Is resistant hypertension really resistant?

BACKGROUND

Managing resistant hypertension is difficult and mostly involves expensive testing seeking an underlying secondary cause. This study was undertaken to determine 1) the extent of the white-coat phenomenon in patients with resistant hypertension, and 2) whether 24-h ambulatory blood pressure (BP) monitoring (ABPM) or having BP recorded by a nurse instead of the referring doctor could clarify how many apparently resistant hypertensives actually have controlled BP.

METHODS

This study involved 611 patients with BP > or = 140/90 mm Hg who were referred for 24-h ABPM by their specialist or general practitioner, including 277 patients who were taking no antihypertensives (group 1), 216 taking one or two antihypertensive drugs (group 2), and 118 taking at least three antihypertensives in combination (group 3). Each had BP recorded by one of two nurses before 24-h ABPM. Controlled BP was defined as awake ambulatory BP <135/85 mm Hg and the white-coat effect was the difference between the BP recorded by the referring doctor or nurse and the average awake ambulatory BP.

RESULTS

Those with resistant hypertension (group 3) were older (61 years (12) v group 1: 46 years (14) and group 2: 56 (14) years; P < .001), but were of similar weight, height, and arm circumference to the other groups. Referral systolic, but not diastolic BP was higher in resistant hypertensives (mean 171/95 v 154/95 mm Hg and 164/94 mm Hg, respectively, P < .001 for systolic BP only). Twenty-eight percent of resistant hypertensives and 32% of those taking no antihypertensive drugs had normal awake ambulatory BP and the white-coat effect attributable to the referring doctor was always greater than that due to the nurse (range 16 to 26/12 to 14 mm Hg v 9 to 17/4 mm Hg, P < .001). Nurse recorded BP was highly sensitive (97%) in identifying awake hypertension but lacked specificity (57%) to replace ABPM.

CONCLUSION

Our results show that approximately one in four patients with apparent resistant hypertension referred for ABPM have controlled BP and one-third of patients referred for initial evaluation of office or clinic hypertension have normal BP using ABPM, ie, white-coat hypertension. Twenty-four-hour ABPM appears an appropriate initial step before further investigating or treating patients with apparently resistant hypertension.

Body composition and energy metabolism in normotensive and hypertensive pregnancy

OBJECTIVE

To determine whether the insulin resistance syndrome and altered body composition are features of hypertensive pregnancy.

DESIGN

Women were recruited in the third trimester of pregnancy from the antenatal clinic, day assessment unit, and maternity ward of St George Hospital, Sydney.

POPULATION

Women with pre-eclampsia (n = 12), gestational hypertension (n = 12), essential hypertension in pregnancy (n = 11), and normotensive pregnancy (n = 10).

METHODS

Energy metabolism was assessed by indirect calorimetry to measure basal metabolic rate and diet-induced thermogenesis. Body composition was measured as lean body mass, total body water and fat mass by bio-electrical impedance. Blood was collected for measurement of glucose, insulin and lipid profiles. Insulin resistance was indirectly assessed by the insulin and glucose concentrations and diet-induced thermogenesis.

RESULTS

Women with essential hypertension and gestational hypertension were heavier than women with normotensive pregnancies both pre-pregnancy and in the third trimester, whereas women with pre-eclampsia were similar to those with normotensive pregnancy. Women with essential hypertension were otherwise similar to normotensive pregnancy but women with gestational hypertension had a reduced diet-induced thermogenesis and almost double insulin levels. Women with pre-eclampsia had a similar body composition and insulin levels but reduced basal metabolic rate, diet-induced thermogenesis and glucose levels compared with normotensive pregnancy.

CONCLUSIONS

Women who develop gestational hypertension, but not pre-eclampsia, are more likely to be overweight. Women with essential hypertension are similar to women with normotensive pregnancy throughout pregnancy. Both gestational hypertension and pre-eclampsia appear to be associated with some degree of insulin resistance, greater than that occurring in normal pregnancy.

Efficient fat storage in premenopausal women and in early pregnancy: a role for estrogen

