Effect of oxybutynin and reboxetine on obstructive sleep apnea: a randomized, placebo-controlled, double blind, crossover trial

STUDY OBJECTIVES

Although recent investigations combining noradrenergic and antimuscarinic drugs have shown promising short-term results to treat obstructive sleep apnea (OSA), the mid-term effect and optimal dosage remain uncertain. The present study aimed to evaluate the effect of one week of 5 mg oxybutynin and 6 mg reboxetine (oxy-reb) on OSA versus placebo.

METHODS

We performed a randomized, placebo-controlled, double-blind, crossover trial comparing the effect of one week of oxy-reb versus one week of placebo on OSA severity. At-home polysomnography was performed at baseline and after each week of intervention.

RESULTS

Fifteen participants (male 66.7%) aged 59 [44-62] years (median [interquartile range]) with a mean body mass index of 33.1 ± 6.6 kg.m -2 were included. No significant difference in apnea-hypopnea index (AHI) was observed between conditions (estimated marginal means (95% confidence interval) at baseline: 39.7 (28.5-55.3); oxy-reb: 34.5 (22.7-52.3); placebo: 37.9 (27.1-52.9); p=0.652), but oxy-reb improved average oxygen desaturation (p=0.016) and hypoxic burden (p=0.011) and lowered sleep efficiency (p=0.019) and rapid eye movement (REM) sleep (p=0.002). Moreover, participants reported reduced sleep quality during the week of oxy-reb compared to the week of placebo (4.7 (3.5; 5.9) vs. 6.5 (5.5; 7.5) on a 0-10 visual analogic scale, respectively; p=0.001). No significant differences in sleepiness, vigilance and fatigue were observed. No serious adverse events occurred.

CONCLUSION

Administration of oxybutynin 5 mg and reboxetine 6 mg did not improve OSA severity assessed by AHI, but did alter sleep architecture and sleep quality. Reduced average oxygen desaturation and hypoxic burden were also observed.

Liquid Chromatographic Method for Determination of Sulfamethazine Residues in Milk: Collaborative Study

Seven laboratories participated in a collaborative study of a liquid chromatographic (LC) method for determination of sulfamethazine (SMZ) residues in raw milk that were previously frozen. The milk is extracted with chloroform, the chloroform is evaporated, and the residue is suspended in hexane and extracted with 0.1 M KH2P04 (PDP) solution. The PDP extract is analyzed by LC on a C18 column with methanol–0.1M PDP (30 + 70) as mobile phase. Individual laboratories were instructed to analyze 5 replicates each of control milk, fortified control milk at 2 levels, and 3 blind samples. Blind samples included raw milk fortified with SMZ at 10 and 20 ppb and 1 sample containing SMZ residue from a dosed cow. For blind fortified samples containing 10 ppb SMZ, average recovery and relative standard deviations for repeatability and reproducibility (RSDr and RSRR) based on the results from 6 of the 7 participating laboratories were 8.21 ppb, 7.16%, and 23.16%, respectively. Similar data, including results from a seventh participant who reported instrumental problems but was not eliminated by the Dixon outlier test, were 9.13 ppb, 8.38%, and 31.94%, respectively. These results demonstrate that the method is suitable for the determination of SMZ residues in milk at 10 ppb and above. The method was adopted first action by AOAC International.

Growing pains: Maturity associated variation in injury risk in academy football

Reducing injuries to youth players is of primary importance to academies, as injuries can result in a significant loss in both training and match time, as well as, negatively affecting player development. In total, 76 talented young football players were analysed over two full competitive seasons. The injury incidence and burden for all non-contact and overuse injuries were recorded. Exposure was calculated as the total number of competitive matches hours played. Somatic maturation was estimated by expressing the current height of each player as a percentage of their predicted adult height [Roche, A. F., Tyleshevski, F., & Rogers, E. (1983). Non-invasive measurements of physical maturity in children. Research Quarterly for Exercise and Sport, 54(4), 364-371.]. The period of circa-peak height velocity (PHV) (24.5 injuries per 1000 h) was associated with a significantly higher injury incidence rate and burden compared to pre-PHV (11.5 injuries per 1000 h; RR:2.15, 95%CI:1.37-3.38, P < .001). No significant differences in injury risk between maturity timing groups were observed. The interaction effect between maturity status and maturity timing confirmed there is a risk period circa-PHV, but this was not dependent on maturity timing. The main practical application of this study is that football academies should regularly assess the maturity status of young footballers to identify those players with increased susceptibility to injury. Moreover, academies should individualise training and injury prevention strategies based on maturation.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Largest GWAS of PTSD (N=20 070) yields genetic overlap with schizophrenia and sex differences in heritability

