Plasma homocysteine concentrations in type II diabetic patients in India: relationship to body weight

Hyperhomocysteinemia has been established as a risk factor for cardiovascular disease and occurs with a high prevalence in patients with type II diabetes and microvascular disease. In order to determine whether plasma homocysteine concentrations vary with body-mass index in patients with type II diabetes, we measured plasma homocysteine in lean, normal weight, and overweight subjects living in India. Plasma homocysteine concentrations were significantly lower in the lean persons with diabetes when compared to those who were obese and compared to control subjects (p < 0.02). We conclude that plasma homocysteine concentrations are lower in lean persons with type II diabetes and that this efficiency in homocysteine metabolism may contribute towards protection from cardiovascular disease in this population.

A retrospective investigation of an intensive outpatient substance abuse treatment program

Outpatient treatment for chemical dependency has been found to be both clinically effective and cost efficient. The purpose of this retrospective investigation was to evaluate program completion data and variables related to attrition for an intensive outpatient substance abuse treatment program. Subjects were 488 clients enrolled in the Smithers Evening Rehabilitation Program between 1991 and 1995. Client drug preference was found to be an important factor related to treatment retention, with cocaine abusers having the highest attrition rates. In addition, increasing age was an advantage in predicting who would complete the initial phase of treatment. Implications for programmatic changes, clinical practice, and future research are considered.

Mechanisms contributing to the deficits in hippocampal synaptic plasticity in mice lacking amyloid precursor protein

Abnormal processing of amyloid precursor protein (APP), in particular the generation of beta-amyloid (Abeta) peptides, has been implicated in the pathogenesis of Alzheimer's disease. This study examined the consequences of deleting the APP gene on hippocampal synaptic plasticity, and upon the biophysical properties of morphologically identified neurones in APP-null mice. The hippocampus of APP-null mice had a characteristic increase in gliosis throughout the CA1 region and a disruption of staining for the dendritic marker MAP2 and the presynaptic marker synaptophysin. The disruption of MAP2 staining was associated with a significant reduction in overall dendritic length and projection depth of biocytin labeled CA1 neurones. In two groups of APP-null mice that were examined at 8-12 months, and 20-24 months of age, there was an impairment in the formation of long-term potentiation (LTP) in the CA1 region compared to isogenic age matched controls. This LTP deficit was not associated with an alteration in the amplitude of EPSPs at low stimulus frequencies (0.033 Hz) or facilitation during a 100 Hz stimulus train, but was associated with a reduction in post-tetanic potentiation. Paired-pulse depression of GABA-mediated inhibitory post-synaptic currents was also attenuated in APP-null mice. These data demonstrate that the impaired synaptic plasticity in APP deficient mice is associated with abnormal neuronal morphology and synaptic function within the hippocampus.

Safety and biological efficacy of an adeno-associated virus vector-cystic fibrosis transmembrane regulator (AAV-CFTR) in the cystic fibrosis maxillary sinus

OBJECTIVE

The host immune response and low vector efficiency have been key impediments to effective cystic fibrosis transmembrane regulator (CFTR) gene transfer for cystic fibrosis (CF). An adeno-associated virus vector (AAV-CFTR) was used in a phase I dose-escalation study to transfer CFTR cDNA into respiratory epithelial cells of the maxillary sinus of 10 CF patients.

STUDY DESIGN

A prospective, randomized, unblinded, dose-escalation, within-subjects, phase I clinical trial of AAV-CFTR was conducted.

PATIENTS

Ten patients with previous bilateral maxillary antrostomies were treated.

MAIN OUTCOME MEASURES

Safety, gene transfer as measured by semiquantitative polymerase chain reaction (PCR), and sinus transepithelial potential difference (TEPD) were measured.

