Enhancing images of facial expressions

Facial images can be enhanced by application of an algorithm--the caricature algorithm--that systematically manipulates their distinctiveness (Benson & Perrett, 1991c; Brennan, 1985). In this study, we first produced a composite facial image from natural images of the six facial expressions of fear, sadness, surprise, happiness, disgust, and anger shown on a number of different individual faces (Ekman & Friesen, 1975). We then caricatured the composite images with respect to a neutral (resting) expression. Experiment 1 showed that rated strength of the target expression was directly related to the degree of enhancement for all the expressions. Experiment 2, which used a free rating procedure, found that, although caricature enhanced the strength of the target expression (more extreme ratings), it did not necessarily enhance its purity, inasmuch as the attributes of nontarget expressions were also enhanced. Naming of prototypes, of original exemplar images, and of caricatures was explored in Experiment 3 and followed the pattern suggested by the free rating conditions of Experiment 2, with no overall naming advantage to caricatures under these conditions. Overall, the experiments suggested that computational methods of compositing and caricature can be usefully applied to facial images of expression. Their utility in enhancing the distinctiveness of the expression depends on the purity of expression in the source image.

Association of interleukin-6 and other biologic variables with depression in older people living in the community

OBJECTIVES

The prevalence of depression increases with age, as does the prevalence of higher levels of the cytokine interleukin-6 (IL-6). This analysis was performed to determine the association between increased levels of this cytokine and depression in a population-based sample.

DESIGN

Cross-sectional cohort study.

SETTING

Rural and urban counties in North Carolina.

PARTICIPANTS

Community-dwelling older people.

MEASUREMENTS

The association between IL-6 and other biologic variables with self-report depression was examined in 1686 persons aged 70 years and older in the third in-person survey wave (1991) of the Duke Established Population for Epidemiologic Studies of the Elderly (EPESE). Bivariate associations were established by the Spearman correlation, adjusted for age. A stepwise linear logistic regression model was used to derive a final model to assess multivariable effects on CES-D scores.

RESULTS

Depression was correlated with IL-6 (P = .011), D-Dimer (P = .017), alpha-1-globulin (P = .023), alpha-2-globulin (P = .002), and beta globulin (P = .012). After controlling for age, race, and gender, IL-6 levels remained the only biologic variable significantly associated with depression (P = .035).

CONCLUSION

These data suggest that the inflammatory marker, IL-6, is associated with depression in older people in this cross-sectional study. These results are compatible with the hypothesis of cytokine (IL-6) stimulation in geriatric depression as part of an overall immunoendocrine dysregulation.

An evaluation of the Team Objective Structured Clinical Examination (TOSCE)

OBJECTIVES

To evaluate the validity, reliability and feasibility of the TOSCE, a new means of formative assessment for medical students, from the perspectives of examiners, simulated patients and students.

DESIGN

Teams of five students rotate through five clinical stations, performing one of four tasks in turn, whilst the fifth member of the team 'rests'.

SETTING

St George's Hospital Medical School, London.

SUBJECTS

Third-year medical students, their examiners and simulated patients.

RESULTS

All participants felt the TOSCE session had high validity although some students were unfamiliar with some subjects. Stations were double-marked and agreement rates and Cohen's Kappa ranged from 67 to 94% and 0.04-0.88, respectively. Analysis of the causes of disagreement led to improved marking schedules and enhanced reliability.

CONCLUSIONS

The feasibility of the exercise as a formative assessment was demonstrated by the confidence of the staff participating both as examiners and simulated patients and from the majority of students who welcomed the learning experience.

Association between insulin-like growth factor I and bone mineral density in older women and men: the Framingham Heart Study

Few studies of the GH axis and bone have focused specifically on elderly people. The objective of this study was to determine the association between insulin-like growth factor I (IGF-I) and bone mineral density (BMD) in 425 women and 257 men aged 72-94 who participated in the Framingham Osteoporosis Study component of the Framingham Heart Study in 1992-1993. Serum IGF-I level was determined by RIA. BMD at three femoral sites and the lumbar spine was determined by dual x-ray absorptiometry, and at the radius by single-photon absorptiometry. IGF-I level was positively associated with BMD at all five sites (Ward's area, femoral neck, trochanter, radius, and lumbar spine) in women after adjustment for weight loss and other factors (P < or = 0.01) and protein intake in a subset of participants (0.006 < P < 0.07). A threshold effect of higher BMD was evident at each of the 3 femoral sites and the spine (P < 0.03) but not at the radius for women in the highest quintile of IGF-I (> or = 179 g/liter) vs. those in the lowest four quintiles. IGF-I was not significantly associated with BMD in men. These results indicate that higher IGF-I levels are associated with greater BMD in very old women, and suggest that future clinical trials employing GH may have a role in the development of treatments for older women with osteoporosis.

Intravenous ketamine for pediatric sedation in the emergency department: safety profile with 156 cases

OBJECTIVES

To determine the safety of i.v. ketamine when administered by emergency physicians (EPs) for pediatric procedures, and to contrast the sedation characteristics of the i.v. and i.m. routes.

METHODS

The study was a retrospective consecutive case series of children aged < or =15 years given i.v. ketamine in the EDs of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine was used by treating physicians. Records were reviewed for adverse effects, indication, dosing, adjunctive drugs, inadequate sedation, and time to release. Results were contrasted with previously reported data for the i.m. route.

RESULTS

During the study period i.v. ketamine was administered 156 times, primarily for laceration repair and fracture reduction. Transient apnea and respiratory depression occurred in one patient each; both were quickly identified and were without sequelae. Laryngospasm or aspiration was not noted in any children. There were 6 children with emesis and 2 with mild agitation during recovery. The median time from initial dose to ED release was 103 minutes (25th to 75th percentiles 76 to 146 minutes). The i.v. and i.m. routes were comparable in terms of adverse effects, inadequate sedation, and time to release.

CONCLUSION

I.v. ketamine can be administered safely by EPs to facilitate pediatric procedures when used in a defined protocol. The sedation characteristics of the i.v. and i.m. routes appear comparable.

