Findings from case studies of state and local immunization programs

BACKGROUND

As part of its examination of federal support for immunization services during the past decade, the Institute of Medicine (IOM) Committee on Immunization Finance Policies and Practices (IFPP) commissioned eight case studies of the states of Alabama, Maine, Michigan, New Jersey, North Carolina, Texas, and Washington; and a two-county study of Los Angeles and San Diego in California. Specifically, the IOM Committee and these studies reviewed the use of Section 317 grants by the states. Section 317 is a discretionary grant program that supports vaccine purchase and other immunization-related program activities. These studies afforded the Committee an in-depth look at local policy choices, the performance of immunization programs, and federal and state spending for immunization during the past decade.

METHODS

The case-study reports were developed through interviews with state and local health department officials, including immunization program directors, Medicaid agency staff, budget analysts, and Centers for Disease Control and Prevention public health advisors to the jurisdiction. Other sources included state and federal administrative records and secondary sources on background factors and state-level trends. The case studies were supplemented by site visits to Detroit, Houston, Los Angeles, Newark, and San Diego.

OBSERVATIONS

The nature of immunization "infrastructure" supported by the Section 317 program is shifting from primarily service delivery to a broader set of roles that puts the public effort at the head of a broad immunization partnership among public health, health financing, and other entities in both the public and private sectors. The rate and intensity of transition vary across the case-study areas. In the emerging pattern, service delivery increasingly takes place in the private sector and is related to managed care. "Infrastructure" is moving beyond supporting a core state staff and local health department service delivery to include such activities as immunization registries, quality improvement, and coordination with programs outside public health agencies. At the same time, the recent decline in federal Section 317 support is forcing difficult choices between old and new activities at the state and local levels.

CONCLUSIONS

Immunization programs function as an organic component of the local health care financing and delivery systems of which they are a part. Immunization efforts are organized and conducted within distinctive state and local fiscal, economic, and health care contexts. Section 317 Financial Assistance grants, while playing a vital role in supporting immunization "infrastructure," have been too unstable and unpredictable to elicit the strategic planning, programming, and own-source spending that would be optimal for state and local programs. The predominant immunization function of state and local public health agencies is becoming assurance of age-appropriate immunization throughout the lifespan. To be successful in this emerging role, the health agencies must be supported with appropriate staffing, interagency collaboration, and clearly articulated authority.

Osteoblast tissue-nonspecific alkaline phosphatase antagonizes and regulates PC-1

Tissue-nonspecific alkaline phosphatase (TNAP) is essential for bone matrix mineralization, but the central mechanism for TNAP action remains undefined. We observed that ATP-dependent (45)Ca precipitation was decreased in calvarial osteoblast matrix vesicle (MV) fractions from TNAP-/- mice, a model of infantile hypophosphatasia. Because TNAP hydrolyzes the mineralization inhibitor inorganic pyrophosphate (PP(i)), we assessed phosphodiesterase nucleotide pyrophosphatase (PDNP/NTPPPH) activity, which hydrolyzes ATP to generate PP(i). Plasma cell membrane glycoprotein-1 (PC-1), but not the isozyme B10 (also called PDNP3) colocalized with TNAP in osteoblast MV fractions and pericellular matrix. PC-1 but not B10 increased MV fraction PP(i) and inhibited (45)Ca precipitation by MVs. TNAP directly antagonized inhibition by PC-1 of MV-mediated (45)Ca precipitation. Furthermore, the PP(i) content of MV fractions was greater in cultured TNAP-/- than TNAP+/+ calvarial osteoblasts. Paradoxically, transfection with wild-type TNAP significantly increased osteoblast MV fraction NTPPPH. Specific activity of NTPPPH also was twofold greater in MV fractions of osteoblasts from TNAP+/+ mice relative to TNAP-/- mice. Thus TNAP attenuates PC-1/NTPPPH-induced PP(i) generation that would otherwise inhibit MV-mediated mineralization. TNAP also paradoxically regulates PC-1 expression and NTPPPH activity in osteoblasts.

Determination of ambulatory blood pressure control in treated patients with controlled office blood pressures

Office blood pressure measurement is the standard for assessing blood pressure control. Many patients, however, take their antihypertensive medication in the morning, so they are likely to have their office blood pressure measured during the maximal antihypertensive effect. It is therefore unknown whether patients deemed by office blood pressure to be controlled do in fact have 24h blood pressure control. The objectives of this study were to determine blood pressure control, including blood pressure control while the patients were awake and during the first 6 hours after awakening, by ambulatory blood pressure monitoring (ABPM) in treated hypertensive patients deemed by office blood pressure measurements to be controlled. A total of 103 patients on a stable antihypertensive regimen and deemed to be controlled in terms of office blood pressure values (mean office blood pressure <140/90mmHg) were enrolled. Patients were stratified by cardiovascular risk status and the number of antihypertensive medications that they were taking. Seventy-eight out of 103 participants successfully completed ABPM. The mean ambulatory blood pressure was greater than 135/85mmHg and 140/90mmHg while awake for 37% (95% confidence interval [CI] 26-48%) and 23% (95% CI 14-32%) of all patients respectively. Forty-eight per cent (95% CI 33-63%) of patients taking monotherapy versus 25% (95% CI 11-39%) of patients on multiple antihypertensive medications were uncontrolled (P=0.039) using 135/85mmHg as the reference value. Thirty-one per cent (95% CI, 17-44%) of patients on monotherapy versus 14% (95% CI 3-25%) of patients on multiple antihypertensive medication were uncontrolled (P=0.064) using 140/90mmHg instead. These results demonstrate that a high number of patients deemed by office blood pressure to be under control do not have adequate blood pressure control based on ABPM.

Rat two-generation reproduction and dominant lethal study of acrylamide in drinking water

Fischer 344 (F344) F(0) weanling rats, 30/sex/group, were exposed to acrylamide in drinking water at 0.0, 0.5, 2.0, or 5.0 mg/kg/day for 10 weeks and then mated. Exposure of F(0) females continued through gestation and lactation of F(1) litters. F(0) males, after F(0) mating, were removed from exposure and mated (one male: two untreated females) for the dominant lethal (DL) assay. Thirty F(l) weanlings/sex/group were exposed for 11 weeks to the same dose levels as their parents, and then mated to produce F(2) offspring. F(0) and F(l) parents and F(1) and F(2) weanlings were necropsied. Prebreeding exposure of F(0) and F(l) animals resulted in systemic toxicity at 2.0 to 5.0 mg/kg/day, with head tilt and/or foot splay increased at 0.5 to 5.0 mg/kg/day. F(0) and F(l) reproductive indices and gestational length were unaffected. Implantations and live pups/litter at birth were reduced at 5.0 mg/kg/day. Survival of F(l) and F(2) pups was reduced at 5.0 mg/kg/day for PND 0 through 4 only. In the DL assay, total and live implants were reduced, pre- and postimplantation loss was increased, and the frequency of DL factors (F(L)%) was increased at 5.0 mg/kg/day. At 5.0 mg/kg/day, adult F(l) male peripheral nerves exhibited axonal fragmentation and/or swelling; F(l) female spinal cord sections were unremarkable. The NOEL for prenatal DL was 2.0 mg/kg/day; the NOEL for adult systemic toxicity, including neurotoxicity, was < or = 0.5 mg/kg/day. Therefore, neurotoxicity and DL were differentially affected.

Genetic counseling and testing: implications for clinical practice

As the genetic basis of many human illnesses becomes known, the provision of genetic counseling to individuals and family has gained importance. Patients concerned about genetic conditions within their family require comprehensive services that address the medical and emotional aspects of disease. The use of these types of genetic services and testing can raise ethical and social concerns. Key components of the genetic counseling process and the complex issues that surround genetic information are discussed.