RESULTS

The highest level of gene transfer was observed in the range of 0.1-1 AAV-CFTR vector copy per cell in biopsy specimens obtained 2 weeks after treatment. When tested, persistence was observed in one patient for 41 days and in another for 10 weeks. Dose-dependent changes in TEPD responses to pharmacologic intervention were observed following treatments. Little or no inflammatory or immune responses were observed.

CONCLUSION

AAV-CFTR administration to the maxillary sinus results in successful, dose-dependent gene transfer to the maxillary sinus and alterations in sinus TEPD suggestive of a functional effect, with little or no cytopathic or host immune response. Further study is warranted for AAV vectors as they may prove useful for CFTR gene transfer and other in vivo gene transfer therapies. A prospective, randomized, double-blind, placebo-controlled, within-subjects, phase II clinical trial of the effect AAV-CFTR on clinical recurrence of sinusitis will determine the clinical efficacy of AAV gene therapy for CF.

Development and validation of the Burton Score: a tool for nutritional assessment

This paper describes the development and validation of the Burton Score, a nutritional assessment tool based on the Waterlow score, with the rationale that since nurses already collect data for one score, it would only lead to unnecessary duplication of effort if a totally different scoring scheme were to be used for nutritional assessment. Initial cut offs were determined by a pilot study of 26 patients on an elderly care ward and validated by comparing the nutritional status of 263 patients estimated by the Burton score with a dietitian's assessment of nutrition. The validation study showed that although there was significant correlation between the Burton and Waterlow scores the Burton score correlated more closely with the dietitian's assessments. The King's Fund report of 1992 stated that all patients should have assessment of nutritional status on admission to hospital: we believe the Burton score could provide a simple tool to achieve this goal.

Pharmacokinetics and pharmacodynamics of sibrafiban (Ro 48-3657), an orally active IIb/IIIa antagonist, administered alone or in combination with heparin, aspirin, and recombinant tissue-type plasminogen activator in beagles

This study characterized the pharmacokinetics (PK) and pharmacodynamics (PD) of sibrafiban (Ro 48-3657) in the presence of aspirin, heparin, and recombinant tissue-type plasminogen activator (rt-PA) in beagles. Sibrafiban is a double prodrug that undergoes bioconversion to the inactive prodrug Ro 48-3656 and to the active IIb/IIIa antagonist, Ro 44-3888, after oral administration. After oral sibrafiban, peak Ro 48-3656 plasma concentrations were observed earlier than Ro 44-3888 and were five- to sixfold higher than Ro 44-3888 peak concentrations. Administration of sibrafiban with heparin and aspirin or heparin and rt-PA did not alter sibrafiban PK. Ro 48-3656 and Ro 44-3888 PK and inhibition of platelet-aggregation profiles in groups treated with sibrafiban and heparin/aspirin or sibrafiban and heparin/rt-PA were similar to those of the group receiving sibrafiban alone. Sibrafiban resulted in >80% inhibition of adenosine diphosphate (ADP)-mediated platelet aggregation and an approximate sixfold increase in bleeding time (BT) compared with baseline measurements. The BT increase was greater in the sibrafiban, heparin, and rt-PA-treated group, during rt-PA administration, compared with the group treated with sibrafiban alone. The recovery of platelet aggregation may be slower after administration of sibrafiban with heparin and rt-PA. Sibrafiban had no effect on rt-PA PK or heparin PD.

Effect of troglitazone on fibrinolysis and activated coagulation in patients with non-insulin-dependent diabetes mellitus

