The Cardiff sib-pair study: suicidal ideation in depressed and healthy subjects and their siblings

Depression is associated with high rates of suicidal ideation, which varies in intensity from transient thoughts of wishing to be dead to the making of plans and, Finally, to attempts to kill oneself. There is limited evidence from family, twin, and adoption studies that completed suicide is familial and has a genetic etiological component. However, it is unclear whether suicidal ideation is also familial. The familiality of suicidal ideation has been examined in the subjects who participated in the Cardiff Depression Study, namely, 108 depressed probands. their nearest-aged siblings, and 105 healthy control subjects and their siblings. The study showed that 66% of depressed subjects had experienced suicidal ideation in the week prior to the interview, and that this was significantly associated with recurrent illness. Suicidal ideation was not shown to be familial. However, somewhat surprisingly, 6% of healthy, never-depressed subjects admitted to having had transient suicidal thoughts. Suicidal ideation was significantly associated with high neuroticism and psychoticism scores and severe threatening life events.

Measuring fitness in healthy older adults: the Health ABC Long Distance Corridor Walk

OBJECTIVES

The Health ABC Long Distance Corridor Walk (LDCW) was designed to extend the testing range of self-paced walking tests of fitness for older adults by including a warm-up and timing performance over 400 meters. This study compares performance on the LDCW and 6-minute walk to determine whether the LDCW encourages greater participant effort.

DESIGN

Subjects were administered the LDCW and 6-minute walk during a single visit. Test order alternated between subjects, and a 15-minute rest was given between tests.

SETTING

The Baltimore Veterans Affairs Medical Center.

PARTICIPANTS

Twenty volunteers age 70 to 78.

MEASUREMENTS

The LDCW, consisting of a 2-minute warm-up walk followed by a 400-meter walk and a 6-minute walk test were administered using a 20-meter long course in an unobstructed hallway. Heart rate (HR) and blood pressure (BP) were recorded at rest and before and after all walks.

RESULTS

All 20 subjects walked a faster pace over 400 meters than for 6 minutes, in which the mean distance covered was 402 meters. From paired t-tests, walking speed was faster (mean difference = 0.23 m/sec; P < .001), and ending HR (mean difference = 7.6 bpm; P < .001) and systolic BP (mean difference = 8.3 mmHg; P = .024) were greater for the 400-meter walk than for the 6-minute walk. Results were independent of test order and subject fitness level.

CONCLUSIONS

Providing a warm-up walk and using a target distance instead of time encouraged subjects to work closer to their maximum capacity. This low-cost alternative to treadmill testing can be used in research and clinical settings to assess fitness and help identify early functional decline in older adults.

Measuring higher level physical function in well-functioning older adults: expanding familiar approaches in the Health ABC study

BACKGROUND

To evaluate development and progression of functional limitation and retain comparability with established approaches, we raised the measurement ceiling of commonly used self-report and performance-based measures of function. This study evaluated the utility and concurrent validity of these expanded measures.

METHODS

The study population consisted of 3075 black and white men and women aged 70 to 79 years, with no reported mobility limitations or disability, participating in the Health, Aging, and Body Composition, or Health ABC study. Self-report measures were expanded by ascertaining ease of performance and including more demanding levels of some tasks. A single foot stand and narrow walk supplemented an established performance battery. For walking endurance, we developed the Long Distance Corridor Walk (LDCW), which includes distance covered in 2 minutes and the time to walk 400 m.

RESULTS

The expanded self-report items identified one half of the men and one third of the women as exceptionally well functioning and 10% to 13% of men and 21% to 36% of women with lower capacity. The supplemented and rescored performance battery discriminated function over the full range. The LDCW further differentiated walking capacity at the high end and also identified a subgroup with limitations. The self-report and performance measures were significantly, but weakly, correlated (0.13-0.35) and were independent predictors of walking endurance.

CONCLUSIONS

Well-functioning persons in their 70s exhibit a broad range of functional capacity readily ascertained by expanded self-report and performance tests. Significant associations among these measures support their concurrent validity, but generally weak correlations indicate they tap different, but important, dimensions of physical function.

Weight change in old age and its association with mortality

OBJECTIVES

Previous studies of weight change and mortality in older adults have relied on self-reported weight loss, have not evaluated weight gain, or have had limited information on health status. Our objective was to determine whether 5% weight gain or loss in 3 years was predictive of mortality in a large sample of older adults.

DESIGN

Longitudinal observational cohort study.

SETTING

Four U.S. communities.

PARTICIPANTS

Four thousand seven hundred fourteen community-dwelling older adults, age 65 and older.

MEASUREMENTS

Weight gain or loss of 5% in a 3-year period was examined in relationship to baseline health status and interim health events. Risk for subsequent mortality was estimated in those with weight loss or weight gain compared with the group whose weight was stable.

RESULTS

Weight changes occurred in 34.6% of women and 27.3% of men, with weight loss being more frequent than gain. Weight loss was associated with older age, black race, higher weight, lower waist circumference, current smoking, stroke, any hospitalization, death of a spouse, activities of daily living disability, lower grip strength, and slower gait speed. Weight loss but not weight gain of 5% or more was associated with an increased risk of mortality that persisted after multivariate adjustment (Hazard ratio (HR) = 1.67, 95% CI = 1.29-2.15) and was similar in those with no serious illness in the period of weight change. Those with weight loss and low baseline weight had the highest crude mortality rate, although the HR for weight loss was similar for all tertiles of baseline weight and for those with or without a special diet, compared with those whose weight was stable.

CONCLUSIONS

This study confirms that even modest decline in body weight is an important and independent marker of risk of mortality in older adults.

The use of pre-cannulation local anaesthetic and factors affecting pain perception in the emergency department setting

STUDY OBJECTIVE

To determine whether the use of subcutaneous local anaesthetic (lignocaine) is associated with a reduction in cannulation pain in the emergency department setting.

