Chronic neuropsychiatric sequelae of SARS-CoV-2: Protocol and methods from the Alzheimer's Association Global Consortium

Introduction

Coronavirus disease 2019 (COVID-19) has caused >3.5 million deaths worldwide and affected >160 million people. At least twice as many have been infected but remained asymptomatic or minimally symptomatic. COVID-19 includes central nervous system manifestations mediated by inflammation and cerebrovascular, anoxic, and/or viral neurotoxicity mechanisms. More than one third of patients with COVID-19 develop neurologic problems during the acute phase of the illness, including loss of sense of smell or taste, seizures, and stroke. Damage or functional changes to the brain may result in chronic sequelae. The risk of incident cognitive and neuropsychiatric complications appears independent from the severity of the original pulmonary illness. It behooves the scientific and medical community to attempt to understand the molecular and/or systemic factors linking COVID-19 to neurologic illness, both short and long term.

Methods

This article describes what is known so far in terms of links among COVID-19, the brain, neurological symptoms, and Alzheimer's disease (AD) and related dementias. We focus on risk factors and possible molecular, inflammatory, and viral mechanisms underlying neurological injury. We also provide a comprehensive description of the Alzheimer's Association Consortium on Chronic Neuropsychiatric Sequelae of SARS-CoV-2 infection (CNS SC2) harmonized methodology to address these questions using a worldwide network of researchers and institutions.

Results

Successful harmonization of designs and methods was achieved through a consensus process initially fragmented by specific interest groups (epidemiology, clinical assessments, cognitive evaluation, biomarkers, and neuroimaging). Conclusions from subcommittees were presented to the whole group and discussed extensively. Presently data collection is ongoing at 19 sites in 12 countries representing Asia, Africa, the Americas, and Europe.

Discussion

The Alzheimer's Association Global Consortium harmonized methodology is proposed as a model to study long-term neurocognitive sequelae of SARS-CoV-2 infection.

Key Points

The following review describes what is known so far in terms of molecular and epidemiological links among COVID-19, the brain, neurological symptoms, and AD and related dementias (ADRD)The primary objective of this large-scale collaboration is to clarify the pathogenesis of ADRD and to advance our understanding of the impact of a neurotropic virus on the long-term risk of cognitive decline and other CNS sequelae. No available evidence supports the notion that cognitive impairment after SARS-CoV-2 infection is a form of dementia (ADRD or otherwise). The longitudinal methodologies espoused by the consortium are intended to provide data to answer this question as clearly as possible controlling for possible confounders. Our specific hypothesis is that SARS-CoV-2 triggers ADRD-like pathology following the extended olfactory cortical network (EOCN) in older individuals with specific genetic susceptibility.The proposed harmonization strategies and flexible study designs offer the possibility to include large samples of under-represented racial and ethnic groups, creating a rich set of harmonized cohorts for future studies of the pathophysiology, determinants, long-term consequences, and trends in cognitive aging, ADRD, and vascular disease.We provide a framework for current and future studies to be carried out within the Consortium. and offers a "green paper" to the research community with a very broad, global base of support, on tools suitable for low- and middle-income countries aimed to compare and combine future longitudinal data on the topic.The Consortium proposes a combination of design and statistical methods as a means of approaching causal inference of the COVID-19 neuropsychiatric sequelae. We expect that deep phenotyping of neuropsychiatric sequelae may provide a series of candidate syndromes with phenomenological and biological characterization that can be further explored. By generating high-quality harmonized data across sites we aim to capture both descriptive and, where possible, causal associations.

Temporary Botulinum Immobilization of Residuum Muscles for Facilitation of the Initial Ingrowth of Skin to the Porous Skin and Bone Integrated Pylon in the Technology of Direct Skeletal Attachment: Large Animal Model

Enhancing the technology of bone-anchored limb prosthetics, we present a modified porcine model for developing an infection-free integration between the skin and a percutaneous bone implant. The deeply porous Skin and Bone Integrated Pylon (SBIP) presented an infection-free skin-implant interface both after implantation into the dorsum and after implantation into the residuum after below-knee amputation. However, deep ingrowth of skin into the porous cladding of the SBIP was achieved better in the dorsal procedure, while implantation to the residuum sometimes developed a stoma, probably due to the high mobility of the skin and soft tissues in the pig's thigh. Uncontrolled high skin mobility during the first week after implantation constituted a limitation for the porcine animal model, which we tried to address in the current study. As our previous studies showed that casting of the leg residuum did not sufficiently limit the skin's movement around the implant, we tested a modified protocol of the implantation, which included injection of botulinum toxin into the thigh muscles. During the course of the study, we identified proper botulinum toxin componentry, dosage, and the period after injections to achieve a maximal effect of immobilization of the muscles affecting skin movements. To verify the immobilization, we used kinetic data on the asymmetry of loading during gait with the Strideway System, Tekscan, Inc., Boston, MA, USA. We found that injections in the four muscles of the distal thigh of the left hind leg with MYOBLOC® (rimabotulinumtoxinB; 5,000 units/muscle) were sufficient to provide noticeable immobilization by the fourth week after the procedure. This conclusion was made based on the analysis of the dynamics of asymmetry in vertical ground reactions on the injected (left hind) and uninvolved (right hind) legs during gait over an instrumented walkway.