The Psychiatric Genomics Consortium-Posttraumatic Stress Disorder group (PGC-PTSD) combined genome-wide case-control molecular genetic data across 11 multiethnic studies to quantify PTSD heritability, to examine potential shared genetic risk with schizophrenia, bipolar disorder, and major depressive disorder and to identify risk loci for PTSD. Examining 20 730 individuals, we report a molecular genetics-based heritability estimate (h2SNP) for European-American females of 29% that is similar to h2SNP for schizophrenia and is substantially higher than h2SNP in European-American males (estimate not distinguishable from zero). We found strong evidence of overlapping genetic risk between PTSD and schizophrenia along with more modest evidence of overlap with bipolar and major depressive disorder. No single-nucleotide polymorphisms (SNPs) exceeded genome-wide significance in the transethnic (overall) meta-analysis and we do not replicate previously reported associations. Still, SNP-level summary statistics made available here afford the best-available molecular genetic index of PTSD-for both European- and African-American individuals-and can be used in polygenic risk prediction and genetic correlation studies of diverse phenotypes. Publication of summary statistics for ∼10 000 African Americans contributes to the broader goal of increased ancestral diversity in genomic data resources. In sum, the results demonstrate genetic influences on the development of PTSD, identify shared genetic risk between PTSD and other psychiatric disorders and highlight the importance of multiethnic/racial samples. As has been the case with schizophrenia and other complex genetic disorders, larger sample sizes are needed to identify specific risk loci.

Discharge on the day of surgery following unicompartmental knee arthroplasty within the United Kingdom NHS

AIMS

Unicompartmental knee arthroplasty (UKA) has been successfully performed in the United States healthcare system on outpatients. Despite differences in healthcare structure and financial environment, we hypothesised that it would be feasible to replicate this success and perform UKA with safe day of surgery discharge within the NHS, in the United Kingdom. This has not been reported in any other United Kingdom centres.

PATIENTS AND METHODS

We report our experience of implementing a pathway to allow safe day of surgery discharge following UKA. Data were prospectively collected on 72 patients who underwent UKA as a day case between December 2011 and September 2015.

RESULTS

A total of 61 patients (85%) were discharged on the same day. The most common reason for failure was logistical; five patients had their operation too late in the day. Three patients failed to mobilise safely, two had inadequate control of pain and one had a leaking wound. The mean length of stay for those who were not discharged on the same day was 1.2 nights (1 to 3). During the same time, 58 patients underwent planned inpatient UKA, as they were deemed inappropriate for discharge on the day of surgery. However, three of these were safely discharged on the same day. Follow-up data, 24 hours post-operatively, were available for 70 patients; 51 (73%) reported no or mild pain, 14 (20%) had moderate pain and five (7%) had severe pain. There were no re-admissions. All patients had a high level of satisfaction.

CONCLUSION

We found that patients can be safely and effectively discharged on the day of surgery after UKA, with high levels of satisfaction. This clearly offers improved management of resources and financial savings to healthcare trusts. Cite this article: Bone Joint J 2017;99-B:788-92.

Epigenetic and genetic variation at SKA2 predict suicidal behavior and post-traumatic stress disorder

Traumatic stress results in hypothalamic pituitary adrenal (HPA) axis abnormalities and an increased risk to both suicidal behaviors and post-traumatic stress disorder (PTSD). Previous work out of our laboratory identified SKA2 DNA methylation associations with suicidal behavior in the blood and brain of multiple cohorts. Interaction of SKA2 with stress predicted suicidal behavior with ~80% accuracy. SKA2 is hypothesized to reduce the ability to suppress cortisol following stress, which is of potentially high relevance in traumatized populations. Our objective was to investigate the interaction of SKA2 and trauma exposure on HPA axis function, suicide attempt and PTSD. SKA2 DNA methylation at Illumina HM450 probe cg13989295 was assessed for association with suicidal behavior and PTSD metrics in the context of Child Trauma Questionnaire (CTQ) scores in 421 blood and 61 saliva samples from the Grady Trauma Project (GTP) cohort. Dexamethasone suppression test (DST) data were evaluated for a subset of 209 GTP subjects. SKA2 methylation interacted with CTQ scores to predict lifetime suicide attempt in saliva and blood with areas under the receiver operator characteristic curve (AUCs) of 0.76 and 0.73 (95% confidence interval (CI): 0.6-0.92, P = 0.003, and CI: 0.65-0.78, P < 0.0001) and to mediate the suppression of cortisol following DST (β = 0.5 ± 0.19, F = 1.51, degrees of freedom (df) = 12/167, P = 0.0096). Cumulatively, the data suggest that epigenetic variation at SKA2 mediates vulnerability to suicidal behaviors and PTSD through dysregulation of the HPA axis in response to stress.

An angiotensin-converting enzyme (ACE) polymorphism may mitigate the effects of angiotensin-pathway medications on posttraumatic stress symptoms

Angiotensin, which regulates blood pressure may also act within the brain to mediate stress and fear responses. Common antihypertensive medication classes of angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) have been associated with lower PTSD symptoms. Here we examine the rs4311 SNP in the ACE gene, previously implicated in panic attacks, in the relationship between ACE-I/ARB medications and PTSD symptoms. Participants were recruited from outpatient wait rooms between 2006 and March 2014 (n=  803). We examined the interaction between rs4311 genotype and the presence of blood pressure medication on PTSD symptoms and diagnosis. PTSD symptoms were lower in individuals taking ACE-Is or ARBs (N = 776). The rs4311 was associated with PTSD symptoms and diagnosis (N = 3803), as the T-carriers at the rs4311 SNP had significantly greater likelihood of a PTSD diagnosis. Lastly, the rs4311 genotype modified the effect of ACE-Is or ARBs on PTSD symptoms (N = 443; F1,443 = 4.41, P < 0.05). Individuals with the CC rs4311 genotype showed lower PTSD symptoms in the presence of ACE-Is or ARBs. In contrast, T- carriers showed the opposite, such that the presence of ACE-Is or ARBs was associated with higher PTSD symptoms. These data suggest that the renin-angiotensin system may be important in PTSD, as ACE-I/ARB usage associates with lower symptoms. Furthermore, we provide genetic evidence that some individuals are comparatively more benefitted by ACE-Is/ARBs in PTSD treatment. Future research should examine the mechanisms by which ACE-Is/ARBs affect PTSD symptoms such that pharmaco-genetically informed interventions may be used to treat PTSD.

