GABA-containing neurons in the rat ventral tegmental area project to the prefrontal cortex

Dopamine-containing projections from the ventral tegmental area (VTA) to the prefrontal cortex (PFC) have been extensively characterized since their discovery over 25 years ago. However, the VTA projection to the PFC also contains a substantial nondopamine component, whose neurochemical phenotype is unknown. To examine if a portion of this nondopamine VTA projection contains GABA, anterograde and retrograde tract-tracing in the rat was combined with GABA immunocytochemistry and electron microscopy. Following injections of Fluoro-Gold (FG) into the PFC, many VTA neurons were retrogradely labeled, as visualized by immunoperoxidase staining for FG. A large portion of FG-labeled somata (58%) and dendrites (33%) within the VTA also contained immunogold-silver labeling for GABA. These dually labeled profiles exhibited a morphology similar to dopamine-containing cells within the VTA. To confirm and extend these findings, anterograde transport of biotinylated dextran amine (BDA) from the VTA was combined with immunogold-silver labeling for GABA within the PFC. Consistent with the results obtained from retrograde tracing, a portion of BDA-labeled terminals in the PFC also contained immunoreactivity for GABA. These dually labeled terminals formed symmetric synapses onto small caliber dendrites and dendritic spines. Some PFC dendrites contacted by GABA-containing VTA terminals were themselves GABA-labeled. The results of this investigation have identified a substantial population of GABA-containing neurons in the VTA that send axons to the PFC where they synapse on the distal processes of both pyramidal and local circuit neurons. This GABA-containing mesocortical pathway may provide substrates for both inhibitory and disinhibitory influences on PFC neuronal activity.

Ultrasonography for cervical length measurement: agreement between transvaginal and translabial techniques

OBJECTIVE

To assess agreement between transvaginal and translabial ultrasonography for measuring cervical length in the second and third trimesters.

METHODS

Eighty-four obstetric patients at 14-40 weeks' gestation were enrolled. Three images of the cervix were obtained by translabial (3.5-MHz curvilinear transducer) and transvaginal (6.5-MHz endovaginal probe) ultrasonography. The mean cervical length obtained by using each method was used for data analysis. The McNemar chi(2) test was used to assess the difference between techniques in their ability to obtain a measurement. The paired t-test was used to evaluate the differences between the measurements. The mean difference and SD for the differences were used to calculate the limits of agreement. An acceptable difference was defined as less than 0.5 cm.

RESULTS

Cervical length measurements were obtained in 84 patients (100%) by using the transvaginal technique and in 80 patients (95%) by using the translabial technique (P =.1). Eighty patients had both transvaginal and translabial measurements for comparison. The mean difference in cervical length was 0.37 cm (P <.001; 95% confidence interval [CI] 0. 21, 0.52). The upper and lower limits of agreement were 1.75 cm (95% CI 1.48, 2.02) and -1.01 cm (95% CI -0.74, -1.28), respectively. The differences between the two measurements were within these limits 95% of the time. These limits of agreement were greater than the acceptable difference of 0.5 cm.

CONCLUSION

Transvaginal and translabial techniques should not be used interchangeably for clinical assessment of cervical length because agreement between the methods is not within an acceptable range.

Farnesyl transferase inhibitors block the farnesylation of CENP-E and CENP-F and alter the association of CENP-E with the microtubules

Human tumor cell lines that are sensitive to the effects of farnesyl transferase inhibitors accumulate in G(2) --> M (except for cells with an activated Ha-ras that accumulate in G(1)). A search for CAAX box proteins from Swiss-Prot revealed more than 300 peptides. Of these, the centromeric proteins CENP-E and CENP-F are preferentially expressed during mitosis and are implicated as mediators of the G(2) --> M checkpoint. Experiments performed here show that peptides from the COOH-terminal CAAX box of CENP-E and CENP-F are substrates for farnesyl transferase but not geranylgeranyl transferase-I. Although both proteins are prenylated in the human tumor cell line DLD-1, their prenylation is completely inhibited by the farnesyl transferase inhibitor, SCH 66336. Immunohistochemical data with the lung carcinoma cell line, A549, showed that preventing the farnesylation of CENP-E and CENP-F by treatment with the farnesyl transferase inhibitor SCH 66336 does not affect their localization to the kinetochores. However, the presence of farnesyl transferase inhibitors alters the association between CENP-E and the microtubules. Our results imply that the inhibition of CENP-E farnesylation results in the alteration of the microtubule-centromere interaction during mitosis and results in the accumulation of cells prior to metaphase.

