Duloxetine in the treatment of major depressive disorder: a placebo- and paroxetine-controlled trial

Objective:

Duloxetine doses of 80 and 120 mg/day were assessed for efficacy and safety in the treatment of major depressive disorder (MDD).

Methods:

In this randomized, double-blind trial, patients age ≥ 18 meeting DSM-IV criteria for MDD were randomized to placebo (N = 99), duloxetine 80 mg/day (N = 93), duloxetine 120 mg/day (N = 103), or paroxetine 20 mg/day (N = 97). The primary outcome measure was mean change from baseline in the 17-item Hamilton rating scale for depression (HAMD17) total score after 8 weeks of treatment; a number of secondary efficacy measures also were assessed. Safety and tolerability were assessed via collection and analysis of treatment–emergent adverse events (TEAEs), vital signs, and weight. The Arizona sexual experiences scale was used to assess sexual functioning. Patients who had a ≥ 30% reduction from baseline in the HAMD17 total score at the end of the acute phase entered a 6-month continuation phase where they remained on the same treatment as they had taken during the acute phase; efficacy and safety/tolerability outcomes were assessed during continuation treatment.

Results:

More than 87% of patients completed the acute phase in each treatment group. Duloxetine-treated patients (both doses) showed significantly greater improvement (P < 0.05) in the HAMD17 total score at week 8 compared with placebo. Paroxetine was not significantly different from placebo (P = 0.089) on mean change on the HAMD17. Duloxetine 120 mg/day also showed significant improvement on most secondary efficacy measures (six of nine) compared with placebo while duloxetine 80 mg/day (three of nine) and paroxetine (three of nine) were significantly superior to placebo on fewer secondary measures. HAMD17 mean change data from this study and an identical sister study were pooled as defined a priori for the purposes of performing a non-inferiority test versus paroxetine. Both duloxetine doses met statistical criteria for non-inferiority to paroxetine. TEAE reporting rates were low in all treatment groups and no deaths occurred in the acute or continuation phases.

Conclusions:

The efficacy of duloxetine at doses of 80 and 120 mg/day in the treatment of MDD was demonstrated. Tolerability, as measured by TEAEs, and safety were similar to paroxetine 20 mg/day and consistent with previous published data on duloxetine in the treatment of MDD.

Aetiology of Canine Infectious Respiratory Disease Complex and Prevalence of its Pathogens in Europe

The canine infectious respiratory disease complex (CIRDC) is an endemic worldwide syndrome involving multiple viral and bacterial pathogens. Traditionally, Bordetella bronchiseptica (Bb), canine adenovirus type 2 (CAV-2), canine distemper virus (CDV), canine herpesvirus (CHV) and canine parainfluenza virus (CPiV) were considered the major causative agents. Lately, new pathogens have been implicated in the development of CIRDC, namely canine influenza virus (CIV), canine respiratory coronavirus (CRCoV), canine pneumovirus (CnPnV), Mycoplasma cynos and Streptococcus equi subspecies zooepidemicus. To better understand the role of the different pathogens in the development of CIRDC and their epidemiological relevance in Europe, prevalence data were collected from peer-reviewed publications and summarized. Evidence of exposure to Bb is frequently found in healthy and diseased dogs and client-owned dogs are as likely to be infected as kennelled dogs. Co-infections with viral pathogens are common. The findings confirm that Bb is an important cause of CIRDC in Europe. CAV-2 and CDV recovery rates from healthy and diseased dogs are low and the most likely explanation for this is control through vaccination. Seroconversion to CHV can be demonstrated following CIRDC outbreaks and CHV has been detected in the lower respiratory tract of diseased dogs. There is some evidence that CHV is not a primary cause of CIRDC, but opportunistically re-activates at the time of infection and exacerbates the disease. The currently available data suggest that CIV is, at present, neither a prevalent nor a significant pathogen in Europe. CPiV remains an important pathogen in CIRDC and facilitates co-infection with other viral and bacterial pathogens. CnPnV and CRCoV are important new elements in the aetiology of CIRDC and spread particularly well in multi-dog establishments. M. cynos is common in Europe and is more likely to occur in younger and kennelled dogs. This organism is frequently found together with other CIRDC pathogens and is significantly associated with more severe respiratory signs. S. zooepidemicus infection is not common and appears to be a particular problem in kennels. Protective immunity against respiratory diseases is rarely complete, and generally only a reduction in clinical signs and excretion of pathogen can be achieved through vaccination. However, even vaccines that only reduce and do not prevent infection carry epidemiological advantages. They reduce spread, increase herd immunity and decrease usage of antimicrobials. Recommending vaccination of dogs against pathogens of CIRDC will directly provide epidemiological advantages to the population and the individual dog.

Occurrence, management and outcome of immune-complex glomerulonephritis in dogs with suspected glomerulopathy in the UK

OBJECTIVES

To determine the proportion of dogs diagnosed with immune-complex glomerulonephritis in a large cohort of UK dogs with clinical suspicion of glomerular disease in which renal histopathology, including routine light microscopy, transmission electron microscopy and immunofluorescence, had been performed. The second objective was to describe treatment and long-term clinical outcome of dogs diagnosed with immune-complex glomerulonephritis.

MATERIALS AND METHODS

Sixty-two UK dogs that underwent renal biopsies for investigation of suspected glomerulopathy (urine protein-to-creatinine ratio persistently >0.5) were included in this retrospective multicentre study. Signalment, clinico-pathological abnormalities, histopathological diagnosis, treatment following diagnosis and survival were recorded.

RESULTS

Seventeen (27%) of the dogs with suspected glomerular disease were diagnosed with immune-complex glomerulonephritis and nine (53%) of these were still alive at the study end point, with a median follow-up of 366 days (range 52 to 1299). Six dogs diagnosed with immune-complex glomerulonephritis were treated with mycophenolate. Four received mycophenolate alone for immunosuppression and two received mycophenolate and chlorambucil; all these six dogs were alive at data collection [median follow-up time 712.5 days (range 73 to 1299)]. Seven dogs diagnosed with immune-complex glomerulonephritis did not receive immunosuppressive treatment; only one of these dogs was alive at study end point [median survival time 302 days (range 52 to 723)].

CLINICAL SIGNIFICANCE

Immune-complex glomerulonephritis may be less common in the UK than previously reported in North America and mainland Europe, reducing the likelihood of treatment modification following renal biopsy. Mycophenolate was the most commonly used immunosuppressant for cases of immune-complex glomerulonephritis.

