Juvenile Neuronal Ceroid Lipofuscinosis (Batten Disease) CLN3 Mutation (Chrom 16p11.2) with Different Phenotypes in a Sibling Pair and Low Intensity in vivo Autofluorescence

BACKGROUND

The neuronal ceroid lipofuscinoses (Batten disease) are a heterogeneous group of autosomal recessively inherited disorders causing progressive neurological failure, mental deterioration, seizures and visual loss secondary to retinal dystrophy. The juvenile type is of special interest to the ophthalmologist as visual loss is the earliest symptom of the disorder.

HISTORY AND SIGNS

We present two siblings with severe retinal dystrophy due to juvenile Batten disease. Sibling A (age 10) presented with visual loss, photophobia and night blindness, starting at age 4. His vision was perception of light by the age of 10.5 years. Fundus examination revealed severe pigmentary retinopathy. Sibling B (age 7) presented with night vision difficulties. Fundus examination revealed a bull's eye maculopathy with minimal peripheral atrophic changes. In vivo autofluorescence level was found to be very low. Electroretinography (ERG) showed generalized retinal dysfunction involving both cone and rod systems, with an electronegative maximal response. In both siblings vacuolated lymphocytes were found on a peripheral blood film and on molecular genetic testing both were homozygous for the commonly reported 1.02-kb deletion of the CLN3 gene.

THERAPY AND OUTCOME

Although there is no effective treatment, the early diagnosis allowed accurate genetic and social counseling.

CONCLUSIONS

Juvenile Batten disease should be considered in children with a retinal dystrophy, especially where there is a bull's eye maculopathy and an abnormal full field ERG. The novel finding of very low in vivo autofluorescence is consistent with histopathological studies and may be secondary to photoreceptor cell loss.

Efficacy of two 65% permethrin spot-on formulations against induced infestations of Ctenocephalides felis (Insecta: Siphonaptera) and Amblyomma americanum (Acari: Ixodidae) on beagles

The efficacy of two formulations of a topically applied 65% permethrin spot-on (Defend Exspot Treatment for Dogs, Schering-Plough Animal Health) was evaluated against experimental infestations of the cat flea Ctenocephalides felis and the lone star tick Amblyomma americanum in dogs. Eighteen dogs were randomly assigned to treatment with 65% permethrin in either diethylene glycol monomethyl ether (DGME; original formulation) or propylene glycol monomethyl ether (PGME) or to be untreated as a control. Treated dogs received either 1 (body weight < 15 kg) or 2 ml (body weight > or =15 kg) of the assigned formulation on Day 0. One hundred unfed, adult C. felis were placed on each dog on Days -6, -1, 4, 11, 18, 25, and 32. Fifty unfed, adult ticks were placed on each dog on Days -1, 3, 9, 16, 23, and 30. Live fleas and ticks were counted and removed on Days 3, 7, 14, 21, and 28. Treatment of dogs with the 65% permethrin in DGME reduced flea numbers by 90.4% to 99.9% from Days 3 through 21 (P < or =.05) and by 48.2% 28 days after treatment. Treatment of dogs with 65% permethrin in PGME reduced flea numbers by 93.7% to 99.7% from Days 3 through 28 and by 78.4% 35 days after treatment (P < or =.05). Treatment with 65% permethrin in DGME reduced tick numbers by 90% or more only on Day 7, whereas treatment with 65% permethrin in PGME reduced the number of live ticks by 90%or more on Days 7 and 14 and approached 90%(87.9%) on Day 21. Efficacy against fleas and ticks for the PGME formulation was significantly better (P < or =.05) than for the DGME formulation on Day 28. Findings in this study indicate that both the DGME and PGME formulations of 65% permethrin performed well in reducing numbers of live C. felis and A. americanum on laboratory beagles; however, the PGME formulation was effective approximately 1 to 2 weeks longer than the DGME formulation.

Age of ovary determines remaining life expectancy in old ovariectomized mice

We investigated the capacity of young ovaries, transplanted into old ovariectomized CBA mice, to improve remaining life expectancy of the hosts. Donor females were sexually mature 2-month-olds; recipients were prepubertally ovariectomized at 3 weeks and received transplants at 5, 8 or 11 months of age. Relative to ovariectomized control females, life expectancy at 11 months was increased by 60% in 11-month recipient females and by 40% relative to intact control females. Only 20% of the 11-month transplant females died in the 300-day period following ovarian transplantation, whereas nearly 65% of the ovariectomized control females died during this same period. The 11-month-old recipient females resumed oestrus and continued to cycle up to several months beyond the age of control female reproductive senescence. Across the three recipient age groups, transplantation of young ovaries increased life expectancy in proportion to the relative youth of the ovary. Our results relate to recent findings on the gonadal input upon aging in Caenorhabditis elegans and may suggest how the mammalian gonad, including that of humans, could regulate aging and determine longevity.

