffs more frequently are retained in breasts and are likely to be seen on mammograms. Radiologists need to be aware of the mammographic findings of a normal cuff, infected cuff, and the site of a surgically excised cuff.

The virtues of extended matching and uncued tests as alternatives to multiple choice questions

The objectives of this study were to compare the reliability and validity of written test formats that are widely used in medical education (multiple choice, uncued, extended matching, and true/false) and evaluate the effects of uncued examinations on long-term retention of medical knowledge. Uncued tests were introduced into a traditional course in general and systemic pathology (six interim tests). In the following year, students were given eight tests written in the four formats, each being used twice. The academic achievement of students in these 2 years was compared with that of students in 2 previous years, in which multiple choice tests were used. Measures of academic achievement included performance on a final comprehensive examination and the United States Medical Licensing Examination (USMLE). Student performance on uncued tests was consistent over time (i.e., there was no learning curve). Mean scores ranged from 77% to 84%, and coefficient alpha reliability estimates on 100-item tests were excellent (0.79 to 0.90). Extended matching tests were also reliable, with a mean coefficient alpha of 0.90. There was no significant relationship between test format and student performance on subsequent comprehensive examinations. Our results indicate that extended matching and uncued tests have considerable advantages over multiple choice and true/false examinations. They are more reliable, better able to discriminate the well-prepared from the marginal student, and well suited for tested core knowledge. Contrary to our expectation, extended matching questions with 20 choices presented to the student were as statistically reliable and valid as uncued queries with several hundred choices.

Relationship of students' perceptions of faculty to scholastic achievement: are popular instructors better educators?

Student evaluation of the faculty is a standard practice in most medical schools. Implied in these evaluations is the motion that popular instructors (ie, those considered outstanding by the students) are better educators, whose teaching translates into higher scores for their students on examinations. We tested this hypothesis by comparing students' evaluations of the faculty with levels of academic achievement in a second-year pathology course. Objective measures of academic achievement included scores on final comprehensive examinations, final course grade, and performance on the United States Medical Licensing Examination (USMLE). During the 4 years studied (1990 to 1995), students belonging to groups with the highest ratings for their instruction performed no better than those with the poorest ratings. There was no correlation between students' perceptions of quality in teaching and their academic achievement. Our results indicate that students' evaluations of the faculty are subjective and do not correlate with objective results used in the assessment of student knowledge. Popular instructors are not necessarily better educators.

Ethanol consumption and susceptibility of the pancreas to cerulein-induced pancreatitis

Despite the fact that alcoholism is one of the major causes of pancreatitis, the pathogenesis of this disorder remains obscure. Factors such as the pattern of ethanol consumption, diet, and genetic predisposition may be contributing factors. The failure to produce alcoholic pancreatitis in experimental animals suggests that experimental provision of ethanol may only increase the predisposition to pancreatitis. To test this possibility, we developed an assay system using the in vitro model of cerulein-induced pancreatitis. In this system, pancreatic lobules were first exposed to a supraphysiologic concentration (10(-6) M) of the cholecystokinin analogue, cerulein, after which homogenates were incubated for up to 6 h. Activation of trypsinogen and chymotrypsinogen was observed only in cerulein-treated preparations. We then investigated the effects of the duration of ethanol feeding on cerulein-induced changes in rat pancreas. The pancreata from rats fed ethanol for 9-12 months were more susceptible to cerulein-induced activation of chymotrypsinogen compared to the pancreata from pair-fed control animals. This susceptibility also paralleled morphologic changes, such as dilatation of endoplasmic reticulum, only in the ethanol-fed group. In contrast, during the early stages (up to 3 months) of ethanol consumption, there was resistance (p < 0.01) to cerulein-induced changes. These results suggest that long-term ethanol consumption increases susceptibility to pancreatitis and raises the possibility that a similar mechanism may operate in human alcoholics.

Temporal lobe epilepsy: correlation of proton magnetic resonance spectroscopy and 18F-fluorodeoxyglucose positron emission tomography

Proton magnetic resonance spectroscopy (MRS) has demonstrated reduction of N-acetylaspartate (NAA) in the epileptogenic temporal lobe. However, the correlation of NAA reduction with cerebral metabolic abnormalities is unknown in temporal lobe epilepsy (TLE). Proton MRS and 18F-fluorodeoxyglucose positron emission tomography (FDG/PET) were used to study 12 unilateral TLE patients with medically intractable seizures and 26 age-matched healthy volunteers. The epileptogenic temporal lobe of each patient was determined by both electroencephalography and FDG/PET. The NAA/choline-plus-creatine (NAA/(Cho+Cr)) ratio correlated significantly with the interictal glucose metabolism (r = 0.54, P < 0.01) in 12 TLE patients. The mean NAA/(Cho+Cr) ratio in the epileptogenic temporal lobe was significantly less than that in the contralateral side (P < 0.01), and less than that in normal control temporal lobes (P < 0.0001). These results suggest that quantitative MRS abnormalities reflect underlying metabolic pathology in TLE.