“Next-to-nothings” and Nothingness: A Study of Attention, Attenuation and the Stimulus Prefix Effect

The stimulus prefix effect, in which a non-recallable item placed at the beginning of a to-be-remembered string of items creates interference, was studied using a 1-s simultaneous visual method of presentation. Two variants on the standard prefix condition were used; in one, the prefix, o, was presented in a different colour from the memory string of seven digits and, in the other, the prefix consisted of three identical zeroes. The three prefix conditions were compared with two control conditions in which either seven or eight digits were presented. No evidence of prefix effects was found in the recall data over serial positions 1–4, for which retrieval was highly efficient, and it was concluded that the action of response set may exclude the prefix from a response buffer (c.f. Morton, 1970). There was also no evidence that the specialized prefixes led to an attenuation of the interference found in the remaining positions. The latter finding is considered to be contrary to a unit-formation hypothesis (Kahneman, 1973) but is consistent with a mode of operation of the logogen model (Morton, 1970).

[Respiratory Muscle Training: State of the Art]

Specific respiratory muscle training (IMT) improves the function of the inspiratory muscles. According to literature and clinical experience, there are 3 established methods: 1.) resistive load 2.) threshold load and 3.) normocapnic hyperpnea. Each training method and the associated devices have specific characteristics. Setting up an IMT should start with specific diagnostics of respiratory muscle function and be followed by detailed individual introduction to training. The aim of this review is to take a closer look at the different training methods for the most relevant indications and to discuss these results in the context of current literature. The group of neuromuscular diseases includes muscular dystrophy, spinal muscular atrophy, amyotrophic lateral sclerosis, paralysis of the phrenic nerve, and injuries to the spinal cord. Furthermore, interstitial lung diseases, sarcoidosis, left ventricular heart failure, pulmonary arterial hypertension (PAH), kyphoscoliosis and obesity are also discussed in this context. COPD, asthma, cystic fibrosis (CF) and non-CF-bronchiectasis are among the group of obstructive lung diseases. Last but not least, we summarize current knowledge on weaning from respirator in the context of physical activity.

Cutaneous and renal glomerular vasculopathy as a cause of acute kidney injury in dogs in the UK

To describe the signalment, clinicopathological findings and outcome in dogs presenting with acute kidney injury (AKI) and skin lesions between November 2012 and March 2014, in whom cutaneous and renal glomerular vasculopathy (CRGV) was suspected and renal thrombotic microangiopathy (TMA) was histopathologically confirmed. The medical records of dogs with skin lesions and AKI, with histopathologically confirmed renal TMA, were retrospectively reviewed. Thirty dogs from across the UK were identified with clinicopathological findings compatible with CRGV. These findings included the following: skin lesions, predominantly affecting the distal extremities; AKI; and variably, anaemia, thrombocytopaenia and hyperbilirubinaemia. Known causes of AKI were excluded. The major renal histopathological finding was TMA. All thirty dogs died or were euthanised. Shiga toxin was not identified in the kidneys of affected dogs. Escherichia coli genes encoding shiga toxin were not identified in faeces from affected dogs. CRGV has previously been reported in greyhounds in the USA, a greyhound in the UK, without renal involvement, and a Great Dane in Germany. This is the first report of a series of non-greyhound dogs with CRGV and AKI in the UK. CRGV is a disease of unknown aetiology carrying a poor prognosis when azotaemia develops.

Musculoskeletal education in general practice: a questionnaire survey

Musculoskeletal education in primary care has previously been shown, in 1995, to be inadequate [1]. The aims of this study were to evaluate the current musculoskeletal education and skills during vocational training for general practice and to see if progress has been made. Questionnaires were sent to General Practice Registrars, in general practice attachments in June 2004. Four UK General Practice Deaneries participated (Northern, Mersey, Yorkshire and Wessex). Questionnaires were received from 251 (44 %) registrars. Of the responders, only 77 % reported receiving specific clinical rheumatology teaching at medical school and 30 % had not received any tutorials on musculoskeletal conditions during their vocational training. Of the registrars, 16 % reported having completed a rheumatology post, and an additional 19 % had been able to attend rheumatology outpatient clinics; 70 % of the registrars had injected or aspirated the knee although less than half of these (22 %) had done this in a primary care setting. Lack of experience was associated with low confidence at knowing when to perform the injection and with performing the injection itself. A significant proportion of registrars reported being pre-dominantly self-taught for performing injections (soft tissue = 10.7 %, joint injections = 8.7 %) and for the management of shoulder pain (20.1 %). Registrars rated their overall musculoskeletal training as inadequate. Primary care musculoskeletal education remains inadequate and needs to be improved to enable registrars to be confident in managing a significant proportion of their workload. Identifying learning needs for primary care would inform future educational interventions.

Control of HIF-1{alpha} and vascular signaling in fetal lung involves cross talk between mTORC1 and the FGF-10/FGFR2b/Spry2 airway branching periodicity clock

Lung development requires coordinated signaling between airway and vascular growth, but the link between these processes remains unclear. Mammalian target of rapamycin complex-1 (mTORC1) can amplify hypoxia-inducible factor-1α (HIF-1α) vasculogenic activity through an NH(2)-terminal mTOR binding (TOS) motif. We hypothesized that this mechanism coordinates vasculogenesis with the fibroblast growth factor (FGF)-10/FGF-receptor2b/Spry2 regulator of airway branching. First, we tested if the HIF-1α TOS motif participated in epithelial-mesenchymal vascular signaling. mTORC1 activation by insulin significantly amplified HIF-1α activity at fetal Po(2) (23 mmHg) in human bronchial epithelium (16HBE14o-) and induced vascular traits (Flk1, sprouting) in cocultured human embryonic lung mesenchyme (HEL-12469). This enhanced activation of HIF-1α by mTORC1 was abolished on expression of a HIF-1α (F99A) TOS-mutant and also suppressed vascular differentiation of HEL-12469 cocultures. Next, we determined if vasculogenesis in fetal lung involved regulation of mTORC1 by the FGF-10/FGFR2b/Spry2 pathway. Fetal airway epithelium displayed distinct mTORC1 activity in situ, and its hyperactivation by TSC1(-/-) knockout induced widespread VEGF expression and disaggregation of Tie2-positive vascular bundles. FGF-10-coated beads grafted into fetal lung explants from Tie2-LacZ transgenic mice induced localized vascular differentiation in the peripheral mesenchyme. In rat fetal distal lung epithelial (FDLE) cells cultured at fetal Po(2), FGF-10 induced mTORC1 and amplified HIF-1α activity and VEGF secretion without induction of ERK1/2. This was accompanied by the formation of a complex between Spry2, the cCBL ubiquitin ligase, and the mTOR repressor, TSC2, which abolished GTPase activity directed against Rheb, the G protein inducer of mTORC1. Thus, mTORC1 links HIF-1α-driven vasculogenesis with the FGF-10/FGFR2b/Spry2 airway branching periodicity regulator.