Dopamine terminals synapse on callosal projection neurons in the rat prefrontal cortex

Dopamine (DA) afferents to the prefrontal cortex (PFC) play an important role in the cognitive functions subserved by this cortical area. Within the PFC, DA terminals synapse onto the distal dendrites of both local circuit neurons and pyramidal projection cells. We have previously demonstrated in the rat PFC that some of the dendrites and spines postsynaptic to DA terminals arise from pyramidal neurons that project to the nucleus accumbens. However, it is not known whether the pyramidal cells that give rise to callosal intercortical connections of the PFC also receive DA synaptic input. To address this question, retrograde tract tracing using an attenuated strain of pseudorabies virus (PRV-Bartha) was combined with immunocytochemistry for tyrosine hydroxylase (TH) to identify DA terminals in the PFC. Thirty-six to 40 hours following injection of PRV into the contralateral PFC, numerous callosal projection neurons were extensively labeled throughout their dendritic trees, with no evidence of PRV trans-synaptic passage. In tissue prepared for electron microscopy, labeling for PRV was distributed throughout pyramidal cell somata and extended into distal dendrites and dendritic spines. Some PRV-labeled dendrites and spines received symmetric synaptic input from terminals containing peroxidase labeling for TH. These results demonstrate that DA terminals synapse onto the distal dendrites of callosally projecting PFC neurons and suggest substrates through which DA may modulate interhemispheric cortical communication.

Two new templates for epidemiology applications: linked micromap plots and conditioned choropleth maps

This paper describes two interactive templates for representing spatially indexed estimates. Both templates use a matrix layout of small panels. The first template, called linked micromap plots, can represent multivariate estimates associated with each spatially indexed study unit. The second template, called conditioned choropleth maps, shows the connection between a dependent variable, as represented in a classed choropleth map, and two explanatory variables. The paper describes the cognitive considerations that motivate the layouts and representation details. The discussion also addresses topics of data quality and access, hypothesis generation, and interactive features such as pan and zoom and dynamic conditioning via sliders. The examples show epidemiological (mortality rates) and environmental (toxic concentrations) applications.

Marital quality and psychological adjustment to widowhood among older adults: a longitudinal analysis

OBJECTIVES

This study examined whether psychological adjustment to widowhood is affected by three aspects of marital quality--warmth, conflict, and instrumental dependence-assessed prior to the loss.

METHODS

The Changing Lives of Older Couples (CLOC) is a prospective study of a two-stage area probability sample of 1,532 married individuals aged 65 and older. The CLOC includes baseline data on marital quality and mental health and data on grief, anxiety, and depression collected 6, 18, and 48 months after spousal loss.

RESULTS

Widowhood was associated with elevated anxiety among those who were highly dependent on their spouses and lower levels of anxiety among those who were not dependent on their spouses. Levels of yearning were lower for widowed persons whose relationships were conflicted at baseline and higher for those reporting high levels of marital closeness and dependence on their spouses. Women who relied on their husbands for instrumental support had significantly higher levels of yearning than men who depended on their wives.

DISCUSSION

The findings contradict the widespread belief that grief is more severe if the marriage was conflicted and suggest a more complex relationship between bereavement and characteristics of the marriage.

Equivalence classes in individuals with minimal verbal repertoires

Studies from two different laboratories tested for equivalence classes in individuals with severe mental retardation and minimal verbal repertoires. In the first study, 3 individuals learned several matching-to-sample performances: matching picture comparison stimuli to dictated-word sample stimuli (AB), matching those same pictures to printed letter samples (CB), and also matching the pictures to nonrepresentative forms (DB). On subsequent tests, all individuals immediately displayed Emergent Relations AC, AD, BC, BD, CD, and DC, together constituting a positive demonstration of equivalence (as defined by Sidman). The second study obtained a positive equivalence test outcome in 1 of 2 individuals with similarly minimal verbal repertoires. Taken together, these studies call into question previous assertions that equivalence classes are demonstrable only in individuals with well-developed language repertoires.