The objective of this study was to determine if treatment of non-insulin-dependent diabetes mellitus (NIDDM) patients with the "insulin sensitizer" troglitazone, both as monotherapy and in combination with insulin, corrects the impaired fibrinolysis and activated coagulation associated with NIDDM. Patients participating in two clinical trials comparing troglitazone and placebo in patients with NIDDM were studied at the time of randomization and after 26 weeks of treatment. Eighteen patients were treated with troglitazone (ten in combination with insulin and eight as monotherapy) and eight were treated with placebo (four in each trial). Plasma concentrations of plasminogen activator inhibitor (PAI-1), prothrombin fragment F1+2, fibrinogen, and von Willebrand Factor (vWF) activity were measured. Plasma PAI-1 concentrations fell significantly from a mean of 68.8 +/- 32.3 ng/mL to 40.4 +/- 20.4 in the troglitazone treated group, but did not change significantly in the placebo treated group. Plasma PAI-1 concentrations were elevated in 15 patients treated with troglitazone and fell to normal in eight of them. There was no significant change in plasma F1+2, vWF, and fibrinogen, but plasma C-peptide and triglyceride concentrations fell significantly with troglitazone. This study demonstrates that troglitazone treatment is associated with a significant fall in plasma PAI-1 antigen concentrations in patients with NIDDM and, therefore, may have a beneficial effect on fibrinolysis.

Prenatal diagnosis of heterozygosity for biotinidase deficiency by enzymatic and molecular analyses

Biotinidase deficiency is characterized by neurological and cutaneous abnormalities that can be prevented or ameliorated by oral biotin therapy. A child with biotinidase deficiency went undiagnosed for a long period and has irreversible neurological deficits despite biotin treatment. This child is homozygous for the most common mutation (G98:d7i3) found in symptomatic children with the disorder. The parents insisted on having prenatal diagnosis in a subsequent pregnancy to alleviate their anxiety about having another affected child. Mutation analysis of DNA obtained directly from amniotic fluid and from cultured amniocytes revealed that the fetus was heterozygous for the mutation. Maternal cell contamination of the amniocytes was excluded by genotype analysis. Biotinidase activity in extracts of cultured amniocytes revealed 40 per cent of mean normal activity. At birth, the infant was confirmed to be heterozygous by serum enzyme analysis. This is the first report of the use of molecular analysis for the prenatal diagnosis for biotinidase deficiency.

Measure the gap! A proposed simplified approach for measuring the descent of the base of the left ventricle

The evaluation of left ventricular systolic function represents a common request for an echocardiographic examination. Several parameters have been proposed to quantitate left ventricular systolic function. The descent of the base of the left ventricle is founded on sound principle but currently requires multiple, time-consuming steps to derive during an echocardiographic examination. This article has reviewed the basic tenet of the descent of the base, reviewed the current required echocardiographic measurements needed to obtain a descent of the base value and has proposed a simplified approach by measuring the gap seen during the routine calculation of left ventricular end-systolic volume, end-diastolic volume, and ejection fraction by the recommended method of discs.

Detection rates and false positive rates for Down's syndrome screening: how precisely can they be estimated and what factors influence their value?

Down's syndrome screening is currently carried out using a combination of biochemical markers measured in maternal serum samples; these include MSAFP, Total hCG, uE3 and Free beta-hCG. Recently a number of papers have compared the effectiveness of different combinations of these markers. Some recommend MSAFP, Total hCG and uE3 (triple test) while others advocate MSAFP and Free beta-hCG (double test). The cases put forward to support these tests rely on estimated detection and false positive rates for the proposed test. A recent paper by Wright used simulation techniques to estimate the effects of sampling error on such error rates. In prospective studies there are two methods commonly used for estimating these rates. We obtain formulae for the standard deviations of these estimates and show that one of them always gives a smaller standard error than the other. We also show that in such studies the accuracy of estimating detection rates and false positive rates depends not only upon the method of calculation but also on the age distribution of pregnant women and the parameters used to calculate patient specific risk. We show that these effects can result in estimation errors of such magnitude that many observed differences in detection rates could be of questionable significance, a conclusion also reached by Wright.