Presence of caprine arthritis-encephalitis virus (CAEV) proviral DNA in genital tract tissues of superovulated dairy goat does

Transmission of caprine arthritis-encephalitis virus (CAEV) is not completely understood and the vertical route of infection from the goat to the embryo or to the fetus needs to be investigated. This route of infection involves the presence of CAEV in the genital tract tissues. Prior studies have detected CAEV-infected cells in genital secretions and in flushing media recovered during embryo collection from infected goats. To specify the origin of these cells, we conducted a double-nested polymerase chain reaction (PCR) test on embryo flushing media and on mammary gland, mammary lymph node, synovial membrane, pelvic lymph node, uterus and oviduct tissues from 25 CAEV-infected (blood PCR positive) embryo donor goats for the presence of CAEV proviral DNA. The presence of proviral DNA was found in 22 of 25 mammary gland samples, 14 of 25 uterus samples, and in 16 of 25 oviduct samples. Nineteen of 25 goats had at least one positive genital tract sample. Flushing media from 11 goats were PCR positive. All goats with positive-flushing media were oviduct positive. Of this group of does, except for 1 of the 11, infection of flushing media correlated with infection of almost all the other tissues examined. The frequency of positive tissues for flushing media-positive goats (61/66; 92%) was significantly higher than that for flushing media-negative goats (50/84; 60%) (P<0.01). This study demonstrated the presence of CAEV-infected cells in the goat genital tract. The presence of CAEV-infected cells in the uterus and oviducts suggests potential for vertical transmission of CAEV from doe to embryo or fetus.

Morinda citrifolia (Noni): a literature review and recent advances in Noni research

Morinda citrifolia L (Noni) has been used in folk remedies by Polynesians for over 2000 years, and is reported to have a broad range of therapeutic effects, including antibacterial, antiviral, antifungal, antitumor, antihelmin, analgesic, hypotensive, anti-inflammatory, and immune enhancing effects. In order to reveal the nutritional and medicinal value of the Noni plant, and to summarize scientific evidence that supports the Polynesians' claim, a literature review and recent advances in Noni research is given below.

Paget's disease in New Zealand: evidence for declining prevalence

The prevalence rate of Paget's disease in New Zealand is believed to be among the highest in the world, but recent data suggest that it may have decreased in recent decades. We estimated the current prevalence of Paget's disease in subjects of European origin (>55 years of age) in two New Zealand cities (Dunedin and Auckland) based on review of nearly 2000 pelvic radiographs. Prevalence rate increased with age (p = 0.022) and was higher in men (p = 0.014), but there was no significant difference between the two cities. The Dunedin data were compared with a 1983 survey from the same city, and prevalence was approximately half its previous level (p = 0.012). In Auckland, the prevalence of an isolated raised plasma alkaline phosphatase level (>150 U/L, normal range <120 U/L) was estimated in over 80,000 blood samples processed at a community laboratory. The prevalence of "biochemical Paget's disease," as assessed by this surrogate marker, was very similar to that observed in the radiographic survey in Auckland for subjects <80 years of age, but not for older subjects. We conclude that the prevalence of Paget's disease in New Zealand has declined over the past two decades, indicating that there are important environmental determinants in its development. Biochemical estimates of the prevalence of Paget's disease agree well with radiographic estimates, except in the elderly. The method used herein offers an alternative way of determining the prevalence of Paget's disease.

Interaction between glucocorticoids and beta2 agonists on bronchial airway smooth muscle cells through synchronised cellular signalling

BACKGROUND

Increased airway smooth muscle bulk is a pathological feature of asthma. Asthma is well controlled by the combined inhalation of glucocorticoids and beta2-adrenoceptor agonists. The basic molecular mechanism of the interaction of the two drugs on proliferation of airway smooth muscle cells is yet to be identified. Our aim was to elucidate how glucocorticoids and beta2 agonists affect the growth of human bronchial airway smooth muscle cells.

METHODS

We assessed the effect of formoterol and budesonide on the activation and function of transcription factors by immunohistochemistry, western blotting, DNA mobility shift assay, and a luciferase reporter gene assay. The effect of the drugs and the involvement of specific transcription factors on cell proliferation was ascertained by direct cell count and confirmed by thymidine incorporation.

FINDINGS

Both classes of drugs (10(-8) mol/L) activated C/EBP-alpha and the glucocorticoid receptor with different kinetic profiles, and inhibited proliferation. The combination of lower doses of drugs (10(-12) to 10(-9) mol/L) resulted in a synchronised activation of the transcription factors and an enhanced antiproliferative effect. The action of the drugs alone or in combination on transcription-factor activity and proliferation was suppressed by either depletion of C/EBP-alpha or in the presence of a glucocorticoid-receptor blocker.

INTERPRETATION

Our findings could provide one explanation for the interaction of beta2 agonists and glucocorticoids at a molecular level, and indicate that the concentration of inhaled glucocorticoids can be reduced when combined with beta2 agonists, minimising the side-effects of the drugs.