Bereavement care in general practice: a survey in South Thames Health Region

BACKGROUND

Studies have shown that bereaved individuals suffer increased rates of physical and mental ill health. Bereavement support has recently been advocated as an area of prevention in primary care, with suggestions that general practitioners (GPs) should adopt protocols for the active follow-up of their bereaved patients, which relies on the early notification of deaths by hospitals and hospices. Little is known about the routine care currently provided by GPs and primary health care teams (PHCTs) to support their bereaved patients.

AIMS

To explore GPs' perceptions of patient death notifications by hospitals and hospices. To describe practice policies relating to patient deaths and the provision of bereavement support.

METHOD

Postal questionnaires were sent to senior partners of a random sample of 500 general practices in South Thames Health Region.

RESULTS

Three hundred and fifty-three practitioners responded (71%). Hospitals were perceived to be significantly slower than hospices in notifying deaths (P < 0.0001). One hundred and ninety-six practices (56%) kept death registers, 230 (65%) discussed deaths together, and 142 (40%) identified bereaved relatives. One hundred and thirty-seven practices (39%) routinely offered bereaved relatives contact with a PHCT member; while 133 (38%) supported only those who asked for help. Routine support was significantly more likely to be provided by practices that kept a death register, discussed deaths together, identified bereaved relatives, and had a special interest in palliative care.

CONCLUSIONS

GPs perceive hospitals to be slower than hospices at notifying deaths, particularly in the first 24 hours. They are divided over whether bereavement support should be proactive or reactive. Keeping a practice death register, discussing deaths together, and identifying newly bereaved relatives are activities related to providing routine bereavement care.

The association of peripheral monocyte derived interleukin 1beta (IL-1beta), IL-1 receptor antagonist, and tumor necrosis factor-alpha with osteoarthritis in the elderly

OBJECTIVE

To examine the association of peripheral blood mononuclear cell (PBMC) derived interleukin 1beta (IL-1beta), IL-1 receptor antagonist (IL-1Ra), tumor necrosis factor alpha (TNF-alpha), and radiographic osteoarthritis (OA) in the elderly.

METHODS

A total of 703 subjects (436 women, 267 men, mean age 78.5+/-4.5 yrs) had both knee and hand radiographs, and cytokines were measured during the 22nd biennial examination of the Framingham Cohort. PBMC derived IL-1beta , IL-1Ra, and TNF-alpha production was assessed using a non-cross reacting polyclonal radioimmunoassay. Knee OA was defined as a score of > 2 using a modified Kellgren and Lawrence scale. The presence of osteophytes and joint space narrowing were scored separately on a 0-3 scale, in which disease was defined a priori as a score > 0 for each feature. Sex-specific odds ratios were calculated for knee OA after adjusting for weight, history of knee injury, and use of estrogen and nonsteroidal antiinflammatory drugs.

RESULT

No uniform associations were found for IL-1beta or IL-1Ra in men, or for TNF-alpha production and radiographic OA in either sex. We found possible associations for the highest levels of IL-1beta production and the presence of knee osteophytes [OR=2.0 (1.2-3.5)] and joint space narrowing [OR=1.7 (1.1-2.8)] in women. Our data suggested a possible protective effect for IL-1Ra production and hand OA in women [OR=0.6 (0.4-1.0)].

CONCLUSION

We found no consistent association of PBMC cytokine production and radiographic OA. However, women with the highest production of IL-1beta and IL-1Ra had respectively higher rates of knee OA and lower rates of hand OA than expected.

Visualization of the human larynx: a three-dimensional computer modeling tool

The larynx is a complex compact organ. A detailed understanding of the anatomical relationships of its various structures is critical to the various workers in the field. To facilitate this goal, a 3-D model of the human larynx has been developed using multiple thin section MRI and CT images taken through a cadaver larynx. A databank of individual laryngeal structures ('units') has been built up. A software package has then been utilized which allows for representation of any of the stored 'units'. In this manner, elements of the larynx can be viewed from any direction, with the larynx static or in motion. Similarities and differences from current CD-ROM packages of the larynx are discussed.

The influence of continuous intravenous prostacyclin therapy for primary pulmonary hypertension on the timing and outcome of transplantation

BACKGROUND

Primary pulmonary hypertension (PPH) is a progressive disease with a median survival of less than 3 years from diagnosis. Medical management has typically consisted of anticoagulation and oral calcium channel blocking agents, whereas lung transplantation (LT) has been reserved for patients who are unresponsive to medical therapy. Continuous intravenous prostacyclin was introduced for patients who did not respond to calcium channel blockers and who would have required LT. We reviewed our experience with prostacyclin in LT candidates to study its effects on the timing and outcome of LT.

METHODS

We retrospectively reviewed the clinic and hospital records of patients with PPH who were both treated with prostacyclin and evaluated for LT. Additional information was obtained from the pulmonary vascular disease and lung transplantation databases.

RESULTS

A total of 42 patients were identified who received prostacyclin for the treatment of PPH and were evaluated for LT. Thirty-seven patients were accepted as LT candidates, 22 at The University of Maryland Medical Center (UMMC), 15 at other LT programs. Overall, 70% (27/37) of LT candidates were removed from the LT waiting list or had listing for LT deferred because of clinical improvement. In patients listed for LT before initiation of prostacyclin therapy, 55% (12/22) were removed from the active waiting list for 27.2+/-17 months (range 8 to 60), and 92% (11/12) remain on the inactive status. In patients who received prostacyclin before listing for LT, listing for LT was deferred in 94% (14/15) for 17.4+/-9 months (range 6 to 33 months) because of clinical stability or improvement. In all, 93% of patients (39/42) experienced an improvement in 1 or more New York Heart Association functional class. The hemodynamic profiles of the eight patients removed from the active waiting list at UMMC demonstrated increases of 55%+/-18% in cardiac output, and decreases of 14.3%+/-4.9% in mean pulmonary artery pressure and 36%+/-8.3% in total pulmonary resistance (p < 0.05). The 1-year survival rate for LT after prostacyclin therapy was 88% (7/8) at UMMC and 60% (3/5) at the other centers.

CONCLUSION

We conclude that prostacyclin therapy is an effective means of delaying, possibly indefinitely, the need for LT in patients with PPH and that excellent results can be obtained when LT is performed after prostacyclin therapy. Consideration should be given to initiating prostacyclin therapy in all patients whose conditions do not respond to conventional therapy before proceeding with transplantation.