Chronic toxicity and oncogenicity studies of ingested 1, 3-dichloropropene in rats and mice

Fischer 344 rats and B6C3F1 mice were administered 1, 3-dichloropropene (1,3-D) via their diets for up to 2 years, at dose levels of 0, 2.5, 12.5, or 25 mg 1,3-D/kg body wt/day for rats and 0, 2.5, 25, or 50 mg 1,3-D/kg body wt/day for mice. The test material was stabilized in the feed by microencapsulation in a starch/sucrose matrix (80/20%). Rats given 12.5 or 25 mg/kg/day, and mice given 25 or 50 mg/kg/day, had decreased body weights and body weight gains. There were no effects on survival or clinical pathology parameters for rats or mice. Histopathologic effects attributed to treatment in rats consisted of basal cell hyperplasia of the nonglandular mucosa of the stomach in males and females given 12.5 or 25 mg/kg/day for 12 and 24 months and an increased number of hepatocellular adenomas in males given 12.5 or 25 mg/kg/day and females given 25 mg/kg/day for 24 months. The increase in hepatocellular adenomas was statistically identified by pairwise comparison only in males given 25 mg/kg/day. An increased incidence of eosinophilic foci of altered cells in the liver was also noted in all treated groups of rats at 24 months. The latter observation, however, was considered of equivocal toxicological significance because of the common spontaneous occurrence of liver foci in aged Fischer 344 rats. The only histologic change attributed to treatment in mice was decreased size of hepatocytes in males given 50 mg/kg/day for 12 months. The decreased size of hepatocytes was consistent with decreased cytoplasmic glycogen content and corresponded to decreased liver weights. This effect was not present at 24 months. There was no oncogenic response observed in mice. The low-dose level of 2.5 mg/kg/day was interpreted as the no-observed-adverse-effect level (NOAEL) for systemic chronic toxicity of 1,3-D in the Fischer 344 rat. The no-observed-effect level (NOEL) for chronic systemic toxicity was 2.5 mg/kg/day in the B6C3F1 mouse.

Asymmetric adaptive modeling of central tarsal bones in racing greyhounds

Fatigue fracture of the cuboidal bones of the foot, especially the navicular tarsal bone, is common in athletes and dancers. The racing greyhound is a naturally occurring animal model of this injury because both microcracking and complete fracture occur in the right central (navicular) tarsal bone (CTB). The right limb is on the outside when racing in a counter-clockwise direction on circular tracks, and is subjected to asymmetric cyclic compressive loading. We wished to study in more detail adaptive modeling in the right CTB in racing greyhounds. We hypothesized that cyclic asymmetric loading of a cuboidal bone induced by racing on a circular track would induce site-specific bone adaptation. We also hypothesized that such an adaptive response would be attenuated in greyhounds that were retired from racing and no longer subjected to cyclic asymmetric loading. Central tarsal bones from racing greyhounds (racing group, n = 6) and retired greyhounds being used for breeding (nonracing group, n = 4) were examined using quantitative computed tomography (CT). Bone mineral density (BMD) was determined in a 3-mm diameter region-of-interest (ROI) in six contiguous 1-mm-thick sagittal CT slices of each CTB. Bones were subsequently examined histomorphometrically and percentage bone area (B.Ar./T.Ar., %) was determined in 10 ROI from dorsal to plantar in a transverse plane, mid-way between the proximal and distal articular surfaces. The BMD of the right CTB was greater than the left in all greyhounds (p < 0. 001). In comparing ipsilateral limbs between groups, BMD of the racing group was greater than the nonracing group for each side (p < 0.005). In sagittal plane histologic sections, bone in the dorsal region of the right CTB had undergone adaptive modeling, through thickening and compaction of trabeculae. B.Ar./T.Ar., % in the right CTB of the racing group was greater than in the contralateral CTB (p < 0.001), and the ipsilateral CTB of the nonracing group (p < 0.001). In the nonracing group, B.Ar./T.Ar., % in the right CTB was not significantly different from left CTB (p > 0.8; power = 80% at Delta = 48%). It was concluded that greyhounds racing on circular tracks develop site-specific bone adaptation with compaction of trabecular bone and increase in BMD in the right CTB in particular, the most common site for fatigue fracture. Our data also suggested that partial reversal of this adaptive process occurred in retired, nonracing greyhounds, after cessation of asymmetric cyclic loading at racing speed. Racing greyhounds provide a model in which to study fatigue fracture and adaptation of cuboidal foot bones subjected to cyclic loading.

A java-based application for differential diagnosis of hematopoietic neoplasms using immunophenotyping by flow cytometry

We describe the implementation of a Java-based application for differential diagnosis of hematopoietic neoplasms using immunophenotyping by flow cytometry. The current version of this Java applet includes the knowledge-base for 33 hematopoietic neoplasms and 43 diagnostic immunophenotyping markers. Java, a new object-oriented computing language, helps facilitate development of this applet, a platform-independent module that can be implemented on the World Wide Web. As the Web rapidly becomes more accessible to users around the world, Web-based software may eventually form the core of decision-support systems in clinical settings. Java-based applications, such as the one described in this paper, are expected to contribute significantly in this area.

Probing the stoichiometry and oxidation states of metal centers in iron-sulfur proteins using electrospray FTICR mass spectrometry

Electrospray ionization (ESI) Fourier transform ion cyclotron resonance mass spectrometry is used to determine the stoichiometry and oxidation states of the metal centers in several iron-sulfur proteins. Samples are introduced into the ESI source under nondenaturing conditions in order to observe intact metal-containing protein ions. The stoichiometry and oxidation state of the metal or metal-sulfur cluster in the protein ion can be derived from the mass spectrum. Mononuclear metal-containing proteins and [4Fe-4S] centers are very stable and yield the molecular ion with little or no fragmentation. Proteins that contain [2Fe-2S] clusters are less stable and yield loss of one or two sulfur atoms from the molecular species, although the molecular ion is more abundant than the fragment peaks. [3Fe-4S]-containing proteins are the least stable of the species investigated, yielding abundant peaks corresponding to the loss of one to four sulfur atoms in addition to a peak representing the molecular ion. Isotope labeling experiments show that the sulfur loss originates from the [3Fe-4S] center. Negative ion mode mass spectra were obtained and found to produce much more stable [3Fe-4S]-containing ions than obtained in positive ion mode. ESI analysis of the same proteins under denaturing conditions yields mass spectra of the apo form of the proteins. Disulfide bonds are observed in the apoprotein mass spectra that are not present in the holoprotein. These result from oxidative coupling of the cysteinyl sulfur atoms that are responsible for binding the metal center. In addition, inorganic sulfide is found to incorporate itself into the apoprotein by forming sulfur bridges between cysteine residues.

A web-based teaching program for laboratory diagnosis of coagulation disorders

OBJECTIVE

To implement an interactive program for teaching coagulation disorders on the World Wide Web.

DESIGN AND RESULTS

The core materials in this program were derived from a personal computer software program previously designed by the authors. Three modules were developed in this program: (1) a coagulation profile to display typical results of coagulation screening tests for each disorder; (2) a differential diagnosis module to generate a list of diagnoses that fit the test results in a given case; and (3) a synopsis of coagulopathy and therapy to provide essential information on disorders and therapeutic options. A total of 41 coagulation disorders were included in the knowledge base.

CONCLUSIONS

Since the World Wide Web is increasingly more accessible to computer users, it has become an ideal medium for teaching purposes. Our experience with this program in teaching medical students and pathology residents at our institution has been very encouraging.

Response to genetic counseling and testing for the APC I1307K mutation

The APC I1307K gene mutation is associated with increased colorectal cancer (CRC) risk in Ashkenazi Jews. Factors predicting acceptance of this and other hereditary colon cancer mutation tests in a clinical setting are unknown. We analyzed sex, age, family history, personal history, and gene test results of patients at increased risk for cancer who sought cancer risk counseling at the Johns Hopkins (JH) CRC Risk Assessment Clinic (n = 91), and those submitting samples to the JH Pathology Molecular Diagnostic Laboratory (n = 256) for APC I1307K testing. Of patients seen at the JH Clinic, 77/91 (84.6%) elected APC I1307K testing after pretest counseling (acceptors). There were no statistically significant differences in demographic characteristics between acceptors and decliners. In comparison, only 8 of 57 (14.0%) patients offered HNPCC testing proceeded with testing (P < 0.001). Of 256 individuals tested at the JH laboratory, most were male (61.3%) and most had a personal or family history of colorectal cancer or polyps. Test positivity correlated with increasing risk of colorectal cancer. Acceptance of testing for the APC I1307K mutation is high, with more men than women pursuing counseling and testing. The reported association between the APC I1307K mutation and colon cancer risk was supported by a correlation in these data between personal or family history of CRC or polyps and a gene mutation.

