Haemoglobin scavenging after subarachnoid haemorrhage

Rapid and effective clearance of cell-free haemoglobin after subarachnoid haemorrhage (SAH) is important to prevent vasospasm and neurotoxicity and improve long-term outcome. Haemoglobin is avidly bound by haptoglobin, and the complex is cleared by CD163 expressed on the membrane surface of macrophages. We studied the kinetics of haemoglobin and haptoglobin in cerebrospinal fluid after SAH. We show that haemoglobin levels rise gradually after SAH. Haptoglobin levels rise acutely with aneurysmal rupture as a result of injection of blood into the subarachnoid space. Although levels decline as haemoglobin scavenging occurs, complete depletion of haptoglobin does not occur and levels start rising again, indicating saturation of CD163 sites available for haptoglobin-haemoglobin clearance. In a preliminary neuropathological study we demonstrate that meningeal CD163 expression is upregulated after SAH, in keeping with a proinflammatory state. However, loss of CD163 occurs in meningeal areas with overlying blood compared with areas without overlying blood. Becauses ADAM17 is the enzyme responsible for shedding membrane-bound CD163, its inhibition may be a potential therapeutic strategy after SAH.

Autoradiographic method for isolation of diverse microbial species with unique catabolic traits

A novel autoradiographic method for isolation of bacteria with unique catabolic traits was developed to overcome many of the limitations of traditional selective enrichment techniques. The method consists of five steps. (i) An environmental sample is directly plated (without enrichment) on a microporous filter atop a solid medium that allows cultivation of diverse kinds of microorganisms. (ii) Once colonies form, two replicas of the filter are prepared and the colonies are regrown. (iii) The replica filters are starved 24 to 72 h to deplete intracellular carbon reserves and then (iv) placed on Na(inf2)(sup35)SO(inf4)-containing solid media with and without a test compound. (v) Following an incubation period, the replica filters are exposed to film in order to identify colonies that incorporate more (sup35)S into cell biomass in the presence of the test compound than in its absence, providing presumptive evidence for metabolism of the compound. The colonies identified in this manner can be recovered from the master filter. To demonstrate this technique, bacteria capable of degrading benzoate were isolated from a single soil slurry by traditional enrichment as well as by autoradiography. From the enrichment culture, a single isolate able to degrade benzoate was obtained. In contrast, 18 distinct strains were obtained by purifying 19 putative benzoate-degrading colonies identified by autoradiography. Each of the 18 strains was able to completely transform the substrate, as determined by high-performance liquid chromatography analyses. The doubling times of a subset of the isolates grown in benzoate medium ranged from 1.4 to 17.1 h, whereas the doubling time of the isolate obtained by enrichment was 2.0 h. These data demonstrate that the method described here can be used to obtain a collection of diverse organisms able to metabolize a specific compound.

Genetic Diversity through the Looking Glass: Effect of Enrichment Bias

The effect of enrichment bias on the diversity of 2,4-dichlorophenoxyacetate (2,4-D)-degrading (2,4-D(sup+)) bacteria recovered from soil was evaluated by comparing the diversity of isolates obtained by direct plating to the diversity of isolates obtained from 85 liquid batch cultures. By the two methods, a total of 159 isolates were purified from 1 g of soil and divided into populations based on repeated extragenic palindromic sequence PCR (rep-PCR) genomic fingerprints. Approximately 42% of the direct-plating isolates hybridized with the tfdA and tfdB genes from Alcaligenes eutrophus JMP134(pJP4), 27% hybridized with the tfdA and tfdB genes from Burkholderia sp. strain RASC, and 30% hybridized with none of the probes. In contrast, the enrichment isolates not only represented fewer populations than the isolates obtained by direct plating but also exhibited, almost exclusively, a single hybridization pattern with 2,4-D catabolic gene probes. Approximately 98% of the enrichment isolates possessed pJP4-type tfdA and tfdB genes, whereas isolates containing RASC-type tfdA and tfdB genes were obtained from only 2 of the 85 enrichment cultures. The skewed occurrence of the pJP4-type genes among the isolates obtained by enrichment suggests that the competitive fitness of 2,4-D(sup+) populations during growth with 2,4-D may be influenced either by specific tfd alleles or by genetic factors linked to these alleles. Moreover, the results indicate that evaluation of the diversity and distribution of catabolic pathways in nature can be highly distorted by the use of enrichment culture techniques.