Trials of 9-amino-20(S)-camptothecin in Boston

9-Amino-20(S)-camptothecin (9-AC) is an analog of camptothecin with limited water solubility which has shown significant preclinical activity in a variety of human solid tumor xenografts. A Phase I trial using a soluble formulation of 9-AC, given as a 72-hour continuous infusion, has been completed. Thirty-one patients with resistant cancers received 5-60 micrograms/M2/h at three week intervals. The Maximum Tolerated Dose (MTD) was 45 micrograms/M2/hour. Neutropenia was the dose limiting toxicity, with few significant non-myelosuppressive toxicities. Minor responses were seen in 3/31 patients. Pharmacokinetic studies of 9-AC lactone (closed ring) showed substantial interpatient variability with a predicted half-life of 36 hours. A phase I/II trial of the same formulation of 9-AC is ongoing in refractory leukemia. Stomatitis and diarrhea are the non-myelosuppressive dose limiting toxicities. Evidence of antineoplastic activity has been seen in 3/15 patients. A Phase II trial in previously untreated metastatic breast cancer is also underway. A Phase I trial of a colloidal dispersion formulation, not yet completed, is better tolerated with a MTD > 45 micrograms/M2/h as a 72-hour continuous infusion. Evidence of antineoplastic activity has also been demonstrated.

Potential gene therapy for lecithin-cholesterol acyltransferase (LCAT)-deficient and hypoalphalipoproteinemic patients with adenovirus-mediated transfer of human LCAT gene

BACKGROUND

Overexpression of human lecithin-cholesterol acyltransferase (LCAT) in transgenic mice results in an increase of the antiatherogenic HDLs.

METHODS AND RESULTS

To investigate the potential use of LCAT for gene therapy, a recombinant adenovirus was constructed in which the human LCAT cDNA was expressed under the control of the human cytomegalovirus immediate/early promoter followed by a chimeric intron (AdCMV human LCAT). Human apolipoprotein (apo) A-I transgenic mice infected with AdCMV human LCAT by intravenous injection accumulated reactive LCAT in the plasma. LCAT activity was increased 201-fold in the plasma of mice infected with 1 x 10(6) pfu AdCMV human LCAT, from 45 +/- 2 to 9068 +/- 812 nmol.mL-1.h-1, in comparison with basal LCAT activity measured in control mice, 5 days after injection. Plasma HDL cholesterol levels rose from 117 +/- 12 to 797 +/- 48 mg/dL, and plasma human apo A-I concentrations increased from 247 +/- 14 to 616 +/- 17 mg/dL, in AdCMV human LCAT infected mice compared with control mice. HDL particles were larger and had a different electrophoretic mobility. Studies of cholesterol efflux by incubation of serum with cholesterol-loaded Fu5AH cells showed that serum from AdCMV human LCAT-infected mice promoted a significantly higher efflux than did that of the controls.

CONCLUSIONS

These data establish the potential of this approach for treatment of subjects with LCAT gene defects as well as patients with low plasma levels of apo A-I and HDL cholesterol.

A mathematical model and a computerized simulation of PCR using complex templates

A mathematical model and a computer simulation were used to study PCR specificity. The model describes the occurrences of non-targeted PCR products formed through random primer-template interactions. The PCR simulation scans DNA sequence databases with primers pairs. According to the model prediction, PCR with complex templates should rarely yield non-targeted products under typical reaction conditions. This is surprising as such products are often amplified in real PCR under conditions optimized for stringency. The causes for this 'PCR paradox' were investigated by comparing the model predictions with simulation results. We found that deviations from randomness in sequences from real genomes could not explain the frequent occurrence of non-targeted products in real PCR. The most likely explanation to the 'PCR paradox' is a relatively high tolerance of PCR to mismatches. The model also predicts that mismatch tolerance has the strongest effect on the number of non-targeted products, followed by primer length, template size and product size limit. The model and the simulation can be utilized for PCR studies, primer design and probing DNA uniqueness and randomness.

Ethanol and cocaine cause additive inhibitory effects on the calcium transients and contraction in single cardiomyocytes

The heart is a major locus for the toxic actions of cocaine and ethanol, each of which has been shown to interfere with excitation-contraction coupling in cardiac muscle cells. Because these drugs are frequently used in combination, the present study was designed to investigate how they interact to modify the Ca2+ transient and associated contraction in fura2-loaded cardiomyocytes. A high-speed imaging technique using a charge-coupled device as detector and short-term image store was used to measure cytosolic Ca2+ and contraction simultaneously from fluorescence images obtained during the contractile cycle. Ethanol (100 mM) and cocaine (50 microM) caused reversible reductions in Ca2+ transient amplitude of 24.3 +/- 3.0% and 25.1 +/- 3.6%, respectively. Neither agent modified basal Ca2+. Ethanol treatment decreased peak shortening by 44.3 +/- 3.5%, whereas the contractile depression by cocaine was 31.4 +/- 5.3%. The relatively greater effect of ethanol on contraction resulted from a Ca2+-independent component of ethanol action on contractility. When cardiomyocytes were exposed simultaneously to ethanol and cocaine, Ca2+ transient amplitude was reduced by 38.7 +/- 3.0%, and peak contraction was decreased by 55.1 +/- 3.5%. These values represent a significantly greater inhibition than observed with either drug alone (p < 0.02) and are compatible with additive effects of the two drugs acting at distinct loci within the excitation-contraction coupling pathway. Thus, simultaneous use of cocaine and ethanol leads to an enhanced depression of myocardial contractility, which is likely to contribute to the cardiotoxic actions of the combination of these two drugs.