METHODS

Patients over 18 with a Glasgow Coma Score (GCS) of 15 and conversational English were allocated into one of three groups: Group 1 were cannulated after routine skin preparation; Group 2 received 1% lignocaine 0.1 ml via a 27 gauge needle and diabetic syringe before cannulation; Group 3 were injected as for Group 2 but saline was substituted for lignocaine. The cannulator and subject were blinded to the ampoule. The pain was measured using a 100 mm visual analogue scale.

SETTING

A large urban university hospital emergency department.

RESULTS

366 patients were recruited and the data on 322 analysed. Those receiving lignocaine before cannulation reported lower pain scores (1.9 cm) than the saline (4.1 cm) or immediate cannulation (3.6 cm) groups, p<0.0001. Other factors such as the experience of cannulator, patient characteristics, the presence of a painful underlying condition and cannula size did not effect pain scores.

CONCLUSION

The use of lignocaine before cannulation reduced cannulation pain in the emergency department setting. Other factors examined did not influence pain perception.

Absolute kinetic characterization of 17-beta-estradiol as a radical-scavenging, antioxidant synergist

We directly measured the absolute reactivity of 17-beta-estradiol (E2) and several phenolic model compounds for E2 toward t-butoxy radical (t-BuO*) by nanosecond time-resolved optical spectroscopy. Compared to other phenols, E2 is a moderate, but not strong deactivator of oxyradicals. The absolute bimolecular rate constant for H-atom transfer from E2 to t-BuO* is 1.3 +/- 0.3 x 10(9) M(-1) x s(-1) (23 degrees C, benzene). We estimate the O-H bond strength of 17-beta-estradiol to be approximately 85 +/- 2 kcal/mol and calculate the reaction rate constant of E2 toward peroxy radical to be 10(5) M(-1) x s(-1) at 37 degrees C. The conjugate phenoxy radical of 17-beta-estradiol, E2O*, is unusually reactive toward alpha-tocopherol and ascorbate by H-atom transfer in homogeneous solution (10(8)-10(9) M(-1) x s(-1)). Our findings suggest that E2 functions in vivo as a highly localized, synergistic biological antioxidant. This may partly explain the clinical effectiveness of ovarian steroids in delaying the manifestations of Alzheimer's Disease as well as in protecting against cardiovascular pathologies. In the absence of complementary antioxidant synergists, E2O* is expected to be a pro-oxidant.

Green tea catechins partially protect DNA from (.)OH radical-induced strand breaks and base damage through fast chemical repair of DNA radicals

The catechins, (-)-epicatechin (EC), (-)-epigallocatechin (EGC), (-)-epicatechin gallate (ECG) and (-)-epigallocatechin gallate (EGCG) are believed to be active constituents of green tea accounting for the reported chemoprevention of certain cancers. The molecular mechanisms by which the measured low concentrations (ca. micromolar) of catechins in humans can reduce the incidence of carcinogenesis is not clear. Using an in vitro plasmid DNA system and radiolytically generating reactive oxygen species (ROS) under constant scavenging conditions, we have shown that all four catechins, when present at low concentrations, ameliorate free radical damage sustained by DNA. A reduction in both prompt DNA single-strand breaks and residual damage to the DNA bases, detected by subsequent incubation with the DNA glycosylases formamidopyrimidine (FPG), endonuclease III (EndoIII) and 5' AP endonuclease exonuclease III (ExoIII), was observed. EGCG was found to be the most active of the catechins, with effects seen at micromolar concentrations. Combined fast-reaction chemistry studies support a mechanism of electron transfer (or H-atom transfer) from catechins to ROS-induced radical sites on the DNA. These results support an antioxidant role for catechins in their direct interaction with DNA radicals.

Sensation-seeking, life events and depression. The Cardiff Depression Study

BACKGROUND

The relationship between adversity and genetic risk factors in depression could be mediated by familial 'hazard prone' traits, as reflected in high levels of sensation-seeking.

AIMS

To examine whether high sensation-seeking scores are associated with more adverse life events resulting in depression.

METHOD

In a sib-pair design, 108 probands with depression and their siblings and 105 healthy control subjects and their siblings were compared for psychopathology, life events and scores on the Sensation-Seeking Questionnaire (SSQ).

RESULTS

The SSQ scores were correlated negatively with depression, were familial and were correlated positively with less severe events, but not the severe events typically associated with depressive onsets.

CONCLUSIONS

The SSQ measures a familial personality trait and depression is associated with lower scores. Although high sensation-seeking is associated with a higher rate of life events, these carry little threat.

The association of bone mineral density and depression in an older population

OBJECTIVE

To evaluate the association between bone mineral density (BMD) and measurements of depression in an older population.

DESIGN

Population-based, cross-sectional study.

SETTING

Study subjects were participants in the Cardiovascular Health Study (CHS), a longitudinal, long-term, follow-up study, at the University of California Davis (Sacramento, California) and the University of Pittsburgh (Pittsburgh, Pennsylvania) clinical centers.

PARTICIPANTS

A random sample of 1,566 Medicare enrollees age 65 and older enrolled in the CHS.

MEASUREMENTS

Total hip BMD, measured using dual energy x-ray absorptiometry (DEXA), after adjustment for multiple covariates, was compared with depression evaluated with the Center for Epidemiological Studies 10-item Depression Scale (CES-Dm). Risk factors for osteoporosis were compared in depressed and nondepressed participants. Potential correlates were entered into a regression model. Depression scores were compared in normal, osteopenic, and osteoporotic individuals.

