A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk

Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75-99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients' values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07-1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.ClinicalTrials.gov: NCT05288517.

“Lock to Live” for firearm and medication safety: Feasibility and acceptability of a suicide prevention tool in a learning healthcare system

Objective

Few patients with suicide risk are counseled on lethal means safety by health providers. This study tested the feasibility of different delivery methods for Lock to Live (L2L), a web-based decision aid of safe storage options for firearms and medications.

Methods

Patients reporting suicide ideation on the PHQ9 depression screener during outpatient health visits were included. Invitation messages to visit L2L were sent via combinations of email, text, Electronic Health Record (EHR) message, mailed letter, or provider referral, followed by a survey about storage behavior and acceptability. Provider interviews evaluated logistical considerations and acceptability.

Results

The population-based method reached 2,729 patients and the best method (EHR message plus 2 email reminders) had 11% uptake (L2L visitation rate). Provider referral had small reach (14 patients) and 100% uptake (all visited). Provider interviews identified several strategies to promote uptake including: EHR reminders, provider training, quality metrics with accountability, a clearly communicated lethal means screening/counseling policy, and strong organizational leadership support.

Conclusion

Despite the low uptake for population-based (11%), far more patients with suicide risk were engaged in the L2L tool through population-based outreach than provider-referral over the same time frame.

Patient-reported outcomes from STARTRK-2: a global phase II basket study of entrectinib for ROS1 fusion-positive non-small-cell lung cancer and NTRK fusion-positive solid tumours

BACKGROUND

Patient-reported outcomes (PROs) are increasingly relevant endpoints in clinical trials, contributing to our understanding of risk-benefit profiles, in addition to efficacy and safety data. We investigated the impact of entrectinib on patient-reported symptoms, functioning, and health-related quality of life.

PATIENTS AND METHODS

STARTRK-2 is a phase II basket study in patients with locally advanced/metastatic neurotrophic receptor tyrosine kinase 1/2/3 (NTRK1/2/3) and ROS proto-oncogene 1 (ROS1) fusion-positive solid tumours. PROs (prespecified secondary endpoint) were evaluated using the European Organization for Research and Treatment of Cancer quality-of-life questionnaire (QLQ-C30), lung cancer module (QLQ-LC13), and colorectal cancer module (QLQ-CR29), and the EuroQoL 5-Dimension 3-Level instruments, completed before cycle 1 day 1 and each subsequent 4-week cycle of entrectinib dosing, and the end of treatment. Adverse events and treatment-related symptoms were assessed in the safety analysis (SA)-PRO population. Tumour-related symptoms, functioning, and global health status were assessed in the efficacy analysis (EA)-PRO population. Data cut-offs: 31 October 2018 NTRK cohort; 01 May 2019 ROS1 cohort.

RESULTS

SA-PRO populations comprised patients with NTRK fusion-positive solid tumours (N = 88) or ROS1 fusion-positive non-small-cell lung cancer (N = 180) who received one or more doses of entrectinib, completed PRO questionnaires on cycle 1 day 1 and answered one or more questions on-study. EA-PRO populations (N = 71) and (N = 145), respectively, comprised SA-PRO patients with measurable baseline disease. Moderate-to-high baseline global health status scores were maintained in EA-PRO populations during treatment. Role and physical functioning scores were moderate-to-high at baseline, with trends towards clinical improvement during treatment. Both cohorts reported low-to-moderate symptom burden at baseline, which was maintained or trended towards clinically meaningful improvement. Symptoms commonly associated with cancer treatment (e.g. nausea, fatigue) remained stable or improved during treatment. All SA-PRO patients experienced one or more adverse events, most frequently constipation or diarrhoea.

CONCLUSIONS

PRO findings were consistent with the favourable safety profile of entrectinib, and further reinforce the positive benefit-risk profile of this treatment, indicating minimal overall treatment burden.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

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.

