A longitudinal study of drinking and cognitive performance in elderly Japanese American men: the Honolulu-Asia Aging Study

OBJECTIVES

This study prospectively describes the relationships between alcohol intake and subsequent cognitive performance among participants in the Honolulu Heart Program (HHP).

METHODS

Alcohol intake was assessed at Exam III of the HHP, and cognitive performance was measured approximately 18 years later with the Cognitive Abilities Screening Instrument (CASI). Complete information was available for 3556 participants, aged 71 to 93 years at follow-up.

RESULTS

In multivariate analyses, the relationship between drinking and later cognitive performance appeared nonlinear, as nondrinkers and heavy drinkers (more than 60 ounces of alcohol per month) had the lowest CASI scores and the highest risks of poor and intermediate CASI outcomes. Compared with nondrinkers, the risk of a poor CASI score was lowered by 22% to 40% among men who consumed 1-60 ounces of alcohol per month.

CONCLUSIONS

We report a positive association between moderate alcohol intake among middle-aged men and subsequent cognitive performance in later life. However, it is possible that the health risks associated with drinking outweight any potential benefits for many elderly persons.

Estimating incidence of dementia subtypes: assessing the impact of missed cases

In many community-based studies on the incidence of dementia, a target population is screened and a subsample is clinically evaluated at baseline and follow-up. Incidence rates are affected by missed cases at both exams and this complicates the estimation of these rates. Recent work proposes a regression-based technique for joint estimation of prevalence and incidence and suggests the use of surrogate information obtained on the entire cohort at both times to calculate the expected score equation contribution for individuals missing clinical exams at one or both times. This helps to quantify the impact of missed diagnosis upon the incidence estimates and their confidence intervals. We extend this work to the setting of subtypes of dementia for use in the Honolulu-Asia Aging Study on incidence of dementia. The technique is applied using two separate models for the effect of age on dementia incidence. Subsequently, shrinkage estimation methods are applied to provide more precise estimates of the rates. Published in 2000 by John Wiley & Sons, Ltd.

Differential preservation of cognitive functions in geriatric patients with lifelong chronic schizophrenia: less impairment in reading compared with other skill areas

BACKGROUND

Our study examined the differential performance of cognitive skills in geriatric, cognitively impaired schizophrenic patients (n = 165) with a lengthy course of institutional stay and a poor overall functional outcome. Their relative deficits were compared with a sample of healthy elderly individuals.

METHODS

Schizophrenic patients were matched one-to-one with healthy individuals of the same age and education and compared on a number of measures of cognitive functioning. The schizophrenic patients' old-learning performance was also compared with their educational level only.

RESULTS

Mini-Mental State Examination (Folstein et al 1975) scores of the patients were in the moderately demented range (M = 20.36), and these patients underperformed healthy control subjects by more than 1 to slightly less than 3 standard deviations on measures of memory, praxis, and verbal skills. Wide Range Achievement Test-Revised word-recognition reading scores were found to be at the 10th-grade level, although the patients on average had completed 11 years of formal education.

CONCLUSIONS

These results suggest that even in schizophrenic patients with significant cognitive impairment, reading scores are relatively consistent with educational attainment. These data indicate that poor performance on measures of cognitive functioning in this population does not necessarily occur on measures of old learning.

Clinical, cognitive and functional characteristics of long-stay patients with schizophrenia: a comparison of VA and state hospital patients

Long-stay patients constitute a small proportion of all patients with schizophrenia, but in both VA and state psychiatric systems these patients account for a majority of the costs associated with treatment of the illness. VA and state patients would be expected to differ in several respects, including age at onset and premorbid educational status. Little additional information is available about the differences between these samples. Seventy-four long-stay male patients at a chronic state psychiatric center were compared with 50 male veterans from long-stay psychiatric facilities on positive and negative symptoms, cognitive deficits and functional status. The two samples did not differ on positive symptom severity, but the state patients had more severe negative and cognitive symptoms as well as functional deficits. Of all of the variables measured, deficit in self care was the only variable that entered a stepwise discriminant analysis. The correlation between functional and symptomatic variables was the same in both groups, and the group differences and correlations were not influenced by differences in educational status. These data indicate that VA patients may have reduced severity of functional and cognitive impairments relative to state hospital patients, but that the relationship between the different illness variables was similar in the two groups.