There is a sexual dimorphism in body fat in humans. Adipose tissue increases with puberty and early pregnancy in women, suggesting gonadal steroids can influence body fat. Previously, we have observed that oral estrogen, compared with transdermal estrogen, reduced postprandial lipid oxidation and increased body fat, possibly due to suppressed hepatic lipid oxidation. If estrogen effects lipid oxidation, we predicted that subjects with significantly different endogenous estrogen production would oxidize lipids at different rates. The aim of this study was to compare energy metabolism in 12 pregnant (19 wk gestation, 29 +/- 1 yr, 1.66 +/- 0.02 m, 73.5 +/- 2.4 kg), 11 nonpregnant premenopausal (29 +/- 2 yr, 1.68 +/- 0.02 m, 63.1 +/- 1.8 kg), and 28 postmenopausal (58 +/- 1 yr, 1.62 +/- 0.01 m, 69.9 +/- 1.0 kg) women who were not receiving estrogen, and to relate these findings to endogenous estrogen concentrations. All women underwent indirect calorimetry under identical situations in the basal and postprandial state following a standard mixed meal. Basal (5998 +/- 184 vs. 5712 +/- 184 vs. 5800 +/- 121 kJ.24 h, respectively) and postprandial energy expenditure (7172 +/- 239 vs. 6964 +/- 210 vs. 6955 +/- 147 kJ.24 h) was similar among groups. However, basal lipid oxidation was reduced in pregnant (45.3 +/- 6.1 mg/min, P < 0.05) and nonpregnant women (44.5 +/- 6.3 mg/min, P < 0.05) compared with postmenopausal women (58.4 +/- 2.9 mg/min). Postprandial lipid oxidation differed among groups, being least in pregnant women (8.8 +/- 6.2 mg/min) compared with nonpregnant (28.9 +/- 6.4 mg/min, P < 0.04) and postmenopausal (48.1 +/- 4.0 mg/min, P = 0.0001) women. There was a significant reciprocal increase in postprandial carbohydrate oxidation. Mean postprandial glucose levels were slightly but nonsignificantly higher in pregnant women. Insulin levels were significantly higher in postmenopausal compared nonpregnant, but not pregnant, women. In a multiple regression analysis, serum estradiol (log transformed) correlated negatively with postprandial lipid oxidation (r = -0.66, P = 0.0001) and positively with postprandial nonesterified free fatty acid levels, whereas no correlation was found with postprandial insulin, glucose, fat free mass, and fat mass. In summary, postprandial lipid oxidation is reduced in pregnancy compared with that in healthy nonpregnant women, who in turn have lower postprandial lipid oxidation than postmenopausal women. This implies that the premenopausal years and early pregnancy are states of efficient fat storage, possibly mediated through reduced lipid oxidation due to estrogen, therefore increasing body fat for reproduction, thus supporting the notion that fat mass can be regulated.

Double-stranded RNA regulates IL-4 expression

dsRNA, as genomic fragment, replicative intermediate, or stem and loop structure in cells infected by viruses, can act to signal the immune system of the presence of viral infections. Although most viral infections are associated with strong Th1 immune responses, Th2-type responses have also been observed. In this study, we characterize the effects of dsRNA on the induction of Th2 responses in human lymphocytes. We report that in addition to the well-known Th1-inducing capabilities of dsRNA, treatment of human lymphocytes with low concentrations of dsRNA (0.1-1 microg/ml) leads to the expression of the prototypic Th2 cytokine IL-4. This induction was accompanied with the concentration-dependent activation of NF-kappaB and NF-AT2 but not NF-AT1. In addition, dsRNA can directly activate an IL-4 promoter-driven chloramphenicol acetyltransferase reporter gene in transiently transfected Jurkat cells. These results are the first demonstration of a non-TCR-associated activator of NF-AT in human cells and suggest that dsRNA directly influences IL-4 gene expression through its effect on NF-AT activation. Our data provide support for the idea that dsRNA at low concentrations in vivo may induce a Th2-dominant response that is not optimal for protective immunity to the virus.

Twenty-four-hour automated blood pressure monitoring as a predictor of preeclampsia

OBJECTIVE

The purpose of this study was to determine the predictive ability of parameters of 24-hour ambulatory blood pressure monitoring for the development of preeclampsia or gestational hypertension in women who are already considered at risk for these disorders.

STUDY DESIGN

One hundred twenty-two pregnant women who were considered high risk for the development of preeclampsia underwent 24-hour ambulatory blood pressure monitoring between 18 and 30 weeks gestation, while their condition was normotensive according to routine mercury sphygmomanometry. One hundred sixty-four healthy primigravid women who were considered at usual risk for preeclampsia underwent the same tests as a parallel study. Routine blood pressure, awake and sleep average blood pressure, and 24-hour mean average blood pressure were entered into multiple logistic regression as predictors of either preeclampsia or gestational hypertension; significant variables were then tested by a series of receiver operator curves.

RESULTS

Eight percent of usual risk and 45% of high risk women experienced the development of preeclampsia or gestational hypertension. In both groups, the average routine mercury blood pressure and awake, sleeping, and 24-hour ambulatory blood pressure monitoring-derived blood pressure were significantly higher in women who later experienced the development of preeclampsia or gestational hypertension. In usual risk women, 24-hour systolic blood pressure of >or=115 mm Hg and sleeping systolic blood pressure of >or=106 mm Hg were predictive of later preeclampsia or gestational hypertension, but sensitivities were low (77% and 54%, respectively). In high risk women, sleeping diastolic blood pressure of >or=62 mm Hg and sleeping mean arterial pressure of >or=79 mm Hg were predictive of preeclampsia or gestational hypertension, but again sensitivities were low (70% and 65%, respectively).