Emergency Thoracotomy: Appropriate Use in the Resuscitation of Trauma Patients

The objective of this study was to evaluate the use of emergency thoracotomy in our institution in an effort to determine whether this procedure is both beneficial and cost effective in blunt and/or penetrating trauma. We conducted a retrospective review of charts and coroner's reports. Our setting was a Level I trauma center in a tertiary-care facility. We examined the cases of trauma patients presenting to the trauma center over a 2-year period. Of 2490 patients who presented to the emergency department over the study period 41 underwent early thoracotomy. Twelve of these were excluded from the study because their cases were not truly emergent. Of the remaining 29 ten were admitted for penetrating injuries and 19 for blunt injuries. The average Injury Severity Scores for penetrating and blunt injuries were 30 and 40 respectively. There were four blunt trauma patients who died in the emergency department, 15 went to the operating room, and five who survived to go to the intensive care unit. All blunt trauma patients requiring emergency thoracotomy died within 9 days of presentation. Of the ten penetrating wound patients two died in the emergency department, four died in the operating room, and four went to the intensive care unit after surgery. One of the four patients who went to the intensive care unit died approximately 6 days after injury. The other three patients survived and are now living normal productive lives. All survivors of penetrating trauma who required emergency thoracotomy had their procedure performed in the operating room. Overall survival rates for penetrating and blunt trauma were 30 and 0 per cent respectively. Pericardial tamponade was found in 50 per cent of the penetrating trauma patients (two of the three survivors) and four of 19 of the blunt trauma patients. This reinforces the importance of a prompt pericardiotomy upon opening the chest. At our institution the algorithm for emergency thoracotomy is liberal and is not cost effective for blunt trauma. We need to re-evaluate our decision-making process concerning the use of emergency thoracotomy especially in the blunt trauma patient. The review also shows the importance of pericardiotomy when performing an emergency thoracotomy.

Emergency thoracotomy: appropriate use in the resuscitation of trauma patients

The objective of this study was to evaluate the use of emergency thoracotomy in our institution in an effort to determine whether this procedure is both beneficial and cost effective in blunt and/or penetrating trauma. We conducted a retrospective review of charts and coroner's reports. Our setting was a Level I trauma center in a tertiary-care facility. We examined the cases of trauma patients presenting to the trauma center over a 2-year period. Of 2490 patients who presented to the emergency department over the study period 41 underwent early thoracotomy. Twelve of these were excluded from the study because their cases were not truly emergent. Of the remaining 29 ten were admitted for penetrating injuries and 19 for blunt injuries. The average Injury Severity Scores for penetrating and blunt injuries were 30 and 40 respectively. There were four blunt trauma patients who died in the emergency department, 15 went to the operating room, and five who survived to go to the intensive care unit. All blunt trauma patients requiring emergency thoracotomy died within 9 days of presentation. Of the ten penetrating wound patients two died in the emergency department, four died in the operating room, and four went to the intensive care unit after surgery. One of the four patients who went to the intensive care unit died approximately 6 days after injury. The other three patients survived and are now living normal productive lives. All survivors of penetrating trauma who required emergency thoracotomy had their procedure performed in the operating room. Overall survival rates for penetrating and blunt trauma were 30 and 0 per cent respectively. Pericardial tamponade was found in 50 per cent of the penetrating trauma patients (two of the three survivors) and four of 19 of the blunt trauma patients. This reinforces the importance of a prompt pericardiotomy upon opening the chest. At our institution the algorithm for emergency thoracotomy is liberal and is not cost effective for blunt trauma. We need to re-evaluate our decision-making process concerning the use of emergency thoracotomy especially in the blunt trauma patient. The review also shows the importance of pericardiotomy when performing an emergency thoracotomy.

Genetic characterization of H1N2 influenza A viruses isolated from pigs throughout the United States

An H1N2 influenza A virus was isolated from a pig in the United States for the first time in 1999 (A. I. Karasin, G. A. Anderson, and C. W. Olsen, J. Clin. Microbiol. 38:2453-2456, 2000). H1N2 viruses have been isolated subsequently from pigs in many states. Phylogenetic analyses of eight such viruses isolated from pigs in Indiana, Illinois, Minnesota, Ohio, Iowa, and North Carolina during 2000 to 2001 showed that these viruses are all of the same reassortant genotype as that of the initial H1N2 isolate from 1999.

Presence of caprine arthritis-encephalitis virus (CAEV) infected cells in flushing media following oviductal-stage embryo collection

To improve the knowledge on the risk of transmission of the caprine arthritis-encephalitis virus (CAEV) during embryo manipulations, we conducted a double-nested polymerase chain reaction (PCR) for CAEV proviral-DNA on flushing media recovered from the oviducts 48 h after the beginning of estrus and on blood from 89 donor does. Sixty-four does had negative blood and flushing media by PCR. Among the 25 CAEV infected goats (blood PCR positive), 11 were PCR flushing media positive (P < 0.01). Cell lysate from flushing media samples that were PCR positive were serially diluted 10 times at 1:100. Starting with the second 1:100 dilution all the cell lysate samples were PCR negative. The mean number of embryos recovered was not significantly different between goats with flushing media PCR positive and goats with flushing media PCR negative (6.0 +/- 5.4 versus 7.8 +/- 4.4, respectively; mean +/- S.D.) nor between goats with blood PCR positive and goats with blood PCR negative (7.0 +/- 5.0 versus 5.9 +/- 5.3; mean +/- S.D.). The presence of CAEV infected cells in oviductal flushing media from infected donor does was indicated for the first time during this study. The absence of flushing media PCR positive for goat blood PCR negative seemed to allow the use of the blood PCR test to confidently predict the absence of CAEV provirus in the oviductal fluid.