Progression of hepatic neoplasms is severely retarded in mice lacking the bisecting N-acetylglucosamine on N-glycans: evidence for a glycoprotein factor that facilitates hepatic tumor progression

The glycosyltransferase termed GlcNAc-TIII is dedicated to the transfer of a single N-acetylglucosamine (GlcNAc) residue (the bisecting GlcNAc), to a subset of N-glycans in glycoproteins. The addition of this GlcNAc is differentially regulated during development and is induced in certain cancers, particularly in hepatic tumorigenesis. To investigate a functional role for the bisecting GlcNAc in the development of liver cancer, the Mgat3 gene that codes for GlcNAc-TIII, was inactivated by targeted gene disruption, and the susceptibility of Mgat3-/- mice to tumor induction was tested. After a single injection with diethylnitrosamine and subsequent treatment with phenobarbitol for 6 months, Mgat3+/+ and Mgat3+/- mice had grossly enlarged livers that contained numerous tumors. By stark contrast, Mgat3-/- mice had livers of normal size, and only 50% of mice had one to four small tumors. However, histological examination showed that Mgat3-/- livers had significant numbers of basophilic foci, and by 10-12 months after diethylnitrosamine injection, tumors had developed in Mgat3-/- mice. Therefore, initiation occurred in Mgat3-/- mice but progression was severely retarded. Assays for Mgat3 gene expression in tumor tissue gave an unexpected result. In contrast to the situation in the rat, hepatic tumor formation in the mouse was not accompanied by a dramatic increase of GlcNAc-TIII activity nor of glycoproteins with a bisecting GlcNAc, nor of Mgat3 gene expression in tumor tissue from wild-type mice. The data suggest that a glycoprotein factor with the bisecting GlcNAc facilitates tumor progression in liver. In the absence of the bisecting GlcNAc in Mgat3-/- mice, the factor is reduced in activity, and tumor progression is severely retarded.

Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases

STUDY OBJECTIVE

To determine the safety of intramuscular ketamine when administered by emergency physicians for pediatric procedures in accordance with a defined protocol.

METHODS

We assembled a consecutive case series of children aged 15 years or younger who were given ketamine in the emergency departments of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine use (4 mg/kg, intramuscularly) was followed. Treating physicians were instructed to complete data forms recording complications and adequacy of sedation concurrent with patient care. Subsequent chart review was used to determine indications, adjunctive drugs, time to discharge, and adverse reactions for all patients.

RESULTS

Intramuscular ketamine was administered 1,022 times, mainly for laceration repair and fracture reduction. Physicians completed data forms for 431 of treated children (42%). Transient airway complications occurred in 1.4%: airway malalignment (n = 7), laryngospasm (n = 4), apnea (n = 2), and respiratory depression (n = 1). All were quickly identified and treated without intubation or sequelae. Emesis occurred in 6.7%, without evidence of aspiration. Mild recovery agitation occurred in 17.6%, moderate to severe agitation in 1.6%. No child required hospitalization for complications caused by ketamine. Ketamine produced acceptable sedation in 98% of patients. The median time from injection to emergency department discharge was 110 minutes for children given a single dose of ketamine.

CONCLUSION

Intramuscular ketamine may be administered safely by emergency physicians to facilitate pediatric procedures in accordance with a defined protocol and with appropriate monitoring. Ketamine is highly effective, has a wide margin of safety, does not require intravenous access, and uniquely preserves protective airway reflexes.

Relative weight, weight change, and risk of coronary heart disease in the Honolulu Heart Program

Risk of coronary heart disease (CHD) among the Honolulu Heart Program participants was examined in relation to body mass index (BMI) at age 25 and two subsequent periods of weight change: age 25 to examination I (1965-1968) and examination I to examination III (1971-1974). During a maximum follow-up period of 17 years after examination III, there were 479 incident cases of CHD among the study sample of 6,176 Japanese-American men. Levels of BMI at age 25 were positively related to CHD incidence after statistical control for age, smoking, and subsequent weight change. Relative risk between the lowest and highest BMI categories was 2.44 (95% confidence interval (CI) 1.61-3.69). Compared with a weight change of less than 2.5 kg between age 25 and examination I, relative risks were 1.41 (95% CI 1.00-1.97) for a weight gain between 2.6 and 5 kg, 1.60 (95% CI 1.22-2.11) for a weight gain between 5.1 and 10 kg, and 1.75 (95% CI 1.32-2.33) for a weight gain of more than 10 kg. During the examination I-III period, in contrast, the highest risk of CHD was found in men who lost the greatest amount of weight; the relative risk of CHD for men who lost more than 2.5 kg was 1.25 (95% CI 0.98-1.60). The authors conclude that levels of relative weight in early adulthood were positively related to risk of CHD occurring much later in the lives of these men. The association between CHD incidence and weight change appeared to be modified by age, with higher risks for earlier weight gain and later weight loss in the lives of these men.

Apolipoprotein E epsilon 2 allele and risk of stroke in the older population

BACKGROUND AND PURPOSE

There is evidence for a role of apolipoprotein E (apoE) in atherosclerosis. Coronary heart disease morbidity is higher in persons carrying an epsilon 4 allele and lower in those carrying an epsilon 2 allele, but the effect on cerebrovascular disease is controversial. We estimated the risk of stroke associated with different apoE genotypes in older persons.

METHODS

At the sixth annual follow-up of the Iowa cohort of the Established Populations for Epidemiologic Studies of the Elderly, 1664 persons aged > or = 71 years and free of stroke were genotyped for apo E. Occurrence of ischemic strokes was prospectively assessed from subsequent hospital discharge records and death certificates.

RESULTS

One hundred fifty persons had an ischemic stroke over the subsequent 5 years (21.2 per 1000 person-years). The presence of epsilon 3 and epsilon 4 did not influence stroke risk. Among persons aged < 80 years at the time of genotyping, epsilon 2 carriers had lower risk of incident stroke, while no effect was detected in the older group. Compared with epsilon 2 carriers aged 70 to 79 years (reference group), those in the same age group and not carrying an epsilon 2 had 2.6-fold higher risk of incident stroke, and those aged > or = 80 years had even higher risk of stroke but without any difference according to presence/absence of epsilon 2 (relative risks 3.6 and 3.3). Results remained substantially unchanged when adjusted for potential confounders and in models estimating the effect of apoE polymorphism on the risk of developing a stroke at ages between 70 and 79 years (56 events) and separately at ages > or = 80 years (94 events).