CONCLUSION

Awake and sleeping blood pressure are higher in midpregnancy in women who later experience the development of preeclampsia or gestational hypertension. Twenty-four-hour ambulatory blood pressure monitoring provides a noninvasive method of selecting some of these women, but this test has a sensitivity no better than that of other predictive tests, even in women at high risk for preeclampsia.

Purification and characterization of nuclear type II [(3)H]estradiol binding sites from the rat uterus: covalent labeling with [(3)H]luteolin

Type II [3H]estradiol binding sites play an important role in normal and malignant cell growth and proliferation and the delineation of the precise function of the type II site in cell growth has been hampered by the inability to purify, sequence and or clone this protein. The present manuscript describes methodology for the solubilization, purification and tentative identification of type II sites from the estrogen-treated rat uterus. This protein(s) chromatographs as a single major peak on DNA-cellulose, Affigel Blue dye affinity resin and during high performance liquid chromatography (HPLC) on hydroxyapatite. The purified fractions from these columns elicited classical [3H]estradiol binding characteristics (sigmoidal saturation curve, hyperbolic Scatchard plot, and Hill coefficient of approximately 4) for type II sites that are typically observed in crude or highly purified nuclear fractions or extracts. The type II binding activity also eluted as a single major component from a ligand affinity resin (GT-18-Sepharose) prepared by coupling 2,6-bis((3-methoxy-4-hydroxyphenyl)methylene)-cyclohexanone to epoxy-activated Sepharose (Pharmacia). The molecular weight of the type II site ([3H]estradiol binding activity) under non-denaturing or denaturing conditions was estimated to be approximately 10-15 kDa by gel filtration HPLC. Similarly, nuclear type II sites covalently labeled with the bioflavonoid, [3H]luteolin, migrated in the 10 kDa range on SDS PAGE. Thus, under these various experimental conditions, nuclear type II sites detected by [3H]estradiol or [3H]luteolin labeling techniques displayed little heterogeneity and appear much smaller than ERalpha or ERbeta or other steroid hormone receptors.

The prevalence and clinical significance of nocturnal hypertension in pregnancy

OBJECTIVE

To determine (a) the prevalence of hypertension during sleep in pre-eclampsia and gestational hypertension, and (b) whether women with hypertension during sleep have worse pregnancy outcomes than hypertensive pregnant women with controlled (normal) blood pressure (BP) during sleep.

DESIGN

Prospective double-blind cohort study.

SETTING

Inpatients and outpatients managed in a day assessment unit (DAU) at St George Hospital, Sydney, Australia.

PARTICIPANTS

A total of 186 hypertensive pregnant women, 158 of whom had successful 24 h BP monitoring; 40% had proteinuric pre-eclampsia (PE), 43% gestational hypertension (GH) and 17% essential hypertension (EH).

INTERVENTIONS

Blood pressure, 24 h non-invasive, monitoring (Spacelabs 90207) was undertaken successfully in 158 women with PE, GH or EH, whether or not they were receiving antihypertensives. Women and clinicians were blinded to results of these BP monitors. Sleep hypertension was defined as BP > 117/68 mmHg at 26-30 weeks or > 123/72 mmHg after 30 weeks gestation.

MAIN OUTCOME MEASURES

Maternal and fetal outcomes were compared between women with and without sleep hypertension and the prevalence of sleep hypertension was determined.

RESULTS

Sleep hypertension was present in 59%, more commonly in PE (79%) than GH/EH (45%), P < 0.0001. Sleep hypertensives also had higher routine sphygmomanometer BPs [137(10)/91(7) mmHg; mean(SD)] than women with normal sleep BP [130(12)/ 87(8) mmHg] P = 0.007, and higher awake ambulatory blood pressure monitoring (ABPM) BPs [137(8)/88(7) versus 127(7)/79(6) mmHg], P < 0.0001. Awake, but not sleep, average heart rate was lower in sleep hypertensives [85(11) versus 91 (10) beats per minute, bpm], P = 0.002. Sleep hypertensives had a significantly greater frequency of renal insufficiency, liver dysfunction, thrombocytopenia and episodes of (awake) severe hypertension (P < 0.05), as well as lower birth weight babies [2715 (808) versus 3224(598) g, P < 0.0001].

CONCLUSIONS

Hypertension during sleep is a common finding in women with hypertensive disorders of pregnancy, particularly pre-eclampsia. These women also have higher awake BPs and a greater frequency of adverse maternal and fetal outcomes. These findings are largely explained by the greater likelihood of pre-eclamptics having sleep hypertension.