Chemical and biological properties in the rhizosphere of Lupinus albus alter soil heavy metal fractionation

To understand better the suitability of white lupin (Lupinus albus L.) for phytoremediation of heavy metal-contaminated soils, the effect of its roots on chemical and biological properties of the rhizosphere affecting soil metal fractionation was studied. Plants were cultivated in two similar soils, with high levels of Zn, Cd, Cu and Pb but differing pH values (4.2 and 6.8). In the rhizosphere of both soils, its roots induced increases in water-soluble carbon, which influenced the fractionation of heavy metals and ultimately their uptake by plant roots. In the rhizosphere of the acid soil, the concentrations of 0.1M CaCl(2)-extractable Mn, Zn and Cu were lower than in the bulk soil, possibly due to their increased retention on Fe (III) hydroxides/oxyhydroxides, while in the neutral soil only the Zn concentration was lower. Higher concentrations of heavy metals were found in plants growing on the acid soil, reflecting their greater availability in this soil. The restricted transfer of heavy metals to the shoot confirms the potential role of this species in the initial phytoimmobilisation of heavy metals, particularly in neutral-alkaline soils.

Teaching medical students musculoskeletal examination skills: identifying barriers to learning and ways of overcoming them

OBJECTIVES

To elicit the barriers to the effective teaching of musculoskeletal examination skills amongst medical students.

METHODS

This was a qualitative study including six focus groups with specialities most often involved in delivering musculoskeletal clinical teaching: rheumatology, orthopaedics, general practice, and geriatrics.

RESULTS

The main barriers to the delivery of effective clinical teaching included the lack of agreement on what to teach, lack of confidence in teaching amongst non-musculoskeletal specialities, and poor communication between specialities.

CONCLUSIONS

There is a need to overcome the identified barriers if musculoskeletal clinical teaching to medical students is to be improved. In particular, there is a need to agree which examination skills medical students should learn.

121 DEVELOPMENT OF IN VITRO-PRODUCED BOVINE EMBRYOS CULTURED IN SEQUENTIAL OR CONTINUOUS MEDIA

Slaughtered bovine females have different characteristics including age, nutritional status, breed, and management system, all of which may affect the results obtained in in vitro embryo production. Another key consideration is that early embryos move from the oviduct to a slightly different environment in the uterus, which has led to development of sequential embryo culture media (e.g. Lane M et al. 2003 Theriogenology 60, 407–419). However, the benefits and importance of using sequential media are not fully known. Therefore, the aim of the present study was to compare developmental rates of oocytes obtained from slaughterhouse-derived ovaries from cows or heifers after culture in sequential media (CDM-1, CDM-2) or in a continuous medium (C-CDM). The experiment was a 3 × 2 × 2 factorial design [bulls (A, B, or C), source (cows or heifers), and medium (sequential or continuous)]. Cumulus–oocyte complexes were aspirated, within 5 h of slaughter, from 3- to 8-mm ovarian follicles of cows (1482 oocytes) and fattened heifers usually fed melengesterol acetate (2818 oocytes). Embryos were produced in vitro as described by De La Torre-Sanchez et al. 2006 Reprod. Fertil. Devel. 18, 585–596, with slight modifications. Presumptive zygotes were vortexed to remove cumulus cells and cultured for 2.5 d in C-CDM (CDM supplemented with 5.0 mm L-lactate, essential and nonessential amino acids, and 0.5% FAF-BSA, or in CDM-1 (De La Torre-Sanchez et al. 2006 Reprod. Fertil. Devel. 18, 585–596) at 39°C in a humidified incubator under 5% CO2, 5% O2, and 90% N2. Cleavage was assessed after 2.5 d; 2- to 6-cell embryos were considered as cleaved, but were not cultured further. Embryos at the 7- to 8-cell stage were cultured for an additional 4.5 d in fresh C-CDM or CDM-2. The percentage blastocysts per oocyte was assessed after 7 and 8 days of culture. Data were arcsin-transformed and evaluated by ANOVA. There was a significant interaction between bull and ovary source for both 8-cell embryos and cleavage rate (P < 0.05); however, this interaction was no longer significant for blastocysts. No other interactions were significant nor a source of ovaries. Culturing embryos in CDM-C refreshed after cleavage evaluation (continuous) or culturing embryos in CDM-1 early and CDM-2 after cleavage evaluation (sequential) resulted in similar cleavage and blastocyst rates (Table 1). We conclude that bovine embryos can be produced using a single chemically defined medium (+BSA) with similar efficacy as a system using 2 sequential media. Table 1. Effects of media on embryonic development (mean ± SE)