140 Endocrine Profiling in Prepubertal Stallions with Abnormal Testicular Development

The use of anti-Müllerian hormone (AMH) as a biomarker for assessment of male gonadal activity has become increasingly widespread. Aberrant AMH concentration successfully detects cryptorchids or pathologic testes in postpubertal stallions, but the ability to use AMH to identify stallions with testicular pathologies during their prepubertal life has not been analysed so far. The objectives of this work were to (1) assess AMH, testosterone, LH, and FSH dynamics in male horses with or without testicular pathologies during the first year of life; and (2) find a reliable diagnostic approach that would enable the identification of animals that will develop abnormal testes at an early stage. Warmblood colts (n = 16) born from February to May on the same stud farm were used. Blood samples for hormone determinations were collected from birth onwards every 4 weeks until the age of 1 year. At 2 years, testicular development was assessed, total testicular volume calculated. and a blood sample collected. Concentrations of AMH, testosterone, LH, and FSH were determined in all samples; AMH (AL-115, Ansh Laboratories, Webster, TX, USA) and testosterone (DE1559, Demeditec, Kiel-Wellsee, Germany) concentrations were determined by ELISA, whereas LH and FSH concentrations were determined by radioimmunoassay. Statistical analysis (SPSS Statistics 24; IBM/SPSS, Armonk, NY, USA) was performed by ANOVA using a general linear model for repeated measures. In 2 stallions, unilateral cryptorchism, and in other 4 stallions, subnormal total testicular volume (<mean minus SD) were diagnosed at 2 years. Concentrations of AMH, testosterone, and FSH changed over time (P < 0.001) but were similar (P > 0.05) within the first year of life irrespective of testicular morphology and location. Concentration of LH at birth was lower (P = 0.05) in stallions with abnormal testes (0.3 ± 0.2 ng mL−1) than in controls (0.6 ± 0.2 ng mL−1), but did not differ thereafter. At 2 years of age, AMH concentration was higher (P < 0.01) in stallions with abnormal testes (39.7 ± 12.7 ng mL−1) than in controls (8.0 ± 0.2 ng mL−1), but no group differences with regard to LH, FSH, and testosterone existed. There was a low but significant negative correlation between AMH and FSH (P < 0.001, r = –0.24), as well as between AMH and LH (P < 0.05, r = –0.15). Also, testosterone concentration was positively correlated with FSH (P < 0.05, r = 0.18) and LH (P < 0.05, r = 0.16) concentrations. In conclusion, AMH determination can be reliably used from 2 years onwards to identify stallions with abnormal testicular development, but it is inconclusive before puberty. We concluded that LH secretion in the perinatal period is involved in testicular development and descent in the horse.

67 INHIBITION OF 5α-REDUCTASE DURING LATE GESTATION IN THE MARE

During the latter half of pregnancy in the mare, circulating concentrations of progesterone (P4) are low and a major bioactive progestogen, 5α-dihydroprogesterone (DHP), is present in high concentrations. DHP is formed through the activity of 5α-reductase, which converts P4 to DHP. Further metabolites of DHP have been attributed to fetal and myometrial quiescence. The purpose of this study was to examine the effects of a 5α-reductase inhibitor (dutasteride) on P4 metabolism and onset of parturition. Pregnant mares (n = 5) were treated with dutasteride (0.01 mg kg–1; IM), and control mares (n = 4) received vehicle alone from 300 to 320 days of gestation or until foaling. Serum concentrations of P4 and DHP were determined with liquid chromatography/tandem mass spectrometry (LC/MS-MS) daily for 9 days preceding parturition. Endocrine data were analysed with a random effects mixed model with time, treatment (TRT), and time × TRT interaction. Gestational data were analysed with a Wilcoxon test. Although there was a significant effect of time on P4 and DHP, there was no effect of TRT or time × TRT on these progestogens. For the ratio of DHP/P4, there were significant effects of time, TRT, and time × TRT interaction such that the ratio of DHP/P4 was greater in the control than dutasteride-treated mares. Birth weight and gestational length were not different (P > 0.2) between the dutasteride-treated and control mares, although placental weights were greater (P < 0.05) in dutasteride-treated mares. Because the ratio of DHP/P4 was suppressed in dutasteride-treated mares, it appears that dutasteride was active in late gestational mares. Although gestational length and neonatal weights were not different between groups, placentas from dutasteride-treated mares were heavier than those from control mares. The reason for the increase in placental weights was not determined.