Application of neurosonography to experimental physiology

When Horsley and Clark invented the stereotaxic technique they revolutionized experimental neurobiology. For the first time it became possible to repeatably place experimental or surgical probes at precise locations within the skull. Unfortunately, variations in the position and size of neuroanatomical structures within the cranium have always limited the efficiency of this technology. Recent advances in diagnostic medical ultrasonography, however, allow for the real-time visualization of anatomical structures, in some cases with resolutions of up to 150 microm. We report here that commercially available ultrasonographs can be used in the laboratory to generate real-time in vivo images of brain structures in both anesthetized and awake-behaving animals. We found that ultrasonic imaging is compatible with many types of experimental probes including single neuron recording electrodes, microinjection pipettes, and electrodes for producing electrolytic lesions. Ultrasonic imaging can be used to place, monitor and visualize these probes in vivo. In our hands, commercially available ultrasonic probes designed for pediatric use allowed us to visualize anatomical structures with sub-millimeter resolution in primate brains. Finally, ultrasonic imaging allowed us to reduce the risk of accidentally damaging major blood vessels, greatly reducing the incidence of stroke as an unintended complication of an experimental neurosurgical procedure. Diagnostic ultrasound holds the promise of reducing the uncertainty associated with stereotaxic surgery, an improvement which would significantly improve the efficiency of many neurobiological investigations, reducing the number of animal subjects employed in this research. While this demonstration focuses on sonographic imaging in non-human primates, similar advances should also be possible for studies in other species, including rodents.

Genetic x environment interactions on blood constituents of Angus, Brahman, and reciprocal-cross cows and calves grazing common bermudagrass or endophyte-infected tall fescue

Over a 2-yr period, effects of genotype and forage on blood metabolites, enzymes, and minerals were determined in Angus, Brahman, Angus x Brahman (sire x dam), and Brahman x Angus cows, and 129 calves from these cows sired by Hereford bulls. Cows and calves continuously grazed either common bermudagrass or endophyte-infected 'Kentucky-31' tall fescue pastures throughout the year. Blood samples were collected via jugular venipuncture in April, August, October (weaning), and November (after 30 d in a feedlot) of each year. Plasma urea N concentrations of cows and calves were affected by forage (P < 0.01) and breed (P < 0.05). Plasma cholesterol and FFA concentrations of cows were affected by forage (P < 0.01) and breed (P < 0.05). In calves, antibody titers to infectious bovine rhinotracheitis virus were not affected by forage but were affected by breed. Serum inorganic P concentrations of calves and cows were affected by forage (P < 0.05). Serum P concentrations and alkaline phosphatase activity of calves were affected by breed (P < 0.05). Calves grazing bermudagrass had higher (P < 0.05) serum concentrations of Fe and total iron binding capacity (TIBC). There was evidence of maternal heterosis for concentrations of free fatty acids, cholesterol, aspartate aminotransferase, Ca, Mg, alkaline phosphatase, ceruloplasmin, Fe, and TIBC. There was evidence of grandmaternal effects for plasma concentrations of urea N, cholesterol, Ca, P, Mg, and alkaline phosphatase. These results suggest that calves and cows grazing tall fescue are generally on a lower plane of nutrition than those grazing bermudagrass and that Brahman x Angus and Angus x Brahman crossbred cows and their calves seen to be more tolerant of the negative effects of tall fescue than the average of their purebred contemporaries.

Vascular reactivity in men and women of reproductive age

OBJECTIVE

This study was undertaken to document vascular reactivity in both phases of normal menstrual cycles and anovulatory cycles of women receiving oral contraceptives and to compare vascular reactivity of women in the follicular phase of the normal menstrual cycle with that of men of a similar age group.

STUDY DESIGN

Forearm blood flow was measured with plethysmography in 15 women with ovulatory cycles during the follicular and luteal phases of the normal cycle, at equivalent times in 14 women receiving oral contraceptives, and in 15 age-matched men. Changes in forearm blood flow, an index of vascular reactivity, were measured during a randomly ordered brachial artery infusion schedule of norepinephrine, sodium nitroprusside, angiotensin II, and Nomega-monomethyl-L -arginine and were analyzed with repeated measures analysis of variance.

RESULTS

Forearm blood flow responses were similar in the two phases of the normal cycle. Responses were similar between women with ovulatory cycles and users of oral contraceptives, apart from a significantly greater response to angiotensin II in the oral contraceptive group during the medication phase than during the withdrawal phase (P =.027). Basal forearm blood flow was higher in men than in women (7 +/- 1.6 vs 5 +/- 1.4 mL/100 mL per minute; P =.015), and men demonstrated a significantly greater vasoconstrictor response to norepinephrine (P <.05) than did women.