Preliminary experience of the Cannulok revision hip prosthesis in late periprosthetic fracture management

We report our preliminary experience of a cannulated, distally locked revision femoral component to manage peri-prosthetic fractures in the elderly. The majority of cases in our series were further complicated by osteolysis secondary to aseptic loosening, the original hip arthroplasties having been in situ for several years. Sixteen patients with an average age of 77 underwent treatment of periprosthetic fractures with the Cannulok Hip. The device combines techniques of revision hip surgery with locked intramedullary nailing. We describe our initial evaluation of this modular prosthesis which has enabled us to satisfactorily treat periprosthetic fractures with early mobilisation and discharge from hospital. In all of our surviving patients the fractures have united within four to six months. All cases were in addition treated with proximal femoral impaction allografting leading to improved local bone stock. We believe this implant may provide a satisfactory alternative for the management of periprosthetic fracture in the presence of a loose femoral component. (Hip International 2002; 1: 1-10).

Changing the chronic care system to meet people's needs

Persons who are likely to be the heaviest users of medical and supportive care services--those with chronic illnesses, disabilities, and functional limitations--are often forced to navigate a system that requires them to perform most of the coordination functions themselves and is generally not organized around their needs. In 1996 an estimated 128 million Americans had at least one of these three conditions, and 9.5 million had all three. This paper examines the current programs designed to assist these persons and suggests changes in eligibility rules, coverage policies, and educational programs to provide a system more oriented to people's chronic care needs.

Out-of-pocket medical spending for care of chronic conditions

We examined out-of-pocket medical spending by persons with and without chronic conditions using data from the 1996 Medical Expenditure Panel Survey (MEPS). Our results show that mean out-of-pocket spending increased with the number of chronic conditions. The level of this spending also varied by age and insurance coverage, among other characteristics. Out-of-pocket spending for prescription drugs was substantial for both elderly and nonelderly persons with chronic conditions. As policymakers continue to use cost sharing and design of benefit packages to contain health spending, it is important to consider the impact of these policies on persons with chronic conditions and their families.

Notch ligand-bearing thymic epithelial cells initiate and sustain Notch signaling in thymocytes independently of T cell receptor signaling

Thymic epithelial cells are specialized to play essential roles at multiple stages of T cell development in the thymus, yet the molecular basis of this specialization is largely unknown. Recently, the Notch family of transmembrane proteins has been implicated in thymocyte development. Such proteins interact with cell surface proteins of the Delta-like and Jagged families. It is known that Notch ligands are expressed intrathymically, and that Notch signaling is regulated by Notch ligands expressed on either the same or third-party cells. However, functional analysis of Notch ligand expression, and elucidation of the mechanism of Notch ligand signaling in thymocyte development, are unclear. Here, we find that Notch ligand expression in the thymus is compartmentalized, with MHC class II(+) thymic epithelium, but not thymocytes nor dendritic cells, expressing Jagged-1, Jagged-2 and Delta-like-1. We also provide evidence that contact with Notch ligands on thymic epithelium is necessary to activate and sustain Notch signaling in thymocytes, and that this can occur independently of positive selection induction. Our data suggest that Notch ligand expression by thymic epithelium may partly explain the specialization of these cells in supporting thymocyte development, by regulating Notch activation via an inductive signaling mechanism independently of signaling leading to positive selection.

Lymphostromal interactions in thymic development and function

The generation of a peripheral T-cell pool is essential for normal immune system function. CD4+ and CD8+ T cells are produced most efficiently in the thymus, which provides a complexity of discrete cellular microenvironments. Specialized stromal cells, that make up such microenvironments, influence each stage in the maturation programme of immature T-cell precursors. Progress has recently been made in elucidating events that regulate the development of intrathymic microenvironments, as well as mechanisms of thymocyte differentiation. It is becoming increasingly clear that the generation and maintenance of thymic environments that are capable of supporting efficient T-cell development, requires complex interplay between lymphoid and stromal compartments of the thymus.

Influence of insulin-like growth factor-I and its interaction with gonadotropins, estradiol, and fetal calf serum on in vitro maturation and parthenogenic development in equine oocytes

The effects of insulin-like growth factor-I (IGF-I) and its interaction with gonadotropins, estradiol, and fetal calf serum (FCS) on in vitro maturation (IVM) of equine oocytes were investigated in this study. We also examined the role of IGF-I in the presence or absence of gonadotropins, estradiol, and FCS in parthenogenic cleavage after oocyte activation with calcium ionophore combined with 6-dimethylaminopurine (6-DMAP), using cleavage rate as a measure of cytoplasmic maturation. Only equine cumulus-oocyte complexes with compact cumulus and homogenous ooplasm (n = 817) were used. In experiment 1, oocytes were cultured in TCM-199 supplemented with BSA, antibiotics, and IGF-I at 0 (control), 50, 100, 200 ng/ml, at 39 degrees C in air with 5% CO(2), 95% humidity for 36 or 48 h. In experiment 2, oocytes were cultured with FSH, LH, estradiol, and FCS with IGF-I at the concentration that promoted the highest nuclear maturation rate in experiment 1. In experiment 3, oocytes from the three experimental groups (IGF-I; hormones; and IGF-I + hormones) were chemically activated by exposure to calcium ionophore followed by culture in 6-DMAP. In experiment 1, IGF-I stimulated equine oocyte maturation in a dose-dependent manner with the highest nuclear maturation rate at a concentration of 200 ng/ml. No significant effect of IGF-I on nuclear maturation was observed in experiment 2. In experiment 3, a significant difference in cleavage rate was observed between the hormone + IGF-I group (15 of 33; 45.4%) compared with IGF-I (10 of 36; 27.8%) and hormone (4 of 31; 12.9%) alone (P < 0.05). These results demonstrated that IGF-I has a positive effect on nuclear maturation rate of equine oocytes in vitro. The addition of IGF-I to an IVM medium containing hormones and FCS did not increase nuclear maturation, but resulted in a positive effect on cytoplasmic maturation of equine oocytes measured by parthenogenic cleavage.