Saturable ethanol binding in rat liver microsomes

The binding of ethanol to rat liver microsomes is shown to be saturable at clinically relevant ethanol concentrations, whereas this effect is not observed in extracted microsomal phospholipids. Brief exposure of the microsomes to heat abolishes saturable ethanol binding. Equilibrium binding data analysis, although only approximate in this context, suggests the presence of at least two groups of specific sites: high capacity sites with affinities near the pharmacological range and low capacity sites at lesser levels. The results indicate that the specificity of ethanol for tissue is considerably greater than previously recognized.

Opposite regulation of human versus mouse apolipoprotein A-I by fibrates in human apolipoprotein A-I transgenic mice

The regulation of liver apolipoprotein (apo) A-I gene expression by fibrates was studied in human apo A-I transgenic mice containing a human genomic DNA fragment driving apo A-I expression in liver. Treatment with fenofibrate (0.5% wt/wt) for 7 d increased plasma human apo A-I levels up to 750% and HDL-cholesterol levels up to 200% with a shift to larger particles. The increase in human apo A-I plasma levels was time and dose dependent and was already evident after 3 d at the highest dose (0.5% wt/wt) of fenofibrate. In contrast, plasma mouse apo A-I concentration was decreased after fenofibrate in nontransgenic mice. The increase in plasma human apo A-I levels after fenofibrate treatment was associated with a 97% increase in hepatic human apo A-I mRNA, whereas mouse apo A-I mRNA levels decreased to 51%. In nontransgenic mice, a similar down-regulation of hepatic apo A-I mRNA levels was observed. Nuclear run-on experiments demonstrated that the increase in human apo A-I and the decrease in mouse apo A-I gene expression after fenofibrate occurred at the transcriptional level. Since part of the effects of fibrates are mediated through the nuclear receptor PPAR (peroxisome proliferator-activated receptor), the expression of the acyl CoA oxidase (ACO) gene was measured as a control of PPAR activation. Both in transgenic and nontransgenic mice, fenofibrate induced ACO mRNA levels up to sixfold. When transgenic mice were treated with gemfibrozil (0.5% wt/wt) plasma human apo A-I and HDL-cholesterol levels increased 32 and 73%, respectively, above control levels. The weaker effect of this compound on human apo A-I and HDL-cholesterol levels correlated with a less pronounced impact on ACO mRNA levels (a threefold increase) suggesting that the level of induction of human apo A-I gene is related to the PPAR activating potency of the fibrate used. Treatment of human primary hepatocytes with fenofibric acid (500 microM) provoked an 83 and 50% increase in apo A-I secretion and mRNA levels, respectively, supporting that a direct action of fibrates on liver human apo A-I production leads to the observed increase in plasma apo A4 and HDL-cholesterol.

Diagnosis of cytomegalovirus (CMV) infection in pediatric transplant patients by the antigenemia, shell vial, and conventional culture assays performed on blood: correlation with CMV disease

BACKGROUND

Human cytomegalovirus (CMV) is a significant cause of morbidity and mortality in transplant recipients. Isolation of CMV from blood leukocytes (CMV viremia) is considered predictive of CMV disease in transplant recipients. Therefore, investigation of methods for the rapid detection of CMV in the blood is important for diagnosis and management of these patients.

OBJECTIVE

To compare three techniques for the diagnosis and monitoring of CMV infection in a pediatric transplant population through the quantitative detection of CMV in peripheral blood leukocytes (PBL).

METHODS

Serial blood specimens were obtained for most patients. After separation of the PBL from each specimen, aliquots of the PBL were used for direct detection of CMV antigenemia by immunoperoxidase staining of acetone-fixed cells (CMV-vue kit, INCSTAR), and by immunofluorescence staining of formaldehyde-fixed cells (Complete 1C3 kit, Biosoft Argene). PBL were also inoculated into conventional cell culture tubes and shell vials. Patients' medical records were reviewed to ascertain the clinical significance of the results.

RESULTS

A total of 154 specimens obtained from 38 pediatric transplant recipients were evaluated. CMV was detected in 16 specimens obtained from eight patients: 11 specimens were found positive with the CMV-vue kit, 10 with the Complete 1C3 kit, four by conventional culture, and one by the shell vial assay. Seven of the eight patients with CMV-positive PBL had clinical signs and other laboratory evidence of active CMV infection. In general, a high-level antigenemia was demonstrated in the presence of clinical disease, but there were exceptions.

CONCLUSIONS

The two antigenemia kits were more sensitive than conventional culture and the shell vial assay for the detection of CMV in the blood of pediatric transplant patients. Our results suggest that CMV antigenemia is a sensitive and specific rapid method for the diagnosis and monitoring of CMV infection in our patient population.