CONCLUSIONS

The conditioning influence of age on the protection conferred by the apoE epsilon 2 allele on stroke risk may account for previous controversies. This hypothesis should be verified in a population with a wider age range.

The association of plasma IL-6 levels with functional disability in community-dwelling elderly

BACKGROUND

IL-6 is a multifunctional cytokine that has been shown to increase with age.

METHODS

Plasma IL-6 was measured by ELISA in 1,727 community-dwelling elderly subjects whose blood was drawn during the third in-person survey of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). Demographics, functional status (disability), and disease states were determined. Correlations of these factors with IL-6 were analyzed with Spearman's Rho while differences between groups were assessed by Wilcoxon test.

RESULTS

IL-6 levels were higher with age (p = .0001) even in this older population (> 70 years). There was a positive correlation between IL-6 and functional disability for each of the functional status measures (p = .0001), as well as a correlation between self-rated health and IL-6. Significantly higher median levels of IL-6 were found in subjects reporting prevalent cancer, heart attack, and high blood pressure, but not diabetes or arthritis. The association between age and functional status with high IL-6 remained when all other variables were controlled, in multivariable analysis.

CONCLUSIONS

This association between increased plasma IL-6 levels and functional status suggests that dysregulation of IL-6 may be related to the functional disability seen with aging, and that IL-6 may be useful as a component of an overall marker of health.

Sagittal diameter minus subcutaneous thickness. An easy-to-obtain parameter that improves visceral fat prediction

Two groups of 99 and 98 women were studied to test if correcting sagittal diameter by subtracting the thickness of subcutaneous abdominal adipose tissue improves its degree of association with visceral adipose tissue. The first group (age, 40 +/- 14 years; body mass index [BMI], 36 +/- 6 kg/m2) was used to calculate the predictive equations for visceral adipose tissue. The second group (age, 43 +/- 14 years; BMI, 37 +/- 6 kg/m2) was used for cross-validation. Various anthropometric parameters were measured by ultrasound and computed tomography. Correlation coefficients with single-slice visceral adipose tissue area, after sagittal diameter was corrected by subtracting subcutaneous thickness, rose from 0.63 to 0.72 in the first group and from 0.64 to 0.71 in the second group. The standard error of residuals of the regression formula for visceral adipose tissue area was 10% lower with modified sagittal diameter than with sagittal diameter alone. During cross-validation, the standard error of differences was 5% lower with modified sagittal diameter. The visceral adipose tissue estimate was also less biased by the size of the area when sagittal diameter minus subcutaneous thickness was used. Results show that subtracting the thickness of abdominal subcutaneous adipose tissue from sagittal diameter significantly improves the predictive power of sagittal diameter for visceral adipose tissue and could be a useful tool for epidemiological studies.

Correlates of performance-based measures of muscle function in the elderly: the Cardiovascular Health Study

BACKGROUND

It is unknown how much age-related changes in muscle performance represent normal aging versus the effects of chronic disease and life style. We examined the correlates of four performance measures-gait speed, timed chair stands (TCS), grip strength, and maximal inspiratory pressure (MIP)-using baseline data from the Cardiovascular Health Study (CHS), a population-based study of risk factors for heart disease and stroke in persons > or = age 65.

METHODS

We analyzed data from the 5,201 CHS participants. Variables were arranged into nine categories: Personal Characteristics, Anthropometry, Physical Condition, Reported Functional Status, Subjective Health, Psychological Factors, Symptoms, Cognitive Status, Habits and Lifestyle, and Prevalent Disease. Independent correlates were identified using stepwise linear regression.

RESULTS

The regression models explained 17.7-25.4% of the observed variability. Although age significantly correlated with each measure, it explained little of the variability (< or = 5.7%). Anthropometric features plus physical condition explained 14.0-17.4% of the variability for grip strength and MIP, but 2.8-12.9% of the variability for gait speed and the log of TCS. Subjective health and psychological factors explained 1.8-9.4% of the variability in gait speed and the log of TCS, but < or = 1.2% of the variability in grip strength and MIP. Variables for prevalent disease explained < or = 1.3% of the variability in each measure.

CONCLUSIONS

After age 64, age explained little of the variability in muscle performance in a large sample of mostly functionally intact, community-dwelling older persons. Complex measures such as gait speed were more associated with subjective factors than were direct measures of strength. Prevalent disease contributed surprisingly little to muscle performance.

Effects of age on body fat distribution and cardiovascular risk factors in women

We conducted a cross-sectional study of body fat distribution and metabolic variables and the interrelations among these factors in 134 women aged 18-71.9 y. Body fat distribution was measured with use of computerized tomography. A significant positive correlation was observed between age and visceral adipose tissue (VAT) and between VAT and body weight. When subjects were divided into five age groups, VAT values were significantly higher in older groups. Values for triacylglycerols, cholesterol, fasting glucose, 2-h glucose, and the sum of glucose values during an oral-glucose-tolerance test were significantly higher in older subjects. After adjustment for visceral fat, no significant differences in any metabolic variable studied, except cholesterol, were found across the five age groups. In conclusion, we found that regional body fat distribution in older women was different from that in younger subjects: older women had larger amounts o visceral fat. Values for metabolic variables were also higher in older subjects. Our data suggest that redistribution of body fat in older subjects is associated with changes in metabolic variables.

Appendicular skeletal muscle mass: effects of age, gender, and ethnicity

This study tested the hypothesis that skeletal muscle mass is reduced in elderly women and men after adjustment first for stature and body weight. The hypothesis was evaluated by estimating appendicular skeletal muscle mass with dual-energy X-ray absorptiometry in a healthy adult cohort. A second purpose was to test the hypothesis that whole body 40K counting-derived total body potassium (TBK) is a reliable indirect measure of skeletal muscle mass. The independent effects on both appendicular skeletal muscle and TBK of gender (n = 148 women and 136 men) and ethnicity (n = 152 African-Americans and 132 Caucasians) were also explored. Main findings were 1) for both appendicular skeletal muscle mass (total, leg, and arm) and TBK, age was an independent determinant after adjustment first by stepwise multiple regression for stature and weight (multiple regression model r2 = approximately 0.60); absolute decrease with greater age in men was almost double that in women; significantly larger absolute amounts were observed in men and African-Americans after adjustment first for stature, weight, and age; and >80% of within-gender or -ethnic group between-individual component variation was explained by stature, weight, age, gender, and ethnicity differences; and 2) most of between-individual TBK variation could be explained by total appendicular skeletal muscle (r2 = 0.865), whereas age, gender, and ethnicity were small but significant additional covariates (total r2 = 0.903). Our study supports the hypotheses that skeletal muscle is reduced in the elderly and that TBK provides a reasonable indirect assessment of skeletal muscle mass. These findings provide a foundation for investigating skeletal muscle mass in a wide range of health-related conditions.