RESULTS

Sixteen percent of participants were clinically depressed; 9% had BMDs in the osteoporotic range. Mean BMD was 40 mg/cm2 lower in those with clinical depression. High CES-Dm scores were associated with lower BMD (P < .001) when adjusted for body mass index (BMI), age, kilocalories of activity, estrogen use, gender, race, smoking and drinking. When stratified by race, this remained true for all Caucasians (P < .01), all African Americans (P < .05), and when stratified by race and gender the association remained only for all Caucasian women (P < .001). In women and Caucasian men there was an increase in depression scores among individuals with osteoporotic-range BMDs.

CONCLUSIONS

A significant association was found between BMD and depressive symptoms after adjustment for osteoporosis risk factors. In Caucasians, depressive symptoms were associated with both osteoporotic and osteopenic levels of BMD. Causality cannot be ascribed, with only one measurement of BMD. We postulate that there may be an unmeasured third factor, such as an endogenous steroid, that is responsible for both low BMD and depression.

General practice survey of the management of chickenpox: appropriate targeting of antiviral therapy

BACKGROUND

A working party of specialists and GPs recently published their consensus on recommended treatments for chickenpox. These are the closest to recommended guidelines available in the UK. They offer a rational basis for targeting those groups most at risk of complications with antiviral treatment.

OBJECTIVES

The aim of the present study was to compare current practice by GPs in the management of chickenpox, particularly in targeting of antiviral therapy, with the working party recommendations.

METHOD

A questionnaire survey was conducted of all GP principals within a single London Health Authority Responses to nine chickenpox clinical scenarios were compared with the working party recommendations.

RESULTS

The response rate was (69.2%) 227/328. In five of the nine scenarios, fewer than 70% of GPs selected the correct response according to the recommendations. There was both underuse and overuse of antivirals according to the recommendations, with only 42% (96/227) advising oral antivirals or referral for an asthmatic treated with oral steroids 1 month previously, and 24% (53/221) advising oral antivirals 3 days after the chickenpox rash appeared.

CONCLUSIONS

The results suggest some high risk groups may be being undertreated with oral antivirals and there may be considerable use of oral antivirals in situations where they are of no proven benefit.

The Cardiff Depression Study: a sib-pair study of dysfunctional attitudes in depressed probands and healthy control subjects

BACKGROUND

Current cognitive theories propose that depression develops as a result of the interaction between dysfunctional cognitive schemata and environmental stressors. There is also consistent evidence of a substantial genetic contribution to depression. This study examines the familiality and stability of dysfunctional attitudes and attempts to distinguish whether they reflect trait vulnerability to depression or the state of being depressed.

METHOD

The 24-item Dysfunctional Attitude Scale (DAS-24) was completed by 108 depressed probands and their nearest-aged siblings and 105 healthy control probands and their nearest-age siblings, at the time of a semi-structured clinical interview and 10-12 months later. Subjects also completed self-report measures of depressed mood on both occasions.

RESULTS

Measures of clinical depression were significantly correlated with DAS scores. At retest, DAS scores remained elevated despite improvement in mood, giving support for earlier findings, that dysfunctional attitudes remain active following recovery. The dependency subscale (DAS-D) of the DAS showed modest familiality, although there were no significant differences for DAS-D scores between the two groups of siblings. In a multiple regression analysis, current mood-state was the overwhelming predictor of DAS scores. However for DAS-D, gender as well as current mood influenced scores on this subscale.

CONCLUSION

Although there was modest evidence for temporal stability and familiality for some DAS-24 subscale scores, dysfunctional attitudes were predominantly influenced by current low mood, and therefore reflect the state of being depressed rather than a familial vulnerability trait underpinning depression.

High plasma insulin and lipids profile in older individuals: the Italian longitudinal study on aging

BACKGROUND

The inverse relationship of insulin level to high-density lipoprotein (HDL)-cholesterol and its positive association with hypertriglyceridemia has been demonstrated in several studies; however, the relationship of insulin to low-density lipoprotein (LDL)-cholesterol in elderly persons is not clear. This study investigates the relationships of fasting plasma insulin and selected metabolic and biological risk factors in an aged population.

METHODS

The present study is based on a cross-sectional analysis of the data collected at baseline of the Italian Longitudinal Study on Aging in 1992 on a random sample of 5632 Italians aged 65-84 years. Analyses were performed to compare the distribution of risk factors, such as blood level of lipids, creatinine, albumin, fibrinogen, apolipoprotein A-1 and B, blood pressure, and body mass index (BMI), by quartiles of insulin, in both diabetic and nondiabetic participants.

RESULTS

Significantly higher levels of triglycerides and BMI and lower levels of HDL-cholesterol were found in the upper quartile of insulin among nondiabetic individuals. In men, we also found significantly higher levels of systolic and diastolic blood pressure. The same trend for these variables, although not significant for HDL-cholesterol and blood pressure, was seen in diabetic men. In diabetic women, total and LDL-cholesterol were significantly lower in the highest insulin quartile (p <.001), while no significant differences were seen in nondiabetic women or in men. We also found higher levels of white blood cells in the highest insulin quartile of diabetic women.

CONCLUSIONS

These results, apparently in disagreement with earlier reports on the clustering of cardiovascular disease risk factors in hyperinsulinemic individuals, could be due to the high frequency of chronic inflammation and the high prevalence of urinary infections in older diabetic women.

Four examples of anti-TSEN and three of TSEN-positive erythrocytes

BACKGROUND

TSEN (MNS33) is a low-incidence antigen in the MNS blood group system encoded by hybrid glycophorin genes. TSEN is expressed by a unique amino acid sequence that results from the junction of GPA(58) to GPB(27), if the GPB carries S antigen. Until this study, only one example of anti-TSEN had been found. Antibody screening red blood cells (RBCs) positive for both S and s (ref. No. C873) reacted with four patient sera. Initially, the RBCs had been typed as S+s+, but later were typed as S-s+ in another laboratory. Two other RBC samples, one from a volunteer blood donor (D.L.), the other from a patient whose serum contained anti-En(a)FR (J.S.), also gave anomalous results when tested with anti-S. We suspected the presence of TSEN-positive hybrids on all three RBC samples.