Intracoronary beta-radiation therapy inhibits recurrence of in-stent restenosis

BACKGROUND

Intracoronary gamma-radiation therapy reduces recurrent in-stent restenosis (ISR). This study, BETA WRIST (Washington Radiation for In-Stent restenosis Trial) was designed to examine the efficacy and safety of the beta-emitter 90-yttrium for the prevention of recurrent ISR.

METHODS AND RESULTS

A total of 50 consecutive patients with ISR in native coronaries underwent percutaneous transluminal coronary angioplasty, laser angioplasty, rotational atherectomy, and/or stent implantation. Afterward, a segmented balloon catheter was positioned and automatically loaded with a 90-yttrium, 0.014-inch source wire that was 29 mm in length to deliver a dose of 20.6 Gy at 1.0 mm from the balloon surface. In 17 patients, manual stepping of the radiation catheter was necessary for lesions >25 mm in length. The radiation was delivered successfully to all patients, with a mean dwell time of 3.0+/-0.4 minutes. Fractionation of the dose due to ischemia was required in 11 patients. At 6 months, the binary angiographic restenosis rate was 22%, the target lesion revascularization rate was 26%, and the target vessel revascularization rate was 34%; all rates were significantly lower than those of the placebo group of gamma-WRIST.

CONCLUSIONS

beta-Radiation with a 90-yttrium source used as adjunct therapy for patients with ISR results in a lower-than-expected rate of angiographic and clinical restenosis.

APOE-epsilon4 predicts incident AD in Japanese-American men: the honolulu-asia aging study

The authors assessed the 3-year incidence of dementia, including subtypes, in 2,603 Japanese-American men 71 to 93 years of age who were dementia free at baseline. There were 137 new cases of dementia according to the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised, including 51 with a primary diagnosis of AD. The rates for all subtypes increased with age. Men with an APOE4 allele had a significantly increased risk of AD of 2.39 (95% CI, 1.07, 5.31), after adjusting for age and education. There was no significant relationship of APOE4 with other subtypes of dementia.

Quality beyond compliance

The service sector within the biopharmaceutical industry has experienced phenomenal growth over the past decade. In the highly regulated Good Laboratory Practices environment, the need for timely, high-quality service, accurate results, and on-time deliverables becomes paramount for the success and profitability of biopharmaceutical companies. The quality assurance process is a vital component of this drug product-development cycle and ensures compliance to the highest domestic and international regulatory standards. Quality-assurance professionals historically have held the role of independent auditors of the processes, who certify that results meet current standards of practice. Covance, a contract research organization that includes Good Laboratory Practices laboratories, reorganized and expanded the functional responsibilities of its quality assurance team in 1997. Auditors and quality assurance professionals have assumed roles beyond traditional compliance auditing and are forging new leadership and mentoring roles as process-improvement specialists. The results have been tangible, measurable benefits for clients and the Covance organization. This article provides an overview of this cultural change and the processes put in place to improve efficiency, productivity, and customer and employee satisfaction.

The longitudinal relationship of clinical symptoms, cognitive functioning, and adaptive life in geriatric schizophrenia

Cognitive dysfunction is increasingly being recognized as a major contributor to the adaptive impairment seen in most patients with schizophrenia. Reported here is a prospective longitudinal evaluation of the relationship between cognitive and adaptive functioning in elderly patients with schizophrenia. It was hypothesized that baseline cognitive and negative, but not positive symptoms, would be predictive of cross-sectional impairment and longitudinal outcome. Subjects were 168 elderly patients with schizophrenia, free of major neurological disorders, who were residents of a long-term psychiatric facility. Subjects were assessed at baseline and again an average of 15months later. The PANSS was used to assess the severity of symptoms of schizophrenia. Cognitive symptoms were assessed using the components of the CERAD cognitive battery. Social and adaptive functioning was assessed using the SAFE scale. Spearman correlations were determined among clinical variables, and the rank ordering of prediction of SAFE scale scores at follow-up was determined using a stepwise regression procedure. At follow-up, adaptive life skills correlated with cognitive performance and negative symptoms (Spearman rho values 0. 41-0.57, all p values <0.0001), but not positive symptoms (r=0.09, n. s.). Among cognitive tasks, verbal learning and memory were most highly correlated with adaptive skills at follow-up. These results confirm and extend previous studies that indicate that cognitive impairments are predictive, both cross-sectionally and longitudinally, of adaptive life skills in persons with schizophrenia. Negative symptoms, but not positive symptoms, were correlated with impaired adaptive skills. Taken together, these results underscore the need to develop more effective treatments for cognitive and negative symptoms in schizophrenia.