A phase Ib trial of IPI-504 (retaspimycin hydrochloride), a novel Hsp90 inhibitor, in combination with docetaxel

3547

Background: IPI-504 is a water-soluble heat shock protein 90 (Hsp90) inhibitor. IPI-504 causes the degradation of a variety of mutated or amplified oncoproteins, including epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 (HER2). The combination of IPI-504 and docetaxel demonstrates additive efficacy in murine xenograft models. This Phase 1b trial was undertaken to identify the maximum tolerated dose (MTD) of IPI-504 in combination with docetaxel. Methods: Eligible patients (pts) had advanced solid tumors that were either refractory to available therapies or for which docetaxel alone was an appropriate therapy. Intravenous (IV) 75 mg/m2 docetaxel was given once every three weeks (q 3- weekly). IPI-504 was administered IV q 3-weekly, with 3 pts per cohort and inter-cohort dose escalation. All pts were evaluated for safety, pharmacokinetics (PK), and tumor response. Results: 16 pts have been enrolled at 3 dose levels of IPI-504 (7 at 300 mg/m2, 6 at 450 mg/m2, and 3 at 550 mg/m2). 6 pts had non-small cell lung cancer (NSCLC). Median age was 59 yrs (range 33–77). Median number of cycles received was 3 (1–11), with 5 pts currently on study. There have been 4 dose-limiting toxicities (DLTs): 1 at 300 mg/m2 (Grade 3 febrile neutropenia); 1 at 450 mg/m2 (Grade 3 fatigue); and 2 at 550 mg/m2 (Grade 1 asymptomatic sinus bradycardia requiring hospitalization for observation, and Grade 3 elevated AST with Grade 3 acute respiratory distress syndrome). All DLTs resolved on trial. No PK interactions between docetaxel and IPI-504 have been observed. The regimen of IPI-504 450 mg/m2 with docetaxel 75 mg/m2 has been identified as the recommended phase 2 dose on a q 3-weekly schedule. Conclusions: In this Phase 1b trial, the MTD of IPI-504 plus docetaxel q 3-weekly was identified. Toxicities were reversible and similar to those seen with docetaxel or IPI-504 alone in this patient population. Given the activity of single-agent IPI-504 against NSCLC and the standard use of docetaxel in that disease, an expanded evaluation of this regimen in pts with previously treated NSCLC is on-going. The combination of IPI-504 and docetaxel on a weekly schedule is also being explored.

[Table: see text]

Modeling bacterial species abundance from small community surveys

Taxon abundance patterns are a central focus in evolution and ecology, providing the basic architecture of natural assemblages and potential clues to their formative processes. To better interpret species abundance patterns in natural microbial communities, we examined the consequences of three fundamental types of abundance patterns--uniform, geometric, and lognormal distributions. Theoretical communities were constructed based on the three pattern types with 2000 to 20,000 species and 10(7) to 10(10) individuals. The "dominant" species (species 1) among models that differed only in pattern type generally varied in abundance by 1 to 3 orders of magnitude. At the extremes among all the models examined, the dominant species comprised as much as 16% and as little as 0.005% of the total community. Analysis of the models and comparison with seven published surveys suggests that entire soil bacterial communities do not routinely exhibit Preston's cannonical subset of lognormal distributions. Use of the models to evaluate survey limitations showed that common diversity indices are generally sensitive to sample size over the range (50 to 200 clones) commonly used for microbial communities, emphasizing the need to compare surveys of similar size. The results collectively demonstrate that uniform, geometric, and lognormal distributions have profoundly different experimental and ecological consequences. Further, defined abundance models provide a simple quantitative tool for evaluating abundance patterns in clone libraries (even small ones) from natural communities.