Use of SMS and tablet computer improves the electronic collection of elective orthopaedic patient reported outcome measures

INTRODUCTION

Electronic patient reported outcome measures (PROMs) enable real time reporting back to the patient and medical team, comparison between similar patient cohorts and long-term cost effective outcome measurement. The primary objective of this three-phase pilot study was to measure uptake using a web-based PROM system following the introduction of two separate process improvements.

METHODS

Eighty consecutive new elective orthopaedic patients in a single surgeon's practice were recruited for the study. Patients in Group 1 (n=26) received only a letter reminding them to complete a symptom score. Those in Group 2 (n=31) also received a reminder SMS (short message service) message via their mobile or home telephone and those in Group 3 (n=23) also had access to a tablet computer in clinic.

RESULTS

The mean patient age in Group 1 was 55 years (range: 24-80 years), in Group 2 it was 60 years (range: 23-85 years) and in Group 3 it was 58 years (range: 37-78 years) (p>0.05). Overall, 79% of patients had internet access, and 35% of Group 1, 55% of Group 2 and 74% of Group 3 recorded an electronic PROM score (p=0.02). In Group 3, 94% of patients listed for an operation completed an electronic PROM score (p=0.006).

CONCLUSIONS

Collecting PROM data effectively in everyday clinical practice is challenging. Electronic collection should meet that challenge and improve healthcare delivery but it is in its infancy. This pilot study shows that the combination of an SMS reminder and access to a Wi-Fi enabled tablet computer in the clinic setting enabled 94% of patients listed for an operation to complete a score on a web-based clinical outcomes system. Additional staff training and telephone call reminders may further improve uptake.

Attention bias toward threat is associated with exaggerated fear expression and impaired extinction in PTSD

BACKGROUND

Post-traumatic stress disorder (PTSD) develops in a minority of traumatized individuals. Attention biases to threat and abnormalities in fear learning and extinction are processes likely to play a critical role in the creation and/or maintenance of PTSD symptomatology. However, the relationship between these processes has not been established, particularly in highly traumatized populations; understanding their interaction can help inform neural network models and treatments for PTSD.

METHOD

Attention biases were measured using a dot probe task modified for use with our population; task stimuli included photographs of angry facial expressions, which are emotionally salient threat signals. A fear-potentiated startle paradigm was employed to measure atypical physiological response during acquisition and extinction phases of fear learning. These measures were administered to a sample of 64 minority (largely African American), highly traumatized individuals with and without PTSD.

RESULTS

Participants with PTSD demonstrated attention biases toward threat; this attentional style was associated with exaggerated startle response during fear learning and early and middle phases of extinction, even after accounting for the effects of trauma exposure.

CONCLUSIONS

Our findings indicate that an attentional bias toward threat is associated with abnormalities in 'fear load' in PTSD, providing seminal evidence for an interaction between these two processes. Future research combining these behavioral and psychophysiological techniques with neuroimaging will be useful toward addressing how one process may modulate the other and understanding whether these phenomena are manifestations of dysfunction within a shared neural network. Ultimately, this may serve to inform PTSD treatments specifically designed to correct these atypical processes.

Phenolic and short-chained aliphatic organic acid constituents of wild oat (Avena fatua L.) seeds

The objective of this research was to identify and quantify the phenolic and short-chained aliphatic organic acids present in the seeds of three wild-type populations of wild oat and compare these results to the chemical composition of seeds from two commonly utilized wild oat isolines (M73 and SH430). Phenolic acids have been shown to serve as germination inhibitors, as well as protection for seeds from biotic and abiotic stress factors in other species, whereas aliphatic organic acids have been linked to germination traits and protection against pathogens. Wild oat populations were grown under a "common garden" environment to remove maternal variation, and the resulting seeds were extracted to remove the readily soluble and chemically bound phenolic and aliphatic organic acid components. Compounds were identified and quantified using gas chromatography-mass spectrometry. Ferulic and p-coumaric acid comprised 99% of the total phenolic acids present in the seeds, of which 91% were contained in the hulls and 98% were in the chemically bound forms. Smaller quantities of OH benzoic and vanillic acid were also detected. Soluble organic acids concentrations were higher in the M73 isoline compared to SH430, suggesting that these chemical constituents could be related to seed dormancy. Malic, succinic, fumaric and azelaic acid were the dominant aliphatic organic acids detected in all seed and chemical fractions.

