Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Liquid Chromatographic Determination of Glyphosate in Water-Soluble Granular Formulations: Collaborative Study

A liquid chromatographic (LC) method for the determination of glyphosate in various water-soluble granular formulations was tested by 28 laboratories. Samples were dissolved in mobile phase and injected directly into an LC system with a 25 cm SAX column and a mobile phase of 96% aqueous buffer solution, 0.0062M KH2PO4, and 4% methanol. Detection was by UV absorption at 195 nm. Manual or automated injections were made via fixed-volume loops. Calculations were based on peak area comparisons with external standards. The collaborative study analyzed 5 matched pairs of 4 water-soluble granular formulations, with one determination per sample. The study generated 138 matched pairs, which were analyzed by using the AOAC spreadsheet and Youden’s matched-pair calculations. Coefficients of variation for the 4 formulations ranged from 0.65 to 1.37%. The LC method for the determination of glyphosate in water-soluble granular formulations has been adopted first action by AOAC INTERNATIONAL.

Arts for the Blues - a new creative psychological therapy for depression: a pilot workshop report

INTRODUCTION

Research over the last decade has identified both strengths and limitations in the use of routinely prescribed psychological therapies for depression. More recently, a focus on how creative art therapies and 'arts on prescription' are developing a growing recognition of their potential additional therapeutic mechanisms for depression.

AIM

In an attempt to develop a new therapeutic intervention for depression, this research aligned both the evidence base surrounding the arts on prescription movement, collating these with client-reported helpful factors and preferences for therapeutic interventions.

METHODS

We developed a framework for a new pluralistic 'meta-approach' of therapy for depression, based on; an interdisciplinary thematic synthesis of active ingredients, considered specific features implemented in therapy, and client-reported helpful factors considered to be the broad features or experiences in therapy from both talking therapies and creative approaches. This framework contributed to the development of a pilot workshop entitled Arts for the Blues - A New Creative Psychological Therapy for Depression. An outline of, and evaluation from this workshop is presented in this article. Workshop participants were recruited via a voluntary workshop taking place at a North West Higher Education Institution Arts and Health conference ( N = 15).

RESULTS

The workshop was evaluated using quantitative measures, with results indicating around a 70% overall satisfaction, followed up with qualitative commentary around areas of good practice and areas for development. These included the positive reflection on the application of creative arts and the multimodal nature of the approach, while others reflected on the potential overwhelming nature of utilising multimodal methods for individuals with depression.

CONCLUSION

Overall feedback from the pilot workshop is discussed in relation to prior research, giving credence to the potential for incorporating arts into therapy.

Performance of Prototype Segmented CdZnTe Arrays

The Burst and All Sky Imaging Survey (BASIS) is a proposed mission to provide ∼3 arc second locations of approximately 90 Gamma-Ray Bursts (GRBs) per year. The BASIS coded aperture imaging system requires a segmented detector plane able to detect the interaction position of (10 - 150 keV) photons to less than 100 μm. To develop prototype detector arrays with such fine position resolution we have fabricated many 15 mm × 15 mm × 2 mm 100 μm pitch CdZnTe strip detectors. We have assembled these fine pitch CdZnTe strip detectors into prototype 2 × 2 and 6 × 6 element arrays read out by ASIC electronics. The assembly and electronics readout of the 6 × 6 flight prototype array will be discussed, and preliminary data illustrating the uniformity and efficiency of the array will be presented.

The comparability conundrum: biosimilars in the United States, Europe and Canada

A biosimilar contains an active ingredient that is similar, but not identical, to the active ingredient in an approved reference drug. This raises the issue of when and how a biosimilar should be allowed to compare to a reference drug for marketing approval. This paper looks at the current regulation of biosimilars in Europe, the United States and Canada. The response to the challenge of regulating biosimilars has been varied. For example, Europe implemented a specialized, abbreviated legal pathway about five years before the United States. In Canada, abbreviated approval by comparison to an approved reference biologic was already available under the existing regulatory framework. Regulators have significant discretion to set criteria establishing when a biosimilar is deemed comparable to a reference biologic. The comparability standards for review of the one biosimilar approved in all three jurisdictions (Omnitrope, a human growth hormone) were largely consistent. Omnitrope may be instructive as to the potential standard of review for future single chain protein biosimilars. In contrast, the United States approved a second-entry low molecular weight heparin with no clinical trials, whereas European guidelines state that clinical trial data will be required.

Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis

OBJECTIVE

To systematically review the evidence that smoking cessation after diagnosis of a primary lung tumour affects prognosis.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

CINAHL (from 1981), Embase (from 1980), Medline (from 1966), Web of Science (from 1966), CENTRAL (from 1977) to December 2008, and reference lists of included studies.

STUDY SELECTION

Randomised controlled trials or observational longitudinal studies that measured the effect of quitting smoking after diagnosis of lung cancer on prognostic outcomes, regardless of stage at presentation or tumour histology, were included.

DATA EXTRACTION

Two researchers independently identified studies for inclusion and extracted data. Estimates were combined by using a random effects model, and the I(2) statistic was used to examine heterogeneity. Life tables were used to model five year survival for early stage non-small cell lung cancer and limited stage small cell lung cancer, using death rates for continuing smokers and quitters obtained from this review.

RESULTS

In 9/10 included studies, most patients studied were diagnosed as having an early stage lung tumour. Continued smoking was associated with a significantly increased risk of all cause mortality (hazard ratio 2.94, 95% confidence interval 1.15 to 7.54) and recurrence (1.86, 1.01 to 3.41) in early stage non-small cell lung cancer and of all cause mortality (1.86, 1.33 to 2.59), development of a second primary tumour (4.31, 1.09 to 16.98), and recurrence (1.26, 1.06 to 1.50) in limited stage small cell lung cancer. No study contained data on the effect of quitting smoking on cancer specific mortality or on development of a second primary tumour in non-small cell lung cancer. Life table modelling on the basis of these data estimated 33% five year survival in 65 year old patients with early stage non-small cell lung cancer who continued to smoke compared with 70% in those who quit smoking. In limited stage small cell lung cancer, an estimated 29% of continuing smokers would survive for five years compared with 63% of quitters on the basis of the data from this review.

CONCLUSIONS

This review provides preliminary evidence that smoking cessation after diagnosis of early stage lung cancer improves prognostic outcomes. From life table modelling, the estimated number of deaths prevented is larger than would be expected from reduction of cardiorespiratory deaths after smoking cessation, so most of the mortality gain is likely to be due to reduced cancer progression. These findings indicate that offering smoking cessation treatment to patients presenting with early stage lung cancer may be beneficial.

Paraffin-based molecular diagnosis of lung cancer reproduces morphologic and molecular subtypes of lung cancer

7579

Background: Molecular profiling of lung cancer by gene expression analyses has documented potential to guide therapy. However, quality ‘fresh’ tissue for RNA analyses is generally unavailable in clinical practice. We introduce a (q)RT-PCR assay and analytic method for profiling lung cancers from clinically obtained formalin-fixed paraffin-embedded tissues. Methods: Approximately 1,000 DNA microarrays were analyzed to select genes distinguishing the major histological variants (adenocarcinoma, small cell carcinoma, etc) and previously described molecular subtypes of lung cancer. Based on gene expression, a classifier of 62 genes was constructed to assign each sample to its morphologic tumor type, as well as to risk stratify by molecular subtypes. A real-time qRT-PCR assay was developed to evaluate the expression of the 62 genes from paraffin-embedded samples. This assay was used to profile RNA extracted from a cohort of surgically treated lung cancer patients. Samples were procured as fresh frozen and formalin-fixed, paraffin-embedded and were archived between 1–15 years. Results: Fifty-eight of 62 genes passed performance criteria and were used for analyses. Normalized gene expression was used for sample classification. The cohort contained a broad spectrum of tumors in proportions consistent with clinical practice. Gene amplification was successful in 139 of 142 (98%) lung cancer samples. Matched frozen-paraffin and replicate paraffin samples had mean correlations of approximately 80%. Linear discriminant analysis of gene expression data agreed with morphologic classification by light microscopy in >99% of cases. More importantly, the method successfully re-identified molecular subtypes of lung cancer for the first time through the use of a paraffin-based assay. Clinical outcomes previously associated with molecular tumor subtypes, including differential survival and metastatic patterns, were again seen in our cohort. Conclusions: We describe for the first time a clinically meaningful and robust molecular diagnosis of a clinical cohort of lung cancer patients which is complementary to morphologic cancer diagnosis. This assay is easily implemented using specimens routinely collected in current patient care.