Diffuse brain injury complicated by acute subdural hematoma and secondary insults in the rodents: the effect of surgical evacuation

Head Trauma associated with acute sudural hematoma (SDH) and complicated by secondary insult is a grave clinical combination with complex pathophysiology. The aim of this study was to develop a clinically relevant injury model, which can be used to study the interaction between injury mechanisms. We present a novel model of SDH combined with diffuse brain injury (DBI) and a hypoxic secondary insult, and investigate the effects of surgical evacuation. Adult Sprague-Dawley rats were given a 300 microliters SDH and 20 minute-hypoxia following Impact Acceleration DBI. Hematoma was evacuated at one hour post-injury. Physiological parameters were measured for 5 hours, together with assessment of brain water content. Secondary insult after traumatic SDH was associated with significant brain swelling and stimulated refractory rise in ICP. In traumatic SDH complicated by secondary insult, brain swelling is exacerbated by surgical evacuation.

The permissive nature of blood brain barrier (BBB) opening in edema formation following traumatic brain injury

The contribution of blood brain barrier opening to traumatic brain edema is not known. This study compares the course of traumatic BBB disruption and edema formation, with the hypothesis that they are not obligately related. Sprague-Dawley rats were divided into three groups: Group A (n = 47)--Impact Acceleration (IAM); Group B (n = 104)--lateral cortical impact (CCI); Group C (n = 26)--IAM + hypoxia & hypotension (THH). BBB integrity was assessed using i.v. markers (Evan's Blue, or gadolinium-DTPA). Edema formation was evaluated with gravimetry, and T1-weighted MRI. In IAM, BBB opened immediately but closed rapidly, and remained closed for at least the next 36 hours whilst 24-hour hemispheric water content (HWC) rose by 0.9% (p < 0.01). In CCI, BBB opened in both hemispheres for up to 4 hours; four hour HWC in the uninjured hemisphere was indistinguishable from Sham, where HWC in the injured hemisphere rose by approximately 1.5% (p < 0.005). We distinguished two THH animals based on Apparent Diffusion Coefficient (ADC) recovery: in ADC-recovery animals 4 hour cortical water content (CWC) was 80.4 +/- 0.6%, cf 81.4 +/- 1.3% in ADC-non-recovery (p < 0.05). In all animals the BBB was open, however two populations of permeability were seen which likely related to flow-limited extravasation of gadolinium. In IAM edema forms despite only brief BBB opening. Although there is diffuse BBB opening with lateral contusion, edema only forms in the injured hemisphere. In THH, edema formation in the face of a widely permeable barrier is driven by ADC changes or cell swelling. Edema formation clearly does not correspond with BBB opening and an open BBB is clearly not required for edema formation. However we hypothesize that a permeable BBB permissively worsens the process, by acting as a low resistance pathway for ion and water movement. These findings are consistent with our general hypothesis that edema formation after TBI is mainly cytotoxic.

The structure of human mitochondrial branched-chain aminotransferase

X-ray crystal structures of three forms of human mitochondrial branched-chain aminotransferase (BCAT) were solved by molecular-replacement methods, using Escherichia coli BCAT as the search model. The enzyme is a homodimer and the polypeptide chain of each monomer has two domains. The small domain is composed of residues 1--175 and the large domain is composed of residues 176--365. The active site is close to the dimer interface. The 4'-aldehyde of the PLP cofactor is covalently linked to the epsilon-amino group of the active-site lysine, Lys202, via a Schiff-base linkage in two of the structures. In the third structure, the enzyme is irreversibly inactivated by Tris. The overall fold of the dimer in human mitochondrial BCAT is similar to the structure of two bacterial enzymes, E. coli BCAT and D-amino acid aminotransferase (D-AAT). The residues lining the putative substrate-binding pocket of human BCAT and D-AAT are completely rearranged to allow catalysis with substrates of opposite stereochemistry. In the case of human mitochondrial branched-chain aminotransferase, a hydrogen-bond interaction between the guanidinium group of Arg143 in the first monomer with the side-chain hydroxyl of Tyr70 in the second monomer is important in the formation of the substrate-binding pocket.