Detection of B-mode polarization in the cosmic microwave background with data from the South Pole Telescope

Gravitational lensing of the cosmic microwave background generates a curl pattern in the observed polarization. This "B-mode" signal provides a measure of the projected mass distribution over the entire observable Universe and also acts as a contaminant for the measurement of primordial gravity-wave signals. In this Letter we present the first detection of gravitational lensing B modes, using first-season data from the polarization-sensitive receiver on the South Pole Telescope (SPTpol). We construct a template for the lensing B-mode signal by combining E-mode polarization measured by SPTpol with estimates of the lensing potential from a Herschel-SPIRE map of the cosmic infrared background. We compare this template to the B modes measured directly by SPTpol, finding a nonzero correlation at 7.7σ significance. The correlation has an amplitude and scale dependence consistent with theoretical expectations, is robust with respect to analysis choices, and constitutes the first measurement of a powerful cosmological observable.

Allopregnanolone infusion induced neurobehavioural alterations in a neonatal foal: is this a clue to the pathogenesis of neonatal maladjustment syndrome?

REASONS FOR PERFORMING THE STUDY

Increased plasma progestagen concentrations have been reported in foals with neonatal maladjustment syndrome (NMS). These steroids may cross the blood-brain barrier and have dampening effects in the central nervous system.

OBJECTIVES

To evaluate if the infusion of a progesterone derivative (allopregnanolone) in a healthy neonatal foal would induce clinical signs compatible with NMS.

METHODS

A healthy neonatal foal from a healthy mare with a normal gestation (length, no complications), birth and placenta was infused with allopregnanolone to observe its neurobehavioural effects. Heparinised blood samples were collected pre- and post infusion to determine various progestagen concentrations using liquid chromatography mass spectrometry. A second healthy neonatal foal was infused with ethanol and saline for comparison of clinical observations.

RESULTS

Infusion of allopregnanolone resulted in obtundation, lack of affinity for the mare and decreased response to external stimuli. These effects were short-lasting and associated with measurable concentrations of progestagens.

CONCLUSIONS AND POTENTIAL RELEVANCE

Infusion of a steroid metabolite to a healthy neonatal foal resulted in neurobehavioural alterations compatible with those observed in foals with NMS. These findings suggest that increased progestagen concentrations may be responsible for some of the behavioural changes observed in foals with NMS.

Community-based child abuse prevention: outcomes associated with a differential response program in California

Traditionally, the American child welfare system intervenes in cases of evident and severe maltreatment. Families in need of help, but who have not reached a crisis, are excluded from typical services. Some suggest that if these families were served, few would be rereferred to the child welfare system. California's Differential Response (DR) has three tracks, of which ''Track 1'' targets families screened out of child protective services (CPS) and refers them to agencies that provide voluntary, home-based services and referrals. This study examined child-welfare trajectories for families receiving Track 1 DR services in one California county. Using survival analysis, treatment group children (N = 134) were compared to children eligible for services but denied due to program capacity (comparison group N = 511). Findings suggest no statistically significant differences between groups on the likelihood of a re-report following program participation, timing of maltreatment reports, or report investigations. The ability to draw strong conclusions from this study, however, is limited by selection bias because prior child maltreatment reports were more common in the treatment group. The intervention may provide families with important supports, but evidence for maltreatment prevention may not be supported. Future studies should examine potential effects on a range of family domains.