Protocols for high efficiency, stage-specific retroviral transduction of murine fetal thymocytes and thymic epithelial cells

Viral vectors have the potential to provide a fast and economic alternative to transgenic methods for manipulating gene expression in studies of immune system development and function. Although protocols exist for the infection of hematopoietic precursors and peripheral T cells in vitro, critical stages of T cell differentiation are strictly dependent upon a three-dimensional thymic architecture and their analysis poses unique technical challenges. Whole fetal thymic lobes have been used as targets for retroviral and adenoviral infection, both in situ and in vitro, but this approach does not allow for discrimination between lymphoid and stromal components. Isolated thymocytes have been infected by co-culture with viral producer cells, but under these conditions they rapidly lose their developmental potential. To overcome these problems we have combined a number of efficient techniques for retroviral production, concentration, and infection that allow us to rapidly achieve significant transduction rates of purified populations of double-negative (DN) and double-positive (DP) thymocytes, single-positive (SP) T lymphocytes, as well as fetal thymic MHC II(+) epithelial cells without the need for co-culture with viral producer cells. Reaggregate thymic organ culture (RTOC) techniques were used to assess the development and function of transduced cells in defined cellular environments. As a demonstration of the utility of these methods, CD80 (B7.1) was transduced into thymic epithelial cells and shown to allow them to mediate negative selection of DP thymocytes, and to act as antigen-presenting cells (APC) to mature T cells. The ability to genetically manipulate primary cells of a specified type and differentiation stage provides a powerful complement to RTOC techniques for the study of T cell development.

Are Fortune 100 companies responsive to chronically ill workers?

We conducted a survey of Fortune 100 companies to determine their response to the growing number of employees with chronic conditions. We found that although all companies cover some services that are particularly beneficial to persons with chronic conditions, gaps in coverage remain. We also found large variations in cost-sharing mechanisms, number of covered visits, and lifetime maximum benefit provisions, which are especially important to persons with chronic conditions. In general, for persons with chronic conditions the benefits offered by these Fortune 100 companies are superior to those offered by Medicare.

Ampicillin-resistant Escherichia coli in gestational pyelonephritis: increased occurrence and association with the colonization factor Dr adhesin

The pattern of ampicillin resistance and possible association with virulence factors of 78 Escherichia coli isolates taken from 78 pregnant women with pyelonephritis were evaluated. The current incidence of ampicillin resistance among pyelonephritis isolates (46%) was significantly higher than that reported in 1985 (22%). Resistance was found more frequently during the first (60%) and third (53%) trimesters than during the second trimester (33%). Of all dra(+) E. coli isolates, 75% were ampicillin resistant, whereas dra(+) isolates of O75 serotype E. coli accounted for 87% of ampicillin-resistant strains. The significant increase of ampicillin resistance among gestational pyelonephritis E. coli and the association with the dra gene cluster encoding colonization and invasive capacity may warrant further study involving obstetric and neonate wards, with the latter being at the higher risk for potential problems.

Relationship among plasma cortisol, catecholamines, neuropeptide Y, and human performance during exposure to uncontrollable stress

OBJECTIVE

Although many people are exposed to trauma, only some individuals develop posttraumatic stress disorder; most do not. It is possible that humans differ in the degree to which stress induces neurobiological perturbations of their threat response systems, which may result in a differential capacity to cope with aversive experiences. This study explored the idea that differences in the neurobiological responses of individuals exposed to threat are significantly related to psychological and behavioral indices.

METHODS

Individual differences in neurohormonal, psychological, and performance indices among 44 healthy subjects enrolled in US Army survival school were investigated. Subjects were examined before, during, and after exposure to uncontrollable stress.

RESULTS

Stress-induced release of cortisol, neuropeptide Y, and norepinephrine were positively correlated; cortisol release during stress accounted for 42% of the variance in neuropeptide Y release during stress. Cortisol also accounted for 22% of the variance in psychological symptoms of dissociation and 31% of the variance in military performance during stress.

CONCLUSIONS

Because dissociation, abnormalities in the hypothalamic-pituitary-adrenocortical axis, and catecholamine functioning have all been implicated in the development of stress disorders such as posttraumatic stress disorder, these data suggest that some biological differences may exist before index trauma exposure and before the development of stress-related illness. The data also imply a relationship among specific neurobiological factors and psychological dissociation. In addition, the data provide clues about the way in which individuals' psychobiological responses to threat differ from one another.

Comparing health system performance in OECD countries. Organization for Economic Cooperation and Development

We present data from the Organization for Economic Cooperation and Development and the World Health Organization on the performance of the health care systems in twenty-nine industrialized countries in 1998. We also compare the performance of the United States with the other industrialized countries for selected indicators in 1960, 1980, and 1998. On most indicators the U.S. relative performance declined since 1960; on none did it improve.

Specialty of principal care physician and Medicare expenditures in patients with coronary artery disease: impact of comorbidity and severity

OBJECTIVE

To explore differences in expenditures for elderly patients with acute and chronic coronary artery disease according to the specialty of the principal care physician.

