Rosiglitazone and pulmonary oedema: an acute dose-dependent effect on human endothelial cell permeability

AIMS/HYPOTHESIS

Peripheral and pulmonary oedema has emerged as the most common drug-related side effect of rosiglitazone in clinical practice, but the underlying mechanisms are not clear. Fluid retention and changes in vascular tone could contribute to oedema formation, but the interpretation of clinical and in vivo studies is particularly difficult and the direct effects of thiazolidinediones on endothelial barrier function have not been previously reported.

METHODS

Human pulmonary artery endothelial cells were seeded and grown on 0.4 microm collagen-coated filters to form a tight monolayer (transendothelial electrical resistance 9-11 ohms.cm(-2) after 2-3 days). Transendothelial albumin flux (expressed as the percentage clearance of albumin relative to control) was measured using Evans blue-labelled albumin after exposure to rosiglitazone 1-100 micromol/l for 1 h to 48 h, and after removal of drug from the monolayer.

RESULTS

Incubation of pulmonary artery endothelial cells with rosiglitazone for 4 h produced immediate concentration-dependent increases in transendothelial albumin flux: e.g., relative to control (100%), 113%+/-13% (1 micromol/l), 215%+/-37% (10 micromol/l, p=0.01) and 461%+/-96% (100 micromol/l, p=0.002) (n=12). There was no effect after 1 h. The acute hyperpermeability response to rosiglitazone, maximal after 4 h, was fully reversible after washing the monolayer. After incubation for 24 to 48 h the effect of rosiglitazone on pulmonary endothelial permeability tended to subside: e.g., 210%+/-59% (24 h) for rosiglitazone 100 micromol/l (p=0.06).

CONCLUSION/INTERPRETATION

Exposure to high-therapeutic concentrations of rosiglitazone causes a reversible fourfold increase in pulmonary endothelial permeability which could be clinically relevant especially at higher doses and at times of peak plasma drug concentration.

Evaluating integrated urban water systems alternatives for Brisbane, Australia

The Brazil Development Study investigates the feasibility of alternative approaches to providing sustainable water services to a 226 ha mixed residential and industrial greenfield development within the city of Brisbane, Australia. The alternatives include techniques such a the use of rainwater tanks, water use efficiency, a local wastewater treatment plant for recycling of reclaimed water and composting toilets amongst others. This paper evaluates a series of urban development scenarios against the objectives of the study. The insights gained into the drivers for cost and environmental impact for this particular site are discussed as well as a number of issues of concern and challenges to Council and the community.

Wastewater services for small communities

Connection to centralised regional sewage systems has been too expensive for small-dispersed communities, and these townships have traditionally been serviced by on-site septic tank systems. The conventional on-site system in Australia has consisted of an anaerobic holding tank followed by adsorption trenches. This technique relies heavily on the uptake of nutrients by plants for effective removal of nitrogen and phosphorus from the effluent, and is very seasonal in its efficiency. Hence, as these small communities have grown in size, the environmental effects of the septic tank discharges have become a problem. In locations throughout Australia, such as rural Victoria and along the Hawkesbury-Nepean River, septic tanks as being replaced with the transport of sewage to regional treatment plants. For some isolated communities, this can mean spending 20,000 dollars-40,000 dollars/household, as opposed to more common connection prices of 7,000 dollars/household. This paper explores some alternative options that might be suitable for these small communities, and attempts to identify solutions that provide acceptable environmental outcomes at lower cost. The types of alternative systems that are assessed in the paper include local treatment systems, separate blackwater and greywater collection and treatment systems both with and without non-potable water recycling, a small township scale treatment plant compared to either existing septic tank systems or pumping to a remote regional treatment facility. The work demonstrated the benefits of a scenario analysis approach for the assessment of a range of alternative systems. It demonstrated that some of the alternatives systems can achieve better than 90% reductions in the discharge of nutrients to the environment at significantly lower cost than removing the wastewater to a remote regional treatment plant. These concepts allow wastewater to be retained within a community allowing for local reuse of treated effluent.