The genetics of obesity

Despite the influence of obesity in predisposing to many diseases, and evidence for high heritability, efforts to identify human genes with major effects on bodyweight have not yet been successful. In contrast, remarkable progress has been made in the identification and characterization of the genes mutated in five monogenic mouse models of obesity. These genes have led to new insights into the etiology of obesity and provide promising targets for therapeutic intervention.

Clarifying the direct relation between total cholesterol levels and death from coronary heart disease in older persons

BACKGROUND

The importance of total cholesterol level as a risk factor for coronary heart disease in older adults is controversial.

OBJECTIVE

To determine whether findings showing that total cholesterol level is not an important risk factor for coronary heart disease in older adults are the result of inadequate adjustment for co-occurring diseases and frailty.

DESIGN

Multicenter, longitudinal study with 5-year follow-up for death.

PARTICIPANTS

4066 men and women from East Boston, Massachusetts; Iowa and Washington counties, Iowa; and New Haven, Connecticut.

MEASUREMENTS

In 1988, participants were interviewed about their health status and had blood samples taken. Mortality follow-up was through 1992.

RESULTS

In analyses that included all fatal coronary heart disease events (252 deaths) and did not adjust for risk factors for coronary heart disease and measures of frailty, persons with the lowest total cholesterol levels (< or = 4.15 mmol/L [< or = 160 mg/dL]) had the highest rate of death from coronary heart disease, whereas those with elevated total cholesterol levels (> or = 6.20 mmol/L [> or = 240 mg/dL]) seemed to have a lower risk for death from coronary heart disease (P for trend = 0.04). After adjustment for established risk factors for coronary heart disease and markers of poor health (including chronic conditions, low serum iron and albumin levels) and exclusion of 44 deaths from coronary heart disease that occurred within the first year, elevated total cholesterol levels predicted increased risk for death from coronary heart disease, and the risk for death from coronary heart disease decreased as cholesterol levels decreased (P for trend = 0.005).

CONCLUSIONS

Elevated total cholesterol level is a risk factor for death from coronary heart disease in older adults, and the apparent adverse effects associated with low cholesterol levels are secondary to comorbidity and frailty. This suggests that excluding older persons from cholesterol screening is inappropriate, but interpretation of screening results in older persons requires clinical judgment. Results from controlled clinical trials are needed to clarify this issue.

Muscle mass and strength: relation to function in population studies

The use of the term sarcopenia to describe the age-related loss in skeletal muscle and its functional consequences is relatively recent. However, interest in the relationship of muscle mass to strength and function predates the concept of sarcopenia as researchers have attempted to understand differences in mass and strength between men and women, young and old. Most of these studies are cross-sectional comparisons in which muscle mass and strength tend to be linearly related, so that those with more muscle tend to be stronger. This article focuses instead on some potential problems with the sarcopenia-function association in old age and presents what little data exist from longitudinal population studies addressing the effect of sarcopenia over time.

Isolation and characterization of mycophenolic acid-resistant mutants of inosine-5'-monophosphate dehydrogenase

Mycophenolic acid (MPA) is a potent and specific inhibitor of mammalian inosine-monophosphate dehydrogenases (IMPDH); most microbial IMPDHs are not sensitive to MPA. MPA-resistant mutants of human IMPDH type II were isolated in order to identify the structural features that determine the species selectivity of MPA. Three mutant IMPDHs were identified with decreased affinity for MPA The mutation of Gln277 --> Arg causes a 9-fold increase in the Ki of MPA, a 5-6-fold increase in the Km values for IMP and NAD, and a 3-fold decrease in kcat relative to wild type. The mutation of Ala462 --> Thr causes a 3-fold increase in the Ki for MPA, a 2.5-fold increase in the Km for NAD, and a 1.5-fold increase in kcat. The combination of these two mutations does not increase the Ki for MPA, but does increase the Km for NAD 3-fold relative to Q277R and restores kcat to wild type levels. Q277R/A462T is the first human IMPDH mutant with increased Ki for MPA and wild type activity. The third mutant IMPDH contains two mutations, Phe465 --> Ser and Asp470 --> Gly. Ki for MPA is increased 3-fold in this mutant enzyme, and Km for IMP is also increased 3-fold, while the Km for NAD and kcat are unchanged. Thus increases in the Ki for MPA do not correlate with changes in Km for either IMP or NAD, nor to changes in kcat. All four of these mutations are in regions of the IMPDH that differ in mammalian and microbial enzymes, and thus can be structural determinants of MPA selectivity.

Anti-M and anti-N reactivity with Tn and T activated cells

Monoclonal (MoAB) anti-N and anti-M were tested against normal, T-activated, and Tn-activated RBCs. In vivo T and Tn activation affects the sialic acid expression on the RBCs which may affect the binding of antibodies to the M and/or N antigens. The majority of MoAB anti-M and anti-N in this workshop demonstrated some effect from in vivo T and Tn activation.

When the hospice patient is manipulative

Oncology and hospice literature have addressed the problem of psychiatric complications, secondary to the stressors of diagnosis and treatment. This literature focuses particularly on depression and anxiety, which not only compound patients' suffering but also may interfere with optimal care. Little attention has been given, however, to the unique challenges of providing hospice care to patients with preexisting psychiatric conditions. As hospice care becomes increasingly mainstream in the health care system, we can expect to meet more patients with such conditions. In order to contribute to collegial dialogue that addresses this minority population in hospice services, a case study is presented in this article of the process of care for a hospice patient with a preexisting psychiatric condition. Interventions are suggested, using a theoretical matrix of hospice philosophy and principles of care for manipulative patients.