CONCLUSION

Vascular reactivity is similar in the two phases of the normal menstrual cycle, but women who use oral contraceptives have an exaggerated response to angiotensin II during the medication phase. Men demonstrate greater vascular reactivity to norepinephrine than do women, perhaps because of the lack of estrogen-mediated protective effects and increased adrenergic activity.

Genotype x environment interactions in milk yield and quality in Angus, Brahman, and reciprocal-cross cows on different forage systems

Milk yield and quality were observed on 93 Angus, Brahman, and reciprocal-cross cows over 3 yr to evaluate the interactions of direct and maternal breed effects and heterosis with forage environment. Forage environments were common bermudagrass (BG), endophyte-infected tall fescue (E+), and a rotational system (ROT) of both forages, in which each forage (BG or E+) was grazed during its appropriate season, usually June through October for BG and November through May for E+. Milk yield was estimated each of 6 mo (April through September) via milking machine and converted to a 24-h basis. Milk fat, milk protein, and somatic cell count were analyzed by a commercial laboratory. Heterosis for milk yield was similar among forages, averaging 2.4 kg (P < 0.01). Expressed as percentages of purebred means, heterosis for milk yield was largest on E+ (52.8%), intermediate on ROT (39.3%), and smallest on BG (23.7%). Direct breed effects for milk yield favored Brahman, and they were similar among forages but tended to be larger for E+ (2.5 kg) and ROT (2.8 kg) than for BG (1.3 kg). Direct breed effects for milk fat favored Brahman and were similar among forages but tended to be larger for E+ (1.0%) and ROT (1.0%) than for BG (0.6%). Purebred cows exceeded crossbreds in milk protein by 0.1% on ROT (P < 0.10). Crossbred cows had lower somatic cell counts than purebreds on BG (P < 0.05), E+ (P < 0.01), or ROT (P > 0.30). Heterosis for somatic cell counts as percentages of purebred means was similar for BG (-68.3%) and E+ (-68.9%) and less favorable for ROT (-31.6%). Maternal breed effects for somatic cell count favored Angus on ROT (P < 0.10) with a similar nonsignificant trend on BG and E+. Direct breed effects for somatic cell count favored Brahman on ROT (P < 0.10) with similar nonsignificant trends on BG and E+. These results suggested that a rotation of cows from E+ to BG in the summer can partially alleviate negative effects of E+ on milk yield. Conclusions also indicated an advantage to crossbred cows in somatic cell count and provided evidence of both direct and maternal breed effects for this trait. The results also suggested that direct breed effects for milk yield, milk fat, and somatic cell count and heterosis for milk yield and somatic cell count (as percentages of purebred means) tended to vary with forage environment, indicating a potential for genotype x environment interaction for these traits.

Polymorphism in codon 17 of the CTLA-4 gene (+49 A/G) is not associated with susceptibility to rheumatoid arthritis in British Caucasians

The role of the CTLA-4 antigen in the development of autoimmune diseases is well documented, with several autoimmune disorders showing association or linkage with the CTLA-4 locus. Its role in the aetiology of rheumatoid arthritis (RA) however, remains unclear, as the functional studies of the B7-CTLA-4 pathway in mouse models of RA and genetic studies in humans have given contrasting results. We have studied the single nucleotide polymorphism at position +49 (A/G) of the CTLA-4 gene, in a cohort of 421 RA cases and 452 healthy controls from the UK. Despite the high statistical power to detect even a weak susceptibility effect, no significant association was found. We also analysed the distribution of the allele and genotype frequencies with respect to the presence of the shared epitope (a known RA susceptibility factor) and found no statistically significant differences. We conclude that, although the importance of the B7-CTLA-4 interaction in the development of RA can not be excluded, the CTLA-4 gene is unlikely to be a predisposing factor to this disease.

Is disease severity in ankylosing spondylitis genetically determined?

OBJECTIVE

To assess the role of genes and the environment in determining the severity of ankylosing spondylitis.

METHODS

One hundred seventy-three families with >1 case of ankylosing spondylitis were recruited (120 affected sibling pairs, 26 affected parent-child pairs, 20 families with both first- and second-degree relatives affected, and 7 families with only second-degree relatives affected), comprising a total of 384 affected individuals. Disease severity was assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and functional impairment was determined using the Bath Ankylosing Spondylitis Functional Index (BASFI). Disease duration and age at onset were also studied. Variance-components modeling was used to determine the genetic and environmental components contributing to familiality of the traits examined, and complex segregation analysis was performed to assess different disease models.