Antidepressant prescribing in nursing homes: is there a place for tricyclics?

OBJECTIVE

To deduce a model describing physicians' choice of antidepressants for treating elderly nursing home patients.

METHODS

Subjects were geriatric residents of 137 skilled nursing facilities who regularly received an antidepressant medication for at least one month (n = 3,440, 28% of all residents). Reasons for prescribing antidepressants and physicians' diagnoses of depression and dementia were identified by medical record audit. Residents were grouped by dementia and antidepressant target symptoms (depression, or one or more non-psychiatric symptoms, i.e. insomnia, pain, incontinence, itching).

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) were prescribed preferentially over tricyclic antidepressants (TCAs) for treating depression in both demented and non-demented residents, but TCAs were nine times more likely to be prescribed for treating non-psychiatric target symptoms alone. When non-psychiatric target symptoms were present without depression or dementia, both amitriptyline and nortriptyline prescribing was increased, but amitriptyline appeared to be the antidepressant of choice. In all subgroups examined, its use was two to five times more prevalent when such symptoms were present. In patients with dementia, amitriptyline prescribing declined whether or not non-psychiatric target symptoms were present, but nortriptyline prescribing did not; nortriptyline was three times more likely than amitriptyline to be prescribed in the presence of dementia.

CONCLUSIONS

Physicians prescribe anticholinergic TCAs principally to treat common non-depressive symptoms in nursing home residents, preferring SSRIs for uncomplicated depression and depression with dementia. They tend to avoid prescribing anticholinergic TCAs other than nortriptyline when they recognize a patient as demented. The data suggest that physicians employ a decision model for antidepressant prescribing that simultaneously recognizes the utility of TCAs in treating non-psychiatric symptoms and the anticholinergic vulnerability of older, especially demented, patients. Whether or not this model leads to optimal patient management requires further study.

Does the angiotensin-converting enzyme (ACE) gene polymorphism affect rate of abdominal aortic aneurysm expansion?

OBJECTIVES

the tissue renin-angiotensin system (RAS), which plays an important role in vascular structure and function, is regulated in part by an insertion-deletion polymorphism of the angiotensin converting enzyme (ACE) gene. We hypothesised that ACE genotype might affect rate of AAA expansion via modulating long-term structural changes associated with RAS activation.

METHODS

fifty-eight patients (50 M, mean age 70 years, mean initial aneurysm size 4.3 cm) with current or previous AAA and serial (>3) annual ultrasound measurements of antero-posterior AAA size provided a sample of leucocyte DNA for ACE genotyping. AAA expansion rate (cm per year) for individual subjects was calculated by linear regression.

RESULTS

median AAA expansion rate was 0.28 cm/year (range 0-1.8 cm/year), and the genotype distribution included DD (n=14), DI (n=29) and II (n=15). Corresponding median AAA expansion rates for each of the three genetic subgroups were 0.22, 0.32 and 0.30 cm/year, respectively (p=0.6, nonparametric).

CONCLUSIONS

the wide inter-individual variability in AAA expansion rate is likely to reflect complex genetic and environmental interactions, but the lack of any relationship with ACE genotype suggests that differences in vascular ACE activity in aortic tissue are not major determinants of the variability in rate of AAA dilatation.

Characterization of humoral and cellular immune responses elicited by meningococcal carriage