MATERIALS AND METHODS

Reactive sera (O.B., E.C., S.K., R.F.) were tested against RBCs with normal MNS phenotypes and with TSEN-positive RBCs. The RBCs of D.L., J.S. and C873 were tested with anti-S whose reactivity with S+s+ TSEN+ RBCs had been established previously, and with the original example of anti-TSEN. Immunoblotting was performed on the C873, D.L. and J.S. RBC membranes using a monoclonal antibody to an epitope common to both glycophorin A and glycophorin B.

RESULTS

The sera from O.B., E.C., S.K. and R.F. were strongly reactive on the indirect antiglobulin test with TSEN+ RBCs. The RBCs of C873, D.L. and J.S. were typed as TSEN+. Immunoblotting pattern of D.L. and C873 were consistent with TSEN heterozygotes, while that of J.S. was consistent with a TSEN homozygote.

CONCLUSIONS

Based on the estimated number of screening events with C873 RBCs, the incidence of anti-TSEN is approximately 1 in 20,000 sera. The antibody is found in patients with and without documented exposure to allogeneic RBCs. All known examples of anti-TSEN are IgG, but their clinical significance is not known.

Comparison of a virtual microscope laboratory to a regular microscope laboratory for teaching histology

Emerging technology now exists to digitize a gigabyte of information from a glass slide, save it in a highly compressed file format, and deliver it over the web. By accessing these images with a standard web browser and viewer plug-in, a computer can emulate a real microscope and glass slide. Using this new technology, the immediate aims of our project were to digitize the glass slides from urinary tract, male genital, and endocrine units and implement them in the Spring 2000 Histology course at the University of Iowa, and to carry out a formative evaluation of the virtual slides of these three units in a side-by-side comparison with the regular microscope laboratory. The methods and results of this paper will describe the technology employed to create the virtual slides, and the formative evaluation carried out in the course. Anat Rec (New Anat) 265:10-14, 2001.

Weight loss from maximum body weight among middle-aged and older white women and the risk of hip fracture: the NHANES I epidemiologic follow-up study

Although weight loss increases bone loss and hip fracture risk in older women, little is known about the relation between weight loss in middle-aged women and subsequent hip fracture risk. The objective of this study was to determine the association between weight loss from reported maximum body weight in middle-aged and older women and the risk of hip fracture. Data were from a nationally representative sample of 2180 community-dwelling white women aged 50-74 years from the Epidemiologic Follow-up Study of the first National Health and Nutrition Examination Survey (NHEFS). In this prospective cohort study, incident hip fracture was ascertained during 22 years of follow-up. The adjusted relative risks associated with weight loss of 10% or more from maximum body weight were elevated for both middle-aged (RR 2.54; 95% CI 1.10-5.86) and older women (RR 2.04; 95% CI 1.37-3.04). For both ages combined, women in the lowest tertile of body mass index at maximum who lost 10% or more of weight had the highest risk of hip fracture (RR 2.37; 95% CI 1.32-4.27). Weight loss from maximum reported body weight in women aged 50-64 years and 65-74 years increased their risk of hip fracture, especially among those who were relatively thin. Weight loss of 10% or more from maximum weight among both middle-aged and older women is an important indicator of hip fracture risk.

Ketamine sedation for pediatric gastroenterology procedures

BACKGROUND

Although the dissociative sedative ketamine is used commonly for pediatric procedural sedation in other settings, the safety of this agent in pediatric gastroenterology is not well-studied. A 5-year experience with ketamine sedation for pediatric gastroenterology procedures was reviewed to document the safety profile of this agent and to identify predictors of laryngospasm during esophagogastroduodenoscopy (EGD).

METHODS

The study was a retrospective consecutive case series of children receiving ketamine administered by pediatric gastroenterologists skilled in basic airway management to facilitate pediatric gastrointestinal procedures during a 5-year period. Patient's records were reviewed to determine indication, dosage, adverse effects, drugs, inadequate sedation, and recovery time for each sedation. A multiple logistic regression analysis was performed to identify predictors of laryngospasm during EGD. Outcome measures were descriptive features of sedation, including adverse effects and predictors of laryngospasm during EGD.

RESULTS

During the study period pediatric gastroenterologists administered ketamine 636 times, primarily for EGD (86%) and primarily by the intravenous route (98%). The median loading dose and total dose were 1.00 mg/kg and 1.34 mg/kg, respectively. Inadequate sedation was noted in seven (1.1%) procedures. Adverse effects included transient laryngospasm (8.2%), emesis (4.1%), recovery agitation (2.4%), partial airway obstruction (1.3%), apnea and respiratory depression (0.5%), and excessive salivation (0.3%). There were no adverse outcomes attributable to ketamine. Nearly half (46%) the subjects had severe underlying illness (American Society of Anesthesiologists (ASA] class > or =3). All instances of laryngospasm occurred during EGD (9.5% incidence), and the only independent predictor of laryngospasm in this sample was decreasing age. The incidence of laryngospasm was 13.9% in preschool-aged (< or =6 years) children and was 3.6% in school-aged (>6 years) children (difference 10.3%, 95% confidence intervals 5.5-14.9%). No dose relationship was noted with laryngospasm, and the risk did not increase with underlying illness.

CONCLUSION

Pediatric gastroenterologists skilled in ketamine administration and basic airway management can effectively administer this drug to facilitate gastrointestinal procedures. Transient laryngospasm occurred in 9.5% of children receiving ketamine for EGD, and its incidence was greater in preschool than in school-aged children.