Intracerebroventricular insulin-like growth factor-1 decreases feeding in diabetic rats

Insulin-like growth factor-1 (IGF-1) is a hormone that is important in the regulation of growth processes and additionally has been demonstrated to modulate metabolic and autonomic responses. Some of its effects are mediated by the central nervous system (CNS), and there are IGF-1 receptors dispersed throughout the CNS. Both IGF-1 and insulin alter peripheral metabolic and autonomic nervous activity by a central mechanism, and the well-defined role of insulin in the regulation of feeding, especially in diabetes, led us to investigate the effect of chronic central administration of IGF-1 on metabolic and feeding parameters in normal and diabetic rats. Normal and diabetic rats with intracerebroventricular cannulas were given IGF-1, insulin (0.5 nmol/animal), or artificial cerebrospinal fluid via cannula twice daily for 4 d. Blood samples were collected on d 2 and 4, and the body weights and food intake were recorded daily. IGF-1 administered intracerebroventricularly did not alter plasma glucose, insulin, body weight, or food intake in normal rats. However, in diabetic animals, IGF-1 decreased food intake but did not alter blood glucose or plasma insulin. In correlated studies, intracerebroventricular insulin decreased food intake in both normal and diabetic animals. From these studies, we conclude that IGF-1 may act centrally to decrease food intake in the hyperphagic diabetic animals but not in normal animals. This suggests that diabetic animals have an increased sensitivity to CNS IGF-1.

Phylogenetic specificity and reproducibility and new method for analysis of terminal restriction fragment profiles of 16S rRNA genes from bacterial communities

Terminal restriction fragment (TRF) analysis of 16S rRNA genes is an increasingly popular method for rapid comparison of microbial communities, but analysis of the data is still in a developmental stage. We assessed the phylogenetic resolution and reproducibility of TRF profiles in order to evaluate the limitations of the method, and we developed an essential analysis technique to improve the interpretation of TRF data. The theoretical phylogenetic resolution of TRF profiles was determined based on the specificity of TRFs predicted from 3,908 16S rRNA gene sequences. With sequences from the Proteobacteria or gram-positive division, as much as 73% of the TRFs were phylogenetically specific (representing strains from at most two genera). However, the fraction decreased when sequences from the two divisions were combined. The data show that phylogenetic inference will be most effective if TRF profiles represent only a single bacterial division or smaller group. The analytical precision of the TRF method was assessed by comparing nine replicate profiles of a single soil DNA sample. Despite meticulous care in producing the replicates, numerous small, irreproducible peaks were observed. As many as 85% of the 169 distinct TRFs found among the profiles were irreproducible (i.e., not present in all nine replicates). Substantial variation also occurred in the height of synonymous peaks. To make comparisons of microbial communities more reliable, we developed an analytical procedure that reduces variation and extracts a reproducible subset of data from replicate TRF profiles. The procedure can also be used with other DNA fingerprinting techniques for microbial communities or microbial genomes.

The important role of residue F268 in ligand binding by LXRbeta

Liver X receptors (LXRs) are nuclear receptors that regulate the metabolism of cholesterol and bile acids. Despite information on the specificity of their natural ligands, oxysterols, relatively little is known about the ligand binding site in LXRs. The helix 3 region in the ligand binding domain (LBD) of peroxisome proliferator-activated receptors (PPARs) has been implicated in ligand entry. Sequence alignment of LXRs, farnesoid X receptor (FXR), and PPARs identified the corresponding helix 3 region in the LXRbeta LBD. Residues F268 and T272, which are conserved in all the aligned sequences and only in LXRs and FXR, respectively, were replaced with alanine. The effects of these mutations on ligand binding and receptor activation were examined using an in vitro ligand binding assay and a cell based reporter assay, respectively. The LXRbeta mutant F268A did not bind ligand. In contrast, conversion of T272 to alanine has no effect on ligand binding. By transiently expressing a chimeric receptor containing Escherichia coli tetracycline repressor (TetR) and LXRbeta LBD and a reporter with a TetR binding site, we show that mutant F268A lost the ability to activate transcription of the reporter, whereas mutant T272A still has an activity similar to that of the wild-type LXRbeta. These data, consistent with the findings in the in vitro ligand binding assay and our 3D modeling, are the first study that identifies a residue critical for ligand binding in LXRbeta.