Chloroplast DNA variation in a rainforest tree (Aucoumea klaineana, burseraceae) in Gabon

One of the dominant savannah colonists in Gabon is Aucoumea klaineana or Okoumé (Burseraceae), an endemic species which belongs to a monotypic genus. Chloroplast DNA (cpDNA) variation was studied in this species by means of PCR amplification of 40 kb of cpDNA sequences, followed by restriction analysis of the resulting fragments. No insertion/deletion events were noted, and a single point mutation was found. The level of differentiation among the 19 populations studied was relatively low (GST = 0.54) compared to other plant species (mean of 0.76), in agreement with the pioneer status of the species. However, cpDNA diversity was geographically structured, with the less frequent haplotype occurring only in populations from southern Gabon. This distribution might suggest either that there were two ancient source populations of Okoumé, one in the north and the other in the south, from which the colonizing process of the savannah began after the last ice age, or alternatively that there was one polymorphic source in the south. The low level of cpDNA diversity could indicate that Okoumé populations in these refugia were quite small.

CD40 ligand (CD154) triggers a short-term CD4(+) T cell activation response that results in secretion of immunomodulatory cytokines and apoptosis

Signals generated through CD28-B7 and CD40 ligand (CD40L)-CD40 interactions have been shown to be crucial for the induction of long-term allograft survivability. We have recently demonstrated that humanized anti-CD40L (hu5C8) prevents rejection of mismatched renal allografts in primates. To investigate potential mechanisms of CD40L-induced allograft acceptance, we coimmobilized hu5C8 with suboptimal amounts of anti-CD3 to stimulate CD4(+) T cells. We now report that anti-CD3/CD40L costimulation results in CD28-independent activation and subsequent deletion of resting T cells. Coligation of CD3 and CD40L increased expression of CD69, CD25, and CD54 on CD4(+) T cells. We also found that costimulation with anti-CD3/CD40L resulted in enhanced production of interleukin (IL)-10, interferon gamma, and tumor necrosis factor alpha but not IL-2 or IL-6. Interestingly, after several days, anti-CD3/CD40L-mediated activation was followed by apoptosis in a significant population of cells. Consistent with that observation, anti-CD3/CD40L did not enhance the antiapoptotic proteins Bcl-2 and Bcl-xL. Further, the addition of CD28 at 24 h failed to rescue those cells induced to die after costimulation with anti-CD3/CD40L. Together, these data suggest that the graft-sparing effect of hu5C8 in vivo may result in part from early and direct effects on CD4(+) T cells, including a vigorous induction of immunomodulatory cytokines and/or apoptosis of allograft-specific T cells.

Prevalence and correlates of parkinsonism in an institutionalized population of geriatric patients with chronic schizophrenia

BACKGROUND

Geriatric patients with chronic schizophrenia are at increased risk for parkinsonism and cognitive impairment, but the relationship between the two has been insufficiently studied.

OBJECTIVES

(1) To determine the prevalence of parkinsonism in a cohort of institutionalized geriatric patients with chronic schizophrenia (N=79). (2) To examine the relationship of parkinsonism to potentially relevant variables including cognitive functioning, positive and negative symptoms, sex, age, age at first hospitalization, psychopharmacological regimen and tardive dyskinesia (TD).

METHOD

Tremor, rigidity and bradykinesia were rated on a five-point severity scale. Clinically significant parkinsonism was defined by the unambiguous presence of at least two of those signs. TD was assessed with the Modified Simpson Dyskinesia Scale. Schizophrenic symptoms were rated with the Positive and Negative Syndrome Scale, and cognitive functioning with the Mini-Mental State Examination and the Consortium to Establish a Registry for Alzheimer's Disease battery.