Targeted immunotherapy with gemtuzumab ozogamicin (GO) following reduced intensity allogeneic stem cell transplantation (RI AlloSCT) to reduce minimal residual disease (MRD) in children with acute myeloid leukemia (AML): MRD monitoring by Wilms tumor gene

9532

Background: RI vs myeloablative (MA) AlloSCT in adults with AML is associated with significantly less transplant related mortality but increased rate of relapse, presumably secondary to MRD (Alyea et al; Blood, 2005). Quantification of the WT1 has been used successfully to detect MRD in children with acute myeloid leukemia (AML) (Kletzel et al; Pediatr Dev Pathol, 2002). GO has induced ORR in >30% of patients with overt relapsed CD33+ AML and may have a better effect in the setting of MRD (Sievers et al; J Clin Oncol, 2001). We have shown that RI AlloSCT followed by 2 doses of GO in average risk AML has resulted in >94% donor chimerism (Roman/Cairo, Clin Can Res, 2005). We explored changes in MRD prior to and after consolidation with 2 doses of GO targeted immunotherapy in children with average risk AML post RI AlloSCT. Methods: 11 pts, 11 years (0.5–21) with CD33+ (8 CR1, 3 CR2) received fludarabine 30 mg/m2x6d and busulfan 3.2–4 mg/kgx2d. Donors: 7 6/6 HLA related peripheral blood stem cells (RPBSC), 1 5/6 RPBSC, 1 6/6 related cord blood (CB) and 2 4/6 unrelated CB. GOx2 was administered =60d post AlloSCTx2 (8wks apart), at 4.5–7.5 mg/m2 (dose escalation). Samples were collected for WT1 analysis prior to and after each dose of GO (n=5). WT1 levels were determined by quantitative RT-PCR and compared with WT1 expression in a K562 leukemia line. Positive MRD was a ratio of K562 WT/patient's WT1>0.5. Results: The MTD for GO post RI AlloSCT has not been reached. 8/11 are NED (3 deaths: 1 relapse, 1 graft failure, 1 cGVHD) Pre GO WT1–0.079±0.07 (n=5), pre GO-dose #2–0.012±0.016 (n=3). One of these patients had detectable MRD (WT1–1.56) prior to the GO-dose #2, no MRD at 1year and is alive and in remission at 2 years post GOx2. The fifth patient entered transplant with +MRD (WT-0.866), relapsed after the first dose of GO and died of relapse prior to receiving the second dose. Conclusions: Targeted therapy with GOx2 may be useful in eradicating MRD in patients post RI AlloSCT. A larger cohort is necessary to assess the impact of GO (at the MTD) on MRD post RI AlloSCT in children with AML.

No significant financial relationships to disclose.

Comparison of long-term outcomes after allogeneic hematopoietic stem cell transplantation from matched sibling and unrelated donors

Long-term survivors of hematopoietic stem cell transplants remain at risk of potentially fatal complications that detract from life quality. Long-term morbidity and mortality were compared between matched recipient cohorts surviving 2 or more years and defined by donor type, HLA matched sibling donor (MSD) or volunteer unrelated donor (URD). Patients were previously entered into the prospective multicenter International Unrelated Search and Transplant Study. Thirty-nine centers provided data on 108 URD and 355 MSD recipients surviving more than 2 years. Long-term survival, performance status, chronic GvHD (c-GvHD), secondary malignancy, endocrine dysfunction, cataracts, bone necrosis and dental pathology were compared between cohorts. Twelve year survival was 77+/-5% for the MSD and 67+/-11% for the URD cohort (P=0.1). Late death occurred in 105 of 463 recipients alive at 2 years, 73 after 355 (21%) MSD and 32 after 108 (30%) URD transplants, P=0.10. Of 105 deaths, the cause was relapse in 60 and unrelated to relapse in 45 cases. Cumulative incidence of extensive c-GvHD (P=0.002), cataracts (P=0.02) and bone necrosis (P=0.02) was higher after URD transplants. No long-term difference in endocrine dysfunction, secondary malignancy and major dental pathology was detected. This landmark study will assist physicians counseling patients pre-transplant and with their long-term care post transplant.

Normalized data for the estimation of fetal radiation dose from radiotherapy of the breast

There can be several reasons why a pregnant patient may receive a radiological examination. It could have been a planned exposure, or the exposure might have resulted from an emergency when a thorough evaluation of pregnancy was impractical. Sometimes the pregnancy was unsuspected at the time of the examination and, with younger women being diagnosed with breast cancer, the likelihood of this will increase in radiotherapy departments. Whatever the reason, when presented with a pregnant patient who has received a radiological examination involving ionizing radiation, the dose to the fetus should be assessed based on the patient's treatment plan. However, a major source of uncertainty in the estimation of fetal absorbed dose is the influence of fetal size and position as these change with gestational age. Consequently, dose to the fetus is related to gestational age. Various studies of fetal dose during pregnancy have appeared in the literature. Whilst these papers contain many useful data for estimating fetal dose, they usually contain limited data regarding the depth and size of the fetus within the maternal uterus. We have investigated doses to the fetus from radiation therapy of the breast of a pregnant patient using an anthropomorphic phantom. Normalized data for estimating fetal doses that takes into account the fetal size (gestational age: 8-20 weeks post-conception) and depth within the maternal abdomen (4-16 cm) for different treatment techniques have been provided. The data indicate that fetal dose is dependent on both depth within the maternal abdomen and gestational age, and hence these factors should always be considered when estimating fetal dose. The data show that fetal dose can be underestimated up to about 10% or overestimated up to about 30% if the dose to the uterus is assumed instead of the actual fetal dose. It can also be underestimated up to about 23% or overestimated up to about 12% if a mean depth of 9 cm is assumed, instead of using the actual depth of the fetus within the maternal abdomen. Multi-segments sMLC technique showed consistently lower fetal doses compared with all the wedged plans employed.

