Genetic association between the APOE ε4 allele, toxicant exposures and Gulf war illness diagnosis

INTRODUCTION

Exposure to nerve agents, pyridostigmine bromide (PB), pesticides, and oil-well fires during the 1991 Gulf War (GW) are major contributors to the etiology of Gulf War Illness (GWI). Since the apolipoprotein E (APOE) ε4 allele is associated with the risk of cognitive decline with age, particularly in the presence of environmental exposures, and cognitive impairment is one of the most common symptoms experienced by veterans with GWI, we examined whether the ε4 allele was associated with GWI.

METHODS

Using a case-control design, we obtained data on APOE genotypes, demographics, and self-reported GW exposures and symptoms that were deposited in the Boston Biorepository and Integrative Network (BBRAIN) for veterans diagnosed with GWI (n = 220) and healthy GW control veterans (n = 131). Diagnosis of GWI was performed using the Kansas and/or Center for Disease Control (CDC) criteria.

RESULTS

Age- and sex-adjusted analyses showed a significantly higher odds ratio for meeting the GWI case criteria in the presence of the ε4 allele (Odds ratio [OR] = 1.84, 95% confidence interval [CI = 1.07-3.15], p ≤ 0.05) and with two copies of the ε4 allele (OR = 1.99, 95% CI [1.23-3.21], p ≤ 0.01). Combined exposure to pesticides and PB pills (OR = 4.10 [2.12-7.91], p ≤ 0.05) as well as chemical alarms and PB pills (OR = 3.30 [1.56-6.97] p ≤ 0.05) during the war were also associated with a higher odds ratio for meeting GWI case criteria. There was also an interaction between the ε4 allele and exposure to oil well fires (OR = 2.46, 95% CI [1.07-5.62], p ≤ 0.05) among those who met the GWI case criteria.

CONCLUSION

These findings suggest that the presence of the ε4 allele was associated with meeting the GWI case criteria. Gulf War veterans who reported exposure to oil well fires and have an ε4 allele were more likely to meet GWI case criteria. Long-term surveillance of veterans with GWI, particularly those with oil well fire exposure, is required to better assess the future risk of cognitive decline among this vulnerable population.

Exposure-response relationship between K. brevis blooms and reporting of upper respiratory and neurotoxin-associated symptoms

In southwest Florida, Karenia brevis (K. brevis) blooms occur frequently, can be very intense and persist over several years. Individuals living in coastal communities around the Gulf of Mexico are particularly vulnerable to brevetoxins released by K. brevis in seawater and carried inland within marine aerosol. Exposure to K. brevis occurs during residential, recreational, and occupational activities and has been associated with upper respiratory tract (URT) symptoms in healthy and medically vulnerable individuals. Additionally, ingestion of brevetoxin-contaminated seafood causes neurotoxic shellfish poisoning (NSP), and severe headaches prompting emergency department visits which occur in excess during K. brevis blooms. The current study examined a dose-response relationship between K. brevis in coastal waters and URT and NSP-like symptoms and headaches among southwest Florida residents. Data on past medical history (PMH) and medical symptoms were collected from the participants (n = 258) in five southwest Florida counties between June 2019 to August 2021. A dose-response relationship was observed between K. brevis blooms and reporting of URT and NSP-like symptoms and headaches. Reporting of NSP-like symptoms was higher among participants with a PMH of migraines, chronic fatigue syndrome (CFS) and mild memory loss, while the association of headaches with K. brevis blooms was accentuated among individuals with a PMH of migraines. These results suggest further investigations into the threshold of aerosolized brevetoxin dose required to elicit URT, headaches and/or NSP-like symptoms. These symptoms ultimately cause significant public health safety concerns, primarily among vulnerable populations with preexisting neurological conditions.

Complication rate among people with diabetes at low risk of foot ulceration in Fife, UK: an analysis of routinely collected data

AIMS

To estimate the rate at which people with diabetes and a low risk of foot ulceration change diabetic foot ulceration risk status over time, and to estimate the rate of ulceration, amputation and death among this population.

METHODS

We conducted an observational study of 10 421 people with diabetes attending foot screening in an outpatient setting in NHS Fife, UK, using routinely collected data from a national diabetes register, NHS SCI Diabetes. We estimated the proportion of people who changed risk status and the cumulative incidence of ulceration, amputation and death, respectively, among people with diabetes at low risk of diabetic foot ulceration at 2-year follow-up.

RESULTS

At 2-year follow-up, 5.1% (95% CI 4.7, 5.6) of people with diabetes classified as low risk at their first visit had progressed to moderate risk. The cumulative incidence of ulceration, amputation and death was 0.4% (95% CI 0.3, 0.6), 0.1% (95% CI 0.1, 0.2) and 3.4% (95% CI 3.1, 3.8), respectively.

CONCLUSIONS

At 2-year follow-up, 5% of people at low risk of diabetic foot ulceration changed clinical risk status and <1% of people experienced foot ulceration or amputation. These findings provide information which will help to inform the current debate regarding optimal foot screening intervals.

Resection of vestibular schwannomas after stereotactic radiosurgery: a systematic review

OBJECTIVE

Multiple short series have evaluated the efficacy of salvage microsurgery (MS) after stereotactic radiosurgery (SRS) for treatment of vestibular schwannomas (VSs); however, there is a lack of a large volume of patient data available for interpretation and clinical adaptation. The goal of this study was to provide a comprehensive review of tumor characteristics, management, and surgical outcomes of salvage of MS after SRS for VS.

METHODS

The Medline/PubMed, Scopus, CINAHL, Cochrane Library, and Google Scholar databases were queried according to PRISMA guidelines. All English-language and translated publications were included. Studies lacking adequate study characteristics and outcomes were excluded. Cases involving neurofibromatosis type 2, previous MS, or malignant transformation were excluded when possible.

RESULTS

Twenty studies containing 297 cases met inclusion criteria. Three additional cases from Rush University Medical Center were added for 300 total cases. Tumor growth with or without symptoms was the primary indication for salvage surgery (92.3% of cases), followed by worsening of symptoms without growth (4.6%) and cystic enlargement (3.1%). The average time to MS after SRS was 39.4 months. The average size and volume of tumor at surgery were 2.44 cm and 5.92 cm3, respectively. The surgical approach was retrosigmoid (42.8%) and translabyrinthine (57.2%); 59.5% of patients had a House-Brackmann (HB) grade of I or II. The facial nerve was preserved in 91.5% of cases. Facial nerve preservation and HB grades were lower for the translabyrinthine versus retrosigmoid approach (p = 0.31 and p = 0.18, respectively); however, fewer complications were noted in the translabyrinthine approach (p = 0.29). Gross-total resection (GTR) was completed in 55.7% of surgeries. Studies that predominantly used subtotal resection (STR) were associated with a lower rate of facial nerve injury (5.3% vs 11.3%, p = 0.07) and higher rate of HB grade I or II (72.9% vs 48.0%, p = 0.00003) versus those using predominantly GTR. However, majority STR was associated with a recurrence rate of 3.6% as compared to 1.4% for majority GTR (p = 0.29).