STUDY DESIGN

Retrospective analysis of Medicare claims.

PATIENTS AND METHODS

A total of 250,514 patients with coronary artery disease (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 410-414) were drawn from a national random sample of 1992 Medicare expenditures. Patients were classified by the physician type with the highest number of Medicare Part B outpatient claims into a cardiologist group and a generalist group. The outcome was mean total expenditures, stratifying (1) by comorbidity as measured by the modified Charlson Index and (2) by severity defined as the proportion of patients with acute myocardial infarction or unstable angina.

RESULTS

Those patients in the cardiologist group had lower comorbidity and higher severity than those in the generalist group. Overall mean expenditures were significantly higher for the cardiologist group than for the generalist group ($7658 vs $6047; P < .001). These differences in mean expenditures were evident at each level of comorbidity. However, when stratified by severity of diagnosis, differences were seen predominantly in those with acute diagnoses. For those with either acute myocardial infarction or unstable angina, the mean expenditures were higher for the cardiologist group than for the combined generalist group ($15,378 vs $12,260; P < .001); however, the mean expenditures for those with only chronic conditions were similar ($4856 vs $4745; P = .53).

CONCLUSION

Expenditures were higher when cardiologists were the principal care physicians treating patients with acute disease but not chronic disease.

Specialisation of thymic epithelial cells for positive selection of CD4+8+ thymocytes

Following their migration into the thymus, hemopoeitic stem cell precursors enter a complex developmental pathway involving proliferation, differentiation and alphabetaT-cell receptor (alphabetaTCR)-mediated selection procedures, in order to generate mature T-cell populations ready for export to the periphery. Thus, a critical stage during intrathymic T-cell development involves the generation of functionally mature CD4+8- and CD4-8+ cells from immature CD4+8- precursor thymocytes, a poorly understood process referred to as positive selection. While interactions between the alphabetaTCR and MHC-peptide complexes are known to be essential for the initiation of positive selection, additional unknown signals are also required. Using an in vitro reaggregate thymic organ culture system which allows comparison of the abilities of various cell types to induce maturation of CD4+8+ precursors, we provide evidence that both MHC-peptide complexes and specialised accessory molecules must be provided by thymic epithelium for efficient mediation of positive selection. Moreover, analysis of positive selection in the presence of thymic and non-thymic stromal cells expressing MHC class II molecules with the same limited peptide array suggests that this unique ability of thymic epithelium to mediate positive selection of CD4+8- cells is not solely due to presentation of a specialised peptide repertoire, but is dependent upon provision of specialised accessory interactions.

Congenital microvillous inclusion disease presenting as antenatal bowel obstruction

Prenatal ultrasound has led to confidence in the antenatal diagnosis of intestinal obstruction allowing counseling and birth planning. We describe a male infant of a diabetic mother who had an antenatal diagnosis of distal bowel obstruction. This baby was subsequently found not to have bowel obstruction, but a congenital enteropathy - microvillous inclusion disease. The antenatal scans had demonstrated polyhydramnios as well as multiple fluid-filled dilated loops of bowel in the fetal abdomen. To our knowledge, similar prenatal ultrasound findings have not been previously described in this condition. The baby was delivered in a pediatric surgical center and postnatally there was no evidence of bowel obstruction either clinically or on abdominal X-ray. This baby initially fed well, but became collapsed and acidotic on his third day, having lost 26% of his birth weight due to excessive stool loss. The diagnosis of microvillous inclusion disease was made by electron microscopy of a small bowel biopsy. Congenital microvillous inclusion disease is a very rare inherited enteropathy with high mortality and morbidity. This condition, and other enteropathies, should be considered in cases in which antenatally diagnosed bowel obstruction is not confirmed after birth.

Nonadherence with ACE inhibitors is common and can be detected in clinical practice by routine serum ACE activity

Our objective was to assess whether serum angiotensin-converting enzyme (ACE) activity during routine clinical practice accurately reflects patient adherence to ACE inhibitor treatment in chronic heart failure (CHF). During 1994-95, ACE was measured in 73 CHF patients who were routinely attending the heart failure clinic at Ninewells Hospital. At the same time, the Medicines Monitoring Unit collected data on whether and when prescriptions for ACE inhibitors were redeemed at community pharmacies, which enabled each patient's adherence over a prolonged period to be assessed. We then correlated whether an elevation in serum ACE was associated with poor adherence with ACE inhibitor treatment. In total, 18% of CHF patients appeared to exhibit less than 70% adherence with their ACE inhibitor treatment, with 34% exhibiting less than 85%adherence and 58% exhibiting less than 100% adherence. A serum ACE activity of more than 12 U/L gave 91% positive predictive accuracy that the patient was less than 100% adherent with his or her ACE inhibitor treatment. At the other extreme, a serum ACE less than 6.5 U/L gave 81% positive predictive accuracy that the patient was more than 85% adherent with ACE inhibitor treatment. Nonadherence with ACE inhibitor treatment, therefore, was found to be common in patients with CHF. The simple, inexpensive test of serum ACE activity can be used in CHF patients to identify many, although not all, nonadherent patients so that adherence-enhancing strategies can be targeted toward them. Further work is clearly required to explore the precise clinical utility of this promising test. (c)2001 by CHF, Inc.