Cyclooxygenase-1 gene polymorphisms in patients with different asthma phenotypes and atopy

Cyclooxygenase-1 (COX-1) regulates the biosynthesis of prostaglandins, which are important mediators in asthma. The possible association of COX-1 gene polymorphisms with asthma has not been investigated. The allele frequencies of 20 COX-1 polymorphisms were determined in a random Australian Caucasian population using MassARRAY technology. Informative and potentially functional promoter (c.8592C > T, c.1676C > T) and coding region (c.22C > T, c.50C > T) polymorphisms were investigated in carefully phenotyped patients with mild (n = 316), moderate (n = 241), severe (n = 86) or aspirin-intolerant asthma (AIA) (n = 58), and in nonasthmatic subjects (n = 477). There were no allelic, genotypic or haplotypic associations between these four polymorphisms and asthma or asthma severity. Over-representation of the c.50TT genotype among AIA patients (3.4%) compared with aspirin-tolerant patients (0.8%), and a global haplotype association with AIA did not reach statistical significance. The c.22TT genotype was less frequent among atopic (0.1%) rather than nonatopic individuals (1.2%; odds ratio = 9.05, 95% confidence interval 1.01-81.29). In conclusion, the present investigation of cyclooxygenase-1 polymorphisms in asthma indicates that they do not appear to play a substantial role in genetic pre-disposition for asthma or asthma severity. However, the c.22TT genotype confers a small protective effect against atopy. Potential associations with aspirin-intolerant asthma were identified and warrant further investigation in a larger population of aspirin-intolerant asthma patients.

Attentional and evaluative biases for smoking cues in nicotine dependence: component processes of biases in visual orienting

The present study investigated attentional and evaluative biases for smoking-related cues in cigarette smokers and non-smokers. Using a visual probe task, we manipulated the presentation conditions of the stimuli to examine: (1). whether smokers have a bias to allocate attention towards smoking-related pictures that appear below the threshold of conscious awareness; and (2). whether attentional biases for smoking-related pictures that appear above the threshold of awareness operate both in initial orienting and in the maintenance of attention. We also obtained explicit and implicit measures of the valence of the smoking-related pictures from pleasantness ratings and from behavioural responses on a stimulus-response compatibility (SRC) task. Results showed that smokers, but not non-smokers, had an attentional bias for smoking-related pictures which had been presented at two exposure durations (200 and 2000 ms). The bias was not found in a brief (17 ms) masked exposure condition, so there was no evidence that it operated preconsciously. Smokers also showed greater preferences for smoking-related than control cues, compared with non-smokers, on both the explicit and implicit indices of stimulus valence. Results are discussed with reference to incentive and cognitive models of addiction.

Longevity in vitro of human CD4+ T helper cell clones derived from young donors and elderly donors, or from progenitor cells: age-associated differences in cell surface molecule expression and cytokine secretion

The effectiveness of the adaptive immune system relies upon extensive proliferation of an initially small number of antigen-specific T cells. At the end of a successful response, the majority die by apoptosis and a small minority joins the memory cell pool. Upon re-challenge with antigen, these memory cells must again undergo clonal expansion in order to mediate an effective response. Thus, T cells are subjected to marked proliferative stress which may result in clonal exhaustion due to replicative senescence. In other systems made up of rapidly proliferating cells (e.g. in the gut) individual clones are identical and are replaced at the end of their lifespan by differentiation from a stem cell reservoir. However, because of the unique clonal distribution of antigen receptors on T cells, mere replacement with other T cells is not sufficient to maintain the integrity of the system. Moreover, the very source of new T cells decreases with age (due to thymic involution). Therefore, the adaptive immune system may be uniquely susceptible to the deleterious effects of replicative senescence. Particularly in humans, in vivo studies of the behaviour of individual T-cell clones in the body is difficult. However, T-cell longevity, measured as proliferative capacity in terms of population doublings, can be usefully modelled at the clonal level in vitro. This paper discusses the surprisingly little that is known about the average longevity, variation between clones, and the maximal longevity of human T cells under clonal culture conditions in vitro. From our own studies, we show that average lifespan of human T cells is as little as 17 PD; however, established clones reach 35 PD on average, with maximum longevity generally in the region of 60-80 PD, regardless of the source of the cloned cells. Expression of surface molecules in general did not differ strikingly between young and old donors, but the frequency of clones secreting IL-10, and the amount secreted per clone was higher in the elderly than in the young. Conversely, the frequency of clones secreting IL-6 and the amount secreted per clone was higher in the young.

