Effects of Activity Tracker Use With Health Professional Support or Telephone Counseling on Maintenance of Physical Activity and Health Outcomes in Older Adults: Randomized Controlled Trial

BACKGROUND

Despite a range of efforts to increase physical activity participation in Australia, inactivity levels in older adults have remained high over recent decades, contributing to increased rates of chronic health conditions. Lifestyle interventions, including telephone counseling (TC), improve physical activity participation and associated health outcomes over the short term; however, ongoing feedback and support is required to maintain these changes. Newer technologies such as wearable activity trackers (ATs) may offer an alternative method for providing ongoing support.

OBJECTIVE

This study aims to investigate whether newer technologies such as wearable ATs assist in providing ongoing support to maintain physical activity levels and health outcomes.

METHODS

Older adults aged >60 years who had just completed a 12-week face-to-face individualized community exercise program in Tasmania, Australia, participated in the study. They were randomized to receive AT, TC, or usual care (UC). All groups received a home exercise program and an optional referral to a community-based exercise program. The AT group also received an AT and text message feedback from an accredited exercise physiologist (AEP). The TC group received phone calls from an AEP throughout the 12-month intervention. The primary outcome was daily steps measured by an ActivPAL (TM) accelerometer at baseline and at 3, 6, and 12 months. Secondary outcome measures included body composition, blood pressure, 10-time sit-to-stand (TTSTS) test, timed up and go test, and cardiorespiratory fitness. This trial was approved by the Tasmanian Health and Medical Human Research Ethics Committee (H0014713).

RESULTS

A total of 117 participants were randomized to the study (AT, n=37; TC, n=38; UC, n=42). At baseline, the participants (75/117, 64.1% female; mean age 72.4 years, SD 6.4) completed an average of 6136 steps (SD 2985) per day. Although there were no significant differences between groups, the TC and AT groups maintained daily step counts (mean difference [MD] -79 steps, 95% CI -823 to 663 steps; P=.81; and MD -588 steps, 95% CI -1359 to 182 steps; P=.09), and UC showed a reduction in daily steps (MD 981 steps, 95% CI -1668 to -294 steps; P=.003) during the 12-month period. Diastolic blood pressure was significantly higher after AT than after UC (MD 5.62 mm Hg, 95% CI 1.30 to 9.94 mm Hg; P=.01), and TTSTS was significantly slower on TC compared with UC (MD 2.36 seconds, 95% CI -0.14 to 4.87 seconds; P=.03).

CONCLUSIONS

The use of an AT with AEP support or TC is effective at maintaining daily step count in older adults over a 12-month period, suggesting that wearable ATs are as effective as TC. Further research to investigate which option is more cost-effective would be beneficial.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12615001104549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369118.

The effectiveness of a four-layer compression bandage system in comparison with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers: a randomised controlled trial

An increasing number of compression systems available for treatment of venous leg ulcers and limited evidence on the relative effectiveness of these systems are available. The purpose of this study was to conduct a randomised controlled trial to compare the effectiveness of a four-layer compression bandage system and Class 3 compression hosiery on healing and quality of life (QL) in patients with venous leg ulcers. Data were collected from 103 participants on demographics, health, ulcer status, treatments, pain, depression and QL for 24 weeks. After 24 weeks, 86% of the four-layer bandage group and 77% of the hosiery group were healed (P = 0·24). Median time to healing for the bandage group was 10 weeks, in comparison with 14 weeks for the hosiery group (P = 0·018). The Cox proportional hazards regression found participants in the four-layer system were 2·1 times (95% CI 1·2-3·5) more likely to heal than those in hosiery, while longer ulcer duration, larger ulcer area and higher depression scores significantly delayed healing. No differences between groups were found in QL or pain measures. Findings indicate that these systems were equally effective in healing patients by 24 weeks; however, a four-layer system may produce a more rapid response.

Long-term histologic and mechanical results of a Permacol™ abdominal wall explant

PURPOSE

We hypothesize that Permacol™ may allow controlled integration over time while providing long-term mechanical stability and native tissue remodeling. The purpose of this report is to investigate these properties in an explanted piece of Permacol™ after 2 years in vivo.

METHODS

A 62-year-old female presented with a complex abdominal wall history having undergone a transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction 10 years ago, followed by an abdominal wall repair with Marlex™ mesh for weakness 3 years later. Two years ago, she developed an abdominal bulge repaired with a Permacol™ overlay. Twenty-three months postoperatively, she presented with abdominal distension. Computed tomography (CT) scanning demonstrated a fluid collection behind the Permacol™. She underwent incision and drainage of the hematoma/bursa and quilting repair of the abdominal wall. A 1 × 6-cm Permacol™ section was resected as part of closure. Histology, immunohistochemistry, and mechanical testing of the Permacol™ explant were performed.

RESULTS

Histology showed fibroblast and blood vessel ingrowth with no cellular infiltrates reflective of inflammation. Immunohistochemistry for human-specific collagen types I and III and elastin detected staining throughout. Sections stained with non-specific control antibody exhibited no discernable staining. Elastin highlighted blood vessels. Native Permacol™ had a breaking strength of ~20 N, while for explanted Permacol™, it was ~33 N.

CONCLUSIONS

Permacol™ maintained durability while allowing vascular ingrowth without residual inflammation. Explant demonstrated integration with human collagen and elastin remodeling throughout. Increase in mechanical strength may reflect newly synthesized collagen and elastin. These histologic findings and clinical result support the use of Permacol™ in complex abdominal wall reconstruction.