CONCLUSIONS

This study showed that the leading cause of MS after SRS was tumor growth at an average of 39.4 months after radiation. There were no significant differences in outcomes of facial nerve preservation, postoperative HB grade, or complication rate based on surgical approach. Patients who underwent STR showed statistically significant better HB outcomes compared with GTR. MS after SRS was considered by most authors to be more difficult than primary MS. These data support the notion that the surgical goals of salvage surgery are debulking of tumor mass, decreasing compression of the brainstem, and not necessarily pursuing GTR.

Neurosarcoidosis Presenting as Isolated Bilateral Cerebellopontine Angle Tumors: Case Report and Review of the Literature

OBJECTIVES

To describe a unique case of isolated bilateral sarcoidosis of the cerebellopontine angle as well as the related imaging in the case. To conduct a literature review of the published articles regarding sarcoidosis of the cerebellopontine angle.

DATA SOURCES

Representative case report from a single institution as well as PubMed and Scopus database searches.

METHODS

In addition to a retrospective review, all published case reports and case series of sarcoidosis involving the cerebellopontine angle from 1960 to July 2018 in the English language were reviewed. Demographic data, presenting symptoms, and outcomes were collected.

RESULTS

We identified 8 total cases with pertinent clinical information that were included.

CONCLUSIONS

Isolated neurosarcoidosis of the cerebellopontine angle is an exceptionally rare phenomenon that, on history and imaging, presents similar to more common retrocochlear pathologies. Surgery may be required in large lesions unresponsive to traditional medical therapy with immunosuppression.

Dural Venous Sinus Thrombosis after Vestibular Schwannoma Surgery: The Anticoagulation Dilemma

Introduction  Dural venous sinus thrombosis (DVST) is a relatively understudied complication of vestibular schwannoma (VS) surgery. Several studies have examined this topic; however, there is limited data on the incidence, clinical progression, and proper management of this patient population. Methods  A retrospective review was performed for patients undergoing surgery for VS at a single institution. All postoperative imaging was reviewed for incidence of DVST. Demographic data were collected including tumor and surgical characteristics along with postoperative course. Results  A total of 63 patients underwent resection of their VS. The incidence of DVST was 34.9%. The operative time was greater in the dural venous sinus thrombosis (DSVT) group, at an average of 6.69 hours versus 4.87 in the no DSVT cohort ( p  = 0.04). Tumor size was correlationally significant ( p  = 0.051) at 2.75 versus 2.12 cm greatest diameter. The translabyrinthine approach was most prevalent (68.2%). The side of the thrombosis was ipsilateral to the tumor and surgery in all patients. The sigmoid sinus was most commonly involved (95.5%). Of them, 85% patients had a codominant or thrombus contralateral to the dominant sinus. All patients were asymptomatic. No patients were treated with anticoagulation. Resolution of thrombus was seen in five (22.7%) of the patients on last follow-up imaging. There were no hemorrhagic complications. Conclusion  The overall incidence of DVST was (34.9%) of 63 patients who underwent VS surgery. All patients were asymptomatic and none were treated with anticoagulation. In our study, continuing to observe asymptomatic patients did not lead to any adverse events.

The development and validation of a multivariable prognostic model to predict foot ulceration in diabetes using a systematic review and individual patient data meta-analyses

AIMS

Diabetes guidelines recommend screening for the risk of foot ulceration but vary substantially in the underlying evidence base. Our purpose was to derive and validate a prognostic model of independent risk factors for foot ulceration in diabetes using all available individual patient data from cohort studies conducted worldwide.

METHODS

We conducted a systematic review and meta-analysis of individual patient data from 10 cohort studies of risk factors in the prediction of foot ulceration in diabetes. Predictors were selected for plausibility, availability and low heterogeneity. Logistic regression produced adjusted odds ratios (ORs) for foot ulceration by ulceration history, monofilament insensitivity, any absent pedal pulse, age, sex and diabetes duration.

RESULTS

The 10 studies contained data from 16 385 participants. A history of foot ulceration produced the largest OR [6.59 (95% CI 2.49 to 17.45)], insensitivity to a 10 g monofilament [3.18 (95% CI 2.65 to 3.82)] and any absent pedal pulse [1.97 (95% CI 1.62 to 2.39)] were consistently, independently predictive. Combining three predictors produced sensitivities between 90.0% (95% CI 69.9% to 97.2%) and 95.3% (95% CI 84.5% to 98.7%); the corresponding specificities were between 12.1% (95% CI 8.2% to 17.3%) and 63.9% (95% CI 61.1% to 66.6%).

CONCLUSIONS

This prognostic model of only three risk factors, a history of foot ulceration, an inability to feel a 10 g monofilament and the absence of any pedal pulse, compares favourably with more complex approaches to foot risk assessment recommended in clinical diabetes guidelines.

Inhibition of ADAM10 promotes the clearance of Aβ across the BBB by reducing LRP1 ectodomain shedding

Background

Transport across the blood–brain barrier (BBB) is an important mediator of beta-amyloid (Aβ) accumulation in the brain and a contributing factor in the pathogenesis of Alzheimer’s disease (AD). One of the receptors responsible for the transport of Aβ in the BBB is the low density lipoprotein receptor-related protein 1 (LRP1). LRP1 is susceptible to proteolytic shedding at the cell surface, which prevents endocytic transport of ligands. Previously, we reported a strong inverse correlation between LRP1 shedding in the brain and Aβ transit across the BBB. Several proteases contribute to the ectodomain shedding of LRP1 including the α-secretase, a desintegrin and metalloproteinase domain containing protein 10 (ADAM10).

Methods

The role of ADAM10 in the shedding of LRP1 and Aβ BBB clearance was assessed through pharmacological inhibition of ADAM10 in an in vitro model of the BBB and through the use of ADAM10 endothelial specific knock-out mice. In addition, an acute treatment paradigm with an ADAM10 inhibitor was also tested in an AD mouse model to assess the effect of ADAM10 inhibition on LRP1 shedding and Aβbrain accumulation.

Results

In the current studies, inhibition of ADAM10 reduced LRP1 shedding in brain endothelial cultures and increased Aβ42 transit across an in vitro model of the BBB. Similarly, transgenic ADAM10 endothelial knockout mice displayed lower LRP1 shedding in the brain and significantly enhanced Aβ clearance across the BBB compared to wild-type animals. Acute treatment with the ADAM10-selective inhibitor GI254023X in an AD mouse model substantially reduced brain LRP1 shedding and increased Aβ40 levels in the plasma, indicating enhanced Aβ transit from the brain to the periphery. Furthermore, both soluble and insoluble Aβ40 and Aβ42 brain levels were decreased following GI254023X treatment, but these effects lacked statistical significance.

Conclusions

These studies demonstrate a role for ADAM10 in the ectodomain shedding of LRP1 in the brain and the clearance of Aβ across the BBB, which may provide a novel strategy for attenuating Aβ accumulation in the AD brain.