A comparative approach to structure-function studies of mammalian aromatases

To date, structure--function studies of aromatase cytochrome P450 (P450arom) have been advanced by point mutation analyses utilizing almost exclusively the human enzyme, in conjunction with computer-generated models of the three-dimensional form of the enzyme based on prokaryotic cytochromes P450. Recent studies have identified duplicated isozymes of porcine P450arom, the gonadal and placental forms of which appear to differ substantially in substrate utilization and inhibitor sensitivity. We present a comparative approach to define regions of P450arom responsible for specific functional characteristics using complimentary DNAs encoding the porcine isozymes. Constructs encoding the native and chimeric porcine and human P450arom enzymes were transiently expressed and activity was assessed using the tritiated water assay. Sensitivity to inhibition by the imidazole etomidate was investigated, and P450arom expression was assessed by immunoblot analysis. All constructs yielded active P450arom, suggesting that exchanging entire structural elements does not preclude catalytic function. The activity of the gonadal isozyme was shown to be inhibited by etomidate at concentrations 185 and 300-fold lower than those required to induce a similar inhibition of the placental and human enzymes, respectively. In contrast, there was only a two-fold difference in the sensitivity of the gonadal and placental isozymes to inhibition by CGS16949A. Analysis of chimeric constructs indicated that the sensitivity to etomidate was associated with residues in the B, B' and C helices of the gonadal P450arom encompassing only one of six putative substrate recognition sites. Additionally, sensitivity to etomidate was not correlated with enzyme activity among the chimeric enzymes. Therefore, it appears that residues of the porcine gonadal P450arom that are responsible for etomidate binding may be distinct from those involved in substrate recognition and metabolism. These data support the notion that a comparative approach employing the use of chimeric enzymes provides a useful tool in directing point mutational analysis to determine residues important in inhibitor and perhaps substrate recognition of P450 enzymes such as P450arom. These studies are currently in progress.

The Sp1-like protein BTEB3 inhibits transcription via the basic transcription element box by interacting with mSin3A and HDAC-1 co-repressors and competing with Sp1

Sp1-like proteins are characterized by three conserved C-terminal zinc finger motifs that bind GC-rich sequences found in promoters of numerous genes essential for mammalian cell homeostasis. These proteins behave as transcriptional activators or repressors. Although significant information has been reported on the molecular mechanisms by which Sp1-like activators function, relatively little is known about mechanisms for repressor proteins. Here we report the functional characterization of BTEB3, a ubiquitously expressed Sp1-like transcriptional repressor. GAL4 assays show that the N terminus of BTEB3 contains regions that can act as direct repressor domains. Immunoprecipitation assays reveal that BTEB3 interacts with the co-repressor mSin3A and the histone deacetylase protein HDAC-1. Gel shift assays demonstrate that BTEB3 specifically binds the BTE site, a well characterized GC-rich DNA element, with an affinity similar to that of Sp1. Reporter and gel shift assays in Chinese hamster ovary cells show that BTEB3 can also mediate repression by competing with Sp1 for BTE binding. Thus, the characterization of this protein expands the repertoire of BTEB-like members of the Sp1 family involved in transcriptional repression. Furthermore, our results suggest a mechanism of repression for BTEB3 involving direct repression by the N terminus via interaction with mSin3A and HDAC-1 and competition with Sp1 via the DNA-binding domain.

Mammalian aromatases

Aromatase is the enzyme complex that catalyses the synthesis of oestrogens from androgens, and therefore it has unique potential to influence the physiological balance between the sex steroid hormones. Both aromatase cytochrome P450 (P450arom) and NADPH-cytochrome P450 reductase (reductase), the two essential components of the enzyme complex, are highly conserved among mammals and vertebrates. Aromatase expression occurs in the gonads and brain, and is essential for reproductive development and fertility. Of interest are the complex mechanisms involving alternative promoter utilization that have evolved to control tissue-specific expression in these tissues. In addition, in a number of species, including humans, expression of aromatase has a broader tissue distribution, including placenta, adipose and bone. The relevance of oestrogen synthesis and possibly androgen metabolism in these peripheral sites of expression is now becoming clear from studies in P450arom knockout (ArKO) mice and from genetic defects recognized recently in both men and women. Important species differences in the physiological roles of aromatase expression are also likely to emerge, despite the highly conserved nature of the enzyme system. The identification of functionally distinct, tissue-specific isozymes of P450arom in at least one mammal, pigs, and several species of fish indicates that there are additional subtle, but physiologically significant, species-specific roles for aromatase. Comparative studies of mammalian and other vertebrate aromatases will expand understanding of the role played by this ancient enzyme system in the evolution of reproduction and the adaptive influence of oestrogen synthesis on general health and well being.