Different expression of placental pyruvate kinase in normal, preeclamptic and intrauterine growth restriction pregnancies

INTRODUCTION

Preeclampsia (PE) and intrauterine growth restriction (IUGR) are two diseases that affect pregnant women and their unborn children. These diseases cause low birth weight, pre-term delivery, and neurological and cardiovascular disorders in babies. Combined they account for 20% of preterm deliveries. Pyruvate kinase M2 (PKM2) is a metabolism enzyme found in developing embryonic and cancer tissues. Our objective is to determine the expression of PKM2 in human PE and IUGR compared to normal pregnancies. Understanding expression of PKM2 in PE and IUGR could help us to better understand the mechanisms and find treatments for PE and IUGR.

METHODS

Human placental tissues were obtained for PKM2 determination and analyzed by immunohistochemistry, Western blot, and a pyruvate assay. Placental samples were homogenized and cytoplasmic and nuclear proteins were extracted for Western blot analysis.

RESULTS

Preeclampsia samples had elevated levels of p-PKM2, p-ERK, and ERK in the cytoplasm. Beta-catenin and lactose dehydrogenase (LDH) were also elevated in preeclampsia placenta samples.

DISCUSSION AND CONCLUSION

We conclude that PKM2 is expressed in normal, PE and IUGR pregnancies. Also, that this expression is increased in the PE placenta at delivery. These results suggest placental metabolism through PKM2 could play a role in human preeclampsia.

Groundwater Iron Assessment and Consumption by Women in Rural Northwestern Bangladesh

In Bangladesh, approximately 97 % of the rural population uses groundwater as a drinking source. In many areas of the country this water is known to have elevated levels of iron. The contribution to iron intake that this exposure provides, and the impact on health, are unknown. In the pre- and post-monsoon seasons of 2008, we measured iron content of household tube well water, explored local water collection methods, and estimated iron intake through consumption of groundwater for 276 women of reproductive age in a rural setting in northwestern Bangladesh. Groundwater samples were analyzed for total iron (mg/L), arsenic (category of µg/L), pH, temperature (oC), and oxidation-reduction potential (Eh). Participants drank [mean (SD); 2.7 (0.8) L] of water per day, all of which was collected from domestic tube wells. Total iron concentration in groundwater was high, [median (IQR) 16.3 (6.9, 28.2) mg/L], and variable throughout the area. Using this value, estimated daily iron intake [median (IQR)] was 41.1 (16.0, 71.0) mg from drinking water alone. The amount of water consumed was unrelated to its iron concentration (r = - 0.06; p = 0.33) despite potentially unpleasant organoleptic qualities of high iron content in water. Groundwater contributes substantially to daily iron intake of rural Bangladeshi women and currently represents an under-assessed potential source of dietary iron.

Replication of a genome-wide association study of birth weight in preterm neonates

OBJECTIVE

To examine associations between rs9883204 in ADCY5 and rs900400 near LEKR1 and CCNL1 with birth weight in a preterm population. Both markers were associated with birth weight in a term population in a recent genome-wide association study of Freathy et al.

STUDY DESIGN

A meta-analysis of mother and infant samples was performed for associations of rs900400 and rs9883204 with birth weight in 393 families from the US, 265 families from Argentina, and 735 mother-infant pairs from Denmark. Z-scores adjusted for infant sex and gestational age were generated for each population separately and regressed on allele counts. Association evidence was combined across sites by inverse-variance weighted meta-analysis.

RESULTS

Each additional C allele of rs900400 (LEKR1/CCNL1) in infants was marginally associated with a 0.069 SD lower birth weight (95% CI, -0.159 to 0.022; P = .068). This result was slightly more pronounced after adjusting for smoking (P = .036). No significant associations were identified with rs9883204 or in maternal samples.

CONCLUSIONS

These results indicate the potential importance of this marker on birth weight regardless of gestational age.

Abstract 3066: Direct detection and enumeration of circulating tumor cells (CTCs) in blood by CastRT-qPCR

Statistical data suggest that only approximately 25% of cancer patients will respond to the same treatment. Enumeration and molecular characterization of circulating tumor cells (CTCs) promise to be valuable for cancer cell diagnosis, survival prognosis, and treatment guidance. However, CTCs are very rare. There is no sensitive and specific assay available for analyzing CTCs from whole blood without extensive enrichment processes. Sample enrichment causes target cells loss, expensive and time-consuming. Here we report a highly specific competitive allele-specific TaqMan-based RT-qPCR (castRT-qPCR) for rare copies of DNA mutation detection. CastPCR can detect rare copies of mutant alleles for up to one in 10 million with a wide dynamic range of more than 6-log orders and <5 copy sensitivity. We have successfully designed and validated cast-PCR assays for more than 80 cancer-related SNPs of KRAS, EGFR, BRAF, KIT, pTEN, p53 and other oncogenes or tumor suppressor genes. CastRT-PCR was used to specifically detect and enumerate CTCs in blood samples with lung cancer cell lines spiking-in and lung cancer patient blood without prior biochemical enrichment processes. EGFR mutation (p.L858R) was detected in all 5 blood samples from late stage lung cancers. Approximately 50% of circulating lung tumor cells with positive EGFR p.L858R mutation had positive EGFR p.T790M mutation. In normal blood samples spiked in cell lines of known Kras and EGFR mutation at the level of 10 cells/mL of whole blood (close to actual patient samples), CastRT-PCR accurately detected the known mutations. Our data suggest that digital castRT-qPCR can be used to enumerate CTCs and detect cancer-related mutations in the blood, which paves the way for future individualized cancer treatment by monitoring CTC level and molecular characterization.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3066. doi:10.1158/1538-7445.AM2011-3066