RESULTS

The prevalence of parkinsonism was 19% and was significantly higher in women than in men. Age was a significant predictor of parkinsonism. Independent of age, bradykinesia was significantly correlated with MMSE, fluency and naming. Tremor, rigidity and medication status did not correlate with any cognitive variable assessed. Cognitive measures did not differ between subjects meeting and not meeting criteria for clinically significant parkinsonism. Rigidity and bradykinesia were significantly correlated with negative symptoms but no parkinsonism sign correlated with positive symptoms. Twelve subjects received ratings consistent with both TD and parkinsonism; however, no parkinsonian variable predicted the co-occurrence of TD.

CONCLUSIONS

The present correlations suggest potential overlap among the neural substrates for bradykinesia, cognitive impairment and negative symptoms; however, further research is required to clarify that issue.

An atypical presentation of Paget's disease in an immunocompromised individual. A case report

Paget's disease of bone is a localized disorder of bony resorption. The mechanism underlying the development of the disease remains controversial. There is substantial evidence suggesting a genetic basis for Paget's disease in some patients. A viral etiology of Paget's disease has been advocated. A further hypothesis implicating an immunological mechanism for this disease is based on growing evidence reviewed in the text. The presented case showed clinical and X-ray features typical of a very aggressive form of Paget's disease. We hypothesize that the extreme local aggressiveness of this case was secondary to the patient's concomitant immunosuppression due to an extended therapy following renal transplant.

Treatment with humanized monoclonal antibody against CD154 prevents acute renal allograft rejection in nonhuman primates

CD154 is the ligand for the receptor CD40. This ligand-receptor pair mediates endothelial and antigen-presenting cell activation, and facilitates the interaction of these cells with T cells and platelets. We demonstrate here that administration of a CD154-specific monoclonal antibody (hu5C8) allows for renal allotransplantation in outbred, MHC-mismatched rhesus monkeys without acute rejection. The effect persisted for more than 10 months after therapy termination, and no additional drug was required to achieve extended graft survival. Indeed, the use of tacrolimus or chronic steroids seemed to antagonize the anti-rejection effect. Monkeys treated with antibody against CD154 remained healthy during and after therapy. The mechanism of action does not require global depletion of T or B cells. Long-term survivors lost their mixed lymphocyte reactivity in a donor-specific manner, but still formed donor-specific antibody and generated T cells that infiltrated the grafted organ without any obvious effect on graft function. Thus, therapy with antibody against CD154 is a promising agent for clinical use in human allotransplantation.

WMS-R and MAS correlations in a neuropsychological population

The present study was an attempt to examine the relationship between the Wechsler Memory Scale-Revised (WMS-R; Wechsler, 1987) and the Memory Assessment Scale (MAS; Williams, 1991). The sample consisted of 51 patients referred for neuropsychological examination. Average age was 55.29 (SD = 20.94). Average education was 11.94 years (SD = 3.18). Average Full Scale IQ was 94.75 (SD = 15.44). The results showed that no MAS index correlated higher than.60 with any of the WMS-R indices. There was minimal specific prediction between instruments across each memory domain. Agreement between the tests clinically was low as well. Corrections for such factors as age, education, intelligence or diagnosis lowered the relationships between the tests although not significantly. Corrections to the correlations for the inherent reliability of each test increased correlations between the tests but still resulted in a maximum common variance of 56% (for the visual measures) down to 40% (for General Memory). These results are consistent with the argument that "general memory" is not as useful a construct as that of "general intelligence" and that these tests of general memory measure different underlying constructs. This has important impact on how we conceive and report memory test results.

Water-soluble, meso-substituted cationic porphyrins--a family of compounds for cellular delivery of oligonucleotides

The delivery of oligonucleotides to appropriate intracellular compartments is crucial to their development as tools in gene function studies and as therapeutics. Here, we report the characterization of meso-substituted cationic porphyrins as a large class of water-soluble reagents for oligonucleotide delivery. These porphyrins form non-covalent complexes with single-stranded oligonucleotides and deliver these molecules into the nuclei of cell lines in culture. The porphyrins protect oligonucleotides from nuclease degradation, and delivery is unaffected by the presence of serum. Delivery capacity is dependent on the charge ratio and concentration of the oligonucleotide and porphyrin used to form the complex, on the chemical substituents of the oligonucleotide and on the identity of the cationic porphyrin. This class of molecules provides a versatile set of water-soluble delivery reagents that could contribute to the development of oligonucleotide drugs.