RESULTS

Both the disease activity and functional capacity as assessed by the BASDAI and the BASFI, respectively, were found to be highly familial (BASDAI familiality 0.51 [P = 10(-4)], BASFI familiality 0.68 [P = 3 x 10(-7)]). No significant shared environmental component was demonstrated to be associated with either the BASDAI or the BASFI. Including age at disease onset and duration of disease as covariates made no difference in the heritability assessments. A strong correlation was noted between the BASDAI and the BASFI (genetic correlation 0.9), suggesting the presence of shared determinants of these 2 measures. However, there was significant residual heritability for each measure independent of the other (BASFI residual heritability 0.48, BASDAI 0.36), perhaps indicating that not all genes influencing disease activity influence chronicity. No significant heritability of age at disease onset was found (heritability 0.18; P = 0.2). Segregation studies suggested the presence of a single major gene influencing the BASDAI and the BASFI.

CONCLUSION

This study demonstrates a major genetic contribution to disease severity in ankylosing spondylitis. As with susceptibility to ankylosing spondylitis, shared environmental factors play little role in determining the disease severity.

Genotype x environment interactions for postweaning performance in crossbred calves grazing winter wheat pasture or dormant native prairie

Data from 403 calves from Angus, Brahman, and reciprocal-cross cows sired by Polled Hereford bulls were used to evaluate the impact of postweaning backgrounding forages on postweaning BW, gains, and carcass traits. Calves were born (spring of 1991 through 1994) and reared on either endophyte-infected tall fescue or common bermudagrass pastures. After weaning, calves were transported 360 km to the Grazinglands Research Laboratory, west of El Reno, OK, and, within breed and preweaning forage, were assigned to one of the following winter stocker treatments: 1) winter wheat pasture or 2) dormant native prairie plus supplemental CP. In March, winter stocker treatments were ended and calves were grazed as a single group on cool-season grasses until early July (1992, 1993, and 1994) or late May (1995), when the feedlot phase began. In the feedlot, calves were fed a high concentrate diet for an average of 120 d until a backfat thickness of > 10 mm was reached. Calves were shipped in truck load lots to Amarillo, TX (350 km), for processing and collection of carcass data. Averaged over calf breed group, calves wintered on wheat pasture gained faster (P < 0.01) during the stocker phase (0.71 vs 0.43 kg); had heavier (P < 0.01) final feedlot weights (535 vs 512 kg); lower feedlot (P < 0.01) ADG (1.37 vs 1.53 kg); heavier (P < 0.01) carcass weights (337 vs 315 kg); larger (P < 0.01) longissimus muscle (84.9 vs 81.8 cm2); higher percentage (P < 0.01) of kidney, heart, and pelvic fat (2.32 vs 2.26); and higher (P < 0.01) dressing percentage (62.2 vs 61.3) than calves backgrounded on native prairie. Maternal heterosis for stocker ADG was evident in calves backgrounded on native prairie but not on winter wheat (P < 0.10), but the two environments were similar in maternal heterosis for feedlot ADG and carcass traits. Calves wintered on native prairie were restricted in growth and expressed compensatory gain during the feedlot phase but not during the spring stocker phase. Dormant native grasses can be used to winter stocker calves excess to the winter wheat pasture needs, but ownership of these calves would have to be retained through the feedlot phase to realize any advantage of built-in compensatory gain. Finally, these data suggest that expression of maternal heterosis for weight gain is more likely in calves backgrounded on native prairie than in calves grazed on winter wheat.

Importance of evaluating organ parenchyma during screening abdominal ultrasonography after blunt trauma

OBJECTIVE

To determine the benefit of screening ultrasonography for parenchymal abnormalities as well as free fluid during screening abdominal ultrasonography in patients with blunt trauma.

METHODS

A total of 2693 patients with blunt trauma who were triaged to a level 1 trauma center underwent screening abdominal ultrasonography in the resuscitation suite. Examinations were performed by experienced sonographers and included a screen for free intraperitoneal fluid and evaluation of the abdominal organ parenchyma and heart for traumatic injury. Screening ultrasonographic findings were reviewed and compared with findings from autopsy, laparotomy, diagnostic peritoneal lavage, computed tomography, repeated ultrasonography, cystography, and clinical outcome. Imaging studies of all patients with confirmed or suspected injuries were reviewed to identify those in whom parenchymal findings aided diagnosis.

RESULTS

One hundred seventy-two patients were found to have evidence of abdominal injury due to blunt trauma on the basis of clinical data, imaging, laparotomy, or autopsy. Forty-four of these patients had no sonographic evidence of hemoperitoneum at the time of initial ultrasonography. Screening ultrasonographic findings were positive for injury in 19 of 44 patients on the basis of parenchymal findings or small retroperitoneal collections of fluid thought to be indicative of trauma. In the remaining 25 patients, screening ultrasonography showed no abnormalities, and injuries were detected by repeated ultrasonography, subsequent computed tomography, or diagnostic peritoneal lavage performed for suspected occult injury on the basis of clinical parameters. In addition, 47 of 126 injured patients with sonographically detected free fluid had parenchymal findings that helped localize injury. Sixteen of those patients were taken to the operating room on the basis of clinical and sonographic findings without undergoing computed tomography.