Abstract 3071: Accurate and sensitive detection of KRAS mutations in heterogeneous cancer specimens

The discovery of pivotal genetic alterations and the understanding of their role in cancer is leading to remarkable successes in therapeutics and patient care. Molecular diagnosis methods such as DNA sequencing and conventional genotyping of tumor biopsies have advanced research in this field, but are limited in sensitivity due to stromal contamination and by genetic heterogeneity in cancer. We have recently developed competitive allele specific TaqMan® PCR (castPCR) assays assays for detecting cancer-associated sequence variations. CastPCR not only maintains the wide dynamic range, high sensitivity and reproducibility of TaqMan® assays but also greatly improves the specificity. The technology enables detection, of as little as 1 mutant allele molecule in 10,000,000 wild type molecules. We report here sensitive and accurate detection of cancer-associated KRAS mutations within formalin-fixed paraffin-embedded (FFPE) heterogeneous cancer specimens. Eight FFPE model cell lines were initially used to validate the assays (NCI-H2009:p.G12A; SW1463:p.G12C; PANC-1:p.G12D; PSN-1: p.G12R; A549:p.G12S; SW480:p.G12V; DLD-1:p.G13D; Jurkat:Wild Type). Mutant FFPE cell line DNAs were titrated in the FFPE wild type cell line DNAs from 100% to 0.1%. Mutations were easily identified at the level of 0.1% with high reproducibility. 24 anonymous tumor tissues and 12 non-tumor tissues from FFPE specimens were also examined. No positive samples were found in non-tumor tissues. The results obtained by castPCR for the 24 tumor tissues were concordant to those previously reported by three different methods (Taqman® PCR, Taqman® PCR + PNA and Sequencing). Our results demonstrate that castPCR, as a new rare mutation detection technology, has greater sensitivity, specificity and can thereby facilitate accurate molecular diagnosis of heterogeneous cancer specimens and enable patient selection for targeted cancer therapies.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3071. doi:10.1158/1538-7445.AM2011-3071

Evaluation of fetal and maternal genetic variation in the progesterone receptor gene for contributions to preterm birth

Progesterone plays a critical role in the maintenance of pregnancy and has been effectively used to prevent recurrences of preterm labor. We investigated the role of genetic variation in the progesterone receptor (PGR) gene in modulating risks for preterm labor by examining both maternal and fetal effects. Cases were infants delivered prematurely at the University of Iowa. DNA was collected from the mother, infant, and father. Seventeen single nucleotide polymorphisms (SNP) and an insertion deletion variant in PGR were studied in 415 families. Results were then analyzed using transmission disequilibrium tests and log-linear-model-based analysis. DNA sequencing of the PGR gene was also carried out in 92 mothers of preterm infants. We identified significant associations between SNP in the PGR for both mother and preterm infant. No etiologic sequence variants were found in the coding sequence of the PGR gene. This study suggests that genetic variation in the PGR gene of either the mother or the fetus may trigger preterm labor.

Intrapartum predictors of uterine rupture

This case-controlled study reviewed 26 cases of uterine rupture at an academic medical center. Controls were selected in a 2:1 design by reviewing the immediate successful vaginal birth after cesarean delivery (VBAC) before and after each case of uterine rupture. At less than 2 hours before delivery or acute uterine rupture, mild and severe variable decelerations, persistent abdominal pain, and hyperstimulation were more common in cases of uterine rupture as compared to controls and had statistically significant positive likelihood ratios (LR). Mild and severe variable fetal heart rate decelerations, especially in the presence of persistent abdominal pain, may predict uterine rupture in patients attempting VBAC.