No significant financial relationships to disclose.

Evaluation of the pharmacokinetics of posaconazole and rifabutin following co-administration to healthy men

OBJECTIVE

Posaconazole is a triazole antifungal agent for the treatment and prophylaxis of invasive fungal infections. This non-randomized, open-label, parallel-group, multiple-dose, drug-interaction study was conducted to evaluate the pharmacokinetics of posaconazole and rifabutin following co-administration to healthy subjects.

METHODS

Subjects were assigned to treatment groups: Group 1 (posaconazole, 200-mg tablet once daily for 10 days) or Group 2 (rifabutin, 300-mg capsule once daily for 17 days [Days -7 to 10] co-administered with posaconazole, 200 mg tablet once daily for 10 days [Days 1-10]). Posaconazole was administered after rifabutin steady-state was reached. Individual plasma concentration-time data for posaconazole (Day 10, Groups 1 and 2) and rifabutin (Days -1 and 10, Group 2) were analyzed using model-independent methods.

RESULTS

Twenty-four men were enrolled in the study. All subjects in Group 1 completed the study; however, four subjects in Group 2 discontinued because of adverse events. When co-administered with rifabutin, posaconazole maximum plasma concentration (C(max)) and area under the plasma concentration-time curve over the dosing interval (AUC([tau])) were reduced 43% (p = 0.005) and 49% (p = 0.008), respectively. Conversely, rifabutin C(max) and AUC([tau]) increased 31% (p = 0.016) and 72% (p < 0.001), respectively, when co-administered with posaconazole.

CONCLUSION

Based on the reduced exposure to posaconazole observed in the limited number of subjects in this study and the increased risk for adverse events associated with elevated rifabutin concentrations, concomitant use of rifabutin and posaconazole should be avoided unless the benefit outweighs the risk.

Comprehensive curation and analysis of global interaction networks in Saccharomyces cerevisiae

BACKGROUND

The study of complex biological networks and prediction of gene function has been enabled by high-throughput (HTP) methods for detection of genetic and protein interactions. Sparse coverage in HTP datasets may, however, distort network properties and confound predictions. Although a vast number of well substantiated interactions are recorded in the scientific literature, these data have not yet been distilled into networks that enable system-level inference.

RESULTS

We describe here a comprehensive database of genetic and protein interactions, and associated experimental evidence, for the budding yeast Saccharomyces cerevisiae, as manually curated from over 31,793 abstracts and online publications. This literature-curated (LC) dataset contains 33,311 interactions, on the order of all extant HTP datasets combined. Surprisingly, HTP protein-interaction datasets currently achieve only around 14% coverage of the interactions in the literature. The LC network nevertheless shares attributes with HTP networks, including scale-free connectivity and correlations between interactions, abundance, localization, and expression. We find that essential genes or proteins are enriched for interactions with other essential genes or proteins, suggesting that the global network may be functionally unified. This interconnectivity is supported by a substantial overlap of protein and genetic interactions in the LC dataset. We show that the LC dataset considerably improves the predictive power of network-analysis approaches. The full LC dataset is available at the BioGRID (http://www.thebiogrid.org) and SGD (http://www.yeastgenome.org/) databases.

CONCLUSION

Comprehensive datasets of biological interactions derived from the primary literature provide critical benchmarks for HTP methods, augment functional prediction, and reveal system-level attributes of biological networks.

A link between prompt optical and prompt γ-ray emission in γ-ray bursts

The prompt optical emission that arrives with the gamma-rays from a cosmic gamma-ray burst (GRB) is a signature of the engine powering the burst, the properties of the ultra-relativistic ejecta of the explosion, and the ejecta's interactions with the surroundings. Until now, only GRB 990123 had been detected at optical wavelengths during the burst phase. Its prompt optical emission was variable and uncorrelated with the prompt gamma-ray emission, suggesting that the optical emission was generated by a reverse shock arising from the ejecta's collision with surrounding material. Here we report prompt optical emission from GRB 041219a. It is variable and correlated with the prompt gamma-rays, indicating a common origin for the optical light and the gamma-rays. Within the context of the standard fireball model of GRBs, we attribute this new optical component to internal shocks driven into the burst ejecta by variations of the inner engine. The correlated optical emission is a direct probe of the jet isolated from the medium. The timing of the uncorrelated optical emission is strongly dependent on the nature of the medium.