205 CAPACITATION OF STALLION SPERMATOZOA EVALUATED BY FERTILIZATION OF BOVINE OOCYTES

In vitro fertilization in the horse does not work reliably. Several methods of capacitating sperm in other species fail in the horse. The goal of this experiment was to develop a method to capacitate equine spermatozoa using calcium ionophore A23187 or phosphatidylcholine 12 (PC12). We also studied effects of maturing bovine oocytes for 24 or 28 h on fertilizability by capacitated equine sperm, hypothesizing that longer maturation would yield oocytes more easily fertilized by equine spermatozoa. Two sets of bovine oocytes were aspirated from 3 to 8 mm follicles of abattoir ovaries 4 h apart, but fertilized at the same time. On the day of fertilization, semen from 1 of 3 stallions was collected, evaluated, and centrifuged through 33% Percoll to remove seminal plasma. The resultant pellet was extended to 5 × 107 cells mL–1 in M199 containing 0.6% BSA, 2 mm caffeine, and 5 mm CaCl2. Sperm were treated with A23187 (1 or 3 μm) or PC12 (40 or 70 μm) or both A23187 and PC12 (1 μm/40 μm) in 500- μL aliquots. Sperm were incubated at 39°C for 10 min (for A23187 and combination treatments) or 15 min (for PC12 treatments), and then diluted 1:20 for fertilization. Oocytes from each maturation time were fertilized using the same semen preparation for each treatment. Oocytes and sperm were incubated together for 18 h in FCDM in 5% CO2 at 39°C (De La Torre-Sanchez et al. 2006 Reprod. Fertil. Devel. 18, 585–596). Presumptive zygotes were cultured for 30 h in CDM-1, vortexed to remove cumulus cells, and evaluated for cleavage. Oocytes were also co-incubated with killed sperm to determine the level of parthenogenesis. Cleaved embryos were stained with orcein to ensure that each cell had a nucleus. Number of cell divisions were recorded as 0 for a 1-cell, 1 for a 2-cell, 1.5 for a 3-cell, etc. More oocytes cleaved after 28 h (18%) than 24 h (14%) maturation (P < 0.01). Sperm of Stallion 1 resulted in higher overall cleavage (24%) than Stallions 2 or 3 (11 and 12%; P < 0.01). Highest cleavage was seen with 28 h maturation and 70 μm PC12 and 3 μm A23187 (27 and 24%, respectively). The most cell divisions were seen with 28 h maturation and 70 μm PC12 (0.48); 28 of the 49 cleaved in this treatment reached ≥4-cell stage. In conclusion, both A23187 and PC12 were able to capacitate equine sperm in a dose-dependent manner as determined from cleavage of bovine oocytes matured for 28 h; maturation for the conventional 24 h was an inferior model for this purpose. Table 1. Mean responses of bovine oocytes fertilized by equine sperm

The novel endocannabinoid receptor GPR55 is activated by atypical cannabinoids but does not mediate their vasodilator effects

BACKGROUND AND PURPOSE

Atypical cannabinoids are thought to cause vasodilatation through an as-yet unidentified 'CBx' receptor. Recent reports suggest GPR55 is an atypical cannabinoid receptor, making it a candidate for the vasodilator 'CBx' receptor. The purpose of the present study was to test the hypothesis that human recombinant GPR55 is activated by atypical cannabinoids and mediates vasodilator responses to these agents.

EXPERIMENTAL APPROACH

Human recombinant GPR55 was expressed in HEK293T cells and specific GTPgammaS activity was monitored as an index of receptor activation. In GPR55-deficient and wild-type littermate control mice, in vivo blood pressure measurement and isolated resistance artery myography were used to determine GPR55 dependence of atypical cannabinoid-induced haemodynamic and vasodilator responses.

KEY RESULTS

Atypical cannabinoids O-1602 and abnormal cannabidiol both stimulated GPR55-dependent GTPgammaS activity (EC50 approximately 2 nM), whereas the CB1 and CB2-selective agonist WIN 55,212-2 showed no effect in GPR55-expressing HEK293T cell membranes. Baseline mean arterial pressure and heart rate were not different between WT and GPR55 KO mice. The blood pressure-lowering response to abnormal cannabidiol was not different between WT and KO mice (WT 20+/-2%, KO 26+/-5% change from baseline), nor was the vasodilator response to abnormal cannabidiol in isolated mesenteric arteries (IC50 approximately 3 micro M for WT and KO). The abnormal cannabidiol vasodilator response was antagonized equivalently by O-1918 in both strains.

CONCLUSIONS

These results demonstrate that while GPR55 is activated by atypical cannabinoids, it does not appear to mediate the vasodilator effects of these agents.

Drug resistance in Pneumocystis carinii: an emerging problem

Pneumocystis carinii pneumonia (PCP) is a frequent opportunistic infection in AIDS patients. Large numbers of HIV-infected individuals take prophylactic medications to prevent this illness. The development of drug resistance, while expected, cannot be monitored by classical means, since the organism cannot be cultivated in vitro. Two drug target genes, dihydropteroate synthase (DHPS) and cytochrome b, have been cloned and sequenced from human-derived P. carinii. Mutations leading to amino acid substitutions in the active sites of both proteins have been detected in patients receiving prophylaxis with sulfonamides and sulfones (DHPS inhibitors) and with atovaquone (cytochrome b inhibitor), suggesting that drug resistance may indeed be developing.

6 TIMING OF DEADENYLATION OF GDF-9 AND CYCLIN 3′ UTR CONSTRUCTS IN BOVINE OOCYTES

The maternal pool of mRNA undergoes major changes during oocyte maturation and early embryonic development. Specific genes are activated or degraded in response to changes in poly-(A) tail length. However, little is known about how the oocyte targets specific transcripts for degradation or translation in a timely manner. The objective of this study was to determine how poly-(A) tail length of different transcripts is affected in bovine oocytes by time of in vitro maturation. Cyclin B1 and GDF-9 32 untranslated regions (UTRs) were cloned into modified p-GEM plasmids containing a poly-(A) tract of 60 or 0 adenosines (A60 or A0, respectively). Each 32 UTR was transcribed in vitro with (A60) or without (A0) a poly-(A) tail to generate UTP32-labeled RNA. Transcriptions producing at least 200 000 counts per min (cpm) per �L were used for subsequent injections into denuded bovine oocytes. Cumulus-oocyte complexes (COCs) recovered from slaughterhouse-derived ovaries (n = 216) were vortexed to remove cumulus cells immediately after aspiration, after 3 h of in vitro maturation, or after 19 h of maturation in a chemically defined medium supplemented with FSH, LH, EGF, and cysteamine. After vortexing, denuded oocytes were injected and snap frozen, or matured in vitro for 1 or 3 h. Eight oocytes were injected with ~0.5 nL (~100 cpm/oocyte) labeled RNA at each time point in 3 replicates. Total RNA was isolated from injected oocyte pools and loaded onto a 5% denaturing acrylamide gel for size separation. Radiolabeled A0 was used as a control point of reference for deadenylation. Gels were dried, and RNA was visualized on a phosphoimager after 24 h exposure to a phosphor screen. Changes in polyadenylation status (transcript size) were evaluated by comparing shifts in bands from gene-specific A60

Vitrification of In Vitro-produced Bovine Embryos by Addition of Ethylene Glycol in One-step