A repeating fast radio burst

Fast radio bursts are millisecond-duration astronomical radio pulses of unknown physical origin that appear to come from extragalactic distances. Previous follow-up observations have failed to find additional bursts at the same dispersion measure (that is, the integrated column density of free electrons between source and telescope) and sky position as the original detections. The apparent non-repeating nature of these bursts has led to the suggestion that they originate in cataclysmic events. Here we report observations of ten additional bursts from the direction of the fast radio burst FRB 121102. These bursts have dispersion measures and sky positions consistent with the original burst. This unambiguously identifies FRB 121102 as repeating and demonstrates that its source survives the energetic events that cause the bursts. Additionally, the bursts from FRB 121102 show a wide range of spectral shapes that appear to be predominantly intrinsic to the source and which vary on timescales of minutes or less. Although there may be multiple physical origins for the population of fast radio bursts, these repeat bursts with high dispersion measure and variable spectra specifically seen from the direction of FRB 121102 support an origin in a young, highly magnetized, extragalactic neutron star.

'Painting a path to wellness': correlations between participating in a creative activity group and improved measured mental health outcome

Responding to a call for quantitative outcome evidence about the therapeutic relationship between creative activity and mental health, this study examined the mental health outcomes of inpatients participating in art- and craft-based creative therapies at a private psychiatric hospital over a 5-year period. The creative activity group sample (n= 403) improved from admission to discharge across four different psychometric measures with moderate to strong mean effect sizes. Reductions from pre- to post-treatment in both self-reported and clinician-rated symptoms are clearly demonstrated for the creative activity group participant sample. Research findings establish that participation in creative activity has potential benefits for people experiencing mental health problems.

The value of FDG positron emission tomography/computerised tomography (PET/CT) in pre-operative staging of colorectal cancer: a systematic review and economic evaluation

OBJECTIVES

In the UK, colorectal cancer (CRC) is the third most common malignancy (behind lung and breast cancer) with 37,514 cases registered in 2006: around two-thirds (23,384) in the colon and one-third (14,130) in the rectum. Treatment of cancers of the colon can vary considerably, but surgical resection is the mainstay of treatment for curative intent. Following surgical resection, there is a comprehensive assessment of the tumour, it's invasion characteristics and spread (tumour staging). A number of imaging modalities are used in the pre-operative staging of CRCs including; computerised tomography (CT), magnetic resonance imaging, ultrasound imaging and positron emission tomography (PET). This report examines the role of CT in combination with PET scanning (PET/CT 'hybrid' scan). The research objectives are: to evaluate the diagnostic accuracy and therapeutic impact of fluorine-18-deoxyglucose (FDG) PET/CT for the pre-operative staging of primary, recurrent and metastatic cancer using systematic review methods; undertake probabilistic decision-analytic modelling (using Monte Carlo simulation); and conduct a value of information analysis to help inform whether or not there is potential worth in undertaking further research.

DATA SOURCES

For each aspect of the research - the systematic review, the handsearch study and the economic evaluation - a database was assembled from a comprehensive search for published and unpublished studies, which included database searches, reference lists search and contact with experts. In the systematic review prospective and retrospective patient series (diagnostic cohort) and randomised controlled trials (RCTs) were eligible for inclusion. Both consecutive series and series that are not explicitly reported as consecutive were included.

REVIEW METHODS

Two reviewers extracted all data and applied the criteria independently and resolved disagreements by discussion. Data to populate 2 × 2 contingency tables consisting of the number of true positives, true negatives, false positives and false negatives using the studies' own definitions were extracted, as were data relating to changes in management. Fourteen items from the Quality Assessment of Diagnostic Accuracy Studies checklist were used to assess the methodological quality of the included studies. Patient-level data were used to calculate sensitivity and specificity with confidence intervals (CIs). Data were plotted graphically in forest plots. For the economic evaluation, economic models were designed for each of the disease states: primary, recurrent and metastatic. These were developed and populated based on a variety of information sources (in particular from published data sources) and literature, and in consultation with clinical experts.

RESULTS

The review found 30 studies that met the eligibility criteria. Only two small studies evaluated the use of FDG PET/CT in primary CRC, and there is insufficient evidence to support its routine use at this time. The use of FDG PET/CT for the detection of recurrent disease identified data from five retrospective studies from which a pooled sensitivity of 91% (95% CI 0.87% to 0.95%) and specificity of 91% (95% CI 0.85% to 0.95%) were observed. Pooled accuracy data from patients undergoing staging for suspected metastatic disease showed FDG PET/CT to have a pooled sensitivity of 91% (95% CI 87% to 94%) and a specificity of 76% (95% CI 58% to 88%), but the poor quality of the studies means the validity of the data may be compromised by several biases. The separate handsearch study did not yield any additional unique studies relevant to FDG PET/CT. Models for recurrent disease demonstrated an incremental cost-effectiveness ratio of £ 21,409 per quality-adjusted life-year (QALY) for rectal cancer, £ 6189 per QALY for colon cancer and £ 21,434 per QALY for metastatic disease. The value of handsearching to identify studies of less clearly defined or reported diagnostic tests is still to be investigated.

CONCLUSIONS

The systematic review found insufficient evidence to support the routine use of FDG PET/CT in primary CRC and only a small amount of evidence supporting its use in the pre-operative staging of recurrent and metastatic CRC, and, although FDG PET/CT was shown to change patient management, the data are divergent and the quality of research is generally poor. The handsearch to identify studies of less clearly defined or reported diagnostic tests did not find additional studies. The primary limitations in the economic evaluations were due to uncertainty and lack of available evidence from the systematic reviews for key parameters in each of the five models. In order to address this, a conservative approach was adopted in choosing DTA estimates for the model parameters. Probabilistic analyses were undertaken for each of the models, incorporating wide levels of uncertainty particularly for the DTA estimates. None of the economic models reported cost-savings, but the approach adopted was conservative in order to determine more reliable results given the lack of current information. The economic evaluations conclude that FDG PET/CT as an add-on imaging device is cost-effective in the pre-operative staging of recurrent colon, recurrent rectal and metastatic disease but not in primary colon or rectal cancers. There would be value in undertaking an RCT with a concurrent economic evaluation to evaluate the therapeutic impact and cost-effectiveness of FDG PET/CT compared with conventional imaging (without PET) for the pre-operative staging of recurrent and metastatic CRC.

Demonstration of safety in Alzheimer's patients for intervention with an anti-hypertensive drug Nilvadipine: results from a 6-week open label study

BACKGROUND

Nilvadipine may lower rates of conversion from mild-cognitive impairment to Alzheimer's disease (AD), in hypertensive patients. However, it remains to be determined whether treatment with nilvadipine is safe in AD patients, given the higher incidence of orthostatic hypotension (OH) in this population, who may be more likely to suffer from symptoms associated with the further exaggeration of a drop in BP.