Assessment of microbial diversity in four southwestern United States soils by 16S rRNA gene terminal restriction fragment analysis

The ability of terminal restriction fragment (T-RFLP or TRF) profiles of 16S rRNA genes to provide useful information about the relative diversity of complex microbial communities was investigated by comparison with other methods. Four soil communities representing two pinyon rhizosphere and two between-tree (interspace) soil environments were compared by analysis of 16S rRNA gene clone libraries and culture collections (Dunbar et al., Appl. Environ. Microbiol. 65:1662-1669, 1998) and by analysis of 16S rDNA TRF profiles of community DNA. The TRF method was able to differentiate the four communities in a manner consistent with previous comparisons of the communities by analysis of 16S rDNA clone libraries. TRF profiles were not useful for calculating and comparing traditional community richness or evenness values among the four soil environments. Statistics calculated from RsaI, HhaI, HaeIII, and MspI profiles of each community were inconsistent, and the combined data were not significantly different between samples. The detection sensitivity of the method was tested. In standard PCRs, a seeded population comprising 0.1 to 1% of the total community could be detected. The combined results demonstrate that TRF analysis is an excellent method for rapidly comparing the relationships between bacterial communities in environmental samples. However, for highly complex communities, the method appears unable to provide classical measures of relative community diversity.

Induction of rat hepatic aryl sulfotransferase (SULT1A1) gene expression by triamcinolone acetonide: impact on minoxidil-mediated hypotension

The hypotensive agent minoxidil (6-imino-1, 2-dihydro-1-hydroxy-2-imino-4-piperidinopyrimidine) depends upon aryl sulfotransferase (SULT1)-catalyzed sulfation for its bioactivation. Previous reports suggest that glucocorticoids induce class-specific SULT1 and isoform-specific SULT1A1 gene expression in rat liver. In the present study, rats were treated with the glucocorticoid triamcinolone acetonide (TA, 5 mg/kg/day i.p. x 3 days) or its vehicle, 2% Tween-20, prior to minoxidil, and subsequent effects on mean arterial pressure (MAP), heart rate (HR), and hepatic SULT1 gene expression were characterized. Minoxidil treatment (1.5 mg/kg) resulted in a steady decline in MAP values of 16.3 to 18.6% relative to basal control levels at 35 to 60 min following minoxidil injection. Pentachlorophenol (PCP, 40 micromol/kg i.p.), an inhibitor of SULT1 enzyme activity, effectively ablated the hypotensive effects of minoxidil. By contrast, pretreatment with TA significantly enhanced minoxidil-induced hypotension. Relative to vehicle-treated controls, TA-treated rats displayed a steeper rate of decline in MAP and more profound levels of hypotension with decreases in MAP following minoxidil administration of 27.8%. TA also produced significant increases in hepatic SULT1 mRNA expression (of 271%) and SULT1A1 immunoreactive protein levels (of 273%), relative to vehicle-treated controls. These results provide physiological evidence to support the biological relevance of SULT1A1 induction by glucocorticoids. The data indicate that steroid treatment induces SULT1A1 gene expression and, as a consequence, accentuates the hypotensive effects of minoxidil.