Cytokines and the acute phase response in post-treatment reactive encephalopathy of Trypanosoma brucei brucei infected mice

Stimulation of the acute phase response during infection of mice with Trypanosoma brucei brucei (T. b. brucei) was investigated in an experimental model of the post-treatment reactive encephalopathy (PTRE), a common side-effect of anti-trypanosome therapy. Plasma levels of the acute phase proteins (APP), haptoglobin (Hp) and serum amyloid P (SAP) increased by day 7 post-infection, but by day 20 had fallen to an intermediate level. This was accompanied by induction of the cytokines, interleukin (IL)-6 and tumour necrosis factor-alpha (TNFalpha) in both liver and brain. Treatment of mice on day 21 with a subcurative dose of diminazene aceturate (Berenil), a procedure known to induce a mild PTRE, cleared the parasite from the circulation with plasma APP and liver expression of mRNA for IL-6 and TNFalpha returning to the levels in the controls. Cytokine mRNA for both IL-6 and TNFalpha was detected in the brains of animals with developing PTRE although TNFalpha was not significantly greater than in the control group. A further subcurative dose of Berenil, leading to a more severe PTRE, was associated with elevated serum concentrations of Hp and SAP, increased TNFalpha mRNA in the liver and detectable IL-6 and TNFalpha mRNA in the brain. mRNA for IL-1alpha was expressed in brain and liver samples from all animals. A severe PTRE caused a systemic acute phase response which was not apparent with a mild PTRE. The pattern of cytokine mRNA induction was similar following both drug treatments. However, the difference in APP production could be caused by a breakdown in the blood-brain barrier during severe PTRE allowing cytokine synthesised in the brain to enter the circulation and maintain a systemic response.

The CD34(+)CD38(neg) population is significantly increased in haemopoietic cell expansion cultures in serum-free compared to serum-replete conditions: dissociation of phenotype and function

Expansion of haemopoietic stem cells is proposed to combat graft failure in adult recipients following cord blood (CB) transplantation. Cultures are traditionally performed in medium containing FCS, but to transfer expansion to the clinic, 'good manufacturing practice' (GMP) standards are required. This study evaluated expansion cultures in culture bags and serum-free (SF) conditions, to comply with GMP, by analysing sub-populations of CD34(+) cells, colony-forming cells (CFC) and long-term culture initiating cells (LTC-IC). CD34(+)cell analysis has previously been used to measure clonogenic capacity and the CD34(+)CD38(neg) surface phenotype to measure primitive cell numbers. In this study, comparison of expansion in serum-replete medium with that in SF conditions demonstrated a lack of expression of CD38 on CD34(+) cells in the absence of serum. These findings must be considered in clinical studies using in vitro expansion in SF conditions, and the CD34(+)CD38(neg) phenotype should not be used to confirm maintenance, or expansion, of primitive progenitor cells.

Development of a district Cord Blood Bank: a model for cord blood banking in the National Health Service

The Bristol Cord Blood Bank was established as a pilot project within existing health services to establish cost-effective recruitment, collection and processing suitable for use in the NHS should cord blood become a routine source of haemopoietic stem cells for transplantation in the UK. An important aim of the project was to evaluate the feasibility of establishing a midwifery-based collection network, thus utilising expertise already in place. Collection was performed on the delivery suite immediately after the placenta was delivered. The clinical experience of the midwife collector/counsellors allowed rapid pre-collection assessment of the condition of the cord and placenta. This prevented collection attempts from diseased or otherwise damaged placentas, leading to conservation of resources by preventing collection of most small volume donations. The bank was established within the National Blood Service, Bristol Centre to achieve Good Manufacturing Practice standards and ensure that processing was subject to the same stringency required for other sources of haemopoietic stem cells. Cord blood is an expensive resource. By utilising existing expertise in district Obstetric and National Blood Services, the Bristol Cord Blood Bank may serve as a model for health economic evaluation of cord blood banking of volunteer donations within the NHS.

Rhabdomyolysis and acute renal failure due to combination therapy with simvastatin and warfarin

Simvastatin, an inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, is widely used to treat hyperlipidaemia. Although myalgias are recognized adverse effects, clinically significant elevations in serum creatine phosphokinase (CPK) levels are uncommon. We describe a case of rhabdomyolysis and acute renal failure associated with concomitant use of simvastatin and warfarin. Rhabdomyolysis and renal failure occurred 7 days after warfarin (5 mg day-1) was added to a chronic stable dose of simvastatin (20 mg day-1) and resolved abruptly after discontinuation of simvastatin. We recommend careful monitoring when warfarin is given to patients receiving simvastatin.