The objective of this study was to simplify two-step addition of cryoprotectant for vitrification of bovine embryos by developing a one-step procedure. Survival was calculated as a percentage of non-vitrified controls developed from the same batch of oocytes. In experiment 1, bovine blastocysts were vitrified following one- or two-step addition of cryoprotectant. Exposure of embryos to cryoprotectant in one-step resulted in survival rates not significantly lower (p > 0.1) than those obtained by two-step addition (85% vs 98%, respectively). Based on these results, experiments 2-4 were designed to test one-step addition of cryoprotectant more rigorously. Experiment 2 exposed day 7 blastocysts to 6, 7 or 8 M ethylene glycol for 2.5 or 3.5 min. At 24 h post-vitrification, survival of embryos was similar, irrespective of ethylene glycol concentration or exposure time (6 M 38%, 7 M 51%, 8 M 59%; 2.5 min 54%, 3.5 min 45%). In experiment 3, blastocysts were exposed to 7 M ethylene glycol for shorter times (30 or 60 s); 30 s exposure resulted in decreased survival (8% vs 31%, p < 0.05). Experiment 4 concerned one-step addition of cryoprotectant to day 6 bovine morulae, exposed to 7 M ethylene glycol for 1 or 1.5 min. There was no difference in survival between exposure times of 1 or 1.5 min (28% vs 45%, respectively; p > 0.1). It is unclear why many embryos survive vitrification with one-step addition of cryoprotectant, but others do not. Although, one-step addition of cryoprotectant simplifies the vitrification procedure, survival rates were inadequate for routine cryopreservation of in vitro-produced bovine embryos.

Duloxetine 60 mg once daily in the treatment of milder major depressive disorder

There is ongoing debate regarding the effectiveness of antidepressants in patients with milder major depressive disorder (MDD). This post-hoc analysis evaluated the efficacy and tolerability of duloxetine in the subset of 159 (75 duloxetine and 84 placebo) patients with milder MDD (baseline HAMD17 total score > or = 15 and < or = 18) who were treated once daily with duloxetine 60 mg or placebo in two identical, 9-week, randomised, double-blind trials. At endpoint, change from baseline on HAMD17 was greater in the duloxetine group (-7.0) than in the placebo group (-4.1) (p = 0.005). Response and remission rates, and improvement on the Clinical Global Impressions-Severity (CGI-S) scale, the Patient Global Impressions-Improvement (PGI-I) scale, and measures of painful symptoms were also significantly better in the duloxetine group (p < 0.05). Tolerability was consistent with that seen in previous studies of duloxetine in patients with more severe depression. In conclusion, duloxetine 60 mg/day is effective and well tolerated in milder MDD.

114 VITRIFICATION OF BOVINE EMBRYOS IN MEDIUM WITH POLYVINYL ALCOHOL REPLACING BSA

Embryos vitrified in medium supplemented with 4.25 μg/mL sodium hyaluronate (SH) and 0.1% polyvinyl alcohol (PVA) survived vitrification better than embryos vitrified in medium supplemented with 0.25% FAF-BSA (Walker and Seidel 2005 Reprod. Fert. Dev. 17, 153). The purpose of the present study was to determine if the small amount of SH was beneficial to in vitro survival and to examine the effects of different concentrations of PVA in vitrification solutions. Day 7 blastocysts (n = 360) were produced in vitro with semen from three bulls, two replicates each. Cryoprotectant solutions were prepared in a 2 × 3 factorial combination with two SH concentrations (0 or 4.25 μg/mL) and three PVA concentrations (0.05, 0.1%, or 0.2%). For vitrification, embryos were placed into chemically defined HEPES-buffered medium (HCDM-2) at room temperature (22–24°C) and then transferred to V1 (5 m ethylene glycol in HCDM-2) for 3 min. Next, embryos were placed in a 6 μL drop of V2 (7 m ethylene glycol, 0.5 m galactose, and 18% w/v Ficoll 70 in HCDM-2) for 45 s. During these 45 s, dilution medium (0.5 m galactose in HCDM-2) was aspirated into 0.25-mL straws, followed by the 6 μL drop of V2 plus embryos and a final short column of dilution medium. When 45 s had elapsed, the heat-sealed end of straw was dipped into liquid nitrogen to cover the embryo, and then the remainder of the straw was immersed slowly. Straws were thawed in air for 10 s and then in 37°C water for 20 s. Next, straws were shaken like a clinical thermometer four times to mix columns, and held in 37°C water for 10 min before embryos were expelled, rinsed and cultured in CDM-2 + 5% FCS. At 48 h, embryo survival (as determined by expansion of blastocysts), embryo quality (1 = excellent, 2 = fair, 3 = poor), inner cell mass (ICM) quality (1 = large and compact, 2 = clearly visible, 3 = not discernable) and blastocyst stage (5 = early, 6 = full, 7 = expanded, 8 = hatching, 9 = hatched) were evaluated and replicate averages were analyzed by ANOVA. Neither bull nor SH concentration nor PVA concentration significantly affected any response (P > 0.10). Averaged over PVA concentrations, vitrification of embryos in 0 μg/mL or 4.25 μg/mL SH resulted in similar survival rates (67% vs. 62%, respectively). When averaged over SH concentrations, 0.2% PVA had a numerically higher survival rate of blastocysts as compared to 0.1% or 0.05% (71% vs. 63% and 60%, respectively). The main effects of 0 μg/mL SH and 0.2% PVA also resulted in numerically higher, but nonsignificant improvements in quality score, ICM score and blastocyst stage as compared to the other doses of SH and PVA. Vitrification of Day 7 in vitro-produced bovine blastocysts in medium containing 0.2% PVA in the absence of SH resulted in a subclass mean of 80% embryo survival. Results of this experiment show no benefit of 4.25 μg/mL SH and that 0.2% PVA may be slightly better than 0.05% or 0.1% in terms of embryo survival. Therefore, our results indicate that 0.2% PVA can be used alone as an effective alternative to animal products in this vitrification procedure for in vitro-derived bovine blastocysts.