Recent developments in understanding the psychosocial aspects of depression

Recent advances in the psychosocial understanding of depression have elaborated an already complex aetiological model. Yet each new strand seems to echo, and forge links with, themes uncovered earlier, making it easier to see what is common about the 'final common pathway' to onset. For example, although recent stressors have for some time been recognised predictors of onset, new insights about the origins of these stressors have overlapped with other new work on depression and childhood adversity to identify a group who 'produce' their own severe life events in response to early negative experience. And recent studies have traced the well-known gender difference in depressive prevalence to differences both in gender role involvement with the provoking life events and in styles of support-seeking/ support-giving. What emerges is the powerlessness, loss and humiliation characterising the final pathway. Both naturalistic studies and controlled trials suggest that psychosocial situations reflecting the opposite emotional meaning, that is new hope, characterise a similar pathway to remission. Conclusions speculate whether awareness of this pathway might enhance purely pharmacological treatment.

An ERP investigation of binding and coreference

This study examines the nature of violations in processing one class of binding construction, namely those involving reflexives and their antecedents. When arguments of verbs appear at the point where a syntactic violation is detected, a centroparietal positivity occurs, peaking at 600 ms after the presentation of the stimulus (P600), as is consistent with other types of syntactic anomalies. However, nonarguments in similar sentences fail to elicit the same response. For example, the reflexive in "John's brothers like himself" is in an argument position and elicits the P600 when compared to its grammatical counterpart. The nonargument, participating in the same type of mismatch, "John's brothers like Bill and himself," does not elicit the same positivity. This provides evidence that there are two processes involved in parsing this binding construction, one syntactic and another as yet unidentified, perhaps involving meaning or pragmatics.

Structural genomics in the biotechnology sector

Commercial efforts in structural genomics focus on providing to pharmaceutical customers information that relates to the suitability of specific proteins as drug targets and the informed selection and refinement of lead compounds generated by high-throughput screening and rational approaches. These efforts follow a variety of business models and are impacted by activities in the public domain, recent technological advances, and the changing intellectual property landscape.

State scholarship, loan forgiveness, and related programs: the unheralded safety net

CONTEXT

In the mid-1980s, states expanded their initiatives of scholarships, loan repayment programs, and similar incentives to recruit primary care practitioners into underserved areas. With no national coordination or mandate to publicize these efforts, little is known about these state programs and their recent growth.

OBJECTIVES

To identify and describe state programs that provide financial support to physicians and midlevel practitioners in exchange for a period of service in underserved areas, and to begin to assess the magnitude of the contributions of these programs to the US health care safety net.

DESIGN

Cross-sectional, descriptive study of data collected by telephone, mail questionnaires, and through other available documents, (eg, program brochures, Web sites).

SETTING AND PARTICIPANTS

All state programs operating in 1996 that provided financial support in exchange for service in defined underserved areas to student, resident, and practicing physicians; nurse practitioners; physician assistants; and nurse midwives. We excluded local community initiatives and programs that received federal support, including that from the National Health Service Corps.

MAIN OUTCOME MEASURES

Number and types of state support-for-service programs in 1996; trends in program types and numbers since 1990; distribution of programs across states; numbers of participating physicians and other practitioners in 1996; numbers in state programs relative to federal programs; and basic features of state programs.

RESULTS

In 1996, there were 82 eligible programs operating in 41 states, including 29 loan repayment programs, 29 scholarship programs, 11 loan programs, 8 direct financial incentive programs, and 5 resident support programs. Programs more than doubled in number between 1990 (n = 39) and 1996 (n = 82). In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state programs, a number comparable with those in federal programs. Common features of state programs were a mission to influence the distribution of the health care workforce within their states' borders, an emphasis on primary care, and reliance on annual state appropriations and other public funding mechanisms.

CONCLUSIONS

In 1996, states fielded an obligated primary care workforce comparable in size to the better-known federal programs. These state programs constitute a major portion of the US health care safety net, and their activities should be monitored, coordinated, and evaluated. State programs should not be omitted from listings of safety-net initiatives or overlooked in future plans to further improve health care access. JAMA. 2000;284:2084-2092.

Genetics, genomics, and drug discovery

Genetics and genomics are altering the drug discovery process and changing the practice of medicine. Genetic mapping and positional cloning will lead to the identification of disease susceptibility alleles of different genes and this will be further enabled by the publication of the DNA sequence of the human genome. Single nucleotide polymorphisms discovered by comparative sequencing and other methods will also speed up positional cloning and allow pharmacogenetics to proceed in a more comprehensive way than heretofore. Gene expression arrays coupled with studies in model organisms will help to define the function of all genes and determine how the products interact-the next big step. High throughput protein structure determination will also provide large-scale descriptions of protein function but with more biochemical clarity. In all of these studies data integration remains the biggest challenge.

Muscle strength and body mass index as long-term predictors of mortality in initially healthy men

BACKGROUND

Muscle weakness, low body weight, and chronic diseases are often observed in the same people; however, the association of muscle strength with mortality, independent of disease status and body weight, has not been elucidated. The aim was to assess hand grip strength as a predictor of all-cause mortality within different levels of body mass index (BMI) in initially disease-free men.

METHODS

Mortality was followed prospectively over 30 years. Maximal hand grip strength tests and BMI assessments were done at baseline in 1965 to 1970. The participants were 6040 healthy men aged 45 to 68 years at baseline living on Oahu, Hawaii.

RESULTS

The death rates per 1000 person years were 24.6 in those with BMI <20, 18.5 in the middle BMI category, and 18.0 in those with BMI > or = 25. For grip strength tertiles, the mortality rates were 24.8 in the lowest, 18.5 in the middle, and 14.0 in the highest third. In Cox regression models, within each tertile of grip strength, BMI showed only minimal effect on mortality. In contrast, in each category of BMI there was a gradient of decreasing mortality risk with increasing grip strength. Among those with BMI <20, the adjusted relative risks (RRs) of mortality over 30 years were 1.36 (95% confidence interval 1.14-1.63) for those in the lowest third of strength at baseline, 1.27 (1.02-1.58) in the middle, and 0.92 (0.66-1.29) in the highest third. Correspondingly, for those with BMI 20-24.99, the RRs of death were 1.25 (1.08-1.45), 1.14 (1.00-1.32), and 1.0 (reference) in the lowest, middle, and highest third of grip strength, respectively. In those with BMI > or =25, the RRs were 1.39 (1.16-1.65) in the lowest, 1.27 (1.08-1.49) in the middle, and 1.14 (0.98-1.32) in the highest third of grip strength. Models were adjusted for age, education, occupation, smoking, physical activity, and body height.