A substance P-opioid chimeric peptide as a unique nontolerance-forming analgesic

To elucidate mechanisms of acute and chronic pain, it is important to understand how spinal excitatory systems influence opioid analgesia. The tachykinin substance P (SP) represents the prototypic spinal excitatory peptide neurotransmitter/neuromodulator, acting in concert with endogenous opioid systems to regulate analgesic responses to nociceptive stimuli. We have synthesized and pharmacologically characterized a chimeric peptide containing overlapping NH(2)- and COOH-terminal functional domains of the endogenous opioid endomorphin-2 (EM-2) and the tachykinin SP, respectively. Repeated administration of the chimeric molecule YPFFGLM-NH(2), designated ESP7, into the rat spinal cord produces opioid-dependent analgesia without loss of potency over 5 days. In contrast, repeated administration of ESP7 with concurrent SP receptor (SPR) blockade results in a progressive loss of analgesic potency, consistent with the development of tolerance. Furthermore, tolerant animals completely regain opioid sensitivity after post hoc administration of ESP7 alone, suggesting that coactivation of SPRs is essential to maintaining opioid responsiveness. Radioligand binding and signaling assays, using recombinant receptors, confirm that ESP7 can coactivate mu-opioid receptors (MOR) and SPRs in vitro. We hypothesize that coincidental activation of the MOR- and SPR-expressing systems in the spinal cord mimics an ongoing state of reciprocal excitation and inhibition, which is normally encountered in nociceptive processing. Due to the ability of ESP7 to interact with both MOR and SPRs, it represents a unique prototypic, anti-tolerance-forming analgesic with future therapeutic potential.

Projections from the rat prefrontal cortex to the ventral tegmental area: target specificity in the synaptic associations with mesoaccumbens and mesocortical neurons

Excitatory projections from the prefrontal cortex (PFC) to the ventral tegmental area (VTA) play an important role in regulating the activity of VTA neurons and the extracellular levels of dopamine (DA) within forebrain regions. Previous investigations have demonstrated that PFC terminals synapse on the dendrites of DA and non-DA neurons in the VTA. However, the projection targets of these cells are not known. To address whether PFC afferents innervate different populations of VTA neurons that project to the nucleus accumbens (NAc) or to the PFC, a triple labeling method was used that combined peroxidase markers for anterograde and retrograde tract-tracing with pre-embedding immunogold-silver labeling for either tyrosine hydroxylase (TH) or GABA. Within the VTA, PFC terminals formed asymmetric synapses onto dendritic shafts that were immunoreactive for either TH or GABA. PFC terminals also synapsed on VTA dendrites that were retrogradely labeled from the NAc or the PFC. Dendrites retrogradely labeled from the NAc and postsynaptic to PFC afferents were sometimes immunoreactive for GABA but were never TH-labeled. Conversely, dendrites retrogradely labeled from the PFC and postsynaptic to PFC afferents were sometimes immunoreactive for TH but were never GABA-labeled. These results provide the first demonstration of PFC afferents synapsing on identified cell populations in the VTA and indicate a considerable degree of specificity in the targets of the PFC projection. The unexpected finding of selective PFC synaptic input to GABA-containing mesoaccumbens neurons and DA-containing mesocortical neurons suggests novel mechanisms through which the PFC can influence the activity of ascending DA and GABA projections.

Evidence for a new Graves disease susceptibility locus at chromosome 18q21

Graves disease (GD) is a common autoimmune thyroid disorder that is inherited as a complex multigenic trait. By using a single microsatellite marker at each locus, we screened the type 1 diabetes loci IDDM4, IDDM5, IDDM6, IDDM8, and IDDM10 and the fucosyltransferase-2 locus for linkage in sib pairs with GD. This showed a two-point nonparametric linkage (NPL) score of 1.57 (P=.06) at the IDDM6 marker D18S41, but NPL scores were <1.0 at the other five loci. Thus, the investigation of the IDDM6 locus was extended by genotyping 11 microsatellite markers spanning 48 cM across chromosome 18q12-q22 in 81 sib pairs affected with autoimmune thyroid disease (AITD). Multipoint analysis, designating all AITD sib pairs as affected, showed a peak NPL score of 3.46 (P=.0003), at the marker D18S487. Designation of only GD cases as affected (74 sib pairs) showed a peak NPL score of 3.09 (P=.001). Linkage to this region has been demonstrated in type 1 diabetes (IDDM6), rheumatoid arthritis, and systemic lupus erythematosus, which suggests that this locus may have a role in several forms of autoimmunity.