Neuromedin C decreases potassium conductance and increases a non-specific conductance in rat suprachiasmatic neurones in brain slices in vitro

Whole-cell recordings were made, in both current and voltage clamp, from suprachiasmatic neurones maintained in coronal rat brain slices. In current clamp doses of 10 and 100 nM neuromedin C (NMC) were shown to increase basal firing rate in 9 out of 32 neurones. The excitatory responses to 100 nM NMC were accompanied by small increases in neuronal input resistance (25.0 +/- 9.9% in 4 out of 7 neurones tested) and depolarisations of membrane potential (9.8 +/- 3.4 mV in 4 out of 7 neurones tested). However, 10 nM NMC caused no changes in either neuronal input resistance or membrane potential despite the clear increases in neuronal firing rate. When voltage-clamped at -60 mV, 100 nM NMC induced an inward current of 14.8 +/- 1.2 pA in 46 of 210 neurones. The NMC-induced inward current was shown to be unaffected by perfusion with 1 microM tetrodotoxin (TTX). The inward current recorded at -60 mV was typically associated with a decrease in membrane conductance. Construction of current-voltage relationships in the absence and presence of 100 nM NMC showed that with the majority of the NMC-sensitive neurones the inward current either reversed polarity close to the potassium reversal potential or decreased at hyperpolarised potentials. This reversal potential was shifted to more depolarised potentials when the extracellular concentration of potassium was increased. The NMC-induced inward current was unaffected by reduction of the extracellular concentration of sodium or by addition of 0.2 mM cadmium. In potassium-free conditions, in both the dialysing pipette solution and perfusing saline, NMC was still able to induce an inward current. The additional reduction of the extracellular concentration of sodium, whilst recording in potassium-free conditions, was also unable to abolish the inward current. Recordings made with an electrode containing the non-hydrolysable guanosine triphosphate analogue, guanosine 5'-thio-triphosphate, resulted in NMC-induced inward currents which failed to recover to baseline. It is concluded that NMC excites a subpopulation of suprachiasmatic neurones by decreasing a resting potassium conductance and increasing a non-specific conductance, via a G-protein link.

Comparison of Wallgraft and Wallstent for treatment of complex iliac artery stenosis and occlusion. Preliminary results of a prospective randomized study

We performed a prospective randomized study to compare the use of a bare metal stent (WALLSTENT Endoprosthesis) with use of a covered stent (WALLGRAFT Endoprosthesis)-both made by Schneider, Inc.; Minneapolis, Minn-for the treatment of complex iliac artery stenosis and occlusion. We report the preliminary results of a study performed at our institution from 1 February 1997 through 31 April 1997. The patient group was composed of 6 women and 4 men, with a mean age of 61.8 years (range, 47 to 73 years). Six WALLGRAFT endoprostheses (4 in the left iliac artery and 2 in the right) and 9 WALLSTENT endoprostheses (5 in the left iliac artery and 4 in the right) were implanted. The mean percent stenosis before treatment was similar in both groups (84.17% in the WALLGRAFT group and 82.14% in the WALLSTENT group). The post-treatment stenosis and peak systolic gradients were negligible or zero in both groups. The devices were safely deployed and technical success (< 30% residual stenosis) was achieved in both groups. The mean thigh-brachial index was similar in the 2 groups, both before treatment (0.65 in the WALLGRAFT group and 0.64 in the WALLSTENT group) and after treatment (1.12 in the WALLGRAFT group and 1.12 in the WALLSTENT group). Evaluation of clinical success revealed that symptoms of intermittent claudication improved markedly in 4 of 5 patients who received the WALLGRAFT Endoprosthesis. In the WALLSTENT group, 1 patient had symptomatic improvement, another had 1 limb improve and the other worsen, and the rest had no improvement. Clinical complications were observed in only 1 patient in the WALLGRAFT group and in 2 patients in the WALLSTENT group. These preliminary results indicate very good technical and early success at the 1-month follow-up with the use of the WALLGRAFT Endoprosthesis in complex iliac artery stenosis and occlusion. Despite these promising preliminary results, a longer follow-up study with a larger number of patients is needed to determine the benefits of the WALLGRAFT Endoprosthesis in patients with complex iliac artery stenosis or occlusion.