Factors related to the process of seeking and completing treatment for drug abuse (qualitative methods in drug abuse research)

Numerous studies have demonstrated the effectiveness of drug abuse treatment. Yet many drug abusers do not enter treatment, many who do enter leave prematurely, and relapse following treatment is common. Understanding motivation for change and treatment readiness is key to understanding how to induct and engage drug users in treatment. To the extent that treatment programs focus initially on reducing drug use, rather than psychosocial problems that motivate individuals to seek treatment, treatment programs may fail to meet the primary needs of users and thus fail to attract or engage them. Outcomes of substance abuse treatment programs historically have been measured by successful program completion, reduced drug use and illegal activity, and improved social functioning (employment, education etc). There is minimal reference to client expectations of treatment and factors that influenced treatment-seeking behavior. Studies that have assessed client dropout from substance abuse treatment have generally focused upon quantitative measures that attempt to determine what types of clients drop out or stay, or what types of characteristics best predict client dropout. Qualitative methods are the most appropriate to fill these gaps in substance abuse treatment research.

An infrared flash contemporaneous with the γ-rays of GRB 041219a

The explosion that results in a cosmic gamma-ray burst (GRB) is thought to produce emission from two physical processes: the central engine gives rise to the high-energy emission of the burst through internal shocking, and the subsequent interaction of the flow with the external environment produces long-wavelength afterglows. Although observations of afterglows continue to refine our understanding of GRB progenitors and relativistic shocks, gamma-ray observations alone have not yielded a clear picture of the origin of the prompt emission nor details of the central engine. Only one concurrent visible-light transient has been found and it was associated with emission from an external shock. Here we report the discovery of infrared emission contemporaneous with a GRB, beginning 7.2 minutes after the onset of GRB 041219a (ref. 8). We acquired 21 images during the active phase of the burst, yielding early multi-colour observations. Our analysis of the initial infrared pulse suggests an origin consistent with internal shocks.

A giant γ-ray flare from the magnetar SGR 1806–20

Two classes of rotating neutron stars-soft gamma-ray repeaters (SGRs) and anomalous X-ray pulsars-are magnetars, whose X-ray emission is powered by a very strong magnetic field (B approximately 10(15) G). SGRs occasionally become 'active', producing many short X-ray bursts. Extremely rarely, an SGR emits a giant flare with a total energy about a thousand times higher than in a typical burst. Here we report that SGR 1806-20 emitted a giant flare on 27 December 2004. The total (isotropic) flare energy is 2 x 10(46) erg, which is about a hundred times higher than the other two previously observed giant flares. The energy release probably occurred during a catastrophic reconfiguration of the neutron star's magnetic field. If the event had occurred at a larger distance, but within 40 megaparsecs, it would have resembled a short, hard gamma-ray burst, suggesting that flares from extragalactic SGRs may form a subclass of such bursts.

Ultrasound biomicroscopy in the management of melanocytoma of the ciliary body with extrascleral extension

AIM

To demonstrate the ultrasound biomicroscopic features of a ciliary body melanocytoma with extrascleral extension, and a conservative approach in its management.

METHOD

Observational case reports. Two cases of ciliary body melanocytoma were suspected at presentation, confirmed histologically by biopsy, and subsequently monitored for change by serial ultrasound biomicroscopic imaging. The main outcome measures were anatomical and functional preservation of the eye, with avoidance of formal surgical excision.

RESULTS

Ultrasound biomicroscopy allows clear visualisation of the tumours, and the ultrasound characteristic is of low homogeneous internal reflectivity. 5 year follow up with observation only demonstrates success with this conservative management approach. Histopathological evaluation confirmed melanocytoma.