Perfusion abnormalities in prodromal AD

Cerebral perfusion abnormalities in patients with established Alzheimer's disease (AD) are most commonly seen in the temporoparietal cortex. As the disease progresses, this perfusion pattern is increasingly prevalent. Recently, investigators have begun to examine the patterns of perfusion among individuals at risk for AD. To date, such studies have been conducted either in individuals who have a progressive memory difficulty but do not yet meet clinical criteria for AD, or in individuals with a genetic risk factor or family history of AD, either with or without a memory problem. These latter studies suggest that a set of brain regions show decreased perfusion during the prodromal phase of AD, and that a brain network or networks with multiple nodes is affected early in the course of AD. These perfusion abnormalities may also shed light on how AD progresses during the prodromal phase of disease and may ultimately lead to improved diagnosis or methods of monitoring response to treatment.

Human mitochondrial DNA polymerase holoenzyme: reconstitution and characterization

We have reconstituted the holoenzyme of the human mitochondrial DNA polymerase from cloned and overexpressed catalytic and accessory subunits. We have examined the polymerization activity of the catalytic subunit alone and of the holoenzyme to establish the function of the accessory subunit in this two subunit enzyme. The accessory subunit associates with the catalytic subunit with a dissociation constant of 35 +/- 16 nM as measured by the concentration dependence of its effect in stimulating maximal DNA binding and polymerization. At saturating concentrations, the accessory subunit contributes to every kinetic parameter examined to facilitate tighter binding of DNA and nucleotide and faster replication. The accessory protein makes the DNA binding 3.5-fold tighter (K(d) of 9.9 +/- 2.1 nM compared to 39 +/- 10 nM for the catalytic subunit alone) without significantly affecting the DNA dissociation rate (0.02 +/- 0.001 compared to 0.03 +/- 0.001 s(-)(1)). The ground-state nucleotide binding is improved from 4.7 +/- 2.0 to 0.78 +/- 0.065 microM, and the maximum DNA polymerization rate is increased from 8.7 +/- 1.1 to 45 +/- 1 s(-)(1) by the addition of the accessory protein. This leads to an increase in processivity from an estimated 290 +/- 46 to 2250 +/- 162. Although the accessory protein has been described as a "processivity factor" because of its effect on the ratio of rate constants defining processivity, this terminology falls short of adequately describing the profound effects of the small subunit on nucleotide-binding and incorporation catalyzed by the large subunit. By using the complete holoenzyme, we can now proceed with a comprehensive analysis of the structural and mechanistic determinants of enzyme specificity that govern toxicity of nucleoside analogues used in the treatment of viral infections such as AIDS.

A relational database for diagnosis of hematopoietic neoplasms using immunophenotyping by flow cytometry

A relational database was developed to facilitate the diagnosis of hematopoietic neoplasms using results of immunophenotyping by flow cytometry. This database runs on personal computers and uses backward-chaining search to arrive at conclusions. Results of immunologic marker studies are processed by the database to obtain a set of differential diagnoses. The current version of this database includes diagnostic immunophenotyping pattern for 33 hematopoietic neoplasms. We tested this database using 92 clinical cases from 2 tertiary care medical centers. The database ranked the actual diagnosis as 1 of the top 5 differential diagnoses in 93% of the cases tested. The user can modify the database contents to suit individual needs. This database has been posted on the World Wide Web for direct access. We propose that this user-friendly database is a potential tool for computer-assisted diagnosis of hematopoietic neoplasms.

An axonemal dynein at the Hybrid Sterility 6 locus: implications for t haplotype-specific male sterility and the evolution of species barriers

Poor sperm motility characterized by a distinct aberration in flagellar waveform known as "curlicue" is a hallmark of t haplotype (t) homozygous male sterility. Previous studies have localized "curlicue" and a flagellar developmental defect, "whipless", to the Hybrid Sterility 6 locus (Hst6), between the markers Pim1 and Crya1. More recent heterospecific breeding experiments between Mus spretus (Spretus) and Mus musculus domesticus (Domesticus) have mapped the primary source(s) of both "curlicue" and "whipless" to a small sub-locus of Hst6, Curlicue a (Ccua). Here we report the complete physical isolation of the Ccua locus and the identification of a candidate gene for expression of both "whipless" and "curlicue" at its proximal end, an axonemal dynein heavy chain gene, Dnahc8, formerly mapped by interspecific backcross analysis near Pim1. Dnahc8 mRNA expression commences in the Domesticus wild-type testis just prior to flagellar assembly and is testis-specific in the adult male. However, expression of Dnahc8 is not readily evident in the testis of either Spretus or "whipless" animals (Domesticus males homozygous for the Spretus allele of Dnahc8). Our results argue that Dnahc8 is fundamental to flagellar organization and function in Domesticus, but not Spretus, and suggest that Dnahc8 is integral to both Hst6- and t-specific male infertility.

Reliability of self-reported blood pressure measurements

BACKGROUND

Home blood pressure (BP) monitoring improves BP control, but it is unknown whether patients accurately report home BP readings to their physician. This study compared self-reported with electronically stored home BP and heart rate (HR) readings and evaluated this agreement in patients with controlled vs. uncontrolled hypertension.

METHODS

A single-blind, randomized clinical trial was conducted in an ambulatory managed care population. Subjects were identified by hypertension-related codes from the International Classification of Diseases, Ninth Revision (401.0, 401.1, and 401.9). Subjects recorded systolic BP (SBP), diastolic BP (DBP), and HR 3 times daily for 1 week by means of a digital BP monitor. Subjects were unaware that the monitor electronically stored results.

RESULTS

Thirty subjects were enrolled (29 complete data sets); their mean age (+/-SD) was 56+/-9 years, and 15 (52%) were women. Sixty-eight percent of subject-recorded SBP, DBP, and HR measurements were identical to electronically stored results. Twenty percent of recorded SBPs and 17% of recorded DBPs differed from stored SBP and DBP by more than 10 mm Hg. Erroneous reporting was evident in 9% of uncontrolled vs 4% of controlled SBPs (P<.001). Similarly, 21% of uncontrolled and 4% of controlled DBPs were erroneously reported (P<.001). In cases where the stored HR exceeded 100 beats/min, 43% of HR readings were recorded as 100 beats/min or less (P<.001).

CONCLUSIONS

Most self-reported BP and HR readings were identical to electronically stored measurements. However, erroneous reporting occurred significantly more often in cases of uncontrolled BP and HR, which may misguide physicians in the optimal treatment of their patients with hypertension.

Genetic testing and counseling for hereditary forms of colorectal cancer

The discovery of genes responsible for inherited forms of colorectal cancer have the potential to improve cancer risk assessment and counseling. Germline mutations (nonsense, frameshift) of APC are associated with familial adenomatous polyposis, an autosomal dominant syndrome, clinically characterized by young onset, hundreds of adenomatous polyps in the colon, and increased risk for extracolonic tumors. Mutations in APC are also associated with forms of attenuated familial adenomatous polyposis. Germline mutations in five mismatch repair related genes (hMSH2, hMLH1, hMSH6, hPMS1, and hPMS2) cause hereditary nonpolyposis colorectal cancer and are associated with increased risk of somatic genetic alterations and high DNA microsatellite instability. Hereditary nonpolyposis colorectal cancer is characterized by young onset colorectal cancer, proximal colon location, and increased risk of extracolonic cancers. A missense mutation in APC (I1307K) is associated with some familial colorectal cancer in Ashkenazic Jews. For persons at risk for hereditary forms of colorectal cancer, testing algorithms and gene test interpretations depend on identification of the pedigree germline gene mutation. Careful evaluation of the kindred for characteristic aggregation of tumor types among affected individuals and the availability of affected persons for testing are important issues in implementing genetic testing and follow-up management. Case reports illustrate the importance of genetic counseling as a component of cancer genetic risk assessment. The genetic counseling process includes exploration of patient risk perception, sources of anxiety related to cancer risk, patient education (specific cancer-related issues, prevention/intervention options), discussion of possible gene test options, test limitations, and consequences of various gene test outcomes.