CONCLUSIONS

In healthy middle-aged men, long-term mortality risk was associated with grip strength at baseline, independent of BMI. The possible interpretation of the finding is that early life influences on muscle strength may have long-term implications for mortality. Additionally, higher strength itself may provide greater physiologic and functional reserve that protects against mortality.

General anesthetic action at an internal protein site involving the S4-S5 cytoplasmic loop of a neuronal K(+) channel

The structural bases of general anesthetic action on a neuronal K(+) channel were investigated using the series of homologous 1-alkanols, electrophysiology, and mutational analysis. Domain swapping between dShaw2 (alkanol-sensitive) and hKv3.4 (alkanol-resistant) and site-directed mutagenesis demonstrated that a 13-amino acid cytoplasmic loop (S4-S5) determines the selective inhibition of native dShaw2 channels by 1-alkanols. The S4-S5 loop may contribute to a receptor for both 1-alkanols and the inactivation particle, because the enhanced 1-alkanol sensitivity of hKv3.4 channels hosting S4-S5 mutations correlates directly with disrupted channel inactivation. Evidence of a discrete protein site was also obtained from the analysis of the relationship between potency and alkyl chain length, which begins to level off after 1-hexanol. Rapid application to the cytoplasmic side of inside-out membrane patches shows that the interaction between dShaw2 channels and 1-alkanols equilibrates in <200 ms. By contrast, the equilibration time is >1000-fold slower when the drug is applied externally to outside-out membrane patches. The data strongly favor a mechanism of inhibition involving a discrete internal site for 1-alkanols in dShaw2 K(+) channels. A new working hypothesis proposes that 1-alkanols lock dShaw2 channels in their closed conformation by a direct interaction at a crevice formed by the S4-S5 loop.

Finding function through structural genomics

The recent availability of whole-genome sequences and large numbers of protein-coding regions from high-throughput cDNA analysis has fundamentally changed experimental biology. These efforts have provided huge databases of protein sequences, many of which are of unknown function. Deciphering the functions of these myriad proteins presents a major intellectual challenge.

Cardiff depression study. A sib-pair study of life events and familiality in major depression

BACKGROUND

An excess of both depression and undesirable life events in first-degree relatives of probands with depression as compared with controls has been reported. This association may have reflected a familial factor in common.

AIMS

To examine the familiality of life events and depression and whether there may be a common familial factor influencing vulnerability to depression and the experiencing of life events.

METHOD

In a sib-pair design, 108 probands with depression and their siblings were compared with 105 healthy controls and their siblings for psychopathology and life events.

RESULTS

The lifetime relative risk of depressive disorder in the siblings of depressed subjects as compared with siblings of controls was 9.74, although these groups did not differ in the life events measures. Several categories of events showed significant sibling correlations, but this was due to the same event affecting both members of the pair.

CONCLUSIONS

Although depressive disorder was strongly familial, the familial effects on life events were largely explained by shared experiences. There was no evidence for a common factor influencing both depression and life events.

Beta2-adrenergic receptor agonists and cAMP arrest human cultured airway smooth muscle cells in the G(1) phase of the cell cycle: role of proteasome degradation of cyclin D1

Hyperplasia of airway smooth muscle (ASM) contributes to the airway hyperresponsiveness that characterizes asthma. We have investigated the relationship between cAMP-induced growth arrest of ASM cells and thrombin-stimulated, extracellular-regulated protein kinase (ERK) activity, cyclin D1, and the restriction protein retinoblastoma. The beta(2)-adrenergic receptor agonist albuterol (100 nM) inhibited DNA synthesis after incubation with ASM for periods as brief as 1 h when these coincided with the timing of the restriction point. Inhibition of thrombin-stimulated DNA synthesis by albuterol (1-100 nM), 8-bromo-cAMP (300 microM), or prostaglandin E(2) (1 microM) was accompanied by a reduction in cyclin D1 protein levels. The ERK kinase inhibitor PD98059 (3-30 microM) attenuated thrombin-stimulated ERK phosphorylation and activity and the increase in cyclin D1 protein levels, as did albuterol (1-100 nM) or 8-bromo-cAMP (300 microM). In contrast, neither albuterol (100 nM) nor PD98059 (30 microM) reduced cyclin D1 mRNA levels between 4 and 20 h after thrombin addition, which suggests that elevation of cAMP regulates cyclin D1 by a post transcriptional mechanism. The proteasome inhibitor MG132 (30 and 100 nM) and the calpain I inhibitor N-acetyl-Leu-Leu-leucinal (10 microM) attenuated the reduction in thrombin-stimulated cyclin D1 levels in ASM exposed to albuterol (100 nM), 8-bromo-cAMP (300 microM), or the phosphodiesterase inhibitor isobutylmethylxanthine (100 microM). Thus, the cAMP-induced arrest of ASM in the G(1) phase of the cell cycle is associated with a proteasomal degradation of cyclin D1 protein and a reduced protein retinoblastoma phosphorylation that prevents passage through the restriction point.

Association between bone mineral density and cognitive decline in older women

OBJECTIVE

To test the hypothesis that bone mineral density (BMD), a marker of cumulative estrogen exposure, is associated with cognitive function in nondemented older women.

DESIGN

A prospective cohort study.