OBJECTIVE

The aim of this study was to investigate the safety and tolerability of nilvadipine in AD patients.

METHODS

AD patients in the intervention group (n = 56) received nilvadipine 8  mg daily over 6-weeks, compared to the control group (n = 30) who received no intervention. Differences in systolic (SBP) and diastolic (DBP) blood pressure, before and after intervention, was assessed using automated sphygmomanometer readings and ambulatory BP monitors (ABP), and change in OH using a finometer. Reporting of adverse events was monitored throughout the study.

RESULTS

There was a significant reduction in the SBP of treated patients compared to non-treated patients but no significant change in DBP. Individuals with higher initial blood pressure (BP) had greater reduction in BP but individuals with normal BP did not experience much change in their BP. While OH was present in 84% of the patients, there was no further drop in BP recorded on active stand studies. There were no significant differences in adverse event reporting between groups.

CONCLUSION

Nilvadipine was well tolerated by patients with AD. This study supports further investigation of its efficacy as a potential treatment for AD.

The risk of foot ulceration in people with diabetes screened in community settings: findings from a cohort study

BACKGROUND

Annual foot checks are recommended in patients with diabetes mellitus (DM) to identify those at risk of foot ulceration. Systematic reviews have found few studies evaluating the predictive value of tests in community-based diabetic populations.

AIM

To quantify the predictive value of clinical risk factors in relation to foot ulceration in a community population.

METHODS

A cohort of 1192 people with diabetes receiving care in community settings was recruited and a screening procedure, covering symptoms, signs and diagnostic tests was conducted at baseline. At an average 1-year follow-up patients who developed a foot ulcer were identified by an independent blind assessor. Multivariable analysis was performed to identify clinical predictors of foot ulceration.

FINDINGS

The incidence of foot ulceration was 1.93% [95% confidence interval (CI) 1.27-2.89). Three time-independent clinical predictors with five factors were selected: previous amputation [odds ratio (OR) 14.7, 95% CI 3.1-69.5), use of insulin before 3 months with inability to distinguish between cool and cold temperatures (OR 2.97, 95% CI 1.9-4.5) and failure to obtain at least one blood pressure reading for the calculation of ankle-brachial index with the failure to feel touch with a 10-g monofilament (OR 1.7, 95% CI 1.3-2.2).

INTERPRETATION

Recommendations for annual diabetic foot check in low-risk, community-based patients should be reviewed as absolute events of ulceration are low. The accuracy of foot risk assessment tools to predict ulceration requires evaluation in randomized controlled trials with concurrent economic evaluations.

A systematic review of oral treatments for fungal infections of the skin of the feet

OBJECTIVE

To synthesize the evidence for the effectiveness and cost-effectiveness of oral treatments for fungal infections of the skin of the feet.

DESIGN

Systematic review.

INTERVENTIONS

Oral treatments for fungal infections.

METHODS

Ten electronic databases, four journals and the bibliographies of all review papers identified were searched. The authors also wrote to international pharmaceutical companies and all podiatry schools in the UK. The studies selected were randomized trials of clinically diagnosed fungal skin infections of the foot that confirmed cure by culture and microscopy. Two reviewers independently selected trials and abstracted data using a structured tool including 12 recognized quality criteria.

RESULTS

Of 26 trials identified, 12 met the inclusion criteria and evaluated five different treatments. Single placebo-controlled trials showed that terbinafine and itraconazole were both effective. Two trials showed that terbinafine cures 50% more patients than griseofulvin. Four trials compared terbinafine with itraconazole, one showed that terbinafine given for 2 weeks had a better cure rate than 2 weeks of itraconazole, but the other three showed that it was no better than 4 weeks of itraconazole.

CONCLUSIONS

There is significant evidence that terbinafine is more effective than griseofulvin, though more costly. There is weak evidence that terbinafine may be more cost-effective than itraconazole. Firm recommendations about the choice between terbinafine and the azoles need further research.

The use of the Index of Orthodontic Treatment Need in dental primary care

OBJECTIVES

The primary objective of this survey was to assess the use of the Index of Orthodontic Treatment Need (IOTN) in dental primary care (Scottish general dental services - SGDS), and to compare orthodontic specialists (OS) and general dental practitioners (GDPs). The secondary objective was to explore the attitudes to mandatory introduction of the IOTN into the SGDS.

DESIGN

Postal, self completed questionnaire.

SETTING

Dental primary care, Scotland.Subjects Randomly selected sample of general dental practitioners (GDPs), n = 315, and all orthodontic specialist practitioners (OS), n = 49, identified as working in the SGDS.

MAIN OUTCOME MEASURES

Prevalence and experience of using the IOTN in the SGDS.

RESULTS

Response rate was 46% (n = 169). Eighty-four percent of respondents did not use the IOTN. Thirty-five percent of respondent GDPs had never heard of the IOTN. Respondents reported using the IOTN as an inter-colleague communication tool and to grade case complexity. GDPs perceived the IOTN as beneficial in setting national standards of practice; OS saw it as a tool to justify the allocation of NHS resources to patients. Responses indicate concerns that IOTN introduction will restrict access to orthodontic care.

CONCLUSIONS

The IOTN is not widely used in the SGDS but is perceived as standardising treatment need assessment by GDPs and justifying the allocation of NHS orthodontic resources to patients amongst OS. Introduction of mandatory IOTN grading is likely to be contentious - the following needs to be considered: the index profile should be raised; its advantages highlighted; concerns about restricted access to orthodontic care addressed; and perceived need for locally accessed training met.

Influence of environmental chemicals on drug therapy in humans: studies with contraceptive steroids

The effects have been studied of various environmental factors on the variability in response to oral contraceptive steroid therapy in women. Ten- to thirty-fold variations in plasma concentrations of norethisterone, L-norgestrel and ethinyloestradiol have been shown in samples taken 12 h after administration of oral contraceptives in mid-menstrual cycle. Factors shown to be responsible for this variation include passage into the enterohepatic circulation, a variable first-pass effect, and changes in metabolism in the gut wall or liver due to diet, disease, smoking or administration of drugs. Phenobarbitone and the antibiotic rifampicin increase both oestrogen and progestogen metabolism in women and in experimental animals by increasing hepatic and gut wall metabolism. In animals, other antibiotics (ampicillin, neomycin and lincomycin) suppress the gut flora that normally hydrolyse steroid conjugates excreted in bile; enterohepatic circulation or oral contraceptive steroids is thus reduced and their plasma concentrations lowered by up to 90%. In the human, ampicillin has a variable but less dramatic effect on elimination of oral contraceptives. Samples of gut wall mucosa obtained from patients with coeliac disease are defective in their ability to metabolize oral contraceptives. Cigarette smokers eliminate ethinyloestradiol more rapidly than non-smokers; an increased production of reactive steroid metabolites may thus be a cause of vascular disease in women who smoke and take contraceptive steroids.

The effect of advance telephone prompting in a survey of general dental practitioners in scotland: a randomised controlled trial

OBJECTIVES

Evaluation of advance telephone prompting on the response rate to a postal, self-completed questionnaire. To provide an estimate of the cost of such a strategy.