High incidence of treatment failure with vincristine, etoposide, epirubicin, and prednisolone chemotherapy with successful salvage in childhood Hodgkin disease

BACKGROUND AND PROCEDURE

In an attempt to further reduce the long-term toxicity of chemotherapy for childhood Hodgkin disease (HD), the Australian and New Zealand Children's Cancer Study Group between 1990 and 1996 enrolled 53 children with biopsy-proven and imaging-staged HD into a chemotherapy-only treatment regimen using 5-6 courses of vincristine, etoposide, epirubicin, and prednisolone (VEEP).

RESULTS

There were 23 events in these children with 3 progressive disease (PD), 8 partial remissions (PR), and 12 relapses. In the stage I patients, there were 8 events (35%). There was no association between the number of events and the stage of HD. Massive mediastinal disease at diagnosis was present in 16 patients, 11 of whom had an event with 3 PD, 3 PR, and 5 relapses. For all patients with an event at 6-24-month follow-up, all but two patients were salvaged with either alkylating agent-based chemotherapy alone or with irradiation and chemotherapy. The event-free survival for the whole group with median follow-up of 33 months was 59%, but only 31% for massive mediastinal disease. Disease-free survival was 78% and overall survival at 60 months was 92%, with one death due to drug-induced aplasia and another from acute myeloid leukemia.

CONCLUSIONS

We conclude that VEEP chemotherapy in childhood HD used as the only treatment modality has an unacceptably high treatment failure rate in patients with massive mediastinal disease and 35% incidence of treatment failure in stage I disease.

Mobilization of peripheral blood stem cells with docetaxel and cyclophosphamide (CY) in patients with metastatic breast cancer: a randomized trial of 3 vs 4 g/m2 of CY

The purpose of this study was to develop a regimen of docetaxel, cyclophosphamide (CY) and filgrastim for mobilization of peripheral blood stem cells (PBSC) in patients with metastatic breast cancer (n = 66). A phase I trial of CY 2, 3 or 4 g/m2 with docetaxel 100 mg/m2, in consecutive cohorts of four patients each, did not reveal any dose-limiting toxicities and subsequent patients were randomized to receive 3 or 4 g/m2 of CY. The median yield of CD34+ cells from all patients was 11.06x10(6)/kg (range, 0.03-84.77) from a median of two aphereses (range, 1-7); 6.52x10(6) CD34+ cells/kg/apheresis (range, 0.01-52.07). Target CD34+ cell doses > or =2.5 and > or =5.0x10(6)/kg were achieved in 89% and 79%, respectively. There were no statistically significant differences in CD34+ cell yields or target CD34+ cell doses achieved following 3 or 4 g/m2 of CY. Patients with only one prior chemotherapy regimen yielded a median of 12.82x10(6) CD34+ cells/kg/apheresis compared to 5.85 for those receiving > or =2 regimens (P = 0.03). It was concluded that the combination of docetaxel, 100 mg/m2, CY 3 g/m2 without mesna could be administered with acceptable toxicity with collection of adequate quantities of PBSC from the majority of patients.

Midlife hand grip strength as a predictor of old age disability

CONTEXT

Poor muscle strength, functional limitations, and disability often coexist, but whether muscle strength during midlife predicts old age functional ability is not known.

OBJECTIVE

To determine whether hand grip strength measured during midlife predicts old age functional limitations and disability in initially healthy men.

DESIGN AND SETTING

A 25-year prospective cohort study, the Honolulu Heart Program, which began in 1965 among Japanese-American men living on Oahu, Hawaii.

PARTICIPANTS

A total of 608945- to 68-year-old men who were healthy at baseline and whose maximal hand grip strength was measured from 1965 through 1970. Altogether, 2259 men died over the follow-up period and 3218 survivors participated in the disability assessment in 1991 through 1993.

MAIN OUTCOME MEASURES

Functional limitations including slow customary walking speed (< or =0.4 m/s) and inability to rise from a seated position without using the arms, and multiple self-reported upper extremity, mobility, and self-care disability outcomes.

RESULTS

After adjustment for multiple potential confounders, risk of functional limitations and disability 25 years later increased as baseline hand grip strength, divided into tertiles, declined. The odds ratio (OR) of walking speed of 0.4 m/s or slower was 2.87 (95% confidence interval [CI], 1.76-4.67) in those in the lowest third and 1.79 (95% CI, 1.14-2.81) in the middle third of grip strength vs those in the highest third. The risk of self-care disability was more than 2 times greater in the lowest vs the highest grip strength tertile. Adding chronic conditions identified at follow-up to the models predicting disability reduced the ORs related to grip strength only minimally.