SETTING

Clinical centers in Baltimore, Maryland, Minneapolis, Minnesota, the Monongahela Valley near Pittsburgh, Pennsylvania, and Portland, Oregon.

PARTICIPANTS

We evaluated 8333 older community-dwelling women enrolled in the Study of Osteoporotic Fractures who were not taking estrogen replacement.

MEASUREMENTS

Calcaneal and hip BMD were measured at baseline and at follow-up (4-6 years later); vertebral fractures were ascertained radiologically at year 6. Women were administered a modified Mini-Mental State Exam, Trails B, and Digit Symbol at baseline and at follow-up.

RESULTS

Compared with women with higher bone mineral density, women with low baseline BMD had up to 8% worse baseline cognitive scores (P = .001) and up to 6% worse repeat cognitive scores (P = .001), even after multivariate adjustments. For 1 SD decrease in baseline hip BMD or calcaneal BMD, women had a 32% (95% CI, 19-47%) or a 33% (95% CI, 20-48%) greater odds of cognitive deterioration (worst 10th percentile of change). Women with vertebral fractures had lower cognitive test scores and a greater odds of cognitive deterioration than those without fractures (OR = 1.29; 95% CI, 1.03-1.60).

CONCLUSIONS

Women with osteoporosis, whether measured by baseline BMD, reductions in BMD, or vertebral fractures, have poorer cognitive function and greater risk of cognitive deterioration. Our findings suggest a link between two of the most common conditions affecting older women. Further understanding of this association may be important for new treatment and prevention directions.

Association between stress and glycemic control in adults with type 1 (insulin-dependent) diabetes

OBJECTIVE

To examine the relationship between stressful life events and alterations in glycemic control in adults with diabetes.

RESEARCH DESIGN AND METHODS

The occurrence of stressful experiences was recorded using the life Events and Difficulties Schedule of Brown and Harris in 55 adults with type 1 diabetes. The two most recent measures of glycemic control (HbA1c) were obtained from medical records, with poor glycemic control defined by the sample median (> or =7.7%).

RESULTS

Subjects whose control deteriorated over time or who remained in poor glycemic control were significantly more likely to report severe personal stressors (SPS) in the month before HbA1c measurement, compared with subjects whose control remained fair or whose control improved (43 and 25% vs. 7 and 0%; P = 0.000). Subjects whose control remained fair or whose control improved were significantly more likely to report only positive life events during the same time period (80 and 11% vs. 0 and 0%, respectively; P = 0.000). Multiple regression analysis demonstrated that SPS, sex, and lack of further education were all significantly associated with either remaining in poor control or deterioration of control.

CONCLUSIONS

The study has shown that recent severe stressors are associated with poorer glycemic control. Positive life events were associated with fair or improved glycemic control. This study has its limitations, and future studies should be prospective in design. While it is not always possible to avoid stress, learning to recognize and cope with stressors may help individuals with diabetes maintain good glycemic control and improve overall quality of life.

Glucocorticoids inhibit proliferation, cyclin D1 expression, and retinoblastoma protein phosphorylation, but not activity of the extracellular-regulated kinases in human cultured airway smooth muscle

We have previously shown that glucocorticoids inhibit mitogen-stimulated proliferation of human cultured airway smooth muscle (ASM) cells. The present study analyzed the effect of glucocorticoids on key regulatory pathways leading to passage of cells through the restriction point of the cell cycle, including those mediated by extracellular-regulated kinases (ERK) 1 and 2; the ERK upstream regulator MAPK kinase (MEK1); cyclin D1 levels; and levels and phosphorylation of retinoblastoma protein (pRb). Fluticasone propionate, a new inhaled glucocorticoid, was at least 10-fold more potent than dexamethasone in inhibiting thrombin-stimulated DNA synthesis and increases in cell number. Thrombin-stimulated increases in the levels and hyperphosphorylation of pRb were inhibited by glucocorticoids, which also reduced thrombin-stimulated cyclin D1 protein and messenger RNA (mRNA) levels. PD98059 (10 microM), an inhibitor of MEK1 activation, markedly attenuated thrombin stimulation of ERK activity and phosphorylation, DNA synthesis, and cyclin D1 levels. However, glucocorticoids had no effect on ERK activity or phosphorylation at 5 min, 2 h, or 12 h after addition of thrombin. In conclusion, glucocorticoid-induced reduction of cyclin D1 mRNA and protein levels, and of pRb phosphorylation, is sufficient to account for inhibition of ASM proliferation. Furthermore, these inhibitory effects of glucocorticoids on cyclin D1 and pRb occur on a component of the mitogen signaling cascade that is either downstream of or parallel to the ERK pathway.

The external urethral barrier for stress incontinence: a multicenter trial of safety and efficacy. Miniguard Investigators Group

OBJECTIVE

To assess the efficacy and safety of an external urethral barrier for the management of mild to moderate stress urinary incontinence in adult women.

METHODS

Four hundred eleven women with the symptom of stress urinary incontinence in 12 United States centers participated. Additional inclusion and exclusion criteria were applied before protocol device use, and ultimately 390 subjects began device use. Outcome measures for efficacy and safety were assessed. Efficacy was evaluated by the number of leakage episodes using a voiding diary, subjective urinary leakage severity, incontinence impact scores, and pad testing. Safety was evaluated by symptom assessment, urinalysis, urine culture, measurement of postvoid residual urine volume, vulvar cytology, vaginal culture, and (n = 81) cystometric testing.

RESULTS

Efficacy was indicated by statistically significant reductions in the number of leakage episodes, subjective leakage severity scores, incontinence impact scores, and pad-test loss during device use. The data also indicated that the device was safe, as evidenced by the lack of statistically significant changes in the percentage of subjects with urinary tract infections during device use or in postvoid residual urine volume and cystometric indices. Symptoms of vulvar irritation or lower urinary tract discomfort occurred in a small percentage of subjects but were generally transient, and only three women discontinued using the device.