In order to study the immune response elicited by asymptomatic carriage of Neisseria meningitidis, samples of serum, peripheral blood mononuclear cells (PBMCs), and saliva were collected from a cohort of more than 200 undergraduate students in Nottingham, United Kingdom, who were subject to high rates of acquisition and carriage of meningococci. Serum immunoglobulin G levels were elevated following increases in the rate of carriage, and these responses were specific for the colonizing strains. In order to investigate T-cell responses, PBMCs from 15 individuals were stimulated with a whole-cell lysate of the H44/76 meningococcal strain (B:15:P1.7,16), stained to detect cell surface markers and intracellular cytokines, and examined by flow cytometry. The cells were analyzed for expression of CD69 (to indicate activation), gamma interferon (IFN-gamma) (a representative T-helper 1 subset [Th1]-associated cytokine), and interleukin-5 (IL-5) (a Th2-associated cytokine). Following a brief meningococcal stimulation, the numbers of CD69(+) IFN-gamma(+) CD56/16(+) NK cells were much higher than cytokine-positive CD4(+) events. Both IFN-gamma(+) and IL-5(+) events were detected among the CD69(+) CD4(+) population, leading to the conclusion that an unbiased T-helper subset response was elicited by meningococcal carriage.

Tissue- and time-dependent effects of endothelin-1 on insulin-stimulated glucose uptake

Hyperendothelinaemia is associated with various insulin-resistant states, e.g., diabetes, obesity and heart failure, but whether endothelin-1 (ET-1) has a direct effect on insulin-mediated glucose uptake is unclear because the interpretation of in vivo metabolic studies is complicated by ET-1 effects on muscle blood flow and insulin secretion. This study investigated the effects of ET-1 (1-10 nM) on basal and insulin-stimulated 2-deoxy-D-[3H]glucose (2-DOG) uptake in cultured L6 myoblasts and 3T3-adipocytes. RT-PCR analysis showed that both cell types express ET(A) but not ET(B) receptors. ET-1 had no effect on basal (non-insulin-mediated) glucose transport, but there was evidence of a tissue- and time-dependent inhibitory effect of ET-1 on insulin-stimulated glucose uptake. Specifically, ET-1 10 nM had a transient (0.5 h) inhibitory effect on glucose uptake in 3T3 cells (C(I-150) [dose of insulin required to increase glucose uptake by 50%, relative to control 100%] increased from 89 +/- 14 nM to 270 +/- 12 nM at 30 mins, P < 0.05) but no effect on insulin sensitivity in L6 myoblasts (C(I-150) was 56 +/- 14 nM [control], 43 +/- 14 [30 mins] and 26 +/- 16 [2 h]). In conclusion, the inhibitory effect of ET-1 on insulin-stimulated glucose uptake is transient and occurs in 3T3-L1 adipocytes but not skeletal muscle-derived cells, perhaps reflecting tissue differences in ET(A)-receptor signaling. It is therefore unlikely that chronic hyperendothelinaemia has a direct insulin-antagonist effect contributing to peripheral (ie muscle/fat) insulin resistance in vivo.

Are routine chest X-rays for students entering university worthwhile?

Mass radiographic screening for tuberculosis has lost favour in many countries. The aim of this study was to determine whether the continued practice of such screening of prospective students at the University of the West Indies was warranted by assessing the yield and the cost of the programme in our setting. In a cross- sectional retrospective study, 12,662 chest X-ray reports collected over the period 1989-1997 were studied. No active case of tuberculosis was detected. Three students reported a previous history of tuberculosis and 10 students had a positive family history of tuberculosis. Three hundred and ninety-nine clinically insignificant abnormalities were reported, such as mild scoliosis and calcified foci. Routine radiological screening of prospective students at the University of the West Indies for tuberculosis has an extremely low yield, places the students at unnecessary risk of radiation exposure and should be discontinued.

Vitellogenin induction in painted turtle, Chrysemys picta, as a biomarker of exposure to environmental levels of estradiol