CONCLUSIONS

Melanocytoma is a rare tumour. However if considered in the differential diagnosis at presentation and confirmed histologically, further management with use of the ultrasound biomicroscope as an accurate mode of imaging is an acceptable technique for preservation of the eye and avoids surgical excision.

Effect of raloxifene on sexual function in postmenopausal women

OBJECTIVE

To determine the effects of raloxifene on sexual function in postmenopausal women with pre-existing vaginal atrophy treated with vaginal estrogen cream.

METHODS

A total of 187 naturally postmenopausal women, 42-80 years of age, with signs of genitourinary atrophy were enrolled in this 6-month, multicenter, parallel-group study. Subjects were randomized to oral raloxifene HCl 60 mg daily or matching placebo; the same subjects were also randomized to receive one application of either vaginal conjugated estrogen cream 0.5 g twice weekly for 6 months or non-hormonal vaginal moisturizer twice weekly for 3 months, followed by conjugated estrogen cream for 3 months. Both investigators and subjects were masked to the identity of the oral medication. The vaginal preparations were administered in an open-label fashion. The Sexual Activity Questionnaire (SAQ) was administered at baseline and at 3 and 6 months. Safety was assessed throughout the study.

RESULTS

A total of 102 women were sexually active at baseline and, of these, 82 were also sexually active at the 6-month end-point. At 6 months, raloxifene and placebo, in the presence of vaginal conjugated estrogen cream, were both associated with improvement from baseline in vaginal dryness and reduced discomfort during sexual activity. There were no significant differences between raloxifene and placebo groups in any SAQ item. Enjoyment of sexual activity significantly increased from baseline with raloxifene but not with placebo. No difference in adverse events was observed between groups.

CONCLUSION

Raloxifene had no negative effects on sexual function in postmenopausal women with vaginal atrophy who were treated concomitantly with vaginal estrogen cream.

Quantitative neuropathological analysis of sudden infant death syndrome

Detailed stereological analyses of specific regions of brains of children who had died from Sudden Infant Death Syndrome (SIDS) was undertaken to determine whether global evidence of an underlying pathology exists, contributing to an increased susceptibility to SIDS. A significant reduction in the total number of neocortical neurones and neurone volume was observed in SIDS normal birth weight (NBW) infants in comparison to controls. A significant reduction in both volume and total neurone number were also noted in the dorsal motor nucleus of the vagus in SIDS NBW group when compared with controls. Anomalies in regions of the brain involved with cardiorespiratory control (brainstem) and arousal (brainstem and neocortex) may play a crucial role in the chain of events resulting in a SIDS event.

Intracellular drug delivery using low-frequency ultrasound: quantification of molecular uptake and cell viability

PURPOSE

To determine the dependence on acoustic parameters of molecular uptake and viability of cells exposed to low-frequency ultrasound.

METHODS

DU145 prostate cancer cells bathed in a solution of calcein were exposed to ultrasound at 24 kHz over a range of different acoustic pressures. exposure times, pulse lengths, and duty cycles. Flow cytometry was employed to quantify the number of calcein molecules delivered into each cell and levels of cell viability.

RESULTS

Both molecular uptake and cell viability showed a strong dependence on acoustic pressure and exposure time, weak dependence on pulse length, and no significant dependence on duty cycle. When all of the data were pooled together, they exhibited good correlation with acoustic energy exposure. Although molecular uptake showed large cell-to-cell heterogeneity, up to approximately 15% of cells achieved an intracellular calcein concentration approximately equal to its extracellular concentration.

CONCLUSIONS

Large numbers of molecules can be delivered intracellularly using low-frequency ultrasound. Both uptake and viability correlate with acoustic energy, which is useful for design and control of ultrasound protocols.