Maturation versus death of developing double-positive thymocytes reflects competing effects on Bcl-2 expression and can be regulated by the intensity of CD28 costimulation

Immature double-positive (DP) thymocytes mature into CD4(+)CD8(-) cells in response to coengagement of TCR with any of a variety of cell surface "coinducer" receptors, including CD2. In contrast, DP thymocytes are signaled to undergo apoptosis by coengagement of TCR with CD28 costimulatory receptors, but the molecular basis for DP thymocyte apoptosis by TCR plus CD28 coengagement is not known. In the present study, we report that TCR plus CD28 coengagement does not invariably induce DP thymocyte apoptosis but, depending on the intensity of CD28 costimulation, can induce DP thymocyte maturation. We demonstrate that distinct but interacting signal transduction pathways mediate DP thymocyte maturation signals and DP thymocyte apoptotic signals. Specifically, DP maturation signals are transduced by the extracellular signal-related kinase (ERK)/mitogen-activated protein kinase (MAPK) pathway and up-regulate expression of the antiapoptotic protein Bcl-2. In contrast, the apoptotic response stimulated by CD28 costimulatory signals is mediated by ERK/MAPK-independent pathways. Importantly, when TCR-activated thymocytes are simultaneously coengaged by both CD28 and CD2 receptors, CD28 signals can inhibit ERK/MAPK-dependent Bcl-2 protein up-regulation. Thus, there is cross-talk between the signal transduction pathways that transduce apoptotic and maturation responses, enabling CD28-initiated signal transduction pathways to both stimulate DP thymocyte apoptosis and also negatively regulate maturation responses initiated by TCR plus CD2 coengagement.

The primate adrenal zona reticularis is defined by expression of cytochrome b5, 17alpha-hydroxylase/17,20-lyase cytochrome P450 (P450c17) and NADPH-cytochrome P450 reductase (reductase) but not 3beta-hydroxysteroid dehydrogenase/delta5-4 isomerase (3beta-HSD)

Biochemical studies suggest that 17,20-lyase activity, and thus efficient synthesis of androgens by human P450c17, requires both reductase and the accessory protein cytochrome b5. Since the human and primate zona reticularis (ZR) secrete androgens, the expression of these proteins, and of 3beta-HSD, was investigated by immunocytochemistry in the adrenal cortex of the mature rhesus macaque. Cytochrome b5 expression was restricted to the cells of the ZR which appeared deficient in 3beta-HSD. However, both P450c17 and reductase were evident throughout the zona fasciculata. These data provide essential evidence in support of a functional role for cytochrome b5 in the regional control of 17alpha-hydroxylase and 17,20-lyase activities of P450c17 and thereby adrenal C19 steroid secretion by the primate adrenal gland.

Patellofemoral design influences function following total knee arthroplasty

The functional influence of patellofemoral design was evaluated by testing two cohorts of patients with total knee arthroplasty while walking, climbing stairs, and rising from a chair. The two cohorts received one of two different designs of total knee arthroplasty. The designs differed primarily in the curvature of the femoral trochlea. These differences in curvature have been shown in in vitro studies to influence the tracking of the patella. One design had a smaller radius on the patellar flange, which caused the patella to articulate more anteriorly and distally than the second design, which had a larger radius in this region. The second design more closely replicated the curvature of the femoral trochlear anatomy. There was a significant functional difference during stairclimbing between the patient groups, whereas there was no difference during walking or chair rising. The group with the design that had nonanatomic tracking of the patella had a higher than normal moment tending to flex the knee (net quadriceps moment) during late stance phase. The increased net quadriceps moment during late stance was concurrent with an increased knee flexion. The abnormal function occurred when the patellar was tracking over the nonanatomic portion of the trochlea. Patients in the group with the anatomic trochlea did not have abnormal function. These results suggest a relationship between a nonanatomic trochlea and abnormal function during stair-climbing.

Porcine aromatases: studies on tissue-specific, functionally distinct isozymes from a single gene?