Percutaneous management of perianastomotic stenosis in arteriovenous fistulae: Results of a prospective study

Surgical creation of new anastomosis has been proposed as the preferred treatment for perianastomotic stenoses of fistulae. However, disadvantages of surgical approach have included (1) frequent conversion of fistula to a graft by using synthetic graft material to create a new anastomosis, (2) shortening the length of the cannulation segment by proximal autologous arteriovenous neoanastomosis, and (3) abandoning the fistula altogether in favor of a synthetic graft. We report the results of a prospective study using percutaneous balloon angioplasty (PTA) to treat fistulae with perianastomotic lesions. Seventy-three consecutive patients undergoing 112 PTA procedures for the treatment of perianastomotic lesions were studied. Primary and secondary patency rates were calculated. Procedure success, procedure-related complications, and conversion of fistulae to grafts were recorded. The initial success rate was 97%. The degree of stenosis before and after PTA was 81 +/- 9 and 11+/-11%, respectively. Primary patency rates at 6, 12, and 18 months were 75, 51, and 41%, respectively. Secondary patency rates at 6, 12, and 18 months were 94, 90, and 90%, respectively. Grade I hematoma occurred in three and vein rupture in two cases. No grafts were inserted. These outcomes are superior to those that have been reported for surgery. The outpatient PTA is safe and effective for the management of perianastomotic stenosis. Because of its advantage of fistula preservation, the percutaneous approach should be considered as the preferred first-line therapy for the management of perianastomotic fistula lesions.

Growth factor gene therapy for Alzheimer disease

The capacity to prevent neuronal degeneration and death during the course of progressive neurological disorders such as Alzheimer disease (AD) would represent a significant advance in therapy. Nervous system growth factors are families of naturally produced proteins that, in animal models, exhibit extensive potency in preventing neuronal death due to a variety of causes, reversing age-related atrophy of neurons, and ameliorating functional deficits. The main challenge in translating growth factor therapy to the clinic has been delivery of growth factors to the brain in sufficient concentrations to influence neuronal function. One means of achieving growth factor delivery to the central nervous system in a highly targeted, effective manner may be gene therapy. In this article the authors summarize the development and implementation of nerve growth factor gene delivery as a potential means of reducing cell loss in AD.

Plasma Angiotensin-(1-7) Is Decreased in Preeclampsia

P18

Angiotensin-(1-7)[Ang-(1-7)] is a bioactive component of the renin-angiotensin system (RAS), which has depressor, vasodilatory, and antihypertensive actions. In normal pregnancy we questioned whether the known rise in plasma Ang II is counterbalanced by an increase in plasma Ang-(1-7) and whether plasma Ang-(1-7)levels are decreased in preeclampsia and may thus be a factor involved in the development of hypertension. Nulliparous preeclamptic patients (PREE) and third trimester normotensive pregnant contols (NPC)(matched for parity, race, and gestational age) were enrolled (n=15/group). A nonpregnant group (CON)(n=15) was also included for comparison. PREE had no previous history of hypertension. Mean gestational age of preeclamptic subjects was 33.9±1.2 vs 33.7±1.2 weeks for normotensive pregnant subjects (n.s.,p=0.9). PREE subjects had significant hypertension (159±3/98±2 mmHg) and all had ≥3† proteinuria. Plasma Ang I, Ang II, and renin activity (PRA) were significantly elevated in normal pregnancy as compared to nonpregnant CON subjects; plasma Ang-(1-7) was increased by 51%(p<0.05). In PREE subjects all components of the RAS were reduced as compared to NPC; however, plasma Ang II remained elevated as compared to nonpregnant CON subjects. These studies confirm that the RAS is activated in the third trimester of normal pregnancy,including an increase in plasma Ang-(1-7)levels. In preeclampsia, the decreased levels of plasma Ang-(1-7)in the presence of persistent elevated plasma Ang II are consistent with the development of hypertension.

Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study

BACKGROUND

The relationship between the protein-energy nutritional status and renal function was assessed in 1785 clinically stable patients with moderate to advanced chronic renal failure who were evaluated during the baseline phase of the Modification of Diet in Renal Disease Study. Their mean +/- SD glomerular filtration rate (GFR) was 39.8 +/- 21.1 mL/min/1.73 m2.

METHODS

The GFR was determined by 121I-iothalamate clearance and was correlated with dietary and nutritional parameters estimated from diet records, biochemistry measurements, and anthropometry.

RESULTS

The following parameters correlated directly with the GFR in both men and women: dietary protein intake estimated from the urea nitrogen appearance, dietary protein and energy intake estimated from dietary diaries, serum albumin, transferrin, percentage body fat, skinfold thickness, and urine creatinine excretion. Serum total cholesterol, actual and relative body weights, body mass index, and arm muscle area also correlated with the GFR in men. The relationships generally persisted after statistically controlling for reported efforts to restrict diets. Compared with patients with GFR > 37 mL/min/1.73 m2, the means of several nutritional parameters were significantly lower for GFR between 21 and 37 mL/min/1.73 m2, and lower still for GFRs under 21 mL/min/1.73 m2. In multivariable regression analyses, the association of GFR with several of the anthropometric and biochemical nutritional parameters was either attenuated or eliminated completely after controlling for protein and energy intakes, which were themselves strongly associated with many of the nutritional parameters. On the other hand, few patients showed evidence for actual protein-energy malnutrition.

CONCLUSIONS

These cross-sectional findings suggest that in patients with chronic renal disease, dietary protein and energy intakes and serum and anthropometric measures of protein-energy nutritional status progressively decline as the GFR decreases. The reduced protein and energy intakes, as GFR falls, may contribute to the decline in many of the nutritional measures.

Risk of repetition of a severe perineal laceration

OBJECTIVE

To compare the outcome of subsequent delivery in women with a history of a third- or fourth-degree laceration with outcomes in women without such a history.