Nitric oxide potentiates response of trigeminal neurones to dural or facial stimulation in the rat

Infusing glyceryl trinitrate as a donor molecule, we have used electrophysiological and c-fos immunostaining techniques to study the effects of nitric oxide on neurones in the nucleus trigeminalis caudalis. Following infusion of glyceryl trinitrate, responses of neurones to electrical stimulation of periorbital cutaneous afferents were potentiated and threshold for activation of neurones by stimulation of dural afferents was reduced. Expression of c-fos was unchanged by glyceryl trinitrate compared to saline controls. Intradermal injection of capsaicin in the periorbital area increased c-fos expression in nucleus trigeminalis caudalis; this was significantly potentiated by glyceryl trinitrate. These results suggest that, in the anaesthetized rat, glyceryl trinitrate alone may not acutely activate the trigeminovascular system to a significant degree at doses that cause headache and later trigger migraine headache in migraineurs. Nevertheless, it is susceptible to exogenous nitric oxide in that activation of trigeminal neurones through cutaneous or dural pathways is potentiated. This may in some measure underlie the pathogenesis of migraine headache.

A common variant of the endothelial nitric oxide synthase (Glu298-->Asp) is a major risk factor for coronary artery disease in the UK

BACKGROUND

Endothelium-derived nitric oxide (NO) is synthesised from L-arginine by endothelial nitric oxide synthase (eNOS) encoded by the NOS 3 gene on chromosome 7. Because reduced NO synthesis has been implicated in the development of coronary atherosclerosis, which has a heritable component, we hypothesised that polymorphisms of NOS 3 might be associated with increased susceptibility to this disorder.

METHODS AND RESULTS

Single-strand conformation polymorphism analysis of NOS 3 identified a G-->T polymorphism in exon 7 of the gene which encodes a Glu-->Asp amino acid substitution at residue 298 of eNOS. We investigated the relationship between this Glu(298)-->Asp variant and atherosclerotic coronary artery disease (CAD) using 2 independent case-controlled studies. In the first study (CHAOS), cases consisted of 298 unrelated patients with positive coronary angiograms and controls were 138 unrelated healthy individuals ascertained through a population health screen. In the second study (CHAOS II), the cases were 249 patients with recent myocardial infarction (MI), and a further 183 unrelated controls. There was an excess of homozygotes for the Asp298 variant among patients with angiographic CAD, and among patients with recent MI when compared with their respective controls (35.9% versus 10.2%, P<0.0001 in CHAOS, and 18.1% versus 8.7%, P<0.02 in CHAOS II). In comparison to Glu(298) homozygotes, homozygosity for Asp(298) was associated with an odds ratio of 4.2 (95% CI, 2.3 to 7.9) for angiographic CAD and 2.5 (95% CI, 1.3 to 4.2) for MI.

CONCLUSIONS

Homozygosity for a common NOS 3 polymorphism (894 G-->T) which encodes a Glu298-->Asp amino acid substitution in eNOS is a risk factor for angiographic CAD and recent MI in this population.

The prognostic value of a normal Tc-99m sestamibi SPECT study in suspected coronary artery disease

BACKGROUND

Myocardial perfusion is widely used for risk stratification of patients with suspected or known coronary artery disease (CAD). Recent years have seen an increasing demand for screening of such patients. The value of a normal stress thallium-201 scanning is well established. The advent of technetium 99m-sestamibi single photon emission computed tomography (SPECT) has enhanced the profile of nuclear cardiology even further as a reliable test for screening. However, in spite of previous reports, there is paucity of large-scale data regarding the prognostic value of a normal Tc 99m-sestamibi scanning result.

METHODS

The aim of our study was to assess the incidence of cardiac death and non-fatal myocardial infarction in patients with an intermediate probability of coronary artery disease (CAD). A total of 473 patients with normal stress Tc-99m-sestamibi SPECT were monitored for 30+/-16 (6 to 56) months to assess serious cardiac events. There were 272 men and 201 women, with a mean age of 56+/-2 years, of whom 89% had symptoms suggestive of CAD, 65% had an abnormal exercise electrocardiography, 6% had known CAD, and 5% had a high risk of CAD. The average workload was 9.14 metabolic equivalents, peak exercise heart rate was 93%+/-13% of the age predicted target.

RESULTS

The annualized mortality rate was 0.2% (95%CI 0.02% to 0.7%) and no infarctions occurred in this group.

CONCLUSIONS

A normal stress Tc-99m-sestamibi is highly predictive of a benign outcome, even in patients with intermediate probability of CAD.