In vitro assessment of a direct transfer vitrification procedure for bovine embryos

We developed a simple vitrification technique for bovine embryos that could permit direct transfer. Embryos were produced in-vitro by standard procedures. The base medium for cryopreservation was a chemically defined medium similar to SOF + 25 mM Hepes and 0.25% fatty acid free bovine serum albumin (FAF-BSA) (HCDM2). In experiment 1, embryos were first exposed to 3.5M ethylene glycol (V1) for 1, 2 or 3 min at room temperature (20-24 degrees C), and then moved to 7 M ethylene glycol (V2) at 4 or 20-24 degrees C and loaded in 0.25-mL straws. After 45 s in 7 M ethylene glycol, straws were placed in liquid nitrogen. Embryos that were loaded at 20-24 degrees C had higher survival rates than those loaded at 4 degrees C (P<0.05). Exposure for 1 min was best for morulae, while 3 min was best for blastocysts. In experiment 2, blastocysts were handled at 24 degrees C and exposed to two concentrations of ethylene glycol in V1 (3.5 or 5 M) followed by V2 as in experiment 1, two warming temperatures (20 or 37 degrees C) and two post-warming holding times until culture (5 or 15 min). Exposure to 5 M ethylene glycol and warming at 37 degrees C was the optimal combination of procedures, and embryos survived well after 15 min in straws if warmed at 37 degrees C. In experiment 3, ethylene glycol concentration (3, 4 or 5 M) and exposure time (0.5 or 1 min) during two-step addition of cryoprotectant were studied for bovine morulae. In experiment 4, morulae were exposed to V2 for 30 or 45 s in HCDM2 or Vigro holding medium and then held in 22-24 degrees C air or 37 degrees C water post-warming. Experiment 5 was like experiment 4 except blastocysts were used. Overall survival rates of blastocysts in experiment 5 averaged 80% of non-vitrified controls after 48 h culture. The survival rates with in vitro-produced morulae in experiments 1, 3 and 4 were unacceptable. Vitrification solutions based on Vigro tended to result in higher survival than HCDM2 for blastocysts, but not morulae. In experiment 6, the survival rate in vitro of in vivo-produced morulae and blastocysts after two-step vitrification was nearly 100%. Our vitrification technique was very effective for in vitro produced blastocysts, but not for in vitro-produced morulae.

Recurrence risk for psoriasis and psoriatic arthritis within sibships

OBJECTIVE

To quantify the frequency of siblings of patients with psoriatic arthritis (PsA) having psoriasis and/or inflammatory arthritis. To describe the similarity or otherwise of patterns of arthritis in siblings.

METHODS

Available and consenting index cases with PsA and one or more siblings living locally were assessed. Mean sibling concordance rates and Weinberg's segregation analysis were calculated. Heritability was also estimated. To assess whether the same type of arthritis occurred within the same sibship, the dually affected sibships were then classified for type of arthritis according to methods suggested by Moll, Helliwell, Veale and McGonagle.

RESULTS

Eighty index cases and 112 siblings were assessed. The median age of index cases was 49 yr (range 24-80 yr) and for siblings 46 yr (range 18-79 yr). The concordance rate for all types of PsA was 14% (9% if enthesitis is excluded) and for psoriasis 21%. There was no difference in the two methods used to calculate concordance rates. Sixteen dually affected sib pairs were found. Four of the 16 sibships (25%) had the same pattern of joint involvement (Moll and Wright classification). The most frequent pattern seen was joint involvement identical to rheumatoid arthritis (3/5). The most common symptom in affected siblings was enthesitis (approximately 5%). When the dually affected sibships were analysed using the other classifications, the simpler the classification the greater the concordance for joint pattern.

CONCLUSION

The concordance for psoriasis is greater than for PsA, but the concordance rate for PsA was similar to that in HLA identical siblings with rheumatoid arthritis. There was discordance in pattern of arthritis for most sib pairs. There is no support for the use of more complex classifications of PsA.

The efficacy and safety of tadalafil: an update

OBJECTIVE

To provide an update on the efficacy and safety of tadalafil, a phosphodiesterase-5 inhibitor, in the treatment of erectile dysfunction (ED).

PATIENTS AND METHODS

In all, 2102 men (mean age 56 years) with mild-to-severe ED of various causes were randomized to placebo or tadalafil, taken as needed with no food restrictions, at fixed 'on-demand' doses of 10 or 20 mg in 11 randomized, double-blind, placebo-controlled trials lasting 12 weeks. The three co-primary outcomes were changes from baseline in the erectile function domain of the International Index of Erectile Function (IIEF) and the proportion of 'yes' responses to questions 2 and 3 of the Sexual Encounter Profile (SEP). Additional efficacy instruments included a Global Assessment Question (GAQ).

RESULTS

Compared with placebo, tadalafil gave significantly better outcomes. Patients receiving either dose of tadalafil had a significant mean improvement of 6.5 and 8.6, respectively, in the IIEF erectile function domain score from baseline (P < 0.001 vs placebo). At both doses the mean success rate for intercourse attempts (SEP-Q3) was 58% and 68%, respectively, compared with 31% in the placebo group (P < 0.001), and 71% and 84% reported improved erections at the endpoint (GAQ), vs 33% on placebo (P < 0.001). Tadalafil was effective up to 36 h after dosing and was effective regardless of disease severity and causes, and in patients of all ages. The most frequent adverse events were headache, dyspepsia, back pain and myalgia.

CONCLUSION

Tadalafil was an effective and well-tolerated treatment for ED.

Serum MMP-1 and TIMP-1 levels are increased in patients with psoriatic arthritis and their siblings

OBJECTIVE

To determine matrix metalloproteinase-1 (MMP-1) and tissue-inhibitor metalloproteinase-1 (TIMP-1) serum levels in patients with psoriatic arthritis (PsA) and to compare this with their siblings and local blood donor controls. PsA is an interesting condition in which to study metalloproteinases because there are variations in the level of destructiveness, including a significant proportion of cases without destructive change. This is unlike rheumatoid arthritis (RA) which is more uniformly destructive and where MMP-1/TIMP-1 levels are known to be elevated.

METHODS

MMP-1 and TIMP-1 serum levels were determined by enzyme-linked immunosorbent assay (ELISA) in (a) index cases with PsA (subtype: RA n = 43, distal interphalangeal disease n = 2, oligoarticular n = 15, spondyloarthropathy n = 9, enthesitis n = 1), (b) siblings with PsA, (c) siblings with psoriasis (Ps), (d) unaffected siblings and (e) local controls. Patients with Ps were divided according to the onset of disease: type I disease, onset before age 40 yr and type II, onset after age 40 yr.

RESULTS

MMP-1 and TIMP-1 levels were significantly increased in both the index cases and the group including all siblings compared with the controls (P < 0.0001). There was no statistical difference in MMP-1 or TIMP-1 levels between index cases and their siblings. There was no difference in serum MMP-1 level between the different subtypes (Moll and Wright) of PsA, but there was an increased level of serum TIMP-1 in patients with rheumatoid pattern (P = 0.05). In the index cases there were increased levels of TIMP-1 in type II onset psoriasis (P = 0.03) but no difference in MMP-1 levels.