CONCLUSIONS

The inability to show injuries with no hemoperitoneum or with delayed hemoperitoneum has been shown to be a limitation of ultrasonography in patients with blunt trauma. In our series, 26% of all patients with documented injuries had no free fluid visible on screening ultrasonography Attention to findings other than free fluid allowed detection in 43% of injured patients without sonographic evidence of hemoperitoneum.

Synthesis of gamma-carboxylated polypeptides by alpha-cells of the pancreatic islets

gamma-Carboxylated proteins were detected in normal human pancreas by immunohistochemistry with a monoclonal antibody (M3B) specific for gamma-carboxyglutamyl residues. Staining appeared to be localized to the glucagon-secreting alpha-cells in the islets of Langerhans. Consistent with this, sections from a glucagonoma were stained much more intensely with the M3B antibody than those from an insulinoma. A murine alpha-cell line (alphaTC1 Clone 9) was cultured and gamma-carboxylated polypeptides, identified immunologically as prothrombin, protein S and (tentatively) Gas6, were isolated from the intracellular compartment by chromatography on an M3B-coupled resin. As in liver, prothrombin is synthesized by alpha-cells as a gamma-carboxylated zymogen that can be cleaved by ecarin to form an active serine protease that is inhibited by hirudin. The pancreas thus appears to be a novel site of synthesis for certain vitamin K-dependent proteins.

Target-Directed Enediynes: Designed Estramycins

The goal of selective targeting of enediyne cytotoxins has been investigated using estrogenic delivery vehicles. A series of estrogen-enediyne conjugates were assembled, and affinity for human estrogen receptor [hERalpha] was determined. The most promising candidate induced receptor degradation following Bergman cycloaromatization and caused inhibition of estrogen-induced transcription in T47-D human breast cancer cells.

Body composition and energy metabolism in pregnancy

The objective of the study was to measure energy metabolism and body composition during pregnancy and postpartum, compared to non-pregnant women, using non-invasive techniques. A longitudinal study of eight normotensive pregnant women was carried out at 19 +/- 1 and 36+/-1 weeks gestation, and postpartum. A cross-sectional study was also performed comparing postpartum to 12 non-pregnant women. Indirect calorimetry was performed while fasting to measure basal metabolic rate (BMR) and postprandially to measure diet-induced thermogenesis (DIT). Body composition consists of fat mass, lean body mass (LBM), and total body water (TBW) and was measured by bio-electrical impedance. Insulin resistance was indirectly assessed by glucose and insulin concentration and DIT.

Us of blunt abdominal trauma: importance of free pelvic fluid in women of reproductive age

PURPOSE

To assess the importance of free fluid and to determine the accuracy of screening ultrasonography (US) in female patients of reproductive age with trauma.

MATERIALS AND METHODS

US was performed in 1,047 patients, aged 10-60 years, to evaluate blunt trauma. Patients were retrospectively assigned to groups on the basis of presence and location of intraperitoneal free fluid. Injury and surgical injury rates were assessed by comparing US results with computed tomographic, repeat US, cystographic, peritoneal lavage, surgical, and/or autopsy findings in 144 patients and with final clinical outcome in 903. US scans were positive if fluid was outside the cul-de-sac or if suspicious parenchymal abnormalities were present.

RESULTS

In 939 patients, no fluid was seen: Eight had injuries; three were surgical. In 56, anechoic fluid was isolated to the cul-de-sac: Two had injuries; one was surgical. In 26, fluid was isolated to the upper abdomen: Fifteen had injuries; five were surgical. In 22, fluid involved the pelvis and abdomen: Nineteen had injuries; 14 were surgical. In four, questionable fluid was isolated to the supravesical space. Patients with fluid in the cul-de-sac had similar injury and surgical injury rates as those with no fluid but had lower rates than those of patients with fluid elsewhere (P<.02 to P<.001). US screening had 89% sensitivity, 98% specificity, 97% accuracy, a 61% positive predictive value, and a 99% negative predictive value.

CONCLUSION

In female patients of reproductive age with trauma, free fluid isolated to the cul-de-sac is likely physiologic; clinical follow-up should suffice. Patients with fluid elsewhere usually have clinically important injury and require further evaluation.