In vivo matrix microdamage in a naturally occurring canine fatigue fracture

Greyhound central tarsal bone (CTB) from animals with (n = 11) and without CTB fatigue fracture (n = 15) was examined histologically for the presence, numerical density, and morphology of in vivo microdamage. Complete fracture of the right CTB is a common occurrence during dog racing, because this is the outside limb when running counterclockwise on a circular or oval track. The CTB consisted of both remodeled cortical bone and inner trabecular bone. Thickening and coalescence of trabeculae were observed, particularly dorsally and medially, causing reduction or elimination of the marrow void spaces. A band of tightly packed transverse osteons was also observed adjacent to the concave proximal joint surface. Typical linear microcracks were most often seen in remodeled cortical and trabecular bone and were often observed adjacent to vascular channels. In contrast, ultra-microcracking, represented by diffuse staining with basic fuchsin, was consistently observed in the plantar process around the attachment site for the plantar ligament complex. Dog status (fractured or intact) and side (left or right) both had a significant effect on microcrack density and microcrack surface density (p < 0.05). Microcrack density and microcrack surface density were increased in the right (fractured) CTB from greyhounds with CTB fracture. There was also a trend for side to have a significant effect on microcrack length, with microcrack lengths being higher in the right CTB of both intact and fractured dogs. These data support the general hypothesis that fatigue fracture occurs because of ongoing cyclic stresses after induction of reparative remodeling. Development of methods for biomechanical testing of small cuboidal bones should allow investigation of relationships between accumulation of loading cycles and bone weakening because of microdamage.

Weight gain in infants breastfed by mothers who take fluoxetine

OBJECTIVE

Despite the manufacturer's recommendation that fluoxetine not be used by women while breastfeeding, many women choose to do so. There is little information available in the literature to suggest that this practice is or is not safe. The purpose of this study was to examine weight gain in infants who are breastfed by mothers who take fluoxetine, compared with weight gain in infants who are breastfed by mothers who do not take any psychotherapeutic medication. A secondary goal was to assess the frequency of reported side effects in infants who are breastfed by mothers who take fluoxetine.

METHODOLOGY

A retrospective cohort study design was used. Subjects were identified from an ongoing pregnancy outcome study conducted through the California Teratogen Information Service and Clinical Research Program. A total of 64 women were interviewed who had taken fluoxetine during a pregnancy between the 1989 and 1997; 26 of these women breastfed their infants and continued to take the medication, and 38 breastfed their infants but did not take the medication. Postnatal weight gain was taken from pediatric records, and the frequency of side effects was measured by maternal response to the interview questionnaire.

RESULTS

Using linear regression analysis, the infants who were breastfed by mothers taking fluoxetine demonstrated a growth curve significantly below that of infants who were breastfed by mothers who did not take the drug. The average deficit in measurements taken between 2 weeks and 6 months of age was 392 g (95% confidence interval: -5, -780). Using a repeated measures analysis of covariance for those infants with more than one postnatal weight measurement available, the difference between the two groups was similar, approximately 1.2 standard deviations (P =.005). In response to interview questions regarding side effects, no mother who breastfed her infant while taking fluoxetine reported any unusual symptoms that could be attributed to the medication.

CONCLUSIONS

These data do not suggest that women who breastfeed while taking fluoxetine are likely to note unusual behavior in their infants that they consider related to use of the medication. However, although there was no excess of infants in the fluoxetine group with postnatal weight measurements >2 standard deviations below the mean, these data indicate that breastfeeding while taking fluoxetine is associated with reduced growth that may be of clinical importance in situations in which infant weight gain is already of concern.

MutS recognition of exocyclic DNA adducts that are endogenous products of lipid oxidation

The ability of the methyl-directed mismatch repair system to recognize and repair the exocyclic adducts propanodeoxyguanosine (PdG) and pyrimido[1,2-alpha]purin-10(3H)-one (M(1)G), the major adduct derived from the endogenous mutagen malondialdehyde, has been assessed both in vivo and in vitro. Both adducts were site-specifically incorporated into M13MB102 DNA, and the adducted genomes were electroporated into wild-type or mutS-deficient Escherichia coli strains. A decrease in mutations caused by both adducts was observed in mutS-deficient strains, suggesting that MutS was binding to the adducts and blocking repair by nucleotide excision repair. This hypothesis was supported by the differences in mutation frequency observed when hemimethylated genomes containing PdG on the (-)-strand were electroporated into a uvrA(-) strain. The ability of purified MutS to bind to PdG- or M(1)G-containing 31-mer duplexes in vitro was assessed using both surface plasmon resonance and gel shift assays. MutS bound to M(1)G:T-containing duplexes with similar affinity to a G:T mismatch but less strongly to M(1)G:C- and PdG-containing duplexes. Dissociation from each of the adduct-containing duplexes occurred at a faster rate than from a G:T mismatch. The present results indicate that MutS can bind to exocyclic adducts resulting from endogenous DNA damage and trigger their removal by mismatch repair or protect them from removal by nucleotide excision repair.

Nitrous acid pretreatment of tendon xenografts cross-linked with glutaraldehyde and sterilized with gamma irradiation

Collagenous xenografts made from kangaroo tail tendon cross-linked with glutaraldehyde have a potential application in the reconstruction of massive digital tendon deficits. However, a limitation to the clinical use of these xenografts has been the optimization of collagen cross-linking, and subsequent bio-incorporation and retention of mechanical properties following implantation. The purpose of this study was to evaluate the effect of nitrous acid on modulating the biologic and mechanical properties of tendon xenografts cross-linked with glutaraldehyde. Tendon xenografts were pretreated with 0.1 or 0.01 M nitrous acid solution, prior to cross-linking in 2% glutaraldehyde and sterilization by gamma irradiation. Xenografts were implanted intramuscularly in rabbits to examine biocompatability, and also used to repair ovine digital extensor tendon deficits to evaluate functional incorporation. Histologically, intramuscularly implanted nitrous acid pretreated xenografts in rabbits had a greater degree of diffuse cellular infiltration into interstitial splits in the graft than controls after 12 weeks. Xenografts implanted in an ovine extensor tendon deficit were evaluated after 26 and 52 weeks. Rate of failure of tenorrhaphies between host tendon and xenografts overall (15/21) was significantly greater (P < 0.05) than for autografts (1/21), suggesting that the holding power of sutures in xenografts was inferior to that obtained in autografts. Tensile failure stress of midsections of both nitrous acid pretreated and control xenografts was about 100 MPa prior to implantation (time zero). After 26 and 52 weeks, failure stress of both types of xenografts was significantly less than at time zero (P < 0.05). At 52 weeks, failure stress of nitrous acid pretreated xenografts (47.4 +/- 3.1 MPa) was significantly less than control xenografts (63.7 +/- 5.4 MPa); (P < 0.05). However, nitrous acid pretreated xenografts were similar to control xenografts in failure load (357 +/- 29 and 354 +/- 26 N, respectively), but they tended to have larger cross-sectional areas (7.6 +/- 0.5 versus 5.7 +/- 0.6 mm2, respectively) which were responsible for the lower calculated value for failure stress. Histologically, autografts maintained their normal tissue architecture and evoked a more limited cellular response in surrounding tissues than xenografts (P < 0.05). Both types of xenograft were surrounded by a thicker cuff of cellular response than autografts. However, compared to control xenografts, nitrous acid pretreated xenografts had more extensive fragmentation and splitting of collagen bundles, and more diffuse cellular and vascular infiltration into these interstitial splits, and these alterations were apparently contributing to the greater 'swelling' of these xenografts. It was concluded that pretreatment of tendon xenografts with nitrous acid modulated their biologic and material properties. Further studies are needed to elucidate the mechanism of these effects, and to determine if the protocol for tendon xenograft preparation could be optimized for improved clinical performance.

The catalytic mechanism of EPSP synthase revisited

Recent analysis of EPSP synthase by solid-state NMR has led to the postulation of a new enzyme reaction pathway and raised once again the question of an intermediate species covalently bound to the enzyme [Studelska, D., McDowell, L., Espe, M., Klug, C., and Schaefer, J. (1997) Biochemistry 36, 15555-15560]. Therefore, we have reexamined the mechanism of the reaction catalyzed by EPSP synthase and analyzed the reaction products formed under the conditions used in preparing samples for solid-state NMR. Single-turnover experiments were carried out using both [1-14C]- and [32P]PEP showing the formation and decay of the previously proposed tetrahedral intermediate species on a time scale comparable with the disappearance of substrate and formation of product, thus unequivocally establishing the kinetic competence. The possible presence of a covalently bound enzyme intermediate species was also investigated, using SDS-PAGE and Centricon concentration analysis of the quenched reaction samples. No covalently bound enzyme intermediates were observed during the reaction. An enzyme assay was also performed repeating the conditions used in sample preparation for the solid-state NMR studies. We show that under these conditions, total turnover of substrates to products was observed within 45 s at -30 degrees C prior to freezing and lyophilization. Following lyophilization, the samples were stored at -20 degrees C and analyzed over a period of 21 days. We observed the conversion of the product EPSP into the side product, a cyclic EPSP ketal, and the breakdown product, pyruvate. Thus, the new species reported by solid-state NMR can be accounted for by previously characterized reaction products and side products formed during sample preparation and upon incubation in the solid-state. Our conclusions are also supported by the solution and solid-state NMR studies recently reported [Jakeman et al. (1998) Biochemistry 37, 12012-12019]. These results once again highlight the importance of kinetic competence as a criterion to be used in defining enzyme intermediates and point to the errors in interpretation of results when the time dependence of formation of the proposed intermediates is not considered.