METHODS

This retrospective study used a perinatal database and chart review from 1978 to 1995. Only women whose first delivery was at our institution at more than 36 weeks' gestation, vaginal singleton, vertex presentation, and birth weight greater than 2500 g, with a subsequent delivery were included. The women were grouped by presence or absence of a third- or fourth-degree (severe) perineal laceration in their first delivery. The subsequent delivery was analyzed for maternal age, weight, birth weight, gestational age, method of delivery, use of episiotomy, and occurrence of a severe laceration. Comparison of data was by Fisher exact and t tests.

RESULTS

Four thousand fifteen women met our starting criteria. In their first delivery, the average birth weight, use of instrumentation, and episiotomy rate were significantly higher in those women sustaining a severe laceration. When compared with women without a history of severe perineal laceration, women with such a history were at more than twice the risk for another in their subsequent delivery. The women at highest risk (21.4%) were those sustaining a laceration in their first delivery who underwent instrumental vaginal delivery with episiotomy in their subsequent delivery. When episiotomy or instrumental delivery was performed in the second vaginal birth, 52 (11.6%) of 449 women with a history of a severe perineal laceration sustained another, compared with 98 (6.5%) of 1509 without such a history (P < .001, odds ratio 1.9, 95% confidence interval 1.3, 2.7).

CONCLUSION

Women delivering their second baby, and in whom episiotomy or instrumentation is used, are at increased risk of severe perineal laceration compared with women delivery spontaneously.

Interactions between color and word processing in a flanker task

To examine interactions between color and word attributes, participants responded, either manually or vocally, to a central target (color patch or word) flanked by a Stroop stimulus. Color and word attributes of the flanker affected both vocal and manual responding to color patches. Color and word flankers also affected manual responding to word targets, but only word flanker affected vocal responding to word targets. These results are not consistent with models (e.g., translational models) of Stroop tasks, which posit that interactions between colors and words occur only when vocal responding is required.

Interactions between color and word processing in a flanker task

To examine interactions between color and word attributes, participants responded, either manually or vocally, to a central target (color patch or word) flanked by a Stroop stimulus. Color and word attributes of the flanker affected both vocal and manual responding to color patches. Color and word flankers also affected manual responding to word targets, but only word flanker affected vocal responding to word targets. These results are not consistent with models (e.g., translational models) of Stroop tasks, which posit that interactions between colors and words occur only when vocal responding is required.

Effect of dietary protein restriction on nutritional status in the Modification of Diet in Renal Disease Study

The safety of dietary protein and phosphorous restriction was evaluated in the Modification of Diet in Renal Disease (MDRD) Study. In Study A, 585 patients with a glomerular filtration rate (GFR) of 25 to 55 ml/min/1.73 m2 were randomly assigned to a usual-protein diet (1.3 g/kg/day) or a low-protein diet (0.58 g/kg/day). In Study B, 255 patients with a GFR of 13 to 24 ml/min/1.73 m2 were randomly assigned to the low-protein diet or a very-low-protein diet (0.28 g/kg/day), supplemented with a ketoacid-amino acid mixture (0.28 g/kg/day). The low-protein and very-low-protein diets were also low in phosphorus. Mean duration of follow-up was 2.2 years in both studies. Protein and energy intakes were lower in the low-protein and very-low-protein diet groups than in the usual-protein group. Two patients in Study B reached a "stop point" for malnutrition. There was no difference between randomized groups in the rates of death, first hospitalizations, or other "stop points" in either study. Mean values for various indices of nutritional status remained within the normal range during follow-up in each diet group. However, there were small but significant changes from baseline in some nutritional indices, and differences between the randomized groups in some of these changes. In the low-protein and very-low-protein diet groups, serum albumin rose, while serum transferrin, body wt, percent body fat, arm muscle area and urine creatinine excretion declined. Combining patients in both diet groups in each study, a lower achieved protein intake (from food and supplement) was not correlated with a higher rate of death, hospitalization or stop points, or with a progressive decline in any of the indices of nutritional status after controlling for baseline nutritional status and follow-up energy intake. These analyses suggest that the low-protein and very-low-protein diets used in the MDRD Study are safe for periods of two to three years. Nonetheless, both protein and energy intake declined and there were small but significant declines in various indices of nutritional status. These declines are of concern because of the adverse effect of protein calorie malnutrition in patients with end-stage renal disease. Physicians who prescribe low-protein diets must carefully monitor patients' protein and energy intake and nutritional status.

A placebo-controlled randomized trial of the terbutaline pump for prevention of preterm delivery

To determine the efficacy of the terbutaline pump for the prevention of preterm delivery, patients in preterm labor defined by progressive cervical change underwent intravenous magnesium sulfate tocolysis (with or without oral indomethacin, as necessary), and once labor was arrested, were randomized to one of three treatment arms: terbutaline by pump, saline by pump (blinded), or oral terbutaline. If recurrent preterm labor occurred despite maximization of therapy, the treatment arm was determined and therapy was changed; saline pump and oral terbutaline were switched to terbutaline pump, terbutaline pump was switched to oral terbutaline. Patients who continued to labor were readmitted for aggressive intravenous therapy. Women randomized to the terbutaline pump (n = 15), saline pump (n = 12), and oral terbutaline (n = 15) groups were similar in terms of gravidity, parity, days of tocolysis before study entry, gestational age at entry, and cervical dilatation at entry. The mean gestational age at delivery was the same in all three groups (35 weeks), as were neonatal outcomes. Terbutaline by pump, saline by pump, and oral terbutaline appear equivalent for the prevention of preterm delivery. The terbutaline pump should remain experimental.