Using the “TOPS,” an Outcomes Instrument for Multidisciplinary Outpatient Pain Treatment

OBJECTIVE

To assess the reliability of an augmented SF-36 instrument, the Treatment Outcomes in Pain Survey ("TOPS"), in patients treated in two pain management programs, and present norms for initial values and treatment-related improvements.

DESIGN

Prospective case series at two sites with longitudinal follow-up.

SETTING

Multidisciplinary, comprehensive outpatient pain treatment centers in university hospitals in Salt Lake City and Boston.

PATIENTS

Nine hundred and forty seven adult outpatients with a range of socioeconomic, demographic, and ethnic characteristics, all referred for evaluation and treatment of chronic pain.

INTERVENTIONS

Usual practice multidisciplinary pain treatment.

OUTCOMES MEASURES

TOPS prior to pain treatment and 5-week nominal follow-up. Means and standard deviations of baseline and follow-up results. Psychometric results for reliability (Cronbach alpha), validity (item discriminant validity, validity coefficients), and related statistical precision measures for group and individual designs.

RESULTS

Several measures were precise enough to permit following individual patients in standard clinic treatment, of which the Total Pain Experience dimension was the most powerful. Similar psychometrics were observed in the Boston and Salt Lake City sites. The Pain Symptom, Objective Family/Social Disability, Objective Work Disability, and Upper Body Functional Limitations scales were validated.

DISCUSSION

The TOPS was designed to satisfy several models of clinical pain treatment. It successfully monitored treatment based on those models. Not all patients improve with treatment, but most do. The TOPS can be administered in a variety of ways, but we found paper and pencil administration with computer scanning of results quick and efficient for making the data available to clinicians as part of treatment.

CONCLUSIONS

The accuracy of the TOPS is sufficient to monitor the response of individual patients during multidisciplinary treatment of chronic pain. The TOPS provides needed documentation (e.g., to third-party payors) of the aggregate value of multidisciplinary outpatient treatment of chronic pain as well as its benefit for individual patients.

Assessing Individual Outcomes during Outpatient Multidisciplinary Chronic Pain Treatment by Means of an Augmented SF-36

OBJECTIVE

To meet the growing demand for objective outcomes measurement during treatment of chronic pain, we developed an instrument to track outcomes of individual patients.

METHOD

In a 2-phase study, existing and novel outcomes instruments were applied in an interdisciplinary pain management program. In the initial phase, 408 patients were administered the Short Form 36-item questionnaire and during phase 2, 437 patients (87 of whom were followed) were given an expanded (191-item) questionnaire.

RESULTS

When applied to individual patients, the Short Form 26-item questionnaire lacked measurement reliability for assessment of treatment outcomes and sensitivity to upper extremity or facial pathology, and failed to separate limitations of work versus everyday activity. A novel group of scales derived from responses to 61 questions, including the Short Form 36-item questionnaire, proved sufficiently reliable for routine follow-up of individual chronic pain patients.

CONCLUSIONS

This new Treatment Outcomes in Pain Survey allows assessment of individual patient outcomes, and aggregate or individual clinician performance, during interdisciplinary treatment of chronic pain.

Maternal hemodynamics and pregnancy outcome in women with prior orthotopic liver transplantation

The aim of this study is to evaluate the hemodynamics and pregnancy outcome of women with prior orthotopic liver transplantation. Hemodynamic measurements by Doppler technique were performed on pregnant subjects with prior orthotopic liver transplantation. Maternal characteristics, renal function, pregnancy complications, delivery indications, delivery mode, and neonatal outcomes were evaluated. Six pregnancies occurred in 5 women after orthotopic liver transplantation at the University of Washington Medical Center (Seattle, WA) between 1991 and 1999. Four of the 6 pregnancies were complicated by chronic hypertension, fetal growth restriction, and preterm delivery. Two pregnancies had worsening hypertension characterized by vasoconstriction in the second trimester despite antihypertensive therapy. These 2 subjects were administered cyclosporine for maintenance immunosuppression and had greater mean arterial pressures preconception and in the first trimester than the other subjects. One of these pregnancies resulted in fetal demise at 25 weeks' gestation. The other subject was delivered at 28 weeks' gestation for nonreassuring fetal status and superimposed preeclampsia. All pregnancies were complicated by renal insufficiency; however, the 2 subjects with poor obstetric outcome had preconception serum creatinine levels greater than 1.5 mg/dL and creatinine clearances less than 40 mL/min. Pregnancies complicated by second-trimester vasoconstriction and moderate renal insufficiency are at risk for preeclamspia, fetal growth restriction, and fetal demise. Good obstetric outcome can occur in women with mild renal insufficiency and well-controlled chronic hypertension. Improved hypertensive control preconception may decrease the risk for preeclampsia and poor obstetric outcome.