Magnetic resonance imaging of normal canine carpal ligaments

Magnetic resonance imaging was conducted on previously frozen left carpi from six normal dogs using a 1.5 Tesla magnet in combination with a transmit/receive wrist coil. Three-millimeter thick T1-weighted spin-echo images and 1-mm thick T2*-weighted gradient-recalled 3-D images were obtained in dorsal and sagittal planes. Carpi were embedded, sectioned, and stained. Anatomic structures on the histologic sections were correlated with the MR images. All of the carpal ligaments plus the radioulnar articular disc and the palmar fibrocartilage were identified on MR images. The accessorio-quartile ligament, which had not been well described previously in dogs, was also identified. It originated on the accessory carpal bone and inserted on the fourth carpal bone. The T2*-weighted gradient echo imaging technique provided better images than T1-weighted technique, largely because thinner slices were possible (1 mm vs. 3 mm), resulting in less volume averaging of thin ligaments with surrounding structures. Although MRI is currently the imaging modality of choice to identify ligamentous injury in humans, further studies are needed to determine if abnormalities can be detected in canine carpal ligaments using MRI.

Comparison of two home blood pressure monitors with a mercury sphygmomanometer in an ambulatory population

We performed a randomized, single-visit, crossover study to compare the precision of a digital monitor and an aneroid monitor relative to a desktop mercury sphygmomanometer (DMS). Three blood pressure measurements per patient, one per device, were taken over 25 minutes. Of 99 patients, 95 had complete blood pressure data. Systolic blood pressures measured with the digital monitor were significantly different from those with the DMS (p<0.01). Thirty-four percent of systolic and 48% of diastolic pressures measured with the digital monitor were within +/- 5 mm Hg of the DMS. The aneroid monitor performed significantly better than the digital monitor, with 54% of systolic (p<0.01) and 58% of diastolic blood pressures within +/- 5 mm Hg of the DMS standard. Health care providers are encouraged to supervise patients' initial use of a home blood pressure monitor and calibrate readings against a standard mercury sphygmomanometer.

Single d(GpG)/cis-diammineplatinum(II) adduct-induced inhibition of DNA polymerization

A 44 nucleotide DNA template containing a single site-specifically placed cisplatin adduct (cis-[Pt(NH3)2[d(GpG)-N7(1),-N7(2)]]) was annealed with a primer, positioning its 3'-end four bases before the adduct in the template strand. DNA polymerization in the presence of all four nucleotides revealed that both HIV-1 reverse transcriptase (RT) and T7 DNA polymerase strongly paused at one nucleotide preceding the first platinated guanine and at the positions opposite the two platinated guanines. Analysis of single nucleotide incorporation at each pause site showed that polymerization occurs with biphasic kinetics. A small percentage of DNA was bound productively, providing a small amplitude (1-3%) of a fast phase of polymerization, whereas most of the bound DNA (1-34%) was positioned at the pause site in a nonproductive manner and therefore elongated slowly (0.04-0.06 s-1). DNA substrates annealed to the cisplatin-modified template bind to HIV-1 RT with an affinity (10-20 nM) similar to that of unmodified substrates (6-9 nM). The cisplatin-DNA cross-link moderately weakened DNA binding to T7 DNA polymerase (12-115 nM) but significantly slowed the rate of incorporation of the next nucleotide (2-7 s-1 ), with larger effects closer to the cisplatin-DNA adduct. The crystal structure of the same cisplatin-DNA adduct [Takahara, P. M., Frederick, C. A., and Lippard, S. J. (1996) J. Am. Chem. Soc. 118, 12309-12321] reveals not only the bent DNA duplex but also the propeller twisted base pairs near the cisplatin-DNA adduct. The twisted base pairs may cause misalignment of the cisplatin-modified DNA at the binding cleft of T7 DNA polymerase and significantly slow the rate of the protein conformational change preceding polymerization, leading to the slight accumulation of intermediates within five base pairs of the adduct. The ground-state binding of the next correct nucleotide to the enzyme.DNA complex was weakened by the adduct with T7 DNA polymerase but unchanged with HIV-1 RT at sites other than the three strong pause sites. Nucleotide binding to both enzymes at the three strong pause sites was significantly weaker and less selective.

5-HT agonist-induced phase-advances of the circadian pacemaker are diminished by chronic antidepressant drug treatment

Serotonin (5-HT) and its agonists alter the timing of the circadian pacemaker. Previous research has shown that when they are injected 4 h before or after the onset of wheel-running, they phase-advance or delay, respectively, the timing of the pacemaker. Because serotonergic interventions alter 5-HT receptor number in the hypothalamus, we asked whether chronic treatment with an antidepressant drug (AD) that modifies serotonergic function could alter the phase-shifting effects of the 5-HT agonist 8-hydroxydipropylaminotetralin (8-OH-DPAT). Hamsters were treated chronically with the monoamine oxidase inhibitor (MAOI), clorgyline, and then injected with 8-OH-DPAT or vehicle (VEH) either 4 h before or after the onset of wheel-running. MAOI treatment decreased the magnitude of both 8-OH-DPAT- and VEH-induced phase advances, but not the magnitude of 8-OH-DPAT-induced phase-delays. The results indicate that 8-OH-DPAT-induced phase-advances and delays are functionally distinct with regard to adaptive changes during chronic AD treatment.

Interlocking nail treatment of diaphyseal long-bone fractures in dogs

OBJECTIVE

To determine results of using interlocking nails (IN) for fixation of diaphyseal long bone fractures in dogs.

DESIGN

Multi-center prospective clinical trial.

ANIMALS

134 dogs with diaphyseal fractures of the femur (n = 92), tibia (23), or humerus (19); 11 had previous unsuccessful treatments, and 103 had comminuted fractures of which 70 were classified as unstable.

PROCEDURE

All fractures were stabilized with 6- or 8-mm-diameter IN with 3.5- or 4.5-mm screws, respectively. Cerclage wires and an autogenous bone graft were used at the surgeon's discretion. Participating surgeons provided information on age, sex, weight, and breed of the dog, details of the surgery, details of any intra- or postoperative complications, fracture healing time, and limb function.

RESULTS

Eight dogs were lost to follow-up evaluation. In 105 of the remaining 126 dogs (83%), fractures healed without complications. For these 105 dogs, limb function was excellent (n = 90), good (12), fair (2), and poor (1). Complications developed for 21 dogs (17%); limb function after additional treatment was excellent (n = 10), good (2), fair (5), poor (1), or unreported (3). Interlocking nails broke in 9 dogs; breakage was attributed to fatigue failure because of use of too small an IN or because of insertion of the IN so that a screw hole was positioned at the fracture site.

CLINICAL IMPLICATIONS

The high success rate and low complication rate suggest that IN can be used to stabilize diaphyseal fractures in dogs. Good technique is necessary for optimal results.

Youth Alternative Sentencing Program: a description and evaluation of an alcohol and marijuana intervention program

An alternative program was designed for youth who were charged with an alcohol or marijuana offense in San Bernardino County, California. In place of a conviction, the youth could attend an extended educational program that emphasized their ability to change behavior and to understand the consequences of risk-taking behavior. An evaluation was completed by the participants, demonstrating that this population of youth began to experiment with alcohol and marijuana around 12 and 13 years of age. A large number of youths were identified for nontraffic offenses, which offered an opportunity to intervene before members of this population become involved in a motor vehicle crash.