Epidural recording of nerve conduction studies and surgical findings in radiculopathy

We developed a method of studying nerve conduction along proximal nerves and nerve roots by delivering supramaximal stimuli to the tibial and peroneal nerves within the popliteal space and recording compound nerve action potentials from an epidural needle electrode at the L4-L5 interspace. For the purpose of investigating lumbar radiculopathies, a battery of averaged potentials was developed that could be read side-to-side for symmetry of amplitude and latency. Decreased amplitude and/or increased latency in peroneal or tibial conduction studies was attributed to L5 or S1 root pathology respectively. We report on 22 patients who were studied with this method and subsequently went to surgery. To evaluate the ability of the procedure to predict surgical findings, we reviewed the last 155 patients that we studied using epidural recording to find those who had subsequently gone to surgery and were sufficiently documented to allow analysis. The review yielded 22 cases and 69 root levels whose condition had been reported at surgery and studied by our method. Agreement was above what might be expected by chance p < .0001 (7.462; sign). The agreement on nerve root condition between nerve conduction studies and surgical findings suggests that the procedure's usefulness for confirming and localizing pathology in nerve root entrapments is similar to that offered by nerve conduction studies for entrapment neuropathies elsewhere.

Class II furcations treated by guided tissue regeneration in humans: case reports

In the cases reported here, the response of Class II mandibular molar furcation defects to guided tissue regeneration (GTR) versus sham operation was evaluated. Base-line information, including probing pocket depth (PD) and clinical attachment level (CAL) measurements, was recorded after completion of the hygienic phase. Eleven experimental and six control furcations, randomly assigned, are included in this report. The furcations were surgically exposed, using a flap approach and the areas were debrided. On the experimental teeth, Gore-Tex periodontal material was adapted and sutured, using a suspensory suture. The flaps were then sutured tightly, assuring complete coverage to the material. For 1 month all patients were seen weekly and rinsed their mouths with an 0.12% chlorhexidine solution daily. After 4 to 6 weeks the Gore-Tex membranes were removed. Clinical measurements were repeated at 3 and 6 months following surgery. Changes from baseline in PD and CAL were calculated for each case. Results indicated that PD measurements were reduced by both procedures, but the reduction was better for GTR at 3 and 6 months. At six months the test sites showed 2.8 +/- 1.0 mm pocket reduction, while the control sites showed an average of 1.6 +/- 0.9 mm reduction in pocket depth. CAL recordings were improved by both treatments, but were better for GTR at 6 months, with an average gain in CAL of 1.8 mm for the GTR and 0.6 mm for the controls. These cases in which GTR was compared to sham-operated controls indicate that GTR can improve the response to therapy of Class II furcation defects.

Detection of excess disease near an exposure point: a case study

Many studies have evaluated the likelihood of adverse health effects associated with environmental contamination from point source exposures. Two statistical measures used in these studies are the ratio, R, of the observed to the expected number of cases occurring in the area containing the point and the average distance, D, between the cases and the point. This paper estimates the probability of detecting an association between disease and exposure when one actually exists (power) for R and D for several specific and plausible statistical models. Results are presented in the context of rare diseases such as congenital malformations. The practical implications of using these measures for the evaluation of risk of disease in environmental epidemiologic investigations are discussed.

An examination of three spatial disease clustering methodologies

Patterns of disease in space are often analysed to determine whether a relationship exists between a disease outcome and environmental exposures. This report examines the performance of three cluster analytical methods when applied to a single data set. These methods, designed to assess the purely spatial variation of events, have been examined to assess their ability to detect clustering in an area where disease rates have previously been shown to be significantly elevated. The ability of these methods to detect spatial clustering was also examined using simulation techniques. All three methods were found to be poor at detecting spatially localized disease rates which were approximately three time the expected rate, as measured by the relative risk.

Stereoselectivity of tocainide pharmacodynamics in vivo and in vitro

Racemic tocainide [R,S-T], which is used in the treatment of ventricular arrhythmias, consists of an R(-)-enantiomer [R-T] and an S(+)-enantiomer [S-T]. The present experiments examined these substances for pharmacodynamic differences. The ability of various doses of R-T, S-T, and R,S-T to both induce ataxia (A) and protect against chloroform-induced ventricular arrhythmias (P) in mice were compared at 20 min after subcutaneous treatment. For A effects, the ED50S (95% Fieller Limits) of R-T, S-T, and R,S-T were 125 (78-802), 125 (84-283), and 90 (61-149) mg/kg, respectively. For P effects, the ED50S were 40 (11-71), 116 (82-204), and 86 (55-187) mg/kg. The ratios of A/P, a measure of the margin of safety, were 3.1, 1.1, and 1.0. Effects upon intracardiac conduction in isolated rabbit hearts also exhibited, qualitatively, similar patterns of selectivity. At 1 X 10(-4) M intraatrial, His-Purkinje, intraventricular conduction times, and the QT interval were prolonged with the following order of potency: R-T greater than R,S-T greater than S-T; A-V nodal conduction was unchanged. R-T also evoked the greatest decrease in contractility. With respect to separation of antiarrhythmic action and the production of ataxia, R-T has a greater margin of safety than either S-T or R,S-T.