METHOD

A sample of 315 GDPs was randomly selected from a randomised database of GDPs practicing in Scotland. 157 GDPs were randomly allocated to receive an advance telephone prompt, via the practice receptionist; 158 were allocated to a control group. Four days after prompting all trial participants were mailed identical questionnaires, cover letter and postage paid return envelope.

RESULTS

Response rates: 53%--advance telephone prompt group and 40%--control group. The effect size, 13%, was found to be statistically significant, p = 0.026. Total estimated strategy costs: 74.00 pounds sterling. The incremental cost was estimated to be 4.93 pounds sterling for each additional response.

CONCLUSIONS

Advance telephone prompting of GDP's, via the practice receptionist, statistically significantly improves the response rate to a postal self-completed questionnaire. This is estimated to be a cost effective strategy for improving response rates to postal questionnaires.

A Bright Millisecond Radio Burst of Extragalactic Origin

Pulsar surveys offer a rare opportunity to monitor the radio sky for impulsive burst-like events with millisecond durations. We analyzed archival survey data and found a 30-jansky dispersed burst, less than 5 milliseconds in duration, located 3 degrees from the Small Magellanic Cloud. The burst properties argue against a physical association with our Galaxy or the Small Magellanic Cloud. Current models for the free electron content in the universe imply that the burst is less than 1 gigaparsec distant. No further bursts were seen in 90 hours of additional observations, which implies that it was a singular event such as a supernova or coalescence of relativistic objects. Hundreds of similar events could occur every day and, if detected, could serve as cosmological probes.

Topical treatments for fungal infections of the skin and nails of the foot

BACKGROUND

Fungal infections of the feet normally occur in the outermost layer of the skin (epidermis). The skin between the toes is a frequent site of infection which can cause pain and itchiness. Fungal infections of the nail (onychomycosis) can affect the entire nail plate.

OBJECTIVES

To assess the effects of topical treatments in successfully treating (rate of treatment failure) fungal infections of the skin of the feet and toenails and in preventing recurrence.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE and EMBASE (from inception to January 2005). We screened the Science Citation Index, BIOSIS, CAB - Health and Healthstar, CINAHL DARE, NHS Economic Evaluation Database and EconLit (March 2005). Bibliographies were searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) using participants who had mycologically diagnosed fungal infections of the skin and nails of the foot.

DATA COLLECTION AND ANALYSIS

Two authors independently summarised the included trials and appraised their quality of reporting using a structured data extraction tool.

MAIN RESULTS

Of the 144 identified papers, 67 trials met the inclusion criteria. Placebo-controlled trials yielded the following pooled risk ratios (RR) of treatment failure for skin infections: allylamines RR 0.33 (95% CI 0.24 to 0.44); azoles RR 0.30 (95% CI 0.20 to 0.45); ciclopiroxolamine RR 0.27 (95% CI 0.11 to 0.66); tolnaftate RR 0.19 (95% CI 0.08 to 0.44); butenafine RR 0.33 (95% CI 0.24 to 0.45); undecanoates RR 0.29 (95% CI 0.12 - 0.70). Meta-analysis of 11 trials comparing allylamines and azoles showed a risk ratio of treatment failure RR 0.63 (95% CI 0.42 to 0.94) in favour of allylamines. Evidence for the management of topical treatments for infections of the toenails is sparser. There is some evidence that ciclopiroxolamine and butenafine are both effective but they both need to be applied daily for prolonged periods (at least 1 year). The 6 trials of nail infections provided evidence that topical ciclopiroxolamine has poor cure rates and that amorolfine might be substantially more effective but more research is required.

AUTHORS' CONCLUSIONS

Placebo-controlled trials of allylamines and azoles for athlete's foot consistently produce much higher percentages of cure than placebo. Allylamines cure slightly more infections than azoles and are now available OTC. Further research into the effectiveness of antifungal agents for nail infections is required.

Predicting foot ulcers in patients with diabetes: a systematic review and meta-analysis

Clinical guidelines recommend that all patients with diabetes should be screened annually to establish their risk of foot ulceration. The aim of this systematic review was to quantify the predictive value of diagnostic tests, physical signs and elements from the patient's history in relation to diabetic foot ulcers. Observational studies were identified from: electronic databases (MEDLINE, EMBASE and CINAHL); bibliographies of studies meeting the inclusion criteria; review articles and clinical guidelines; direct contact with authors. Published reports of cohort and case-control studies were considered for inclusion. Pooled estimates were calculated from absolute numbers as weighted mean differences, standard mean differences or odds ratios. Adjusted odds ratios from published reports were also extracted. We identified five case-control and 11 cohort studies. The incidence of foot ulcers ranged from 8% to 17% in the cohort studies, with varying lengths of follow-up. Diagnostic tests and physical signs that detect peripheral neuropathy (biothesiometry, monofilaments and absent ankle reflexes), and those that detect excessive plantar pressure (peak plantar pressure and joint deformity) were all significantly associated with future diabetic foot ulceration. However, there was a paucity of evidence concerning the predictive value of symptoms and signs. Further research is needed to establish the independent factors associated with diabetic foot ulceration, particularly elements from a patient's history and physical examination.

Elucidation of some Bax conformational changes through crystallization of an antibody–peptide complex

The Bcl-2 family member Bax plays a critical role in apoptosis. In healthy resting cells, Bax resides in the cytoplasm and loosely attached to the mitochondrial membrane. Apoptotic stimuli induce Bax activation, which is characterized by translocation and multimerization on the mitochondrial membrane surface resulting in exposure of an amino terminal epitope recognized by the monoclonal antibody 6A7. To understand the structural changes that occur during Bax activation, we determined the crystal structure of a Bax peptide bound to the 6A7 Fab fragment to a resolution of 2.3 A. The structure reveals the conformation of the 6A7 peptide epitope on Bax in the activated form and elucidates the extensive structural changes that Bax must undergo during the conversion from its native to its activated conformation.

Clinical trials in dental primary care: what research methods have been used to produce reliable evidence?

OBJECTIVE

To identify controlled clinical trials done exclusively in dental primary care and to classify the research according to design. Details of any procedures used to recruit general dental practitioners and any special organisational arrangements were also collected.

DESIGN

A scoping literature review.

SETTING

Dental primary care defined as general dental practice, community and school dental settings.

PARTICIPANTS

Published randomised controlled trials using randomised or quasi randomised approaches and controlled clinical trials were considered for inclusion in the review. Reports were excluded if they did not describe either a randomised controlled trial or a controlled trial. Studies were excluded if the setting was not primary dental care or the intervention was for non-dental conditions. Conference abstracts without a full report and trials published in a language other than English were also excluded.

MAIN OUTCOMES

Experimental and quasi-experimental designs, clinical areas and different kinds of strategies used to recruit dentists, any organisational arrangements made to support research in dental primary care.