CONCLUSION

MMP-1 and TIMP-1 serum levels are elevated in PsA. This is greatest in RA pattern PsA. These levels were also elevated in unaffected siblings suggesting that genetic factors may be important. TIMP-1 levels were elevated in psoriasis alone, more so in late onset psoriasis, suggesting that the pathological processes of early and late onset psoriasis may be different.

Measured ambulation and self-reported health status following total joint replacement for the osteoarthritic knee

OBJECTIVE

To quantify the increase in ambulation produced by total knee replacement for osteoarthritis (OA) of the knee and to compare this with questionnaire-derived data.

METHODS

We compared the measured ambulatory activity and self-reported Nottingham Health Profile (NHP) data of 19 subjects with OA of the knee before and after total knee replacement (TKR).

RESULTS

Subjects were considerably restricted in their measured activity before operation compared with subjects with less severe disease. At 6 months the activity had increased by an average of 79% (P=0.02). The pain scale of the NHP had significantly improved at 3 months, as had the mobility scale. Between 3 and 6 months, however, at the same time the measured activity was increasing, self-reported mobility declined.

CONCLUSIONS

Replacement of a knee for OA is an effective way of improving ambulation. At 6 months the average increase amounted to 79%. Self-reported mobility did not correlate with mobility measured objectively.

Lack of effects of ethanol pretreatment on the abuse liability of nitrous oxide in light and moderate drinkers

AIMS

To determine effects of ethanol-use history and ethanol pretreatment on abuse liability of nitrous oxide (N(2)O).

DESIGN

Placebo-controlled, double-blind, cross-over design evaluating effects of N(2)O, 0% (100% O(2), placebo) and 30% (in O(2)), in the presence of three doses of ethanol: 0 g/kg (placebo), 0.35 g/kg and 0.7 g/kg.

SETTING

Subjects sat in a reclining chair in a hospital laboratory.

PARTICIPANTS

Eight healthy light drinkers (one drink or less/week) and eight healthy moderate drinkers (seven or more drinks/week) with no history of drug dependence completed the study.

INTERVENTION

On three sessions (1, 3, 5) subjects drank a beverage that contained one of the three ethanol doses, then sampled for 10 minute each 0% and 30% N(2)O. During choice sessions (2, 4, 6), subjects received the same ethanol dose as in the previous session, then chose six times, once every 5 min, between 0% and 30% N(2)O.

MEASUREMENTS

Subjective (self-reported) drug effects, reinforcing effects of N(2)O as assessed by choice, and psychomotor effects were measured.

FINDINGS

Choice of N(2)O did not differ between light (mean = 3.4 choices) and moderate (mean = 3.2 choices) drinkers and was not influenced by ethanol dose (0 g/kg: 3.3 choices, 0.35 g/kg: 3.5 choices, 0.7 g/kg: 3.1 choices). Subjective effects of N(2)O also did not depend on ethanol-use history or ethanol dose. N(2)O liking and desire to inhale the drug again were positively correlated with N(2)O choice.

CONCLUSIONS

Ethanol pretreatment and ethanol-use history had no effect on the abuse liability of N(2)O as assessed in the present study.

Joints: if relevant. Do available textbooks contain adequate information about musculoskeletal examination skills for medical students?

The objective was to determine whether routinely available textbooks describe the core musculoskeletal examination skills for medical students. Textbooks were evaluated for content against a list of 27 core examination skills as perceived by rheumatologists, orthopaedic surgeons and general practitioners. The study took place in Newcastle upon Tyne, libraries of the rheumatology department, teaching hospital and medical school. The main outcome was the inclusion of a description of examination skills by available textbooks. Median score for each textbook was only 19 (range 1-24) of a possible 27 core skills. Screening examination was not included in general texts. General principles were well covered but detail was insufficient, particularly in texts aimed at students taking final examinations. It is not easy for students to access adequate information about core items of musculoskeletal examination from textbooks readily available to them. This may reflect a general view of the lack of importance of musculoskeletal clinical examination skills.

Within- and between-subject variability in the reinforcing and subjective effects of nitrous oxide in healthy volunteers

Within- and between-subject variability in the reinforcing and subjective effects of nitrous oxide (N(2)O) was studied across five sessions. Twelve volunteers with no history of drug dependence sampled 30% N(2)O and 100% oxygen for 10 min each, then chose nine times, once every 5 min, among N(2)O (e.g. "Agent A"), oxygen (e.g. "Agent B"), or "drug-free air." Choice varied across subjects but was stable within subjects. Quantitative differences in subjective effects occurred within and across subjects. Some subjective effects were correlated with choice and/or differed between subjects who were consistent choosers of N(2)O versus those who were not. However, drug liking and euphoria, two face-valid measures of abuse liability, were unrelated to choice. Thus, the present study found individual differences (i.e. between-subject variability) in subjective and reinforcing effects of N(2)O and, in terms of within-subject variability, suggested that subjective effects fluctuate across sessions to a relatively greater extent than do reinforcing effects. The varying degrees of correlation between N(2)O choice and its subjective effects emphasize the need for obtaining multiple measures when characterizing abuse liability of this drug.

Extraction and validation of a lower limb HAQ by comparison with objective measurement of ambulatory activity

OBJECTIVES

Both the Health Assessment Questionnaire (HAQ) and the measurement of spontaneous ambulatory activity are measures that can be used to evaluate disability in RA.

METHODS

A cross sectional survey was conducted of 105 RA patients where the HAQ was compared with ambulatory activity from the Numact monitor. Rank correlation was used to evaluate the relationships between activity and the complete and individual sections of the HAQ.

RESULTS

Correlation of activity with total HAQ produced significant results (r= -0.29 to -0.48). Correlation with individual sections showed the strongest association with "Hygiene", followed by "Activities", and "Walking". A lower limb HAQ was devised using these and the dressing and rising items.

CONCLUSIONS

HAQ and recorded activity measure different but related aspects of disability. Activity should be used if the ability to quantify the result outweighs the extra effort involved in the study.

Subjective, psychomotor, and physiological effects of cumulative doses of mixed-action opioids in healthy volunteers

RATIONALE

Conducting complete dose-response evaluations of multiple drugs in a single within-subjects experiment is very time-consuming when a complete session is required for evaluation of each dose.