CONCLUSIONS

Among healthy 45- to 68-year-old men, hand grip strength was highly predictive of functional limitations and disability 25 years later. Good muscle strength in midlife may protect people from old age disability by providing a greater safety margin above the threshold of disability.

Convergence of cognitive and adaptive decline in late-life schizophrenia

Cognitive impairment has proven to be a major predictor of overall functional deficit in schizophrenia. Despite the significant impairments seen on the part of many patients with schizophrenia that implicate decline at some point in time, there have been no longitudinal studies of adaptive decline in patients with schizophrenia. In this study, 57 geriatric patients with chronic schizophrenia were examined with measures of clinical symptoms, cognitive impairments, and adaptive functioning while living in a chronic psychiatric hospital and followed up an average of two and a half years after their referral to nursing home care. Cognitive functioning and adaptive functioning both declined over the follow-up period, whereas there was no change in schizophrenic symptoms. Changes in cognitive functioning accounted for 25% of the variance in adaptive decline, whereas the baseline severity of cognitive impairment and schizophrenia symptoms were uncorrelated with adaptive decline. These data indicate that cognitive decline may predict deterioration in overall functional status and imply that treatment of cognitive impairment might have a beneficial effect on global functional status.

Cognitive decline in late-life schizophrenia: a longitudinal study of geriatric chronically hospitalized patients

BACKGROUND

Geriatric schizophrenic patients with a chronic course of institutionalization manifest cognitive and functional impairments that implicate decline at some time point after the onset of illness. The rate of change in cognitive and functional status in these patients has not yet been identified with a longitudinal study.

METHODS

Three hundred and twenty-six schizophrenic patients entered a 30-month follow-up study with two separate assessments of the patients. Overall functional and cognitive status was indexed with the Clinical Dementia Rating (CDR). Survival analysis was used to examine changes in cognitive and functional status, including worsening for the less impaired patients and improvements on the part of more impaired patients.

RESULTS

Approximately 30% of the patients who had baseline scores in the less impaired range manifested a worsening of their CDR ratings to a score of 2.0 (moderate) or more severe, whereas only 7% of the sample with lower scores at baseline appeared to improve in their functioning. Several characteristics of the patients at baseline assessment predicted increased risk for cognitive and functional decline, including lower levels of education, older age, and more severe positive symptoms.

CONCLUSIONS

Cognitive and functional decline can be detected in a short-term follow-up in a subset of geriatric long-stay patients with schizophrenia. This decline appears distributed across patients and not due to the presence of progressive degenerative dementing conditions. Later research will have to identify the causes of this decline, possibly on the basis of the risk factors identified in this study.

Grip strength changes over 27 yr in Japanese-American men

The aim of this study was to describe changes in grip strength over a follow-up period of approximately 27 yr and to study the associations of rate of strength decline with weight change and chronic conditions. The data are from the Honolulu Heart Program, a prospective population-based study established in 1965. Participants at exam 1 were 8,006 men (ages 45-68 yr) who were of Japanese ancestry and living in Hawaii. At follow-up, 3,741 men (age range, 71-96 yr) participated. Those who died before the follow-up showed significantly lower grip-strength values at baseline than did the survivors. The average annualized strength change among the survivors was -1.0%. Steeper decline (>1.5%/yr) was associated with older age at baseline, greater weight decrease, and chronic conditions such as stroke, diabetes, arthritis, coronary heart disease, and chronic obstructive pulmonary disease. The risk factors for having very low hand-grip strength at follow-up, here termed grip-strength disability (</=21 kg, the lowest 10th percentile), were largely same as those for steep strength decline. However, the age-adjusted correlation between baseline and follow-up strength was strong (r = 0.557, P < 0.001); i.e., those who showed greater grip strength at baseline were also likely to do so 27 yr later. Consequently, those in the lowest grip-strength tertile at baseline had about eight times greater risk of grip-strength disability than those in the highest tertile because of their lower reserve of strength. In old age, maintenance of optimal body mass may help prevent steep strength decrease and poor absolute strength.