Association analysis of the cytotoxic T lymphocyte antigen-4 (CTLA-4) and autoimmune regulator-1 (AIRE-1) genes in sporadic autoimmune Addison's disease

Although autoimmune Addison's disease (AAD) may occur as a component of the monogenic autoimmune polyendocrinopathy type 1 syndrome (APS1), it is most commonly found as an isolated disorder or associated with the autoimmune polyendocrinopathy type 2 syndrome (APS2). It is likely that sporadic (non-APS1) AAD is inherited as a complex trait; however, apart from the major histocompatibility complex, the susceptibility genes remain unknown. We have examined polymorphisms at two non-major histocompatibility complex candidate susceptibility loci in sporadic (non-APS1) AAD: the cytotoxic T lymphocyte antigen-4 (CTLA-4) gene and the autoimmune regulator (AIRE-1) gene. DNA samples from AAD subjects (n = 90) and local controls (n = 144 for CTLA-4; n = 576 for AIRE-1) were analyzed for the CTLA-4A/G polymorphism in exon 1 of the CTLA-4 gene and for the common mutant AIRE-1 allele (964de113) in United Kingdom subjects with APS1, by using the restriction enzymes Bst7II and BsrBI, respectively. There was an association of the G allele at CTLA-4A/G in AAD subjects (P = 0.008 vs. controls), which was stronger in subjects with AAD as a component of APS2 than in subjects with isolated AAD. In contrast, the mutant AIRE-1 964del13 allele was carried in one each of the 576 (0.2%) control subjects and the 90 (1.1%) AAD subjects as a heterozygote (P = 0.254, not significant), suggesting that this common AIRE-1 gene abnormality does not have a major role in sporadic (non-APS1) AAD.

Nissen-type fundoplication and its effects on the emetic reflex and gastric motility in the ferret

Recurrent vomiting with failure to thrive is a common problem in neurologically impaired children. Many undergo fundoplication to control the underlying gastro-oesophageal reflux. The results of surgery are not always satisfactory and post-operative retching may be a major problem - a symptom indicative of activation of the emetic reflex. An animal model of antireflux surgery has been developed and used to investigate the effects of such surgery upon the emetic reflex and vagal influences on gastric motility. Following surgery, animals responded to a previously subemetic dose of a centrally acting opiate receptor agonist (loperamide), suggesting that fundoplication may sensitize the emetic reflex. A gastric vago-vagal reflex (tonic inhibition of corpus tone) and responses to direct stimulation of vagal motor efferents (both cholinergic and nonadrenergic noncholinergic responses) were not significantly affected by antireflux surgery. Mechanisms by which neural damage may sensitize the emetic reflex are discussed, together with the possible clinical implications for the management of post-operative symptoms in neurologically impaired children.

The older adult driver

More adults aged 65 and older will be driving in the next few decades. Many older drivers are safe behind the wheel and do not need intensive testing for license renewal. Others, however, have physiologic or cognitive impairments that can affect their mobility and driving safety. When an older patient's driving competency is questioned, a comprehensive, step-by-step assessment is recommended. Many diseases that impair driving ability can be detected and treated effectively by family physicians. Physicians should take an active role in assessing and reducing the risk for injury in a motor vehicle and, when possible, prevent or delay driving cessation in their patients. Referral to other health care professionals, such as an occupational or physical therapist, may be helpful for evaluation and treatment. When an older patient is no longer permitted or able to drive, the physician should counsel the patient about using alternative methods of transportation.

Characteristics of motor vehicle crashes of drivers with dementia of the Alzheimer type

OBJECTIVE

To determine whether there is a difference in crash rates and characteristics between drivers with dementia of the Alzheimer type (DAT) and nondemented older persons who were controls.

DESIGN

A pilot study using a 5-year retrospective analysis of state-recorded crash data and crash characteristics followed by patient enrollment into a study on road test skills.