Competitive repopulation of retrovirally transduced haemopoietic stem cells

Gene transfer into haemopoietic stem cells (HSC) may be useful in gene therapy for a variety of inherited and acquired human diseases. Cell division is required for retroviral transduction, and cytokine stimulation is often used to increase mitosis of quiescent HSC. Exposure to cytokines has been shown to have an unfavourable effect on the engraftment of these cells when competed with unmanipulated HSC. We now show that a similar engraftment defect is present when HSC are manipulated and transduced with the human multiple drug resistance (MDR) gene. The extent of the unfavourable competition depended on the relative numbers of cytokine-treated and fresh cells when the two populations of cells were administered simultaneously into marrow-ablated isogenic mice. When the manipulated transduced cells were given 2 or 4 d before the unmanipulated cells there was a much greater engraftment of the manipulated cells. The data suggested that the manipulated cells were at a relative disadvantage for marrow engraftment as compared to fresh cells, presumably due to the more efficient homing and engraftment properties of these latter unmanipulated cells. However, the manipulated cells had no intrinsic inability to engraft when they were the predominant donor cell population. In all cases the percent of MDR transduced cells in the engrafting manipulated cells remained relatively constant at about 25-30%. These results have implications for the use of manipulated transduced stem cells in gene therapy, suggesting that administering them before adding fresh cells can overcome their engraftment defect.

Impact of obstetric factors on cord blood donation for transplantation

Recent reports have shown that low nucleated cell dose significantly decreases survival after cord blood transplantation. Prior to starting clinical cord blood banking we investigated the impact of obstetric factors on cell dose and volume of cord blood donations. Cord blood was obtained from 114 normal full-term deliveries. Mean volume collected was 93.5 ml, mean total nucleated cell count (TNC) was 13.1 x 108. Statistical analysis was by backwards stepwise regression. Significant factors affecting nucleated cell yield were volume of blood collected (P < 0.001), length of gestation (P < 0. 0001), time from delivery of the infant to cord clamping (P = 0.018) and total length of labour (P = 0.002). In clinical cord blood banking we have successfully used these findings for pre-collection assessment of placentae. Out of 476 cord blood donations subsequently collected for banking, only 29 (6.1%) have been discarded due to low volume. The mean TNC of the 409 banked units following volume reduction was 10.1 x 108. Despite careful optimization of collection, processing and storage techniques, cell dose still limits cord blood transplantation to smaller recipients.

Different behaviour of fresh and cultured CD34+ cells during immunomagnetic separation

In-vitro expansion of human cord blood (CB) cells could enhance peripheral blood recovery and ensure long-term engraftment of larger recipients in the clinical transplant setting. Enrichment of CD34+ cells using the MiniMACS column has been evaluated for the preparation of CB CD34+ cells before and after expansion culture. Repurification of CD34+ cells after culture would assist accurate phenotypic and functional analysis. When fresh CB mononuclear cells (MNC) were separated, the MACS positive (CD34+) fraction (90.1% pure) contained a mean (+/- SD, n = 5) of 93.0 +/- 8.0% of the eluted CD34+ cells, 99.6 +/- 0.7% of the CFU-GM and all of the eluted long-term culture-initiating cells (LTC-IC). Cord blood CD34+ cells were then cultured for 14 d with IL-3, IL-6, SCF, G-CSF and GM-CSF, each at 10 ng/ml. The total cell expansion was 2490 +/- 200-fold and the CD34+ cell expansion was 49 +/- 17-fold. The percentage of CD34+ cells present after expansion culture was 1.2 +/- 0.85%. When these cells were repurified on the MiniMACS column, the MACS positive fraction only contained 40.3 +/- 13.4% of the eluted CD34+ cells which was enriched for the mature CD34+ CD38+ subset, 24.4 +/- 8.8% of the eluted CFU-GM and 79.5 +/- 11.0% of the LTC-IC. The remaining cells were eluted in the MACS negative fraction. In conclusion, repurification of cultured CD34+ cells does not yield a representative population and many progenitors are lost in the MACS negative fraction. This can give misleading phenotypic and functional data. Cell losses may be important in the clinical setting if cultured cells were repurified for purging.

Frequencies of cytotoxic T lymphocyte precursor estimate in three different populations

There is speculation that high cytotoxic T lymphocyte precursor frequencies (CTLpf) correlate with poor clinical outcome of bone marrow/organ transplantation. It is also believed that human umbilical cord blood is immunologically naive, and, therefore cord blood T cells may be less able to mediate graft versus host disease than marrow-derived T cells. CTLpf were determined in peripheral blood mononuclear cells collected from healthy adults, human umbilical cord blood and renal dialysis patients who were randomly selected and entered into this study. A highly sensitive non-radioactive Europium release cytotoxicity assay was optimized and modified to carry out the CTLpf estimation by using the principle of limiting dilution analysis. The results of CTLpf in healthy adults ranged from 1/694 to 1/66,666, median 1/7,339 (n=10); cord blood ranged from 1/1,562 to 1/35,714, median 1/10,162 (n=6) and dialysis patients ranged from 1/1,054 to 1/17,857 median 1/5,208 (n=9). The results demonstrated that there is little difference of CTLpf median values between the groups, but there is a wide variation of CTLpf between individuals within a population. It suggests that this variation should be taken into account when considering CTLpf assay as pre-transplantation cross-match procedure.