State health agencies and quality improvement in perinatal care

The origin of the federal-state partnership in Maternal and Child Health (MCH) can be traced from the Children's Bureau grants of 1912, through the Sheppard-Towner Act, to the creation of Title V and other programs of today that mandate planning, accountability, and systems development. In the past decade with the transformation of the health care system and the emergence of managed care, there has been a resurgence of interest in public, professional, and governmental interest in quality measurement and accountability. Regional perinatal systems have been implemented in all states with varying levels of involvement by state health agencies and the public sector. This historical framework discusses two primary themes: the decades of evolution in the federal-state partnership, and the emergence in the last three decades of perinatal regional system policy, and suggests that the structure of the federal-state partnership has encouraged state variation. A survey of state MCH programs was undertaken to clarify their operational and perceived role in promoting quality improvement in perinatal care. Data and information from the survey, along with five illustrative state case studies, demonstrate great variation in how individual state agencies function. State efforts in quality improvement, a process to make things better, have four arenas of activity: policy development and implementation, definition and measurement of quality, data collection and analysis, and communication to affect change. Few state health agencies (through their MCH programs and perinatal staff) are taking action in all four arenas. This analysis concludes that there are improvements MCH programs could implement without significant expansion in their authority or resources and points out that there is an opportunity for states to be more proactive as they have the legal authority and responsibility for assuring MCH outcomes.

The Kaiser Permanente/USC Patient Consultation Study: patient satisfaction with pharmaceutical services. University of Southern California

The impacts of two models of pharmacist consultation on patient satisfaction with pharmaceutical services relative to a control model were studied. Patients in the random-assignment and areawide studies of the Kaiser Permanente/USC Patient Consultation Study were asked to rate their satisfaction with six aspects of the service they received at the pharmacy. The patients were receiving pharmaceutical services under the Kaiser Permanente (KP) model of consultation, a state-mandated model, or a control model. They were assigned to risk categories according to their pattern of prescription drug use. Differences in satisfaction among the three consultation models for all patients and for each risk group and correlations between satisfaction items were determined. The KP and state models of consultation were associated with better satisfaction than the control model on five of the six satisfaction items. In the high-risk patient groups, the KP and state models were associated with higher levels of satisfaction than the control model. In the low-risk group, the state model was associated with higher levels of satisfaction than the control model; results for low-risk patients assigned to the KP model were inconsistent between the random-assignment study and the areawide study. Overall satisfaction appeared to be a suboptimal measure of satisfaction with consultation. Overall satisfaction was more closely related to satisfaction with waiting time and with whether the pharmacy staff was helpful and caring than with the three items reflecting satisfaction with the content of the consultation. Patients were more satisfied under the state model of pharmacist consultation or the KP model of consultation, which resulted in more-intensive counseling for fewer patients, than under a control model.

Chronic toxicity/oncogenicity study of styrene in CD rats by inhalation exposure for 104 weeks

Groups of 70 male and 70 female Charles River CD (Sprague-Dawley-derived) rats were exposed whole body to styrene vapor at 0, 50, 200, 500, or 1000 ppm 6 h/day 5 days/week for 104 weeks. The rats were observed daily, body weights and food and water consumption were measured periodically, and a battery of hematologic and clinical pathology examinations was conducted at weeks 13, 26, 52, 78, and 104. Nine or 10 rats per sex per group were necropsied after 52 weeks of exposure and the remaining survivors were necropsied after 104 weeks. Control and high-exposure rats received a complete histopathologic examination, while target organs, gross lesions, and all masses were examined in the lower exposure groups. Styrene had no effect on survival in males, but females exposed to 500 or 1000 ppm had a dose-related increase in survival. Levels of styrene in the blood at the end of a 6-h exposure during week 95 were proportional to exposure concentration. Levels of styrene oxide in the blood of rats exposed to 200 ppm or greater styrene were proportional to styrene exposure concentration. There were no changes of toxicologic significance in hematology, clinical chemistry, urinalysis, or organ weights. Males exposed to 500 or 1000 ppm gained less weight than the controls during the first year and maintained the difference during the second year. Females exposed to 200, 500, or 1000 ppm gained less weight during the first year; those exposed to 500 or 1000 ppm continued to gain less during months 13-18. Styrene-related non-neoplastic histopathologic changes were confined to the olfactory epithelium of the nasal mucosa. There was no evidence that styrene exposure caused treatment-related increases of any tumor type in males or females or in the number of tumor-bearing rats in the exposed groups compared to controls. In females, there were treatment-related decreases in pituitary adenomas and mammary adenocarcinomas. Based on an overall evaluation of eight oncogenicity studies, there is clear evidence that styrene does not induce cancer in rats.

The Kaiser Permanente/USC Patient Consultation Study: change in use and cost of health care services

The impacts of three alternative models of pharmacist consultation on the use and cost of health care services were studied. Two studies were conducted concurrently in an HMO over two years. In one, 6000 patients were randomly assigned to one of three consultation models; in the other, the three models were implemented in six geographic regions of California (4600 patients). The models were (1) consultation about new or changed prescriptions as mandated by state law (state model), (2) consultation focused on selected high-risk ambulatory care patients (Kaiser Permanente [KP] model), and (3) a control model. The patients were surveyed three times about their health status and satisfaction, and computerized data on health care use and cost were collected. The effect of the consultation models on the use and cost of health care services was examined across five risk groups that were based on drug-use profiles. An additional 37,750 patients (10% of the patients residing in the areawide study sites) were included in a supplemental analysis of the use and cost of health care services. There was no indication in the random-assignment study that pharmacist consultations affected either drug costs or the cost of office visits. Similar results were found in the areawide study, with the exception that the KP model was associated with lower drug costs than the control model. In the 10% sample, the KP model appeared to be associated with lower office visit costs but higher drug costs. Both models were associated with a lower likelihood of a hospital admission and with lower total health care costs for some high-risk patients compared with the control model. Counseling patients about their medications may be unlikely to reduce medication costs or the cost of office visits but may reduce the likelihood of hospital admissions and the overall costs of health care services; a combination of counseling patients at high risk for drug-related problems and counseling all patients about any new or changed prescription should be considered.

Maternal fever and birth outcome: a prospective study

Although maternal fever has been implicated as a human teratogen in several studies, no prospective study has adequately addressed the full spectrum of birth outcomes following such exposure in pregnancy. The purpose of this study was to determine whether or not maternal fever is associated with an increased risk for structural malformations, prematurity, growth retardation, or pregnancy loss. Using a prospective cohort study design, we ascertained women who had called the California Teratogen Information Service and Clinical Research Program between 1979-1996 with questions regarding fever in a current pregnancy. Of these women, 115 who reported a fever of at least 38.9 degrees C lasting for at least 24 h (high fever group) and 147 women who reported a fever of either less than 38.9 degrees C or lasting less than 24 h (low fever group) were enrolled in the cohort. An additional 298 pregnant women who reported having no fever at any time in pregnancy were enrolled in a control group. All pregnancies were followed in a similar fashion, and outcomes were compared among the three groups. The combined prevalence of all major structural malformations was increased, but not significantly so, in the offspring of women who had a high fever in the first trimester of pregnancy compared to those with a lower fever or to controls (relative risk 1.80 for high fever group compared to controls; 95% confidence interval, 0.54, 6.03; relative risk 1.21 for low fever group compared to controls; 95% confidence interval, 0.36, 4.03). However, 2/34 or 5.9% of women who had a high fever during the critical period for neural tube closure carried fetuses with anencephaly compared to none in the low fever group or controls. Specific minor defects were found more frequently in the high fever group compared to controls and were consistent with the pattern of defects previously reported in a retrospective case series. In addition, stillbirth occurred more frequently in the high fever group compared to controls (2.6% vs. 0%). These data support the conclusion that high maternal fever early in pregnancy is a human teratogen. Women who experience fevers of 38.9 degrees C or higher for extended periods of time in the first month of pregnancy should be considered at increased risk for neural tube defects and should be provided appropriate counseling.

Characterization of the murine gene encoding Aop2 (antioxidant protein 2) and identification of two highly related genes

The mouse Aop2 (antioxidant protein 2) cDNA recently cloned from liver and kidney is a member of the thiol-specific antioxidant gene family. We have isolated the mouse gene encoding Aop2 and have shown that it comprises five exons and four introns. Analysis of the sequence upstream of the translation start site revealed several potential Sp1-binding sites and two putative transcription initiation sites. Primer extension studies were used to determine the 5' end of the Aop2 transcript. This upstream region also contains consensus recognition sequences for the transcription factors USF, SREBP, and ADR1, all of which have been shown to regulate genes involved in lipid metabolism, and multiple consensus binding sites for HSF, whose activity is modulated by oxidative stress. Since Aop2 has recently been proposed as a candidate gene for atherosclerosis susceptibility differences in mice, the presence of these binding sites may have biological significance. We also isolated two highly related intronless genes and determined their chromosomal locations. Further characterization of this highly conserved gene family and its regulation will help to elucidate their biological functions.