SETTING

Alzheimer's Disease Research Center at Washington University in St. Louis, Missouri. Subjects were enrolled as volunteers in a longitudinal study of aging and DAT.

PARTICIPANTS

One hundred twenty-one subjects (58 nondemented, older drivers and 63 drivers with DAT) with a mean age of 77 years met the inclusion criteria for this study. DAT was diagnosed using validated clinical diagnostic criteria and was staged by the Clinical Dementia Rating (CDR) Scale. All subjects with DAT were in the very mild (CDR = 0.5) or mild (CDR = 1) stages.

MAIN OUTCOME MEASURE

State-recorded traffic crashes. Also, a daily driving diary was completed by each subject and used to estimate miles traveled per year.

RESULTS

Subjects diagnosed with mild DAT (CDR = 1) reported less roadway exposure (average number of miles driven per year) than did drivers with very mild DAT (CDR = 0.5) or controls. Crashes in both groups were infrequent, with 0.07 state-recorded crashes per driver per year in the nondemented group (CDR = 0), 0.06 in the very mild DAT group (CDR = 0.5), and 0.04 in the mild DAT group (CDR = 1). There was no statistical difference in the crash frequency between groups, even when adjusting for exposure. Drivers with DAT had trends toward more at-fault crashes, crashes with injuries, and crashes in which the officer on the scene cited failure to yield.

CONCLUSIONS

In our sample, individuals with very mild or mild DAT who continued to drive seemed to have crash rates similar to those of the controls. There may be significant differences between the causes and the consequences of crashes involving drivers with DAT when compared with cognitively intact age-matched controls, but none were found in this pilot study. Further research on crash characteristics is needed in larger samples of community-based drivers with DAT across wider ranges of dementia severity to address issues such as driving competency and public safety.

Dopamine terminals in the rat prefrontal cortex synapse on pyramidal cells that project to the nucleus accumbens

Afferents to the prefrontal cortex (PFC) from dopamine neurons in the ventral tegmental area have been implicated in working memory processes and in the pathogenesis of schizophrenia. Previous anatomical investigations have demonstrated that dopamine terminals synapse on dendritic spines and shafts of pyramidal cells in the PFC. Moreover, neurochemical and physiological studies suggest that dopamine modulates the activity of PFC neurons that project to the nucleus accumbens. However, whether this modulation involves direct synaptic input to cortico-accumbens projection neurons has not been determined. To address this question, retrograde transport of an attenuated strain of pseudorabies virus (PRV) from the nucleus accumbens was combined with immunoperoxidase labeling of tyrosine hydroxylase (TH) to identify dopamine terminals in the PFC. At survival times <48 hr, extensive dendritic distribution of immunogold labeling for PRV was observed in cortico-accumbens neurons. However, evidence consistent with trans-synaptic passage of PRV within this timeframe was observed only rarely. When examined at the electron microscopic level, immunogold labeling for PRV was localized to neuronal somata, proximal and distal dendrites, and dendritic spines. Some of these dendritic processes received symmetric synaptic input from TH-immunoreactive terminals. These data represent the first demonstration of dopamine synaptic contacts onto an identified population of pyramidal cells in the PFC. The findings have important implications for understanding how dopamine modulates cortical outflow to limbic regions in normal brain and pathological states such as schizophrenia.

Toward a canon of the pain and analgesia literature: a citation analysis

The purpose of this study was to use citation analysis to identify major themes and contributors to the pain and analgesia literature over the past two decades. A citation analysis was performed on a database of more than 110,000 articles in the biomedical literature from January 1981 through June 1997, and in the interval from January 1988 through June 1997. Articles and authors related to pain and analgesia research and practice were identified by searching approximately 7,700 journals. The 20 articles and 20 authors with the most citations were then checked by hand to ensure relevance to pain or analgesia. Most of the high-impact articles identified pertained to research on basic pain pathways. Nearly all the articles concerned opioids, nonsteroidal antiinflammatory drugs, and consequences of analgesic use. None of the highest-impact articles address assessment of clinical pain. Few women were first authors of any most frequently cited paper. Citation analysis is a useful tool in identifying important contributions to the biomedical literature. Recent and continuing research trends include the use of nonsteroidal antiinflammatory drugs, opioid mechanisms, and persistent pain disorders. Current trends expected to become stronger include description of pain from the patient's perspective and mechanisms of the transition from acute to chronic pain.