Tramadol and seizures: a surveillance study in a managed care population

STUDY OBJECTIVE

To investigate the occurrence of tramadol-associated seizures.

DESIGN

Retrospective cohort and case-control studies.

SETTING

UnitedHealth Group-affiliated independent practice model health plans, from different regions of the United States, contracting with large networks of physicians.

INTERVENTION

Analysis of administrative data from a large U.S. managed care population.

PATIENTS

A cohort of 9218 adult tramadol users and 37,232 concurrent nonusers.

MEASUREMENTS AND MAIN RESULTS

Fewer than 1% of users (80) had a presumed incident seizure claim after the first tramadol prescription. Risk of seizure claim was increased 2- to 6-fold among users adjusted for selected comorbidities and concomitant drugs. Risk was highest among those aged 25-54 years, those with more than four tramadol prescriptions, and those with history of alcohol abuse, stroke, or head injury. A case-control study among users was conducted to validate incident seizure outcomes from medical records. Only eight cases were confirmed, and all had cofactors associated with increased seizure risk.

CONCLUSION

In a general population, risk of seizure may be associated with long-term therapy with tramadol or the presence of cofactors, or confined to a small sensitive population subset.

Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care

OBJECTIVE

Intensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists manage ICU patients, a dramatic national shortage of these specialists precludes most hospitals from implementing an around-the-clock, on-site intensivist care model. Alternate strategies are needed to bring expertise and proactive, continuous care to the critically ill. We evaluated the feasibility of using telemedicine as a means of achieving 24-hr intensivist oversight and improved clinical outcomes.

DESIGN

Observational time series triple cohort study.

SETTING

A ten-bed surgical ICU in an academic-affiliated community hospital.

PATIENTS

All patients whose entire ICU stay occurred within the study periods.

INTERVENTIONS

A 16-wk program of continuous intensivist oversight was instituted in a surgical ICU, where before the intervention, intensivist consultation was available but there were no on-site intensivists. Intensivists provided management during the intervention using remote monitoring methodologies (video conferencing and computer-based data transmission) to obtain clinical information and to communicate with on-site personnel. To assess the benefit of the remote management program, clinical and economic performance during the intervention were compared with two 16-wk periods within the year before the intervention.

MEASUREMENTS AND MAIN RESULTS

ICU and hospital mortality (observed and Acute Physiology and Chronic Health Evaluation III, severity-adjusted), ICU complications, ICU and hospital length-of-stay, and ICU and hospital costs were measured during the 3 study periods. Severity-adjusted ICU mortality decreased during the intervention period by 68% and 46%, compared with baseline periods one and two, respectively. Severity-adjusted hospital mortality decreased by 33% and 30%, and the incidence of ICU complications was decreased by 44% and 50%. ICU length of stay decreased by 34% and 30%, and ICU costs decreased by 33% and 36%, respectively. The cost savings were associated with a lower incidence of complications.

CONCLUSIONS

Technology-enabled remote care can be used to provide continuous ICU patient management and to achieve improved clinical and economic outcomes. This intervention's success suggests that remote care programs may provide a means of improving quality of care and reducing costs when on-site intensivist coverage is not available.

Hypertension and its treatment in postmenopausal women: baseline data from the Women's Health Initiative

Little is known about the patterns of treatment and adequacy of blood pressure control in older women. The Women's Health Initiative, a 40-center national study of risk factors and prevention of heart disease, breast and colorectal cancer, and osteoporosis in postmenopausal women, provides a unique opportunity to examine these issues in the largest, multiethnic, best-characterized such cohort. Baseline data from the initial 98 705 women, aged 50 to 79 years, enrolled were analyzed to relate prevalence, treatment, and control of hypertension to demographic, clinical, and risk-factor covariates, and logistic regression analyses were performed to estimate odds ratios after adjusting for multiple potential confounders. Overall, 37.8% of the women had hypertension, which is defined as systolic blood pressure >/=140 mm Hg and/or diastolic blood pressure >/=90 mm Hg or being on medication for high blood pressure; 64.3% were treated with drugs, and blood pressure was controlled in only 36.1% of the hypertensive women, with lower rates of control in the oldest group. After adjustment for multiple covariates, current hormone users had higher prevalence than did nonusers (odds ratio 1.25). Hypertensive women had more comorbid conditions than did nonhypertensive women, and women with comorbidities were more likely to be treated pharmacologically. Diuretics were used by 44.3% of hypertensives either as monotherapy or in combination with other drug classes. As monotherapy, calcium channel blockers were used in 16%, angiotensin-converting enzyme inhibitors in 14%, beta-blockers in 9%, and diuretics in 14% of the hypertensive women. Diuretics as monotherapy were associated with better blood pressure control than any of the other drug classes as monotherapy. In conclusion, hypertension in older women is not being treated aggressively enough because a large proportion, especially those most at risk for stroke and heart disease by virtue of age, does not have sufficient blood pressure control.

Microenvironmental regulation of T cell development in the thymus

T cell development in the thymus occurs through a series of events beginning with thymic colonization by migrant precursors and ending with the emigration of functionally competent CD4+ and CD8+ T cells to the periphery. It is well accepted that signals through the pre-T cell receptor (pre-TCR) and alpha-beta TCR (alphabetaTCR) complex play pivotal roles in the maturation of CD4-8- and CD4+8+ thymocytes, respectively. It is clear that stromal cells constituting the thymic microenvironment provide non-TCR-mediated interactions which are essential for several developmental events. Examples of such will be discussed here in relation to early and late events in T cell development.