Summary of serological test results on the monoclonal antibodies to non-specific erythrocytes antigens

Monoclonal antibodies from the 2D3 Section (Other Non-specific Erythrocyte Antigens) of the Third International Workshop & Symposium on Monoclonal Antibodies Against Human Red Blood Cell and Related Antigens were tested using standard serological tube methods. Each antibody was tested to determine the presence of prozoning. A selected panel of red blood cells was tested against each antibody at different phases. Anti-CD44 specificities were weaker or non-reactive with Lu(a-b-) InLu cells and 2 sources (2D3-1 and 2D3-2) were slightly decreased with Ko cells. Anti-CD47 and antibodies to Rh related molecules showed decreased or no reactivity with Rh null cells. Anti-CD99 showed weak or no reactivity with Gy-, LW:-3 and cord blood cells.

Self-report of difficulty in performing functional activities identifies a broad range of disability in old age

OBJECTIVE

To describe a broad range of physical disability by examining the association between a four-level measure of disability, based on self-report of difficulty in performing functional activities, and previously identified risk factors for disability.

DESIGN

Cross-sectional.

SETTING

Community-based.

PARTICIPANTS

A total of 2373 noninstitutionalized men and women aged 65 and older from the Veneto Region of Italy.

MEASUREMENTS

Odds ratios for the association of the four levels of disability (none, mild, moderate, and ADL disability) differentiated by this new measure with known risk factors for physical disability.

MAIN RESULTS

This summary measure of physical disability distinguished older persons with disability from the population typically classified as nondisabled. Twenty-one percent of study participants were identified as having Activities of Daily Living (ADL) disability (defined as self-report of difficulty in one or more ADLs), and an additional 40% had mild or moderate disability based on degree of difficulty in Instrumental Activities of Daily Living (IADLs) and physical functional activities. Hip fracture and lower extremity performance were strongly independently associated with each level of disability. The association of a range of established risk factors for disability and health care utilization measures with the levels of disability identified in our study, and the trend toward increasing odds with increasing disability, provide evidence of the construct validity of this measure.

CONCLUSIONS

Self-report of difficulty in performing functional activities identifies older persons with physical disability not ascertained by self-report of the need for help, the measure typically used to identify disability in older populations. Further studies should evaluate the potential for self-reported difficulty in functional activities to predict important disability-related outcomes.

Linkage analyses of schizophrenia to chromosome 6p24-p22: an attempt to replicate

The present study evaluates evidence for linkage of schizophrenia to chromosome 6p24-p22. An independent sample of 211 families ascertained on the basis of having an affected sib-pair diagnosed with schizophrenia or schizoaffective disorder was assessed with seventeen polymorphic markers spanning a 37cM region. Linkage analysis was performed with parametric and non-parametric methods to test for cosegregation using 4 models of inheritance. Neither two-point nor multipoint non-parametric analyses reached significance at a level less than 0.01 for any markers examined in the region and lod score analyses were not suggestive of linkage. Based on initial findings in the present data set and recently published linkage results, two specific areas were densely covered with markers and tested for linkage disequilibrium. After correcting for multiple comparisons within each locus, no significant deviation from expected allele transmission ratios was observed. The present findings together with the published literature fail to find consistent evidence of a linkage for schizophrenia to a single locus on chromosome 6.

Metabolically active component of fat-free body mass: influences of age, adiposity, and gender

Fat-free body mass (FFM) is often considered the metabolically active compartment and is widely used to adjust between-subject differences in resting energy expenditure for body composition. The use of FFM as the metabolically active portion of body weight makes the assumption that the body cell mass (BCM) component which is more difficult to measure, maintains a relatively constant relationship to FFM within and between subjects. The aim of this study was to test the hypothesis that BCM and FFM are associated independently of age, adiposity (as represented by body density), and gender in healthy white women and men. BCM and FFM were estimated by whole-body 40K-counting and dual-energy x-ray absorptiometry (DXA), respectively. Multiple regression analysis was used to model the relationships between BCM as the dependent variable and FFM, age, body density, and gender as potential independent variables. FFM alone explained 51% and 63% of between-individual BCM differences in women (n = 269) and men (n = 204) (both P = .0001), respectively. Age contributed significantly (P = .0001) to BCM prediction after adjusting first for FFM in both women and men. Body density also added significantly (P = .004 and P = .0001) to FFM and age prediction of BCM in women and men, respectively. Lastly, gender contributed significantly to the composite model, with 91% of between-individual differences in BCM explained by FFM, age, body density, and gender. Hence, BCM does not maintain a fixed relationship to FFM, as often assumed, but varies significantly and independently of FFM with age, adiposity, and gender. These findings have implications for the study of metabolic indices such as resting energy expenditure.

Prevention in practice: results of a 2-year follow-up of routine health promotion interventions in general practice

BACKGROUND

The effectiveness of health promotion activity in general practice on risk factor reduction for coronary heart disease remains the subject of active debate.

OBJECTIVE

The study aimed to assess the impact of practice-based health check-ups on health behaviours over a 2-year period.

METHOD

A general practice cohort of 7123 patients from 18 practices was surveyed. Eight hundred and forty (12%) patients had been offered a health check within a 12-month period from September 1992 and 621 (9%) received one. Two hundred and fifty patients (40%) were asked back for follow-up after their health check.

RESULTS

Over a 2-year period there was no difference in smoking cessation, alcohol consumption, weight loss nor the amount of exercise taken between those who attended for a health check and those who did not. The food score chosen to assess dietary change (Oxcheck) showed a statistically significant 1.16-point rise for the whole sample over the survey period. There was a significant difference in mean food score change between health check attenders and non-attenders (Mann-Whitney U test: P < 0.002). Maintenance of dietary improvement over a 2-year period was not affected by health check attendance.

CONCLUSIONS

This study confirms the low impact of health checks on the self reported modification of cardiovascular risk factors and shows that maintenance of appropriate health behaviour change is no more likely in those who have received a health check.

Review: the effects of antihypertensive agents on serum lipids

Because various antihypertensive drugs adversely affect lipid metabolism, these drugs may increase associated risks for coronary artery disease and thus offset some of the beneficial effects of blood pressure reduction. In this paper the current literature regarding the effects of antihypertensive agents on serum lipids is reviewed. Differing effects of various classes of antihypertensives are assessed to further our understanding of this very important subject.