The structural and mechanochemical cycle of kinesin

Kinesin is a microtubule-based motor protein that pulls vesicles or organelles towards the plus end of microtubules. Structural changes in the protein that drive motility are coupled to ATP binding and hydrolysis. Here, we attempt to integrate recent structural and kinetic results into a picture of the mechanochemical cycle of kinesin.

The imaging of Burkitt's and Burkitt-like lymphoma

We describe the radiological findings at presentation and follow up in 24 adult patients with Burkitt's and Burkitt-like lymphoma, age range 17-67 years. This is an older age group than previously described in North American series, but the clinical and imaging characteristics appear similar. Disease confined to the abdomen was seen in 12 (50%) at presentation, of whom 11 had bowel or mesenteric tumours. Of those with bowel involvement, five patients had disease that had arisen in the ileocaecal region. Intra-abdominal disease was large volume (greater than 5 cm) in the majority of patients. Four patients (17%) had small isolated masses in the head and neck region, two (8%) had isolated unilateral axillary lymphadenopathy. Six (25%) patients presented with disseminated disease, all with hepatic and/or splenic involvement, intra-abdominal and peripheral lymphadenopathy. Three of these patients with disseminated disease were human immunodeficiency virus (HIV) positive. Neurological symptoms were present in a total of five patients at presentation or relapse but positive imaging findings were present in only two patients who had MRI. Computed tomography (CT) head scans performed in four patients were normal. Disease recurrence most commonly occurred within the abdomen.

Selective inhibition of HIV-1 reverse transcriptase by an antiviral inhibitor, (R)-9-(2-Phosphonylmethoxypropyl)adenine

(R)-9-(2-Phosphonylmethoxypropyl)adenine (PMPA) is an acyclic nucleoside phosphonate that has been shown to be effective in the treatment of AIDS although it has a shorter separation between the adenine and phosphorus than dideoxy-AMP and dAMP. By using pre-steady state kinetic methods, we examined the incorporation of the diphosphate of PMPA, 2',3'-dideoxyadenosine 5'-triphosphate (ddATP), and dATP catalyzed by wild-type human immunodeficiency virus type 1 (HIV-1) reverse transcriptase, an exonuclease-deficient T7 DNA polymerase (T7 exo-), and wild-type rat DNA polymerase beta in order to evaluate the selectivity of PMPA as an antiviral inhibitor. With a DNA/DNA or DNA/RNA 22/43-mer duplex, the diphosphate of PMPA (PMPApp) is as effective as ddATP in reactions catalyzed by HIV-1 reverse transcriptase in that both analogs have similar substrate specificity constants (kp/Kd) which are only 5-fold lower than dATP. In contrast, PMPApp is a much weaker inhibitor of the reaction catalyzed by T7 exo- (with the DNA/DNA 22/43-mer duplex) in that PMPApp has a 5 x 10(-4)-fold lower kp/Kd than ddATP and dATP. The lower kp/Kd of PMPApp is due to a 1000-2000-fold lower incorporation rate (kp) and a 35-45-fold lower binding constant (Kd). Similarly, PMPApp is 800-fold less inhibitory toward polymerase beta with the DNA/DNA 22/43-mer duplex, whereas in studies with a single nucleotide gapped DNA (22-20/43-mer) PMPApp is 13-fold less inhibitory than ddATP. Although parallel studies will need to be performed using appropriate human polymerases, these results begin to define the mechanistic basis for the reported lower toxicity of PMPA in the treatment of AIDS.

DNA secondary structure effects on DNA synthesis catalyzed by HIV-1 reverse transcriptase

The effect of DNA secondary structure on polymerization catalyzed by human immunodeficiency virus (HIV-1) reverse transcriptase (RT) was studied using a synthetic 66-nucleotide DNA template containing a stable hairpin structure. Four RT pause sites were identified within the first half of the hairpin stem. Additionally, five weak pause sites within the second half of the stem and the loop of the hairpin were identified at low temperatures. These weak pause sites were relocated to the site of the first few stem base pairs of two new hairpins formed due to a change in DNA secondary structure. Each pause site was correlated with a high free energy barrier of melting the stem base pair. Pre-steady state kinetic analysis of single nucleotide incorporation showed that polymerization at each pause site occurred by both a fast phase (10-20 s-1) and a slow phase (0. 02-0.07 s-1) during a single binding event. The reaction amplitudes of the fast phase were small (4-10% of enzyme sites), whereas the amplitudes of the slow phase were large (14-40%) at the pause sites. In contrast, only a single phase with a large reaction amplitude (32-50%) and a fast nucleotide incorporation rate (33-87 s-1) was observed at the non-pause sites. DNA substrates at all sites had similar dissociation rates (0.14-0.29 s-1) and overall binding affinity (16-86 nM). These results suggest that the DNA substrates at pause sites were bound in both productive and non-productive states at the polymerase site of RT. The non-productively bound DNA was slowly converted into a productive state upon melting of the next stem base pair without dissociation of the DNA from RT.

Decreased sensitivity to light of the photic entrainment pathway during chronic clorgyline and lithium treatments

Certain antidepressant drugs (ADs) cause disturbances in sleep that could result from their capacity to alter the timing of circadian rhythms. Effects on the timing of rhythms could be due to the drugs' known capacity to alter the frequency of the intrinsic rhythm of the circadian pacemaker, or to a capacity to modify the pacemaker's response to external stimuli that serve as time cues (Zeitgebers) that regulate the timing (phase) of its rhythm. To examine the possibility that ADs alter the sensitivity of the system that mediates the phase-shifting effects of light, hamsters were treated chronically with the MAOI, clorgyline, and lithium. Each hamster was then exposed to a single 5-min light pulse (intensity range = 0.00137 to 137 microW/cm2) at circadian phases known to elicit phase advances (CT18) and phase delays (CT13.5) in the daily onset of wheel running. The half-saturation constant (sigma), photic sensitivity (1/sigma), and maximum phase-shifting response to light were estimated from the best-fit stimulus response curves. In addition, threshold sensitivity, the light intensity required to produce a threshold phase-shifting response, was determined. Clorgyline decreased the magnitude of light-induced phase advances at each of the light intensities tested. Clorgyline also decreased the magnitude of light-induced phase delays at low light intensities, but increased the magnitude of phase delays at higher light intensities. Clorgyline decreased the sensitivity of the photic phase-shifting system, as indicated both by the threshold sensitivities at CT13.5 and CT18, and by 1/sigma at CT13.5. Lithium decreased the threshold sensitivity at CT18, and 1/sigma at CT13.5. Lithium decreased the magnitude of phase delays, but not phase advances. Clorgyline's effects on the photic entrainment pathway may be mediated by its effects on serotonin, which has been shown to modulate the pacemaker's response to morning and evening light, and by tolerance to this effect of serotonin. The fact that both clorgyline and lithium decrease the photic sensitivity of the entrainment pathway suggests that other psychoactive drugs might also share this property. It is possible that the decreased sensitivity to light of the entrainment pathway affects the clinical response to these and other psychoactive medications.

Preclinical prediction of Alzheimer's disease using SPECT

BACKGROUND

Regional cerebral perfusion measured by single photon emission computed tomography (SPECT) was examined as a preclinical predictor of the development of Alzheimer's disease (AD).

METHODS

Singular value decomposition was used to produce 20 SPECT factors (known as vectors) (n=152). Vector scores were then computed for four groups (n=136), differing in cognitive status: Group 1--normal controls at both baseline and follow-up; Group 2--subjects with "questionable" AD at both baseline and follow-up; Group 3--subjects with questionable AD at baseline who converted to AD on follow-up (Converters); Group 4--subjects with AD at baseline. All SPECT data in the analyses were gathered at baseline.

RESULTS

The four groups could be distinguished on the basis of their baseline SPECT data (p < or = 0.00005; hit rate=83%). Regional decreases in perfusion were most prominent among Converters in the hippocampal-amygdaloid complex, the posterior cingulate, the anterior thalamus, and the anterior cingulate. Inclusion of apolipoprotein E status did not significantly improve the discrimination.

CONCLUSIONS

SPECT data gathered and analyzed in this manner may be useful as one aspect of the preclinical prediction of AD. Three of the four brain regions important for discriminating Converters from normal controls involve a distributed brain network pertaining to memory, suggesting that this network may be selectively affected in the earliest stages of AD.