The impact-acceleration model of head injury: injury severity predicts motor and cognitive performance after trauma

This study examines neuropsychological dysfunction after varying severities of the Impact Acceleration Model of diffuse traumatic brain injury. Adult rats (340 g-400 g) were divided into five groups, and exposed to varying degrees of Impact Acceleration Injury (1 m, 2 m, 2.1 m/500 g and second insult). After injury, animals were allowed to recover; acute neurological reflexes, beam walk score, beam balance score, inclined plane score, and Morris Water Maze score were then assessed at multiple time points. Injury of all severities caused significant motor and cognitive deficits. With milder injuries these effects were transient; however, with more severe injuries no recovery in function was seen. The addition of hypoxia and hypotension made a moderate injury worse than a severe injury. The acute neurological reflexes, the beam balance test and the inclined plane test distinguished between the more severely injured groups, but were affected less by mild injury. The beam walk test was sensitive to mild injury, but appeared unable to distinguish between the severe groups. The Morris Water Maze was sensitive for all injury groups, but appeared to adopt a different response profile with secondary insult. This study has for the first time characterized the degree of motor and cognitive deficits in rodents exposed to differing severities of Impact Acceleration Injury. These data confirm that the tests considered, and the Injury Model used, provide a useful system for the consideration of potential therapies which might ameliorate neuropsychological deficits in diffuse brain injury.

Removal of bedrails on a short-term nursing home rehabilitation unit

Our goal was to determine whether bedrails could be removed safely on a geriatric rehabilitation unit. Staff attended in-services about bedrails, assessment, and possible alternatives. Residents in the study group were assessed by an interdisciplinary team, following which a determination was made about the use of bedrails or alternatives. Eighty percent of residents in the study group were free of bedrails, which suggests that bedrails can be safely removed from most short-stay nursing home rehabilitation residents.

Leukaemia in the vicinity of two tritium-releasing nuclear facilities: a comparison of the Kruemmel Site, Germany, and the Savannah River Site, South Carolina, USA

In 1991, an increased rate of childhood leukaemia was reported from the small northern German community of Elbmarsch, which is located on the banks of the River Elbe opposite the Kruemmel nuclear power plant. Owing to the fact that the increase occurred six years after the start-up of the plant, radioactive discharges were suspected as being implicated in the development of the cases. Previous investigations have failed to identify any exposure which might be associated with the cluster. Nonetheless, concern regarding the increased tritium burden in the environment remains. To further assess the impact of tritium releases to the environment upon population cancer rates, the releases and leukaemia rates at the Savannah River site, USA, were compared with the Kruemmel site. Based on the data from 1991 to 1995, the incidence of childhood leukaemia in the vicinity of the Savannah River site was non-significantly less than expected compared with the significantly higher than expected rates close to the German plant. In contrast, tritium releases from the Savannah River site exceed those from the Kruemmel site by several orders of magnitude. The results of this observational study suggest that factors other than environmental tritium releases are associated with the increased number of leukaemia cases near the Kruemmel site.

Levels of bacterial community diversity in four arid soils compared by cultivation and 16S rRNA gene cloning

Techniques based on amplification of 16S rRNA genes for comparing bacterial communities are now widely used in microbial ecology, but calibration of these techniques with traditional tools, such as cultivation, has been conspicuously absent. In this study, we compared levels of bacterial community diversity in two pinyon rhizosphere soil samples and two between-tree (interspace) soil samples by analyzing 179 cultivated bacterial isolates and 801 16S rRNA genes amplified from extracted soil DNA. Phylotypes were defined by performing a restriction fragment length polymorphism analysis of 16S rRNA gene sequences with the enzymes RsaI and BstUI. The average level of 16S rRNA gene sequence similarity of members of a phylotype was 86.6% based on an analysis of partial sequences. A total of 498 phylotypes were identified among the 16S ribosomal DNA (rDNA) clones, while 34 phylotypes occurred among the cultivated isolates. Analysis of sequences from a subset of the phylotypes showed that at least seven bacterial divisions were represented in the clone libraries, whereas the isolates represented only three. The phylotype richness, frequency distribution (evenness), and composition of the four culture collections and the four clone libraries were investigated by using a variety of diversity indices. Although cultivation and 16S rRNA cloning analyses gave contradictory descriptions of the relative phylotype richness for one of the four environments, the two methods identified qualitatively consistent relationships when levels of evenness were compared. The levels of phylotype similarity between communities were uniformly low (15 to 31%). Both methods consistently indicated that one environment was distinct from the other three. Our data illustrate that while 16S rDNA cloning and cultivation generally describe similar relationships between soil microbial communities, significant discrepancies can occur.