RESULTS

The search of the Cochrane Oral Health Group Controlled Trials Register found 174 articles. Forty-three randomised controlled trials met the inclusion criteria. Trials to evaluate the effects of interventions for types of anaesthesia, periodontal diseases, smoking cessation techniques, dental materials, organisational aspects of dental care, patient anxiety, post extraction healing rates, antibiotics were identified. All were done in general dental practice. Trials in school and community settings were also included.

CONCLUSIONS

Practice-based research needs to be encouraged to provide dental primary care with relevant evidence upon which effective treatment can be based. This review shows there are few trials done in dental primary care to inform clinical practice, most of which have been reported since 1997. The range of trial designs shows that this method of evaluation can be used to evaluate dental primary care interventions and this is promising for those with an interest in improving dental patient outcomes. More research on how to recruit dentists into clinical trial research must be done.

Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down

OBJECTIVE

To determine whether motivational interviewing--a behavioural therapy for addictions-provided at home by specially trained midwives helps pregnant smokers to quit.

DESIGN

Randomised controlled non-blinded trial analysed by intention to treat.

SETTING

Clinics attached to two maternity hospitals in Glasgow.

PARTICIPANTS

762/1684 pregnant women who were regular smokers at antenatal booking: 351 in intervention group and 411 in control group.

INTERVENTIONS

All women received standard health promotion information. Women in the intervention group were offered motivational interviewing at home. All interviews were recorded.

MAIN OUTCOME MEASURES

Self reported smoking cessation verified by plasma or salivary cotinine concentration.

RESULTS

17/351 (4.8%) women in the intervention group stopped smoking (according to self report and serum cotinine concentration < 13.7 ng/ml) compared with 19/411(4.6%) in the control group. Fifteen (4.2%) women in the intervention group cut down (self report and cotinine concentration less than half that at booking) compared with 26 (6.3%) in the control group. Fewer women in the intervention group reported smoking more (18 (5.1%) v 44 (10.7%); relative risk 0.48, 95% confidence interval 0.28 to 0.81). Birth weight did not differ significantly (mean 3078 g v 3048 g).

CONCLUSION

Good quality motivational interviewing did not significantly increase smoking cessation among pregnant women.

Interventions for treating plantar heel pain

BACKGROUND

Ten percent of people may experience pain under the heel (plantar heel pain) at some time. Injections, insoles, heel pads, strapping and surgery have been common forms of treatment offered. The absolute and relative effectiveness of these interventions are poorly understood.

OBJECTIVES

The objective of this review was to identify and evaluate the evidence for effectiveness of treatments for plantar heel pain.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (September 2002), the Cochrane Central Register of Controlled Trials Register (The Cochrane Library issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1988 to September 2002) and reference lists of articles and dissertations. Four podiatry journals were handsearched to 1998. We contacted all UK schools of podiatry to identify dissertations on the management of heel pain, and investigators in the field to identify unpublished data or research in progress. No language restrictions were applied.

SELECTION CRITERIA

Randomised and quasi-randomised trials of interventions for plantar heel pain in adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently evaluated randomised controlled trials for inclusion, extracted data and assessed trial quality. Additional information was obtained by direct contact with investigators. No poolable data were identified. Where measures of variance were available we have calculated the weighted mean differences based on visual analogue scale (VAS) scores.

MAIN RESULTS

Nineteen randomised trials involving 1626 participants were included. Trial quality was generally poor, and pooling of data was not conducted. All trials measured heel pain as the primary outcome. Seven trials evaluated interventions against placebo/dummy or no treatment. There was limited evidence for the effectiveness of topical corticosteroid administered by iontophoresis, i.e using an electric current, in reducing pain. There was some evidence for the effectiveness of injected corticosteroid providing temporary relief of pain. There was conflicting evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term (6 and 12 weeks) and therefore its effectiveness remains equivocal. In individuals with chronic pain (longer than six months), there was limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. There was no evidence to support the effectiveness of therapeutic ultrasound, low-intensity laser therapy, exposure to an electron generating device or insoles with magnetic foil. No randomised trials evaluating surgery, or radiotherapy against a randomly allocated control population were identified. There was limited evidence for the superiority of corticosteroid injections over orthotic devices.

REVIEWER'S CONCLUSIONS

Although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in randomised controlled trials. At the moment there is limited evidence upon which to base clinical practice. Treatments that are used to reduce heel pain seem to bring only marginal gains over no treatment and control therapies such as stretching exercises. Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. Orthoses should be cautiously prescribed for those patients who stand for long periods; there is limited evidence that stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than eight hours per day. Well designed and conducted randomised trials are required.

Confirmation of association between D10S583 and Alzheimer's disease in a case--control sample

Several independent studies have reported that loci on chromosome 10 are associated/linked with Alzheimer's disease (AD), including a family-based study demonstrating an association between the marker D10S583 and AD. We have examined the D10S583 polymorphic marker and apolipoprotein E (APOE) gene in a case-control study. We observed the expected association of the APOE allele varepsilon4 with AD, and an inverse association between the D10S583 allele 209 and AD. These data support the original findings that suggest the presence of a candidate gene for AD in this region of chromosome 10. The nearby insulin degrading enzyme gene has been previously proposed as a candidate gene; however, a number of other putative candidate genes are also located in this region. The ongoing investigation of the genetic source of association and linkage in this region is clearly warranted.

"Walk in to Work Out": a randomised controlled trial of a self help intervention to promote active commuting

STUDY OBJECTIVE

To determine if a self help intervention, delivered via written interactive materials (the "Walk in to Work Out" pack), could increase active commuting behaviour (walking and cycling).

DESIGN

Randomised controlled trial. The intervention group received the "Walk in to Work Out" pack, which contained written interactive materials based on the transtheoretical model of behaviour change, local information about distances and routes, and safety information. The control group received the pack six months later. Focus groups were also conducted after six months.

SETTING

Three workplaces in the city of Glasgow, Scotland, UK.

PARTICIPANTS

295 employees who had been identified as thinking about, or doing some irregular, walking or cycling to work.

MAIN RESULTS

The intervention group was almost twice as likely to increase walking to work as the control group at six months (odds ratio of 1.93, 95% confidence intervals 1.06 to 3.52). The intervention was not successful at increasing cycling. There were no distance travelled to work, gender, or age influences on the results. Twenty five per cent (95% confidence intervals 17% to 32%) of the intervention group, who received the pack at baseline, were regularly actively commuting at the 12 month follow up.

CONCLUSION

The "Walk in to Work Out" pack was successful in increasing walking but not cycling. The environment for cycling must be improved before cycling will become a popular option.

Oral treatments for fungal infections of the skin of the foot

BACKGROUND

About 15% of the population have fungal infections of the feet (tinea pedis or athlete's foot). Whilst there are many clinical presentations of tinea pedis the most common are between the toes (interdigital) and on the soles, heels and sides of the foot (plantar) which is known as moccasin foot. Once acquired the infection can spread to other sites including the nails, which can be a source of reinfection. Oral therapy is usually used for chronic conditions or when topical treatment has failed.