Use of singular value decomposition to characterize age and gender differences in SPECT cerebral perfusion

The main objective of this study was to characterize changes in brain perfusion associated with normal aging and gender.

METHODS

Perfusion SPECT images using 99mTc-hexamethyl propyleneamine oxime (HMPAO) were obtained from 152 healthy subjects (67 men, 85 women) aged 50-92 yr. An automated method was developed to objectively assess image data from a large number of brain regions. Image data were reduced with singular value decomposition (SVD), which produced 20 eigenvectors capturing 97.05% of the total information content of 4320 regions from each subject. Subjects were scored individually on each vector.

RESULTS

Multivariate analyses demonstrated that there were no significant differences in whole-brain HMPAO uptake with age, but age-related regional declines were seen in lateral ventricular regions. Women had higher HMPAO uptake than men in estimates of global perfusion and regional perfusion in the midcingulate/corpus callosum, inferior temporal and inferior parietal areas.

CONCLUSION

These discriminations demonstrate that singular value deomposition of SPECT data may be used to assess differences in perfusion patterns between groups of subjects. They replicate several previous findings, both with respect to age-related changes in perfusion and with respect to gender differences. In addition, they identify a previously unreported gender difference in biparietal regions.

Protocol design considerations that relate to demonstrating the safety and effectiveness of chemopreventive agents

As with other drugs, applications for marketing approval of new chemopreventive agents in the United States must include data from adequate and well-controlled clinical trials that demonstrate effectiveness and safety for the intended use. Knowledge of a drug's pharmacologic actions and metabolism may benefit protocol design, by identifying the patient populations and dosing schedules associated with a favorable risk/benefit profile. With availability of appropriate preclinical data, including standard assessments of an agent's toxicology, effects on reproductive performance, and genotoxicity, initial Phase I studies of 1-3 months may be performed in normal volunteers or an appropriate higher risk population. For chronic dosing studies of longer duration, preclinical toxicology studies of longer duration are relevant. Enrollment in chemoprevention studies should be directed toward individuals at sufficient risk of developing cancer so that potential benefit may counterbalance the unpredictable and possibly serious adverse effects that may be observed with prolonged administration of a study drug. Phase I and II studies with clinical dosing lasting up to 12 months often afford opportunities to assess drug effect on surrogate endpoint biomarkers that may correlate with endpoints of clinical effectiveness. Phase III and late phase II chemopreventive investigations should routinely utilize a prospective, randomized study design (double-masked and placebo-controlled, when possible). To support marketing approval, there must be evidence that a chemopreventive agent significantly delays or prevents the occurrence of malignancy, with acceptable safety. In some circumstances, modulation of a surrogate marker may provide a basis for marketing approval, before more definitive endpoint data become available. However, the acceptability of a surrogate depends on the nature and quality of the data supporting its predictive value. Given the considerations of large study size, long duration, and high cost that may hamper development of potential agents, studies designed to examine the predictive value of surrogate endpoint biomarkers are of great importance to the future development of chemoprevention research.

Expression, purification, and initial kinetic characterization of the large subunit of the human mitochondrial DNA polymerase

Faulty replication of the human mitochondrial genome is thought to be the cause of many diseases; moreover, the low selectivity of the mitochondrial DNA polymerase has been implicated as the cause of many side effects observed in the treatment of viral infections such as HIV. To better understand how the mitochondrial genome is replicated, we cloned a cDNA encoding the large subunit of human DNA polymerase gamma, the enzyme that replicates the mitochondrial genome. The large subunit was recombinantly expressed and purified to near homogeneity. The purified enzyme demonstrated both polymerase and 3'-5' exonuclease activity. The purified protein was examined in single nucleotide incorporation assays, demonstrating that the enzyme had a maximum polymerization rate of 3.5 s-1 and a dissociation rate from the DNA substrate of 0.03 s-1, affording a calculated processivity of 116. The dissociation constants for the enzyme binding to DNA and nucleoside triphosphate were 39 nM and 14 microM, respectively. The 3'-5' exonuclease rate was measured at 0. 18 s-1. Though the slow rate of polymerization suggests that the large subunit of human DNA polymerase gamma may require accessory factors to increase its processivity of polymerization, the kinetic parameters indicate that the large subunit of DNA polymerase gamma could replicate the mitochondrial genome in a physiologically relevant time frame. This study provides the initial characterization of the large subunit of DNA polymerase gamma and establishes the baseline for examination of the effects of accessory proteins such as the putative small subunit.

Bimanual co-ordination in Parkinson's disease

The basal ganglia may be involved in bimanual co-ordination. Parkinson's disease (which impairs basal ganglia output) is clinically reported to cause difficulties in the performance of co-ordinated bimanual movements. Nevertheless, any bimanual co-ordination difficulties may be task specific, as experimental observations are equivocal. To infer the role of the basal ganglia in co-ordinating the two arms, this study investigated the bimanual co-ordination of patients with Parkinson's disease. Sixteen Parkinson's disease patients and matched control subjects performed a bimanual cranking task, at different speeds (1 and 2 Hz) and phase relationships. All subjects performed the required bimanual in-phase movement on a pair of cranks, at fast (2 Hz) and slow (1 Hz) speeds. However, the Parkinson's disease patients were unable to perform the asymmetrical anti-phase movement, in which rotation of the cranks differed by 180 degrees, at either speed; but instead reverted to the in-phase symmetrical movement. For Parkinson's disease patients, performance of the in-phase movement was more accurate and stable when an external timing cue was used; however, for anti-phase movement, the external cue accentuated the tendency for patients to revert to more symmetrical, in-phase movements.

Effect of level and source of dietary selenium on concentrations of thyroid hormones and immunoglobulins in beef cows and calves

Our objective was to determine the effect of level and chemical form of dietary selenium on productivity of beef cows, concentrations of triiodothyronine (T3), and thyroxine (T4) in plasma, and immunoglobulins (IgG and IgM) in plasma and colostrum of cows. Pregnant cows (n = 60) were randomly allocated among four dietary treatments of 20, 60, or 120 ppm Se as selenite and 60 ppm as selenomethionine from selenized yeast (SeY) in salts offered free-choice. Treatments began 90 d prepartum and continued through the second parturition. Treatments did not affect the final body weights of cows or birth weights or weaning weights of calves. At parturition, cows given salt with 20 ppm Se as selenite had lower (P < . 05) concentrations of Se in blood than cows with access to higher-Se salts. Treatments affected (P < .01) the concentration of T3 and the ratio of T3:T4 in plasma of cows. The concentration of T3 in plasma of cows with access to salt with 20 ppm Se was 14% lower than that in cows supplemented with 60 ppm Se as selenite or SeY. Plasma IgG in cows and calves, colostrum, and Se concentrations in colostrum, casein, and whey were lowest (P < .01) for cows given salt with only 20 ppm Se. Thus, salts with concentrations of 60 and 120 ppm Se improved measures of Se status in cows and calves. Consideration should be given to the concentrations of T3 and IgG when determining the nutritional requirements for Se in cattle.

Disruption of the activity-rest cycle by MAOI treatment: dependence on light and a secondary visual pathway to the circadian pacemaker

The disruptive effects on the activity-rest cycle of the monoamine oxidase inhibitor (MAOI) clorgyline and of continuous light were examined in Syrian hamsters. When administered in dim and moderate light intensities, clorgyline delayed the daily onset of wheel-running. When administered in bright light, it dissociated the circadian rhythm of wheel-running. This dissociation was prevented by lesions of the intergeniculate leaflet of the ventral lateral geniculate nucleus. Constant darkness restored the circadian rhythm of wheel-running in hamsters with disrupted circadian rhythms. The phase of the restored rhythm of wheel-running was shifted 6-12 h later than the phase of wheel-running prior to dissociation. Our results suggest that MAOI treatment weakens the coupling between oscillators that comprise the circadian pacemaker, and augments the disruptive effects of continuous light acting via the intergeniculate leaflet region of the ventral lateral geniculate nucleus. These effects on the circadian pacemaker may be responsible for disruptions of the sleep-wake cycle that occur as side effects when MAOIs are used clinically to treat depression and might play a role in the induction of mania and rapid cycling by antidepressants.

Advances in transient-state kinetics

Advances in transient-state kinetic methods of data collection by chemical-quench-flow and fluorescence stopped-flow, and in computer simulation analysis have enhanced our ability to establish reaction pathways with greater precision. These methods improve our ability to explore the functions of biologically important structures by direct measurements of single reaction steps.