IMPLICATIONS

We performed a citation analysis to identify important contributions and contributors to the biomedical literature. Recent pain and analgesia research has been focused on mechanisms of pain, but evidence suggests the importance of understanding the pain experience from the patient's perspective and the transition from acute to chronic pain.

Acute decreases in cerebrospinal fluid glutathione levels after intracerebroventricular morphine for cancer pain

Intracerebroventricular (ICV) morphine administration is effective for the management of refractory cancer pain. Recent preclinical observations of acute depletion of the major endogenous intracellular antioxidant glutathione (GSH) in brain and peripheral organs after ICV morphine in rodents led us to apply microchemical methods to profile the neurochemical effects of ICV morphine in three patients treated for intractable cancer pain. Assessment of morphine, morphine-6-glucuronide, and a panel of endogenous compounds and metabolites in ventricular and cisternal cerebrospinal fluid (CSF) demonstrated transient, postdose increases in morphine and morphine-6-glucuronide in ventricular and cistemal CSF, accompanied by acute decreases in CSF GSH levels. Significant changes were also observed in the CSF levels of 4-hydroxybenzoic acid, homovanillic acid, 5-hydroxyphenyllactic acid, and uric acid. These pilot clinical observations of acute central GSH depletion after ICV morphine suggest a novel mechanism for neuropsychiatric toxicity or preclinical findings, such as hyperalgesia or increased motoric activity observed in nonhuman species after central morphine administration. Because ICV morphine is a mainstay of treatment for refractory cancer pain, elucidation of a mechanism's (or mechanisms') mediating a potential pro-oxidant state in the central nervous system induced by ICV morphine is important.

IMPLICATIONS

We observed acute decreases in glutathione levels in cerebrospinal fluid sampled from patients after intracerebroventricular doses of morphine for intractable cancer pain. Such doses may, by depleting the antioxidant glutathione, render the central nervous system vulnerable to damage from oxidative stress.

Maintenance oral nifedipine for preterm labor: a randomized clinical trial

OBJECTIVE

This study was undertaken to evaluate the efficacy of maintenance oral nifedipine in patients initially treated with intravenous magnesium sulfate for preterm labor.

STUDY DESIGN

Patients with a diagnosis of preterm labor between 24 and 33.9 weeks' gestation were randomly assigned to receive either maintenance tocolytic therapy with oral nifedipine (20 mg every 4-6 hours) or no treatment (control) after discontinuation of magnesium tocolysis. Pregnancy and neonatal outcomes were evaluated. A sample size of 50 patients was required to detect a 10-day difference in mean time gained (beta =.2, alpha =.05). Statistical analyses were based on intent to treat. The t, chi(2), and Fisher exact tests were performed.

RESULTS

Seventy-four patients were randomly assigned to receive either oral nifedipine (n = 37) or no treatment (n = 37). There were no statistically significant differences in age, race, parity, preterm delivery risk factors, enrollment gestational age, results of cervical examination, delivery gestational age, time gained, or neonatal complications between the groups. Delivery gestational age (mean +/- SD) was 35.4 +/- 3.2 weeks for patients randomly assigned to receive nifedipine and 35.3 +/- 3.2 weeks for patients who received no treatment (P =.9). Time gained during pregnancy was 37 +/- 23.9 days in the nifedipine group and 32.8 +/- 20.4 days in the control group (P =.4).

CONCLUSION

Maintenance therapy with oral nifedipine does not significantly prolong pregnancy in patients initially treated with intravenous magnesium sulfate for preterm labor.

Analogues of 1-(3,10-dibromo-8-chloro-6,11-dihydro-5H-benzo-[5,6]-cyclohepta [1,2-b]pyridin-11-yl)piperidine as inhibitors of farnesyl protein transferase

The synthesis of several 4-pyridylacetyl N-oxide derivatives of 4-(3-bromo-6,11-dihydro-5H-benzo[5,6]-cyclohepta[1,2-b]-pyridin-11-yl)pi perazine/piperidine 3 is described. This study was aimed at identifying fomesyl protein transferase (FPT) inhibitors in these two series of tricycles containing different phenyl ring substituents. The in vitro activity profile of the initial group of compounds 7a-7g led to the synthesis of the 8-methyl-10-methoxy and 8-methyl-10-bromo analogues 7i, 13i, and 13j. The 11R(-) enantiomers of these compounds were found to exhibit potent in vitro FPT inhibition activity.