Supermirror hard-x-ray telescope

The practical use of a grazing x-ray telescope is demonstrated for hard-x-ray imaging as hard as 40 keV by means of a depth-graded d-spacing multilayer, a so-called supermirror. Platinum-carbon multilayers of 26 layer pairs in three blocks with a different periodic length d of 3-5 nm were designed to enhance the reflectivity in the energy range from 24 to 36 keV at a grazing angle of 0.3 deg. The multilayers were deposited on thin-replica-foil mirrors by a magnetron dc sputtering system. The reflectivity was measured to be 25%-30% in this energy range; 20 mirror shells thus deposited were assembled into the tightly nested grazing-incidence telescope. The focused hard-x-ray image was observed with a newly developed position-sensitive CdZnTe solid-state detector. The angular resolution of this telescope was found to be 2.4 arc min in the half-power diameter.

Randomised controlled trial of vitamin E in patients with coronary disease: Cambridge Heart Antioxidant Study (CHAOS)

BACKGROUND

Vitamin E (alpha-tocopherol) is thought to have a role in prevention of atherosclerosis, through inhibition of oxidation of low-density lipoprotein. Some epidemiological studies have shown an association between high dietary intake or high serum concentrations of alpha-tocopherol and lower rates of ischaemic heart disease. We tested the hypothesis that treatment with a high dose of alpha-tocopherol would reduce subsequent risk of myocardial infarction (MI) and cardiovascular death in patients with established ischaemic heart disease.

METHODS

In this double-blind, placebo-controlled study with stratified randomisation, 2002 patients with angiographically proven coronary atherosclerosis were enrolled and followed up for a median of 510 days (range 3-981). 1035 patients were assigned alpha-tocopherol (capsules containing 800 IU daily for first 546 patients; 400 IU daily for remainder); 967 received identical placebo capsules. The primary endpoints were a combination of cardiovascular death and non-fatal MI as well as non-fatal MI alone.

FINDINGS

Plasma alpha-tocopherol concentrations (measured in subsets of patients) rose in the actively treated group (from baseline mean 34.2 micromol/L to 51.1 micromol/L with 400 IU daily and 64.5 micromol/L with 800 IU daily) but did not change in the placebo group. Alpha-tocopherol treatment significantly reduced the risk of the primary trial endpoint of cardiovascular death and non-fatal MI (41 vs 64 events; relative risk 0.53 [95% Cl 0.34-0.83; p=0.005). The beneficial effects on this composite endpoint were due to a significant reduction in the risk of non-fatal MI (14 vs 41; 0.23 [0.11-0.47]; p=0.005); however, there was a non-significant excess of cardiovascular deaths in the alpha-tocopherol group (27 vs 23; 1.18 [0.62-2.27]; p=0.61). All-cause mortality was 36 of 1035 alpha-tocopherol-treated patients and 27 of 967 placebo recipients.

INTERPRETATION

We conclude that in patients with angiographically proven symptomatic coronary atherosclerosis, alpha-tocopherol treatment substantially reduces the rate of non-fatal MI, with beneficial effects apparent after 1 year of treatment. The effect of alpha-tocopherol treatment on cardiovascular deaths requires further study.

Overachievement and coping strategies in adolescent males

How to assist young people to achieve to their potential is a universal concern of educators. The relationship between achievement above that expected on the basis of IQ alone (often referred to as overachievement) in school assessment and preferred coping style, as assessed by the Adolescent Coping Scale (ACS, Frydenberg & Lewis, 1993a), was investigated in a group of 374 boys in Grades 9, 10 and 11 at an independent boys' school in metropolitan Melbourne. Separate partial correlation analyses for each of the three year levels showed that three of the coping strategies, Work and Achieve, Solve the Problem, and Social Support positively correlated with overachievement at all three levels. Other subscales also correlated significantly at one or other of the grade levels. It was concluded that overachievement may be better regarded as approaching one's full potential by the use of optimal coping strategies and avoidance of alternative responses to stress which appear to be non-productive.

Sonohysterographic imaging of the endometrial cavity

Vaginal ultrasound is the most effective method of imaging the contents of the true pelvis in the female. Saline influsion sonohysterography (SIS) is a simple refinement of the standard vaginal sonographic exam. Here, we briefly describe and demonstrate our use of this latter technique.