Ponds within cattle farms often support turtle and fish populations and are impacted by manure runoff. Cattle excrete metabolized (glucuronide-conjugated) hormones in feces and urine into these ponds, and bacteria cleave the glucuronide metabolites to active steroids, which can be stable for several weeks in wastewater. The objectives of this study were to (1) assess levels of xenoestrogens found in ponds near livestock pastures; and (2) assess whether these levels of xenoestrogens induce vitellogenin (VTG) in painted turtles in the laboratory and field. We collected water twice, 6 weeks apart, and placed turtle traps weekly into two ponds, which receive runoff from beef cattle pastures, and into one pond with no cattle farm effluents. Water E(2) levels were analyzed using C(18) solid phase extraction disks and detected in a radioimmunoassay (RIA). Plasma was collected from painted turtles (Chrysemys picta) captured from these ponds and VTG levels were measured via enzyme linked immunosorbent assay (ELISA). Nine additional turtles were collected from a pond at the South Carolina Botanical Gardens, which receives no farm runoff, and were exposed in the laboratory to nominal concentrations of 0.15, 1.5, and 15 ng/l estradiol (static renewal) over a 28-day period, followed by 14 days in clean water. Plasma samples were taken weekly for VTG measurement via ELISA. Levels of free estradiol in the water column of farm ponds range from 0.05 to 1.80 ng/l, as measured by RIA, and up to 7.4 ng/l as measured by ER-beta binding affinity. This is similar to what has been reported in streams receiving sewage treatment works (STW) effluents. In the laboratory, plasma VTG in male painted turtles could not be induced even at the high E(2) dose (9.45 ng/l) after 28 days. In the field, VTG levels were induced only in females when compared with animals from the SC Botanical Gardens. Adult male turtles need to be primed with high doses of E(2) prior to being able to respond to exogenous E(2). Given that males would not typically be sensitized in the wild, environmentally relevant levels of E(2) may not be sufficient to affect them. However, higher VTG levels in females could potentially change their reproductive fitness by altering egg size or by shifting energy allocations away from other survival needs. Long-term studies are needed to study potential impacts of VTG induction on female turtle reproductive success.

Epidemiology of over-the-counter drug use in community dwelling elderly: United States perspective

Among US community dwelling individuals aged > or = 65 years, about as many persons take nonprescription drugs as take prescription drugs. A review of US data from the last 2 decades indicates that the average number of over-the-counter (OTC) drugs taken daily is around 1.8, but varies with geographical area (highest in the Midwest) and race/ethnicity (lowest use among Hispanics, followed by African Americans. and highest use among Whites). Use has consistently been found to be higher in women than in men. While OTC use appears to be increasing over time, it also decreases with increase in age. The most common OTC classes used are analgesics, laxatives and nutritional supplements. Our ability to explain or to predict OTC use and change in use is poor, and further studies, particularly on use by elderly individuals of minority races, are needed.

Effects of active, passive or no warm-up on metabolism and performance during high-intensity exercise

The aim of this study was to determine the influence of type of warm-up on metabolism and performance during high-intensity exercise. Eight males performed 30 s of intense exercise at 120% of their maximal power output followed, 1 min later, by a performance cycle to exhaustion, again at 120% of maximal power output. Exercise was preceded by active, passive or no warm-up (control). Muscle temperature, immediately before exercise, was significantly elevated after active and passive warm-ups compared to the control condition (36.9 +/- 0.18 degrees C, 36.8 +/- 0.18 degrees C and 33.6 +/- 0.25 degrees C respectively; mean +/- sx) (P< 0.05). Total oxygen consumption during the 30 s exercise bout was significantly greater in the active and passive warm-up trials than in the control trial (1017 +/- 22, 943 +/- 53 and 838 +/- 45 ml O2 respectively). Active warm-up resulted in a blunted blood lactate response during high-intensity exercise compared to the passive and control trials (change = 5.53 +/- 0.52, 8.09 +/- 0.57 and 7.90 +/- 0.38 mmol x l(-1) respectively) (P < 0.05). There was no difference in exercise time to exhaustion between the active, passive and control trials (43.9 +/- 4.1, 48.3 +/- 2.7 and 46.9 +/- 6.2 s respectively) (P= 0.69). These results indicate that, although the mechanism by which muscle temperature is elevated influences certain metabolic responses during subsequent high-intensity exercise, cycling performance is not significantly affected.