Ovarian cancer tumor marker behavior in asymptomatic healthy women: implications for screening

Ovarian cancer screening protocols generally have been limited by inadequate recognition of the normal behavior of tumor markers in women at risk of ovarian cancer. We have characterized the behavior of five serum tumor markers in a large cohort of healthy women and examined the implications for screening. Serial measurements of CA125, HER-2/neu, urinary gonadotropin peptide, lipid-associated sialic acid, and Dianon marker 70/K were obtained during 6 years of follow-up of 1257 healthy women at high risk of ovarian cancer. We analyzed individual-specific tumor marker behavior and explored methods that can exploit this information to develop individual-specific screening rules. These five tumor markers behaved approximately independently. Substantial heterogeneity was observed among women in the behavior of each tumor marker, particularly CA125. Intraclass correlation (ICC), or the proportion of total variability that occurs between individuals, was approximately 0.6 for log-transformed CA125 and urinary gonadotropin peptide, and less than 0.4 for the other markers. This degree of tumor marker heterogeneity among healthy women, and the relative independence of these markers, has important implications for screening and diagnostic tests. Independence of markers results in the clinically useful fact that the combined false positive rate from screening with multiple markers may be estimated by the sum of individual false positive rates. Heterogeneity of tumor marker patterns in healthy women implies that a fixed screening cutoff level is suboptimal to a degree that depends strongly on ICC. Using information on longitudinal measurements and ICC, individual-specific screening rules may be developed with the potential to improve early detection of ovarian cancer.

An essential role for the IL-7 receptor during intrathymic expansion of the positively selected neonatal T cell repertoire

Intrathymic T cell development is a multistage process involving discrete phases of proliferation as well as differentiation. From studies on IL-7 or IL-7Ralpha-deficient mice, it is clear that the IL-7 receptor (IL-7R) plays a critical role during the initial stages of intrathymic CD4-8- precursor development. In contrast, the role of IL-7R in later stages of thymocyte development are unclear. Here, we have used various approaches to investigate directly the role of the IL-7R in thymocyte positive selection and the recently described phase of postselection proliferation. First, we show that positive selection involves selective up-regulation of IL-7Ralpha- and IL-7Rgamma-chains, with the majority of CD4+ and CD8+ cells being IL-7R+. Second, MHC class II+ thymic epithelium-which drives postselection proliferation-expresses IL-7 mRNA. Finally, analysis of positive selection and postselection proliferation in thymocytes from IL-7Ralpha-/- neonates shows that positive selection occurs normally, whereas postselection expansion is drastically reduced. Thus, our data provide the first evidence that, as well as playing a role during early phases of thymic development, IL-7R mediates intrathymic expansion of positively selected thymocytes, which may aid in establishment of the neonatal peripheral T cell pool.

MAM: a "new" high-incidence antigen found on multiple cell lines

BACKGROUND

Three women have been identified with an antibody to a "new" high-incidence antigen found on multiple cell lines.

CASE REPORTS

The proposita, M.A.M., presented during her third pregnancy with an antibody reacting with all RBCs tested except her own. She delivered a thrombocytopenic infant with a 3+ DAT, but without symptoms of HDN. The second example, A.N., presented during her third pregnancy with an antibody reacting with all RBCs tested except her own and those of M.A.M. She delivered a slightly thrombocytopenic but severely anemic infant. The third example, F.K., a sister of A.N., has an antibody reacting with all RBCs tested except her own and those of M.A.M. and A.N.

CONCLUSION

This "new" high-incidence antigen has been named MAM and assigned high-incidence antigen number 901016 by the International Society of Blood Transfusion. The corresponding antibody, anti-MAM, has been shown to cause HDN and has the potential to shorten RBC survival after the transfusion of incompatible RBC units, as determined by monocyte monolayer assay. Immunoblotting and flow cytometry show that this new antibody reacts with various WBC lines in addition to RBCs. This antibody also appears to react with platelets in some assays.

Studies on the role of IL-7 presentation by mesenchymal fibroblasts during early thymocyte development

T cell precursor development depends upon poorly defined interactions between thymocyte precursors and stromal cells involving cell surface molecules, extracellular matrix (ECM) components and soluble growth factors. To determine whether presentation of soluble factors by ECM is involved in early T cell development, we analyzed expression of ECM components in individual thymic stromal subsets and investigated their ability to present ECM-associated IL-7, a factor known to be important during early thymocyte development. We show that MHC class II(+) thymic epithelium and fibroblasts - essential requirements for development of CD4(-)8(-)precursors - both show surface expression of ECM components such as fibronectin and heparan sulfate. Use of biotinylated IL-7 protein indicates that both cell types bind IL-7, while enzymatic disruption of specific ECM components indicates that IL-7 presentation by both cell types is dependent upon heparan sulfate. However, disruption of IL-7 presentation specifically on fibroblasts does not affect their ability to contribute to T cell development. Collectively, these data suggest that while ECM-mediated presentation of IL-7 may be a general function of thymic stromal cells during thymocyte development, heparan sulfate-mediated IL-7 presentation specifically by fibroblasts is not essential and that the specific requirement for fibroblasts in early development involves additional undefined interactions.