Skin and soft tissue infections: development of a collaborative management plan between community and hospital care

The commonest indication in the US for referral to an outpatient/home i.v. antibiotic therapy programme is the management of skin and soft tissue infections. In the UK, however, these infections account for 10% or more of admissions to infection units. The main indication for hospitalisation is to receive parenteral antibiotics. A retrospective audit of one year of admissions to a regional infection unit revealed that, although most of these patients do not progress to complications ('low risk'), they occupy a mean time of five days in hospital and for nearly half of that time they receive parenteral antibiotics. This period in hospital reflected 11.4% of the unit's bed occupancy. Even if 75% of these patients were treated in the community with parenteral therapy, this would result in bed savings of 8.55%, nearly one-tenth of the unit's occupied capacity. This type of audit should help key decision makers thinking of developing similar services in their region. Outpatient or home parenteral antimicrobial therapy (OHPAT) should be delivered as part of a complete disease management programme in collaboration with primary care.

Staff perceptions of emergency and home-care telemedicine

The utilization of a low-bandwidth telemedicine system for emergency and for home-care was studied in a pilot trial. The emergency setting was the emergency department of a small urban hospital and its emergency medical service (EMS); the home-care setting was the home-health agency affiliated to the hospital. Utilization data were obtained through baseline and follow-up interviews with EMS technicians, emergency department and home-health nurses, and the project coordinator. The results indicated that initial enthusiasm for the use of the telemedicine system was not followed by a commitment to the system's utilization during the trial by the relevant administrations. Barriers to optimum utilization were identified, but the actual value of the system to patient care could not be determined. We conclude that the value of a telemedicine system to patient care cannot be realized unless there is an organizational commitment from the top to system utilization.

The effect of denaturants on protein structure

Virtually all studies of the protein-folding reaction add either heat, acid, or a chemical denaturant to an aqueous protein solution in order to perturb the protein structure. When chemical denaturants are used, very high concentrations are usually necessary to observe any change in protein structure. In a solution with such high denaturant concentrations, both the structure of the protein and the structure of the solvent around the protein can be altered. X-ray crystallography is the obvious experimental technique to probe both types of changes. In this paper, we report the crystal structures of dihydrofolate reductase with urea and of ribonuclease A with guanidinium chloride. These two classic denaturants have similar effects on the native structure of the protein. The most important change that occurs is a reduction in the overall thermal factor. These structures offer a molecular explanation for the reduction in mobility. Although the reduction is observed only with the native enzyme in the crystal, a similar decrease in mobility has also been observed in the unfolded state in solution (Makhatadze G, Privalov PL. 1992. Protein interactions with urea and guanidinium chloride: A calorimetric study.

The structure of L-aspartate ammonia-lyase from Escherichia coli

The X-ray crystal structure of l-aspartate ammonia-lyase has been determined to 2.8 A resolution. The enzyme contains three domains, and each domain is composed almost completely of alpha helices. The central domain is composed of five long helices. In the tetramer, these five helices form a 20-helix cluster. Such clusters have also been seen in delta-crystallin and in fumarase. The active site of aspartase has been located in a region that contains side chains from three different subunits. The structure of the apoenzyme has made it possible to identify some of the residues that are involved in binding the substrate. These residues have been examined by site-directed mutagenesis, and their putative roles have been assigned [Jayasekera, M. M. K., Shi, W., Farber, G. K., & Viola, R. E. (1997) Biochemistry 36, 9145-9150].