Clinical application of in vitro expansion of cord blood

Expansion of cord blood (CB) haemopoietic cells has been investigated with the aim of reducing cytopenia following transplantation. We investigated the increase in total nucleated cells, colony-forming cells (CFC), CD34+ cells and long-term culture-initiating cells (LTC-IC) by limiting dilution after a 14-day culture of CB CD34+ cells (5 x 10(3)/ml) with SCF, IL-3, IL-6, GM-CSF and G-CSF all at 10 ng/ml. On average nucleated cells increased 2500-fold, CD34+ cells 39-fold and CFU-GM 49-fold with maintenance of BFU-E. The more primitive LTC-IC expanded on average 2.5-fold. Expansion of a 20% aliquot of a CB donation could provide a 5-7-fold increase in progenitor cells, and a 1570-fold increase in post-progenitor cells compared to an untreated donation.

Is in vitro expansion of human cord blood cells clinically relevant?

Peripheral blood recovery after cord blood (CB) transplantation is delayed compared with marrow. Expansion of CB haemopoietic cells has been investigated with the aim of reducing cytopenia following transplantation. Mature cells, post-progenitors, progenitors and long-term culture-initiating cells (LTC-IC) from expansion products may contribute to peripheral blood recovery. We investigated the increase in total nucleated cells, colony-forming cells (CFC), CD34+ cells and LTC-IC by limiting dilution after a 14 day culture of CB CD34+ cells (5 x 10(3)/ml) with SCF, IL-3, IL-6, GM-CSF and G-CSF all at 10 ng/ml. On average, nucleated cells increased 2500-fold, CD34+ cells 39-fold and CFU-GM 49-fold with maintenance of BFU-E. The more primitive LTC-IC expanded on average 2.5-fold but effects on long-term marrow-repopulating cells (LTRC) during culture are unknown. A practical application of in vitro expansion of CB might be to expand a 20% aliquot of a CB donation and infuse the remainder unmanipulated. This could provide a 5- to 7-fold increase in progenitor cells, an estimated 1570-fold increase in post-progenitor cells and maintenance of LTC-IC compared to an untreated donation. Combined with in vivo post-transplant growth factor therapy this could prompt early peripheral blood recovery after CB transplantation, without significant loss of LTC-IC or donor lymphocytes.

Basal activity profiles of NPH and [Nepsilon-palmitoyl Lys (B29)] human insulins in subjects with IDDM

[Nepsilon-palmitoyl Lys (B29)] human insulin is a fatty acid-acylated derivative of insulin with extended action compared to unmodified insulin when infused intravenously (i.v.) secondary to its binding to circulating albumin. The duration and activity profile of the acylated (A) and NPH (B) insulins were assessed following subcutaneous (s.c.) doses of (A) 6 nmol/kg and (B) 1.2 nmol/kg (equivalent to 0.2 U/kg) in 9 subjects with IDDM. After overnight i.v. infusion of regular human insulin, morning glucose was (A) 6.9 +/- 0.1 and (B) 6.8 +/- 0.1 mmol/l. After the s.c. injection, i.v. human insulin or glucose was infused to maintain near-basal glycaemia and tracer glucose to assess hepatic glucose production (HGP). An activity profile was deduced for each study by expressing the glucose infusion rate at each time point, as a fraction (%) of the basal (measured) HGP, and the i.v. insulin infusion rate as a fraction (%) of the basal requirement. The two fractions are combined by adding the fractional glucose infusion rate and subtracting the fractional insulin infusion rate. Infusion rates of i.v. insulin in the morning were (A) 0.96 +/- 0.096 and (B) 1.22 +/- 0.09 pmol x kg(-1) x min(-1). After insulin injection, i.v. insulin requirements decreased and were below 10% of basal between 100 and 150 min. A constant activity profile of 0% represents a perfect substitution of the basal i.v. insulin infusion by the s.c. dose. The actual profile is defined by deviations from this (above) and was -17 +/- 11, 7 +/- 10, -9 +/- 6 and -18 +/- 18% for [Nepsilon-palmitoyl Lys (B29)] human insulin and 17 +/- 12, 5 +/- 6, -9 +/- 15, 22 +/- 18% for NPH insulin at 3, 6, 9 and 12 h after s.c. injection. HGP was similar for the two insulins, demonstrating similar metabolic actions and profiles both peripherally and at the liver.

Immunization services for adolescents within comprehensive school health programs

Every school day, more than 95% of the nation's five- to 17-year-olds attend one of almost 110,000 elementary and secondary schools where they receive instruction in how to avoid major health-threatening behaviors. School is also the place where children and adolescents can be given preventive health care services, including administration of vaccines and monitoring of immunization levels. This article addresses how expanding school health services could improve immunization levels of school-aged youth.

Endothelial cell precursors are normal components of human umbilical cord blood

Endothelial cells are part of the normal bone marrow stroma. We have previously shown human umbilical cord blood (UCB) does not produce stroma in standard long-term cultures. Highly enriched (93-98%) UCB CD34+ cells were cultured for 6 weeks with interleukin-2 and conditioned medium from the 5637 carcinoma cell line (n = 4). The resulting 'fibroblast like' cells were shown to be endothelial by expression of von Willebrand factor (VWF), ICAM-1 (CD54), E-selectin (CD62E) and PECAM (CD31). Endothelial monolayers seeded with CD34+ UCB cells supported expansion of colony forming cells and CD34+ cells. We conclude that endothelial cell precursors circulate in UCB, and may be derived from the CD34+ cell fraction.