Genetic control of bone density and turnover: role of the collagen 1alpha1, estrogen receptor, and vitamin D receptor genes

Genetic factors are known to influence both the peak bone mass and probably the rate of change in bone density. A range of regulatory and structural genes has been proposed to be involved including collagen 1alpha (COL1A1), the estrogen receptor (ER), and the vitamin D receptor (VDR), but the actual genes involved are uncertain. We therefore studied the role of the COL1A1 and VDR loci in control of bone density by linkage in 45 dizygotic twin pairs and 29 nuclear families comprising 120 individuals. The influences on bone density of polymorphisms of COL1A1, VDR, and ER were studied by association both cross-sectionally and longitudinally in 193 elderly postmenopausal women (average age, 69 years) over a mean follow-up time of 6.3 years. Weak linkage of the COL1A1 locus with bone density was observed in both twins and families (p = 0.02 in both data sets), confirming previous observations of linkage of this locus with bone density. Association between the MscI polymorphism of COL1A1 and rate of lumbar spine bone loss was observed with significant gene-environment interaction related to dietary calcium intake (p = 0.0006). In the lowest tertile of dietary calcium intake, carriers of "s" alleles lost more bone than "SS" homozygotes (p = 0.01), whereas the opposite was observed in the highest dietary calcium intake (p = 0.003). Association also was observed between rate of bone loss at both the femoral neck and the lumbar spine and the TaqI VDR polymorphism (p = 0.03). This association was strongest in those in the lowest tertile of calcium intake, also suggesting the presence of gene-environment interaction involving dietary calcium and VDR, influencing bone turnover. No significant association was observed between the PvuII ER polymorphism alone or in combination with VDR or COL1A1 genotypes, with either bone density or its rate of change. These data support the involvement of COL1A1 in determination of bone density and the interaction of both COL1A1 and VDR with calcium intake in regulation of change of bone density over time.

Patterns of fluid accumulation on screening ultrasonography for blunt abdominal trauma: comparison with site of injury

The objectives of this study were to define where fluid accumulation is shown on screening ultrasonography after blunt abdominal trauma and to determine how fluid accumulation patterns are associated with the site of injury. From 1994 to 1998, 2,693 screening examinations for blunt abdominal trauma were performed, in which 7 regions were examined for fluid. On the basis of a preliminary analysis of patients with solitary injuries, all 194 patients with sonographically detected fluid were grouped by fluid accumulation pattern. Fluid patterns were compared with sites of injury. The patterns differed between hepatic and splenic injuries. Fluid in the left upper quadrant, in both upper quadrants, or diffusely distributed suggested splenic injury, whereas fluid in the right upper quadrant or the right upper quadrant and lower recesses suggested hepatic injury (P < .0001). Fluid accumulation was random after enteric injury. Patients with extraperitoneal injury had no fluid or had fluid focally at the injury site. The ability to predict the injury site on the basis of fluid patterns should expedite treatment of hemodynamically unstable patients with blunt abdominal trauma.

Quantification of fluid on screening ultrasonography for blunt abdominal trauma: a simple scoring system to predict severity of injury

A simple ultrasonographic method of fluid quantification, which counted the number of fluid recesses, was developed to predict the severity of injury after blunt abdominal trauma. From 1994 to 1998, 2,693 screening ultrasonographic examinations were performed for blunt abdominal trauma. Of this group, 2,499 patients had a fluid score of 0 (no fluid), and 1.4% had injuries (0.4% requiring surgery); 110 had a score of 1 (fluid in a single examined region), and 59% had injuries (13% requiring surgery); 33 had a score of 2, and 85% had injuries (36% requiring surgery); 30 had a score of 3, and 83% had injuries (63% requiring surgery); and 21 had a score of 4, and 95% had injuries (81 % requiring surgery). Patients with scores of 3 or greater had significantly higher rates of injury (P < .002) and injury requiring surgery (P < .0001) than patients with lower scores. The ability to predict injury severity on the basis of a simple ultrasonographic scoring system should expedite treatment of patients with severe trauma.

Whole-genome screening in ankylosing spondylitis: evidence of non-MHC genetic-susceptibility loci

Ankylosing spondylitis (AS) is a common inflammatory arthritis predominantly affecting the axial skeleton. Susceptibility to the disease is thought to be oligogenic. To identify the genes involved, we have performed a genomewide scan in 185 families containing 255 affected sibling pairs. Two-point and multipoint nonparametric linkage analysis was performed. Regions were identified showing "suggestive" or stronger linkage with the disease on chromosomes 1p, 2q, 6p, 9q, 10q, 16q, and 19q. The MHC locus was identified as encoding the greatest component of susceptibility, with an overall LOD score of 15.6. The strongest non-MHC linkage lies on chromosome 16q (overall LOD score 4.7). These results strongly support the presence of non-MHC genetic-susceptibility factors in AS and point to their likely locations.