OBJECTIVES

To assess the effects and costs of oral treatments for fungal infections of the skin of the foot (tinea pedis).

SEARCH STRATEGY

Randomised controlled trials were identified from MEDLINE, EMBASE and CINAHL from the beginning of these databases to January 2000. We also searched the Cochrane Controlled trials Register (Cochrane Library issue 1, 2000) the Science Citation Index, BIOSIS, CAB-Health, Health star and Economic databases. Bibliographies were searched, podiatry journals hand searched and the pharmaceutical industry and schools of podiatry contacted.

SELECTION CRITERIA

Randomised controlled trials including participants who have a clinically diagnosed tinea pedis, confirmed by microscopy and growth of dermatophytes in culture.

DATA COLLECTION AND ANALYSIS

Study selection was done by two independent reviewers. Methodological quality assessment and data collection was also assessed by two independent reviewers.

MAIN RESULTS

Twelve trials, involving 700 participants, were included. The two trials comparing terbinafine and griseofulvin produced a pooled risk difference of 52% (95% confidence intervals 33% to 71%) in favour of terbinafine's ability to cure infection. No significant difference was detected between terbinafine and itraconazole; fluconazole and either itraconazole and ketoconazole; or between griseofulvin and ketoconazole, although the trials were generally small. Two trials showed that terbinafine and itraconazole were effective compared with placebo. Adverse effects were reported for all drugs, with gastrointestinal effects most commonly reported.

REVIEWER'S CONCLUSIONS

The evidence suggests that terbinafine is more effective than griseofulvin and that terbinafine and itraconazole are more effective than no treatment.

The microtubule associated protein Tau gene and Alzheimer's disease--an association study and meta-analysis

Several studies have suggested an association between polymorphisms and an extended haplotype of the microtubule associated protein tau gene and Alzheimer's disease (AD) in synergy with apolipoprotein E (APOE) epsilon 4 status. However these findings have not been consistently replicated. We investigated the role of the tau haplotype in AD by conducting an association study as well as a meta-analysis of all the studies conducted to date. We examined six polymorphisms known to be in the extended tau haplotypes, one in exon 7 and five in and around exon 9 in 200 late onset AD and 189 control samples. All the polymorphisms examined fell into the recognised tau haplotypes. There was no statistical significant association with any of the polymorphisms and late onset AD. Stratification of data by APOE epsilon 4 status also produced no strongly significant association. The meta-analysis showed no significant differences between AD cases and controls, however stratification of data by APOE epsilon 4 status showed a small significant decrease in the H1 haplotype in AD before correction for multiple testing.

Cholesterol accumulates in senile plaques of Alzheimer disease patients and in transgenic APP(SW) mice

Mounting evidence suggests that cholesterol may contribute to the pathogenesis of Alzheimer disease (AD). We examined whether cholesterol might be present in senile plaques, a hallmark neuropathological feature of AD. We employed 2 different fluorometric-staining techniques (filipin staining and an enzymatic technique) for the determination of cholesterol in brains of postmortem confirmed AD patients and in nondemented, age-matched histopathologically normal controls. AD patient brains showed abnormal accumulation of cholesterol in congophilic/birefringent dense cores of senile plaques that was essentially absent in histopathologically normal controls. To determine whether increased senile plaque-associated cholesterol occurred generally in all plaques or was restricted to a specific subset, quantitative analysis was performed. Data indicate abnormal accumulation of cholesterol in cores of mature plaques but not in diffuse or immature plaques. Additionally, transgenic mice that overexpress the "Swedish" amyloid precursor protein (Tg APP(SW), line 2576) exhibited a similar pattern of abnormal cholesterol accumulation in mature, congophilic amyloid plaques at 24 months of age that was absent in their control littermates or in 8-month-old Tg APP(SW) mice (an age prior to amyloid deposition). Taken together, our results imply a link between cholesterol and AD pathogenesis and suggest that cholesterol plays an important role in the formation and/or progression of senile plaques.

TCR-induced transmembrane signaling by peptide/MHC class II via associated Ig-alpha/beta dimers

Previous findings suggest that during cognate T cell-B cell interactions, major histocompatability complex (MHC) class II molecules transduce signals, leading to Src-family kinase activation, Ca2+ mobilization, and proliferation. Here, we show that antigen stimulation of resting B cells induces MHC class II molecules to associate with Immunoglobulin (Ig)-alpha/Ig-beta (CD79a/CD79b) heterodimers, which function as signal transducers upon MHC class II aggregation by the T cell receptor (TCR). The B cell receptor (BCR) and MHC class II/Ig-alpha/Ig-beta are distinct complexes, yet class II-associated Ig-alpha/beta appears to be derived from BCR. Hence, Ig-alpha/beta are used in a sequential fashion for transduction of antigen and cognate T cell help signals.

Extracts from "Clinical evidence": Athlete's foot and fungally infected toenails

Definition Athlete's foot is a cutaneous fungal infection that causes the skin to itch, flake, and fissure. Nail involvement is characterised by ungual thickening and discoloration.

CD45 opposes beta-amyloid peptide-induced microglial activation via inhibition of p44/42 mitogen-activated protein kinase

Reactive microglia have been suggested to play a role in the Alzheimer's disease (AD) process, and previous studies have shown that expression of CD45, a membrane-bound protein-tyrosine phosphatase (PTP), is elevated in microglia in AD brain compared with controls. To investigate the possible role of CD45 in microglial responsiveness to beta-amyloid (Abeta) peptides, we first co-treated primary cultured microglia with a tyrosine phosphatase inhibitor [potassium bisperoxo (1,10-phenanthroline) oxovanadate (phen), 5 micrometer] and freshly solubilized Abeta peptides (1000 nm). Data show synergistic induction of microglial activation as evidenced by tumor necrosis factor alpha (TNF-alpha) production and nitric oxide (NO) release, both of which we show to be dependent on activation of p44/42 mitogen-activated protein kinase (MAPK). Furthermore, co-treatment with phen and Abeta peptides results in microglia-induced neuronal cell injury. Stimulation of microglial CD45 by anti-CD45 antibody markedly inhibits these effects via inhibition of p44/42 MAPK, suggesting that CD45 is a negative regulator of microglial activation. Accordingly, primary cultured microglia from CD45-deficient mice demonstrate hyper-responsiveness to Abeta, as evidenced by TNF-alpha release, NO production, and neuronal injury after stimulation with Abeta peptides. As a validation of these findings in vivo, brains from a transgenic mouse model of AD [transgenic Swedish APP-overexpressing (Tg APP(sw)) mice] deficient for CD45 demonstrate markedly increased production of TNF-alpha compared with Tg APP(sw) mice. Taken together, these results suggest that therapeutic agents that stimulate the CD45 PTP signaling pathway may be effective in suppressing microglial activation associated with AD.