Transformations of maps to investigate clusters of disease

An approach is presented to display and analyze epidemiologic data using population density equalized maps (cartograms). The algorithm for generating these maps is discussed. A specific method for statistically analyzing plotted data is given, followed by an application of maps and analysis to 73 sets of age-, race-, sex-, and site-specific cancer incidence data. The data were obtained from the Surveillance, Epidemiology and End Results project for San Francisco City/County (1978-1981) and combined with 1980 U.S. Census data.

Intra-oral effects on acid-softened enamel of NaF lozenges administered in divided daily doses

The purpose of this investigation was to study the intra-oral effects of multiple daily applications of NaF lozenges upon acid-softened enamel. Bovine enamel slabs were softened with 0.1 mol/L lactate buffer at pH 4.0 for 14 hrs and subsequently mounted in a mandibular removable Hawley appliance. Control slabs were worn for seven days by eight adult male subjects who brushed their natural dentition daily with a fluoride-free dentifrice. Test slabs were exposed to one 0.55-mg NaF lozenge (0.25 mg F) 4x/day for seven days and the natural dentition brushed with a fluoride-free dentifrice. The efficacy of 0.25-mg F lozenges used 4x/day over that of a 1-mg F lozenge administered 1x/day was established by a pilot study with two subjects. Microhardness testing was performed after intra-oral exposure (IOE) and following immersion in 0.01 mol/L lactate buffer containing Ca and PO4 for 24 hrs at a pH of 4.0. Fluoride uptake was measured on separate control and test slabs after KOH wash and after acid-resistance-testing (ART). Recovery of microhardness following IOE was 40.9% for controls and 53.9% for treated slabs, while control slabs retained 1.3% resistance to ART, compared with 25.6% for test slabs. The F content of the control slabs was significantly less than that of lozenge-treated and lozenge-treated-ART slabs throughout the depth of the lesion. The F content of the lozenge-treated-ART slabs was significantly less than that of the lozenge-treated slabs only at the 0-5-microns depth.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of renal function on enalapril kinetics

Enalapril maleate (MK-421), a nonmercapto-containing angiotensin converting enzyme (ACE) inhibitor, is converted in vivo to enalaprilat (MK-422), the active diacid. We evaluated serum profiles and urinary excretion of oral enalapril maleate in patients with renal disease (group I, creatinine clearance less than 3 ml/min, patients undergoing dialysis, n = 10; group II, creatinine clearance 10 to 79 ml/min, n = 9) compared with healthy subjects (group III, creatinine clearance greater than 80 ml/min, n = 10). Group I received a 10 mg dose during a day while not receiving dialysis and a 10 mg dose 1 hour before dialysis 2 weeks later. Groups II and III received a single 10 mg dose. Blood samples and urine were collected for 48 hours. Impaired renal function resulted in elevated serum and plasma concentrations of enalapril maleate and decreased excretion rates and urinary recovery of enalapril maleate and enalaprilat. The data suggest an apparent increase in the extent of metabolism of enalapril maleate to enalaprilat or an increase in nonrenal elimination of unchanged enalapril maleate in renal disease compared with normal health. Enalaprilat was dialyzable.

Control of ACTH and vasopressin in neurohypophysectomized conscious dogs

Adrenocorticotropin (ACTH), cortisol, and vasopressin responses to clamped decreases in blood pressure (MAP) and to ovine corticotropin-releasing factor (CRF) infusion (20 ng X kg-1 X min-1) in intact and neurohypophysectomized (NHX) conscious dogs were examined. Mean arterial blood pressure was decreased 28 mmHg by a controlled infusion of sodium nitroprusside. Hypotension induced large increases in ACTH (peak 164 +/- 25 pg/ml), cortisol (peak 12.5 +/- 2.5 micrograms/dl), and vasopressin (peak 221 +/- 64 pg/ml) in intact (n = 7) dogs. NHX (n = 7) significantly attenuated these responses to hypotension. CRF infusion induced increases in ACTH similar in intact (n = 4) and NHX (n = 4) dogs. However, cortisol responses were significantly attenuated by NHX. Interestingly, CRF infusion induced small but significant increases in vasopressin from 3.0 +/- 1.1 to 8.1 +/- 2.0 pg/ml. We conclude that NHX attenuates ACTH and vasopressin responses to hypotension and cortisol responses to CRF-induced increases in ACTH. CRF seems to stimulate vasopressin release.