Weight, height and body mass index distributions in geographically and ethnically diverse samples of older persons. Ad Hoc Committee on the Statistics of Anthropometry and Aging

We compared anthropometric data (height, weight and body mass index) from 19 geographically and ethnically varied samples of community-dwelling elderly people. Participants were stratified into three age groups, 60-69, 70-79 and 80 years or older. We present age-group-specific means and standard deviations for height, weight and body mass index (BMI, weight/height2) and the prevalence of underweight (BMI < 20) and overweight (BMI > or = 30). Across studies there are large differences in the prevalence of overweight and underweight, but in all studies mean height and BMI decreased with age. In general, mean BMI among 70-79-year-old women is greater than that for men of a similar age, and the Mediterranean samples are heavier for height than samples from Western Europe, Asia, Africa and the United States. The comparisons suggest that the sensitivity and specificity of a fixed cut-off for underweight and overweight are likely to differ by sex, age, and geographic location in samples of older persons.

Weight change between age 50 years and old age is associated with risk of hip fracture in white women aged 67 years and older

BACKGROUND

Although changes in body weight with aging are common, little is known about the effects of weight change on health in old age.

OBJECTIVES

To study the effects of weight loss and weight gain from age 50 years to old age on the risk of hip fracture among postmenopausal white women aged 67 years and older and to determine if the level of weight at age 50 years modifies this risk.

METHODS

The association between weight change and the risk of hip fracture was studied in 3683 community-dwelling white women aged 67 years and older from three sites of the Established Populations for Epidemiologic Studies of the Elderly.

RESULTS

Extreme weight loss (10% or more) beginning at age 50 years was associated in a proportional hazards model with increased risk of hip fracture (relative risk [RR], 2.9; 95% confidence interval [CI], 2.0-4.1). This risk was greatest among women in the lowest (RR, 2.3; CI, 1.1-4.8) and middle (RR, 2.8; CI, 1.5-5.3) tertiles of body mass index at age 50 years. Among the thinnest women, even more modest weight loss (5% to < 10%) was associated with increased risk of hip fracture (RR, 2.3; CI, 1.0-5.2). Weight gain of 10% or more beginning at age 50 years provided borderline protection against the risk of hip fracture (RR, 0.7; CI, 0.4-1.0). The RRs for weight gain of 10% or more were protective only among women in the middle and high tertiles of body mass index at age 50 years and were not significant (middle tertile RR, 0.8; CI, 0.3-1.8; high tertile RR, 0.6; CI, 0.2-1.9).

CONCLUSIONS

Weight history is an important determinant of the risk of hip fracture. Weight loss beginning at age 50 years increases the risk of hip fracture in older white women, especially among those who are thin at age 50 years; weight gain of 10% or more decreases the risk of hip fracture. Physicians should include weight history in their assessment of postmenopausal older women for risk of hip fracture.

Examination of several instruments for the electrical detection of holes in latex gloves during use

The initial purpose of this research was to investigate the use of electrical conductivity for detecting holes in latex gloves, while they are being worn, using both recently developed devices and laboratory equipment. The individual devices were not evaluated or critically compared. The use of this technique as a quality assurance procedure, and to determine the degradation of latex gloves due to storage and exposure to disinfectants, was also investigated. The following conclusions were reached: (1) These devices alarm if the latex is breached by an object of at least 300 um-diameter and both the inside and outside of the glove are wet with a conductive fluid. False alarms from latex hydration is the primary disadvantage. (2) This technique is a sensitive QA procedure if any hole to be detected is wet with a conductive liquid. (3) Sealed, sterile latex gloves may degrade over many months. (4) There was no obvious degradation of latex gloves after two hours' exposure to three commonly used disinfectants.

How useful is body mass index for comparison of body fatness across age, sex, and ethnic groups?

This study tested the hypothesis that body mass index (BMI) is representative of body fatness independent of age, sex, and ethnicity. Between 1986 and 1992, the authors studied a total of 202 black and 504 white men and women who resided in or near New York City, were ages 20-94 years, and had BMIs of 18-35 kg/m2. Total body fat, expressed as a percentage of body weight (BF%), was assessed using a four-compartment body composition model that does not rely on assumptions known to be age, sex, or ethnicity dependent. Statistically significant age dependencies were observed in the BF%-BMI relations in all four sex and ethnic groups (p values < 0.05-0.001) with older persons showing a higher BF% compared with younger persons with comparable BMIs. Statistically significant sex effects were also observed in BF%-BMI relations within each ethnic group (p values < 0.001) after controlling first for age. For an equivalent BMI, women have significantly greater amounts of total body fat than do men throughout the entire adult life span. Ethnicity did not significantly influence the BF%-BMI relation after controlling first for age and sex even though both black women and men had longer appendicular bone lengths relative to stature (p values < 0.001 and 0.02, respectively) compared with white women and men. Body mass index alone accounted for 25% of between-individual differences in body fat percentage for the 706 total subjects; adding age and sex as independent variables to the regression model increased the variance (r2) to 67%. These results suggest that BMI is age and sex dependent when used as an indicator of body fatness, but that it is ethnicity independent in black and white adults.

How useful is body mass index for comparison of body fatness across age, sex, and ethnic groups?

This study tested the hypothesis that body mass index (BMI) is representative of body fatness independent of age, sex, and ethnicity. Between 1986 and 1992, the authors studied a total of 202 black and 504 white men and women who resided in or near New York City, were ages 20-94 years, and had BMIs of 18-35 kg/m2. Total body fat, expressed as a percentage of body weight (BF%), was assessed using a four-compartment body composition model that does not rely on assumptions known to be age, sex, or ethnicity dependent. Statistically significant age dependencies were observed in the BF%-BMI relations in all four sex and ethnic groups (p values < 0.05-0.001) with older persons showing a higher BF% compared with younger persons with comparable BMIs. Statistically significant sex effects were also observed in BF%-BMI relations within each ethnic group (p values < 0.001) after controlling first for age. For an equivalent BMI, women have significantly greater amounts of total body fat than do men throughout the entire adult life span. Ethnicity did not significantly influence the BF%-BMI relation after controlling first for age and sex even though both black women and men had longer appendicular bone lengths relative to stature (p values < 0.001 and 0.02, respectively) compared with white women and men. Body mass index alone accounted for 25% of between-individual differences in body fat percentage for the 706 total subjects; adding age and sex as independent variables to the regression model increased the variance (r2) to 67%. These results suggest that BMI is age and sex dependent when used as an indicator of body fatness, but that it is ethnicity independent in black and white adults.