Strengthening partnerships between state programs for children with special health care needs and managed care organizations

The roles and responsibilities of state Title V Programs for Children with Special Health Care Needs (CSHCN) are changing with the rapid expansion of managed care. The authors surveyed Title V CSHCN programs to learn about critical issues and examples of collaboration with managed care organizations in the following areas: (1) defining and identifying children with special health care needs, (2) enrollment assistance and family participation, (3) pediatric provider and service requirements, (4) education and training, (5) quality of care, and (6) pediatric risk-adjusted capitation mechanisms. This article also includes recommendations developed by the federal Maternal and Child Health Bureau's Work Group on Managed Care.

Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study

OBJECTIVE

To determine whether a low ankle brachial pressure index is associated with an increased risk of cardiovascular events and death, and whether the prediction of such events could be improved by including this index.

DESIGN

Cohort study.

SETTING

11 practices in Edinburgh, Scotland.

SUBJECTS

1592 men and women aged 55-74 years selected at random from the age-sex registers of 11 general practices and followed up for 5 years.

MAIN OUTCOME MEASURES

Incidence of fatal and non-fatal cardiovascular events and all cause mortality.

RESULTS

At baseline 90 (5.7%) of subjects had an ankle brachial pressure index < or = 0.7, 288 (18.2%) had an index < or = 0.9, and 566 (35.6%) < or = 1.0. After five years subjects with an index < or = 0.9 at baseline had an increased risk of non-fatal myocardial infarction (relative risk 1.38, 95% confidence interval 0.88 to 2.16), stroke (1.98, 1.05 to 3.77), cardiovascular death (1.85, 1.15 to 2.97), and all cause mortality (1.58, 1.14 to 2.18) after adjustment for age, sex, coronary disease, and diabetes at baseline. The ability to predict subsequent events was greatly increased by combining the index with other risk factors--for example, hypertensive smokers with normal cholesterol concentrations had a positive predictive value of 25.0%, increasing to 43.8% in subjects with a low index and decreasing to 15.6% in those with a normal index.

CONCLUSION

The ankle brachial pressure index is a good predictor of subsequent cardiovascular events, and improves on predictions by conventional risk factors alone. It is simple and accurate and could be included in routine screening of cardiovascular status.

Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population

BACKGROUND

Intermittent claudication is associated with a poor prognosis, but less is known of the risks associated with asymptomatic peripheral arterial disease. The aims of this study were to determine the incidence and natural history of claudication, and the incidence of cardiovascular events in symptomatic and asymptomatic peripheral arterial disease.

METHODS

In 1988, 1592 subjects aged 55-74 years were selected randomly from the age-sex register of 10 general practices in Edinburgh, Scotland. The presence of peripheral arterial disease was determined by the World Health Organization questionnaire on intermittent claudication, the ankle brachial pressure index and a reactive hyperaemia test. This cohort was followed prospectively over 5 years for subsequent cardiovascular events and death.

RESULTS

One hundred and sixteen new cases of claudication were identified (incidence density 15.5 per 1000 person-years). Of those with claudication at baseline, 28.8% and still had pain after 5 years, 8.2% underwent vascular surgery or amputation, and 1.4% developed leg ulceration. Claudicants had a significantly increased risk of developing angina compared with normals (RR: 2.31, 95% CI: 1.04-5.10), and asymptomatic subjects had a slightly increased risk of myocardial infarction and stroke. Deaths from cardiovascular disease were more likely in both claudicants (RR: 2.67, 95% CI: 1.34-5.29) and subjects with major (RR: 2.08, 95% CI: 1.13-3.83) or minor asymptomatic disease (RR: 1.74, 95% CI: 1.09-2.76). Subjects with major asymptomatic disease also had an increased risk of non-cardiovascular death (RR: 2.19, 95% CI: 1.33-3.59), and therefore had the highest overall risk of death (RR: 2.44, 95% CI: 1.59-3.74).

CONCLUSIONS

Subjects with asymptomatic peripheral arterial disease appear to have the same increased risk of cardiovascular events and death found in claudicants.