Aromatase cytochrome P450 (P450arom) is expressed in a variety of tissues. Pigs express P450arom as bilaminar blastocysts in utero, and thereafter in the gonads, adrenal glands and placenta. Our studies also demonstrate the existence of porcine isozymes of P450arom which differ substantially in their amino acid composition and function. The placental isoform, most similar to P450arom in other mammals, consists of 503 amino acids. The ovarian isoform, expressed in both theca and granulosa cells, is a 501 amino acid protein exhibiting less than 20% of the activity of the placental isozyme. Furthermore, it is inhibited not only by CGS16949A but also by etomidate which does not inhibit the placental P450arom. Partial sequences generated by the rapid amplification of the cDNA ends (RACE) procedure indicate that the expression of a third isoform in the blastocyst is switched to the placental isozyme during differentiation of the fetal membranes. In addition, these transcripts, and others from the theca, granulosa, testes, adrenal glands and placenta demonstrate differences in the 5'-untranslated region (putative exon I) suggestive of tissue-specific alternative splicing. An identical 5'-untranslated sequence was obtained from transcripts expressed in the theca and granulosa. Testes and adrenal transcripts also have identical 5' ends, which differ substantially from the ovarian sequence. Blastocyst and placenta 5'-untranslated sequences differ from each other and from those expressed in the gonads and adrenals. Several tissue-specific transcripts thus encode porcine P450arom. Interestingly, distinct 5' sequences exist for ovarian and testes P450arom mRNAs, suggesting different promoters and therefore regulation in the male and female gonads. The molecular origins of the functional isoforms and the tissue-specific transcripts are uncertain, however partial genomic sequence and other genetic analyses suggest the existence of multiple genes. However, sequence alignment of the placental and ovarian isoforms indicates complete conservation of putative exon III, so that complex splicing remains a possibility. Clearly, the regulation of P450arom expression is more complex in the pig than in other vertebrates investigated to date.

Complications of a cable grip system

From a group of 643 total hip arthroplasties, 98 patients required trochanteric osteotomies, and in 68 the trochanteric osteotomies were repaired with the Dall-Miles cable grip system (Howmedica, Rutherford, NJ). Trochanteric nonunion occurred in 17 of these patients (25%), with fraying and fragmentation of the cable present in 15 (88%). Of the 51 patients with radiographic union, 18 (35%) also had signs of fraying and fragmentation. Bone destruction around the cable in the area of the lesser trochanter was seen in seven patients (10%). Large deposits of metal debris at the inferior border of the acetabulum were seen in eight hips (12%). Multifilament cable did not appear to offer significant advantages over standard monofilament wire, and the potential problems of fraying, fragmentation, and free-floating metallic debris must be considered.

Complications of a cable grip system

From a group of 643 total hip arthroplasties, 98 patients required trochanteric osteotomies, and in 68 the trochanteric osteotomies were repaired with the Dall-Miles cable grip system (Howmedica, Rutherford, NJ). Trochanteric nonunion occurred in 17 of these patients (25%), with fraying and fragmentation of the cable present in 15 (88%). Of the 51 patients with radiographic union, 18 (35%) also had signs of fraying and fragmentation. Bone destruction around the cable in the area of the lesser trochanter was seen in seven patients (10%). Large deposits of metal debris at the inferior border of the acetabulum were seen in eight hips (12%). Multifilament cable did not appear to offer significant advantages over standard monofilament wire, and the potential problems of fraying, fragmentation, and free-floating metallic debris must be considered.

Participatory decision making: issues and guidelines

The concept of shared responsibility in decision making through the use of participatory decision making has received considerable support in nursing education. There are important omissions in the discussions and applications of this concept. Problems in the use of participatory decision making as related to information transmission; conflict, consensus, and coalitions; and faculty/administrator role differences are analyzed. Criteria and guidelines for the appropriate use of participatory decision making are provided.

Relationship of demographic characteristics of interviewers to blood pressure measurements

This report describes findings from the Hypertension Detection and Follow-Up Program (HDFP) on the relationship between traits of interviewers and outcome of blood pressure measurements taken during home interviews. Mean diastolic blood pressure readings and prevalence data for 137,417 respondents taken by 617 interviewers are analyzed. Findings from regression analysis show that the magnitude of the absolute or relative difference in outcome of blood pressure measurements is associated much more positively with the characteristics of race and sex of the respondent than these characteristics in the interviewer.