CONCLUSION

The external urethral barrier appears to be a safe nonsurgical alternative to absorbent products for the management of mild to moderate stress urinary incontinence in adult women.

Longitudinal association of vascular and Alzheimer's dementias, diabetes, and glucose tolerance

OBJECTIVE

To assess the relationship between impaired glucose tolerance and both vascular dementia and AD.

BACKGROUND

Diabetes and abnormalities of glucose metabolism have been associated with stroke and poor cognitive function. In addition, glycoproteins and glycosylation have been postulated to be associated with the development of neuritic plaques characteristic of AD.

METHODS

A historical prospective cohort study of Japanese-American men (n = 3,774), who were examined at ages 45 to 68 (1965 through 1968) and again at ages 71 to 93 (1991 through 1993). Measurements were obtained by clinical and home examinations: assessment of glucose intolerance (nonfasting 1 hour after glucose load) from 1965 through 1968 and history of diabetes diagnosed by a physician at examinations given from 1965 through 1968 and from 1976 through 1978. At the 1991 through 1993 examinations, the Cognitive Assessment Screening Instrument (CASI)-an instrument designed for use in cross-cultural settings combining features of the Folstein Mini-Mental State Examination, the Modified Mini-Mental State Examination, and the Hasegawa Dementia Screening Scale-was used. Diagnosis and classification of AD and vascular dementia were made by a consensus panel using neuropsychologic assessment data, a neurologist's evaluation, and information from a family informant. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised criteria were used to establish dementia, and subclassification by cause was based on other published criteria.

RESULTS

No association between AD and diabetes, present either 25 or 15 years previously, was found after adjustment for age and education in a multiple regression model. A significant association was found between impaired glucose tolerance at baseline and vascular dementia (p < 0.01).

CONCLUSIONS

These findings confirm expected relationships between impaired glucose tolerance and stroke-related dementia but do not support an association of disordered glucose metabolism with AD.

Befriending as an intervention for chronic depression among women in an inner city. 2: Role of fresh-start experiences and baseline psychosocial factors in remission from depression

BACKGROUND

Volunteer befriending promoted remission of chronic depression when clinical and other treatment variables were controlled.

AIMS

To examine the role of other psychosocial factors relevant for outcome.

METHOD

Factors measured at baseline interview were examined in multivariate analyses along with psychosocial factors occurring during follow-up, such as 'fresh-start' experiences and new severe events and difficulties.

RESULTS

Fresh-start experiences and a standard attachment style were found to enhance chances of remission, with new severe stressors and markedly poor coping strategies liable to prevent it, with volunteer befriending continuing to play a role.

CONCLUSIONS

The positive result reported in the preceding paper is unlikely to be an artefact. However, fresh-start experiences, absence of new severe stressors and standard attachment style were more important predictors of remission. This knowledge might profitably be incorporated into the evaluation of existing treatments.

Befriending as an intervention for chronic depression among women in an inner city. 1: Randomised controlled trial

BACKGROUND

Earlier work on the protective role of social support in onset and course of depressive disorder suggested that its provision might be relevant for outcome.

AIMS

To evaluate volunteer befriending as an intervention among women with chronic depression in inner London.

METHOD

A randomised controlled trial, with a waiting list control design, with outcome measured as Present State Examination (PSE)-based full or partial remission after one year.

RESULTS

A statistically significant effect upon remission was found for befriending. Other treatments monitored naturalistically did not relate to remission, nor did initial duration of chronic episode or comorbidity, but there was an association with initial PSE score. The findings are discussed in relation to standard drug-trial results and to another befriending intervention with the elderly.

CONCLUSIONS

The results are not unpromising. Additional trials with less restricted intake conditions, and in more naturalistic general practice settings, might confirm volunteer befriending as a useful adjunct to current treatments.

A case-control study of the factors associated with spontaneous resolution of hepatitis C viremia

OBJECTIVE

Infection with the hepatitis C virus (HCV) becomes chronic in 85% of the infected individuals. We studied risk factors that may predict clearance of HCV.

METHODS

A case-control study compared the association between risk factors and viral clearance. Viral clearance was defined as presence of a positive HCV antibody test plus negative HCV test by polymerase chain reaction (PCR). Forty-four cases and 214 controls with persistent viremia were identified in a database of patients evaluated at the Gastroenterology Clinic of the University of New Mexico.

RESULTS

Of all 258 HCV-antibody-positive patients, 17% had a negative test by PCR. The multivariate logistic regression revealed that a history of parenteral exposure and a long time interval since the most recent exposure were both associated with an increased likelihood of persistent viremia, whereas subjects who had been monogamous for longer time periods were more likely to have cleared HCV from their serum. A low serum level of ferritin also conferred protection against persistent viremia. Case and control subjects did not differ with respect to their demographic characteristics, occurrence of comorbid disease, previous medical history, occurrence of sexually transmitted diseases, blood group, and risky health or sexual practices.

CONCLUSIONS

These data suggest that route of exposure and time when exposure occurred are important in the development of persistent HCV infection.

Body mass index, weight change, and incidence of self-reported physician-diagnosed arthritis among women

OBJECTIVES

This study examined the relationship between body mass index (BMI), weight change, and arthritis in women.

METHODS

Data were taken from the 1982-1984 National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study of 3617 women, aged 25 to 74 years.

RESULTS

Women with a BMI greater than 32 at initial interview were at significantly higher risk of developing arthritis than women with a BMI of 19 to 21.9. Compared with stable-weight women with a BMI of less than 25, women who were obese at initial interview (BMI > 29) and who subsequently maintained their weight or gained more than 10% of their body weight were at significantly higher risk of developing arthritis.

CONCLUSIONS

Attaining and maintaining a healthy weight may reduce the risk of developing arthritis.