Vocational training for general practice in inner London. Is there a dearth? And if so what's to be done?

OBJECTIVE

To identify the nature and extent of any vocational training deficit within the London initiative zone and investigate the reasons.

DESIGN

Collation of statistics and postal questionnaire surveys.

SETTING

Thames regions inside and outside the London initiative zone.

SUBJECTS

General practice registrars, trainers, principals from non-training practices, and vocational training course organisers.

MAIN OUTCOME MEASURES

Trends in numbers of general practice registrars, proportions of trainers, views on current vocational training in inner London.

RESULTS

Numbers of general practice registrars fell significantly between 1988 and 1993 within the London initiative zone and in England overall. The number of registrars within the zone fell by more than in the rest of the Thames regions, where the decline was not statistically significant. A lower proportion of principals were approved as trainers within the zone than in the rest of the Thames regions and England overall. In their responses to the survey (88% of inner London registrars responded and 81% of outer Thames registrars) registrars suggested that improving remuneration and personal safety would make training in London more attractive. Trainers and non-trainers (response rates 89% and 66% respectively) also suggested increasing remuneration for trainers together with more protected time for training.

CONCLUSIONS

Less vocational training takes place within the London initiative zone than in the rest of the Thames regions and England overall, although there are discrepancies in official statistics. As well as specific recommendations for improving recruitment to vocational training in inner London, measures to tackle inner city deprivation should also remain high on the political agenda.

Hepatic overexpression of insulin-like growth factor-II in adulthood increases basal and insulin-stimulated glucose disposal in conscious mice

The physiological role of circulating insulin-like growth factor-II (IGF-II) in adult humans is poorly understood. We recently generated an IGF-II transgenic murine model of persistent IGF-II production (plasma IGF-II approximately 30-fold increased above normal) through over-expression of the transgene driven by the major urinary protein promoter (Rinderknecht, E., and Humbel, R. E. (1978) J. Biol. Chem. 269, 13779-13784). To determine whether in vivo insulin action is improved in these transgenic mice, we performed euglycemic insulin (18 milliunits/kg.min) clamp studies in conscious IGF-II transgenic and in age- and weight-matched control mice. Plasma glucose and insulin concentrations were significantly lower in the IGF-II transgenic compared with both control grouoff Despite decreased plasma glucose concentration, basal hepatic glucose production (HGP) and glucose clearance were increased. During the insulin clamp studies in IGF-II transgenic mice compared with control mice (a) the rates of glucose infusion and glucose uptake were increased by approximately by 65 and approximately 55%, respectively; (b) glycolysis was increased by approximately 12% while glycogen synthesis was approximately 2-fold higher; (c) while the suppression of plasma free fatty acid was similar, the increment in plasma lactate concentration was significantly higher; (d) although HGP was similarly inhibited by insulin, phosphoenolpyruvate gluconeogenesis was enhanced and accounted for a larger portion of HGP (64% versus approximately 40% in control mice). Our data suggest that the persistence of circulating IGF-II in adult mice to levels commonly observed in adult humans (50-70 nM) causes a marked improvement in peripheral (skeletal muscle) insulin action, which is not due to changes in body composition. These results suggest that circulating IGF-II may exert a regulatory role on insulin sensitivity and body composition in humans.

Do older women use estrogen replacement? Data from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE)

OBJECTIVES

The primary purpose of this study was to determine the prevalence of current and past estrogen use among older, community-dwelling, postmenopausal women. The secondary purpose was to describe factors associated with estrogen use in this population.

DESIGN

A survey.

SETTING

The Piedmont region of North Carolina.

PARTICIPANTS

The sample included 2602 community-dwelling women over the age of 65 who were interviewed for the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE).

MEASUREMENTS

Current and past use of estrogen.

RESULTS

Of the women surveyed, 6.1% reported current estrogen use, and 18.5% reported past use. Approximately half of the participants reported using estrogen for more than 2 years. Multivariate analysis demonstrated that current estrogen users were younger, more affluent, had smaller families, and were more likely to be white and to live in an urban area than were never users. Current users were also more likely to drink alcohol and to take calcium supplements; and compared with past estrogen users, they were more likely to be white, have smaller families, and to drink alcohol.

CONCLUSION

Estrogen replacement therapy is used by a small minority of older women, especially blacks. Moreover, although women with some risk factors for osteoporosis are more likely to use estrogen, the chief determinants of estrogen utilization are socioeconomic.

International comparison of hip fracture rates in 1988-89

A comparison of hip fracture rates among nine countries (Canada, Chile, Finland, Hong Kong, Scotland, Sweden, Switzerland, the United States and Venezuela) was made using national hospital discharge data for the same time interval. The rates increased by age and were higher for females than males in all nine countries. When based on overall discharge rates, the incidence of hip fracture appeared high in three European countries (Finland, Scotland and Sweden) relative to the other countries. However, when transfer cases were removed and adjustments made for differences in case definition, the risk of hip fracture for both men and women was much similar among the four European and two North American countries, but higher than in Hong Kong. Rates of fracture were lowest in Venezuela and Chile, varying from three to 11 times less than for residents of the other seven countries. Although there are limitations in using hospital discharge data as a measure of incidence, the wide variation in the risk of hip fracture across the nine countries appears real but differences between North American and north European countries may not be as great as previously reported. Such cross-national comparisons may help clarify different etiologic hypotheses.

Sustained nonischemic ventricular tachycardia during dobutamine stress echocardiography

Dobutamine stress echocardiography has become widely accepted as a safe, reliable and cost effective modality for the evaluation of patients with suspected myocardial ischemia or for prognostic stratification and outcome assessment in patients with known coronary artery disease. while the benefits of this means of cardiovascular testing are very clearly apparent, it is important to understand and recognize possible complications. This paper discusses the occurrence of sustained, nonischemic ventricular tachycardia during dobutamine stress echocardiography in the absence of functional, physiologic or anatomic evidence of coronary artery disease or cardiomyopathy.