OBJECTIVE

To evaluate a within-session cumulative-dosing procedure as a potentially efficient method for conducting dose-response evaluations of mixed-action opioids.

METHODS

Fifteen healthy volunteers received intravenous injections of saline, butorphanol, nalbuphine, pentazocine, or morphine in a randomized, double-blind, crossover design. Subjects received one injection per hour for the first 4 h, and a 3-h recovery period followed. Saline was injected first, then saline or increasing doses of each drug (except pentazocine, see below) were administered every hour for the next 3 h. The absolute doses per injection were morphine and nalbuphine 2.5, 5, and 10 mg/70 kg, butorphanol 0.5, 1, and 2 mg/70 kg, and pentazocine 7.5, 15, and 0 mg/70 kg. (The highest dose of pentazocine was omitted because of the risk of dysphoria and psychotomimesis). These injections resulted in cumulative doses of morphine or nalbuphine 2.5, 7.5, and 17.5 mg/70 kg, butorphanol 0.5, 1.5, and 3.5 mg/70 kg, and pentazocine 7.5 and 22.5 mg/70 kg. Mood, psychomotor performance, and vital signs were assessed.

RESULTS

Effects of all opioids were similar, with some exceptions. Butorphanol had the strongest effects on psychomotor performance and some subjective effects. Morphine was associated with delayed or prolonged side effects.

CONCLUSIONS

Orderly dose-response functions and replication of results of single-dosing studies confirmed that the cumulative-dosing procedure is an efficient way of determining dose-response functions for multiple opioids within the same subjects.

Weight change and atypical antipsychotic treatment in patients with schizophrenia

Schizophrenic patients who have been prescribed atypical antipsychotics have a potential risk of gaining weight. The implications of weight gain for clinical care may differ depending on whether a patient is underweight or overweight at baseline. The exact mechanism for weight gain is not known, but several factors have been identified that can help predict which patients are at risk for gaining weight. These factors include better clinical outcome, increased appetite, and low baseline body mass index. In patients treated with olanzapine for up to 3 years, weight gain trended toward a plateau at approximately 36 weeks. Weight gain interventions, including behavioral modifications, show promise in controlling or reducing weight in patients treated with antipsychotics.

Modelling sedimentation processes in a constructed stormwater wetland

The design and operation of constructed wetlands for the treatment of stormwater relies heavily on promoting sedimentation, and being able to predict accurately the expected effectiveness of the pond in removing material from the inflows. A study of sediment behaviour has been carried out in a stormwater wetland in Adelaide, Australia where computer predictions, based on solving the hydrodynamic equations and the transport equation, have been compared to deposition patterns observed in the field. The long-term residence time distribution has been shown to be useful in predicting overall sediment removal rates. Comparisons between the model and field observations indicate generally good agreement. Sources of potential error identified include the variable nature of the runoff concentrations entering the pond and the sediment size distribution. The importance of the transient nature of the flow events was highlighted by the spread of sediment throughout the whole pond.

Mechanisms of artemisinin resistance in the rodent malaria pathogen Plasmodium yoelii

Artemisinin and its derivatives are important new antimalarials which are now used widely in Southeast Asia. Clinically relevant artemisinin resistance has not yet been reported but is likely to occur. In order to understand how the malaria parasite might become resistant to this drug, we studied artemisinin resistance in the murine malaria parasite Plasmodium yoelii. The artemisinin-resistant strain (ART), which is approximately fourfold less sensitive to artemisinin than the sensitive NS strain, accumulated 43% less radiolabeled drug in vitro (P < 0.01). Within the parasite, the drug appeared to react with the same parasite proteins in both strains. The translationally controlled tumor protein, one of the artemisinin target proteins, did not differ between the strains. No DNA sequence difference was found, but the resistant strain was found to express 2.5-fold-more protein than the sensitive strain (P < 0.01). Thus, the phenotype of artemisinin resistance in P. yoelii appears to be multifactorial.

Spontaneous ambulatory activity as a quantifiable outcome measure for rheumatoid arthritis

OBJECTIVE

To validate the objective monitoring of ambulatory activity as an outcome measure for rheumatoid arthritis (RA).

METHODS

We have compared ambulatory activity to a range of currently favoured outcome measures, ranging from subjective opinions to X-ray damage, in a population of 93 RA sufferers.

RESULTS

Correlations were stronger with measures of joint damage and disability, and less strong with measures of disease activity. Sensitivity to change was good. Three different interventions were compared for the quantity of the response, and the results agree with clinical experience, with steroid injection of the knee and use of non-steroidal anti-inflammatory drugs (NSAIDs) having a similar response and the provision of surgical shoes producing a more modest increase in ambulation.

CONCLUSION

The measurement of ambulatory activity has validity for RA assessment. It provides different but related data to the currently used measures. It is objective, relevant, quantifiable and of unlimited scale. It could be used to quantify interventions aimed at increasing ambulation, in carefully constructed studies.

Venous stasis wounds

Lower extremity wounds related to venous insufficiency are increasing. As the number of adults over the age of 65 increases, so do wounds related to changes in the vascular system. Venous stasis wounds can present as a real challenge to experienced practitioners. This article describes the many factors associated with venous wounds as well as the need for a comprehensive treatment plan.

Genetic analysis of multiplex rheumatoid arthritis families

To examine the genetic contribution of HLA and non-HLA genes in the etiopathogenesis of rheumatoid arthritis (RA), 60 Caucasian multiplex families were identified and DNA analyzed for over 52 markers including DRB1, DQA1 and DQB1 alleles. Many of the markers were chosen because of close proximity to candidate genes suggested by previous studies or models of pathogenesis. Sibling pair analysis (SIBPAL), relative pair analysis (RELPAL) and linkage studies using two different models of inheritance suggested linkage for the MHC and two additional chromosomal regions: chromosome 2 (D2S443 near CD8 and IGk; 2p13-2p11.1), and chromosome 15 (CYP19-estrogen synthase; 15q15). No support was found for two chromosomal regions, 1p36 and 3q13, recently suggested by other studies. We used transmission disequilibrium testing (TDT), conditional logistic regression, and segregation analysis to study the contributions that the shared epitope and TNF-c have in contributing to risk for RA. These studies provide additional evidence that the association of HLA alleles in RA patients from multiplex families is similar to that observed in sporadic disease, suggest candidate regions for further analysis and find additional support for an association of TNF-c alleles with RA susceptibility.