Direct enumeration of Borrelia-reactive CD4 T cells ex vivo by using MHC class II tetramers

We characterized antigen-specific CD4(+) T cells in six patients with treatment-resistant Lyme arthritis, using an HLA-DRB1*0401 major histocompatibility complex (MHC) class II tetramer covalently loaded with OspA(164-175), an immunodominant epitope of Borrelia burgdorferi. Direct analysis of OspA-tetramer binding CD4(+) cells in patients expressing the HLA-DRB1*0401 allele revealed frequencies of between <0.005 and 0.1% in peripheral blood (n = 6), and between <0.005 and 3.1% in synovial fluid (n = 3). OspA-tetramer(+)CD4(+) cells were directly cloned at 1 cell per well and expanded by mitogen and IL-2 on allogeneic feeder cells. As measured by [(3)H]thymidine incorporation, 95% of 168 T cell clones from synovial fluid binding the OspA-tetramer were antigen-reactive. Clones generated from peripheral blood revealed a different pattern of responsiveness when compared with clones generated from synovial fluid, as measured by proliferation, IFN-gamma, and IL-13 secretion. These clones, selected on the basis of their peptide binding, also responded to whole protein, but with a different cytokine profile. Our studies demonstrate that MHC class II tetramers can be used in humans to directly identify, isolate, and characterize antigen-reactive T cells from an inflammatory compartment.

Apolipoprotein-E epsilon 4 allele frequency and conferred risk for Cuban Americans with Alzheimer's disease

The authors compared Apo-E epsilon 4 frequencies for Cuban American and white non-Hispanic persons with and without Alzheimer's disease (AD). The Apo-E epsilon 4 allele conferred as large a risk for AD in Cuban Americans as for white non-Hispanics, a finding that differs from those for Hispanic subjects as a whole.

A pilot study to establish a randomized trial methodology to test the efficacy of a behavioural intervention

How can pregnant women be helped to stop smoking? This was a pilot study of midwife home-based motivational interviewing. Clients were 100 consecutive self-reported smokers booking at clinics in Glasgow from March to May 1997. Smoking guidance is routinely given at booking. In addition, intervention clients received a median of four home-based motivational interviewing sessions from one specially trained midwife. All sessions (n = 171) were audio-taped and interviews (n = 49) from 13 randomly selected clients were transcribed for content analysis. Three 'experts' assessed intervention quality using a recognized rating scale. Cotinine measurement on routine blood samples confirmed self-reported smoking change from late pregnancy telephone interview. Postnatal telephone questionnaire measured client satisfaction. Focus groups of routine midwives explored acceptability, problems and disruption of normal care. Fisher exact, chi 2 and Mann-Whitney tests compared enrolment characteristics. Two-sample t-tests assessed outcome between groups. Motivational interviewing was satisfactory in more than 75% of transcribed interviews. In this pilot study, self-reported smoking at booking (100 of 100 available) corroborated by cotinine (93 of 100) compared with late pregnancy self-reports (intervention 47 of 48; control 49 of 49) and cotinine (intervention 46 of 48; control 47 of 49) showed no significant difference between groups. Tools have been developed to answer the question: 'Can proactive opportunistic home-based motivational interviewing help pregnant smokers reduce their habit?'.

No association between the very low density lipoprotein receptor gene and late-onset Alzheimer's disease nor interaction with the apolipoprotein E gene in population-based and clinic samples

It is now commonly known that possession of one of the three common alleles of the apolipoprotein E (APOE) gene (allele epsilon 4) confers an increased risk for both familial and sporadic Alzheimer's disease (AD), and that this risk is dose-dependent. Other genes that may play a role in AD, either through independent association with the disease or through modification of the existing APOE risk, are under investigation. One such gene, the very low density lipoprotein receptor (VLDL-R) gene, was reported by Okuizumi et al. to be independently associated with AD in a Japanese population, but not interactive with the APOE4 conferred risk. Their clinic-based data set demonstrated a 2-fold increased risk conferred by the 5-repeat allele of a polymorphism in VLDL-R. As recruitment from a clinic rather than a population-based sample may result in a distortion of allele frequencies, as has been shown with APOE allele frequencies, it is important to investigate this association in a population-based study. We have genotyped both population and clinic-based AD data sets at this VLDL-R polymorphism, and we find no independent association between the VLDL-R gene and the occurrence of AD in either sample. Further, despite the biochemical relationship between the VLDL-R and APOE proteins, we find no significant statistical interaction between the alleles at these loci.

Elevated A beta and apolipoprotein E in A betaPP transgenic mice and its relationship to amyloid accumulation in Alzheimer's disease

BACKGROUND

Amyloid-beta (A beta) accumulates in plaques and as cerebral amyloid angiopathy (CAA) in the brains of both Alzheimer's disease (AD) patients and transgenic A betaPPswe/tg2576 (tg2576) mice. Increasingly, evidence in humans and mice shows this process to be modulated by apolipoprotein E (apoE).

MATERIALS AND METHODS

To explore this relationship, we measured apoE and A beta levels in brains of tg2576 mice and controls at intervals between 2 and 20 months. In addition, A beta concentrations in plasma and muscle of these animals were also quantified.

RESULTS

Quite strikingly, we found that the amount of tg2576 mice brain apoE was elevated by an average of 45%, relative to the control mice from 2 months on. The level of brain apoE soared after 14 months to almost 60% greater than the level found in control mice. A beta concentrations in brains before 9 months were less than 2 ng/mg of protein, but by 14 months concentrations rose to 8.7 ng/mg, and by 20 months to 47 ng/mg. In plasma, we noted that the levels of A beta in tg2576 mice declined from above 30 ng/ml prior to 12 months to 14 ng/ml by 14 months. Histology showed that A beta plaques and CAA began to be discernible in the tg2576 mice at about 9 and 20 months of age, respectively.

CONCLUSIONS

ApoE was immunocytochemically detected in neuritic plaques that were positive for thioflavine-S. We suggest that the elevation of brain apoE in tg2576 mice participates in an age-related dysregulation of A beta clearance and signals the start of A beta sequestration during the time of cognitive dysfunction.

A beta vasoactivity in vivo

Bilateral temporoparietal hypoperfusion has been frequently observed early in the Alzheimer's disease (AD) process. The beta-amyloid (A beta) peptide is believed to play a central role in the pathogenesis of AD. In vitro experiments have shown that freshly solubilized A beta enhances constriction of cerebral and peripheral vessels. We proposed that in vivo, A beta would also have vasoactive properties. To test this hypothesis, we intraarterially infused freshly solubilized A beta 1-40 in rats and observed changes in peripheral blood pressure, cerebral blood flow, and cerebrovascular resistance. We found that infusion of A beta in vivo significantly increased the blood pressure in hypotensive rats but not in normotensive and hypertensive rats. Moreover, A beta infusion also resulted in a decreased blood flow and increased vascular resistance specifically in cerebral cortex but not in heart or kidneys. These data suggest that A beta has a direct and specific constrictive effect on cerebral vessels in vivo, which may contribute to the cerebral hypoperfusion observed early in the AD process.