Ecologic regression analysis and the study of the influence of air quality on mortality

This presentation focuses entirely on the use and evaluation of regression analysis applied to ecologic data as a method to study the effects of ambient air pollution on mortality rates. Using extensive national data on mortality, air quality and socio-economic status regression analyses are used to study the influence of air quality on mortality. The analytic methods and data are selected in such a way that direct comparisons can be made with other ecologic regression studies of mortality and air quality. Analyses are performed by use of two types of geographic areas, age-specific mortality of both males and females and three pollutants (total suspended particulates, sulfur dioxide and nitrogen dioxide). The overall results indicate no persuasive evidence exists of a link between air quality and general mortality levels. Additionally, a lack of consistency between the present results and previous published work is noted. Overall, it is concluded that linear regression analysis applied to nationally collected ecologic data cannot be used to usefully infer a causal relationship between air quality and mortality which is in direct contradiction to other major published studies.

Influence of vasopressin and angiotensin on baroreflexes in the dog

Cardiovascular responses to step-changes of carotid sinus pressure were evaluated at normal and elevated levels of plasma arginine vasopressin in anesthetized neurohypophysectomized dogs (n = 12). Arginine vasopressin influenced autonomic function in two ways: first, maximum carotid reflex gain increased; second, cardiac output was decreased. The enhancement of reflex strength was observed only in response to decreases of intrasinus pressure below the equilibrium point (pressures of between 60 and 105 mm Hg). Aortic pressure rose twice as high for a given decrease of intrasinus pressure, elevations of total peripheral resistance responses were triple those observed at normal plasma arginine vasopressin. In this way, arginine vasopressin more than doubled the ability of the carotid reflexes to return a drop in arterial pressure to normal. Arginine vasopressin enhancement of reflex gain was not observed with elevations of intrasinus pressures above the equilibrium point. Elevation of aortic pressure expected from the vasoconstrictor actions of infused arginine vasopressin were buffered by associated reductions in cardiac output. Vagally mediated bradycardia was consistently observed with elevated arginine vasopressin, but the reflex response of heart rate to step-changes of intrasinus pressure was unchanged. Time control studies in five neurohypophysectomized dogs indicated no significant change in carotid reflex response over the 3- to 4-hour protocol. Comparison of reflex responses in anephric dogs (n = 8) at low and elevated levels of angiotensin II indicated that this vasoactive peptide did not significantly alter reflex responsiveness. We conclude that arginine vasopressin enhances the ability of the carotid reflexes to normalize decreases of arterial pressure, but buffers a rise in pressure from its own vasoactive properties by initiating a fall of cardiac output.

Inability of seven-pinhole myocardial tomography to obtain accurate 201Tl kinetic data

Seven-pinhole myocardial tomography has been reported to enhance the accuracy of thallium-201 (201Tl) studies in detecting patients with coronary artery disease. To determine if this approach can accurately assess regional 201Tl kinetics, 12 dogs with temporary occlusion (mean 15 min) of either the left anterior descending (LAD) (n = 6) or left circumflex (LCX) (n = 6) coronary artery were studied. Thallium-201 was injected and serial 7-pinhole images were acquired during occlusion and following reflow (mean duration 175 min). Time-activity analysis was obtained from normal and ischemic regions of interest in the central pinhole image and the reconstructed tomographic images (TOMO-ROI). Time-activity data from corresponding normal and ischemic regions were also obtained using a circumferential graph program (TOMO-MAX). In addition, regional myocardial 201Tl activity was recorded continuously with a cadmium telluride radiation probe sutured directly to the posterior myocardial wall. Defects in 201Tl distribution with subsequent partial or complete redistribution were present in 11 of 12 central pinhole images and tomographic studies. In the normal and ischemic anterior myocardial segments the percentage change in 201Tl activity in the central pinhole image from occlusion to the end of reflow correlated well with the percentage change in activity for both TOMO-ROI (r = 0.93) and TOMO-MAX (r = 0.85). In the normal posterior segments the percentage change in 201Tl activity in the central pinhole image correlated well with TOMO-ROI (r = 0.98) and TOMO-MAX (r = 0.87).(ABSTRACT TRUNCATED AT 250 WORDS)

An alternative to ecologic regression analysis of mortality rates

A number of recent papers have used geographically defined data and linear models to study the relationship between a series of epidemiologic factors and the frequency of disease. This "ecologic regression" approach involves serious problems of interpretation. An alternate approach is discussed that does not depend on statistical models, produces easily interpreted results and yields statistical summaries that approximately parallel regression analysis. This alternative procedure is illustrated by using acute lymphocytic leukemia mortality data on a county level from among white females less than five years of age between 1969-1977.

Requirement for OKT8+ suppressor cell proliferation for suppression by human newborn T cells

The percentage of cells bearing the suppressor phenotype OKT8+increases in PWM-stimulated cultures of human newborn lymphocytes. Prevention of this increase either by adding 50 microM deoxyguanosine to the cultures of by pretreating the newborn cells with OKT8 and complement reduced the suppressor activity of newborn T cells. These results suggest that newborn T cells are not intrinsically suppressive, but that they become so in vitro after stimulation by PWM.