Effect of cruciferous vegetable consumption on heterocyclic aromatic amine metabolism in man

The consumption of cooked meat appears to predispose individuals to colonic cancer and heterocyclic aromatic amines (HA), formed during the cooking of meat, have been suggested as aetiological agents. Consumption of cruciferous vegetables is thought to protect against cancer. To study the effect of cruciferous vegetables on heterocyclic aromatic amine metabolism in man, a three-period, dietary intervention study has been carried out with 20 non-smoking Caucasian male subjects consuming cooked meat meals containing known amounts of these carcinogens. A high cruciferous vegetable diet (250 g each of Brussels sprouts and broccoli per day) was maintained during period 2 but such vegetables were excluded from periods 1 and 3. At the end of each period, subjects consumed a cooked meat meal and urinary excretion of the HA 2-amino-3,8-dimethylimidazo(4,5-f)quinoxaline (MeIQx) and 2-amino-1-methyl-6-phenylimidazo(4,5-b)pyridine (PhIP) was measured. Following a 12 day period of cruciferous vegetable consumption (period 2), induction of hepatic CYP1A2 activity was apparent from changes in the kinetics of caffeine metabolism. Excretion of MeIQx and PhIP in urine at the end of this period of the study was reduced by 23 and 21%, respectively, compared with period 1. This reduction in excretion is probably due to an increase in amine metabolism that might be expected given the observed increase in CYP1A2 activity, since this enzyme has been shown to be primarily responsible for the oxidative activation of MeIQx and PhIP in man. In period 2, urinary mutagenicity was increased relative to period 1 by 52 and 64% in the absence and presence, respectively, of a human liver microsomal activation system, yet no evidence was found of PhIP adduction to lymphocyte DNA, a potential biomarker of the activation process. After another 12 days without cruciferous vegetables (period 3 of the study), the kinetics of caffeine metabolism had returned to original values but excretion of MeIQx and PhIP was still reduced by 17 and 30%, respectively, and urinary mutagenicity (with metabolic activation) was still elevated compared with period 1. This prolonged response of amine metabolism to the cruciferous vegetable diet, shown especially with PhIP, suggests that enzyme systems other than CYP1A2 are involved and affected by a cruciferous vegetable diet.

The aging voice: a review, treatment data and familial and genetic perspectives

This paper will provide a review of aspects of vocal aging within the context of general body aging and describe two data sets related to the aging voice. Data will be presented which document pre- to posttreatment improvement in select voice characteristics (sound pressure level, subglottal air pressure, thyroarytenoid laryngeal muscle activity and voice quality) following application of an intensive voice treatment program (the LSVT) to 3 individuals with aged voice. Additionally, physiological data (forced expiratory volume, visual accommodation, bone density, taste discrimination, white blood count and resting heart rate) and select perceptual (perceived age) and acoustic measures (reflecting both cycle-to-cycle and longer-term intensity and frequency stability) from 67 subjects will be reviewed from the work of Gray and colleagues to document the differential impact of the global aging process across organ systems including the aging voice.

Are there still effects on Indian Subcontinent ethnic tuberculosis of return visits?: a longitudinal study 1978-97

OBJECTIVE

To assess whether return visits to the Indian Subcontinent (ISC) are associated with increased risks of developing clinical tuberculosis.

METHODS

Descriptive analysis of epidemiological records over a period of 1978-97 inclusive in Blackburn, Hyndburn and Ribble Valley for individuals of ISC ethnic origin notified with tuberculosis. Those cases diagnosed through local contact tracing exercises were excluded.

RESULTS

Of 1032 eligible individuals notified with tuberculosis, 228 (22.1%) reported prior visits to the ISC. Of these 151 (66%) reported having visits within 3 years of that notification, including 60% of the United Kingdom (U.K.) born without prior exposure to the ISC.

CONCLUSION

The clinical observations are consistent with the hypothesis that return visits to the ISC carry a risk of acquiring tuberculosis. This cannot be confirmed, however, without information about the return visits in the ISC population as a whole. A case-control study may be required to confirm the hypothesis.