Resistance training and bone mineral density during growth

This study examined the efficacy of two different resistance training programs in enhancing bone modeling and bone mineral density (BMD) in maturating rats. One exercise mode involved lifting a lighter weight with more repetitions (LI), while the other regimen involved lifting a heavier weight with fewer repetitions (HI) where the total volume of work between exercise programs was equivalent by design. Twenty-three male rats were randomly divided into control (Con, n = 8), LI (n = 7), and HI (n = 8) groups. The LI and HI groups were conditioned to climb a vertical ladder with weights appended to their tail 4 days/wk for 6 wks. After training, serum osteocalcin (OC) was significantly (p < 0.05) higher in both HI (45.2 +/- 1.7 ng/ml) and LI (39.1 +/- 2.2 ng/ml) when compared to Con (29.9 +/- 0.9 ng/ml). Left tibial BMD was significantly (p < 0.05) greater for HI (0.231 +/- 0.004 g/cm (2)) when compared to both LI (0.213 +/- 0.003 g/cm (2)) and Con (0.206 +/- 0.005 g/cm (2)) with no significant difference between LI and Con. The results indicate that both HI and LI are effective in elevating serum OC, implicating an osteogenic response; however, only HI resulted in a significant elevation in BMD.

Economic evaluation of therapeutic interventions to prevent Type 2 diabetes in Canada

AIMS

To compare the health and economic outcomes of using acarbose, an intensive lifestyle modification programme, metformin or no intervention to prevent progression to diabetes in Canadian individuals with impaired glucose tolerance (IGT).

METHODS

A model was developed to simulate the course of individuals with IGT under each treatment strategy. Patients remain in the IGT state or transition from IGT to diabetes, to normal glucose tolerance (NGT) or to death. Effectiveness and resource use data were derived from published intervention trials. A comprehensive health-care payer perspective incorporating all major direct costs, reported in 2000 Canadian dollars, was adopted.

RESULTS

Over a decade, 70 of the 1000 untreated patients are expected to die and 542 develop diabetes. Intensive lifestyle modification is estimated to prevent 117 cases of diabetes, while metformin would prevent 52 and acarbose 74 cases. The proportion of those who return to NGT also increases with any treatment. While lifestyle modification is more effective, it can increase overall costs depending on how it is implemented, whereas acarbose and metformin reduce costs by nearly $1000 per patient. Lifestyle modification was cost effective, varying from CAD $10 000/LYG vs. acarbose. Acarbose costs somewhat more than metformin, but is more effective: CAD $1798/LYG.

CONCLUSION

The results of this model suggest that the treatment of IGT in Canada is a cost-effective way to prevent diabetes and may generate savings. While pharmacological treatments tended to be less costly, intensive lifestyle modification, if maintained, led to the greatest health benefits at reasonable incremental costs.

Expression of mCLOCK and other circadian clock-relevant proteins in the mouse suprachiasmatic nuclei

Circadian timing in mammals is based upon the cell-autonomous clockwork located in the suprachiasmatic nuclei (SCN) of the hypothalamus. It is thought to involve interlocked feedback loops in which periodic transcriptional drive to core clock genes is mediated by CLOCK/BMAL1 heterodimers. Negative-feedback actions of the encoded proteins PER and CRY terminate this phase of the cycle. In lower species, rhythmic abundance of the mCLOCK homologue initiates the subsequent cycle. By contrast, it is proposed that the new circadian cycle in mammals is triggered by indirect, positive transcriptional actions leading to a subsequent surge in BMAL1. The aim of this study was to test predictions made by this model concerning the behaviour of the native clock factor mCLOCK in the mouse SCN. Using in situ hybridization, immunocytochemistry, Western blotting and immunoprecipitation, we demonstrate constitutive expression of mCLOCK as a nuclear antigen in the SCN. mCLOCK forms alternating, periodic associations with either mBMAL1 or the negative regulators mPER and mCRY. The results confirm predictions made by the "two-loop" model of the mouse clock, and further highlight the role of interlocked cycles of positive and negative transcriptional regulatory complexes at the heart of the circadian clockwork.

Utilization of health care services by patients with chronic obstructive pulmonary disease

In order to identify healthcare resource use patterns associated with chronic obstructive pulmonary disease (COPD), resource utilization (RU) data collection was integrated into a randomized, double-blind placebo-controlled study of Viozan (sibenadet HCl). This study enrolled patients with symptomatic, smoking-related COPD, randomized to receive sibenadet or placebo for a 52-week treatment period. A questionnaire establishing typical pre-trial, COPD-related RU was completed by each patient. Subsequent data were collected by means of an Interactive Voice Response System (IVRS) at 30-day intervals (14 time points) during the study and in the follow-up period. The IVRS system facilitated data collection and minimized inconvenience to the patient. Compliance with the requirement to record details of the healthcare services during the year-long study was high. No overall trend for lower RU was associated with sibenadet therapy, which correlates with the lack of sustained clinical effect seen in studies conducted concurrently. These data do, however, provide valuable information on RU associated with COPD and insights into adjustments associated with changes in disease course. Physicians were seen to be the most common source of care for patients with COPD and more of the patients with severe COPD (stage III) than mild (stage I) were seen to utilize the most expensive resources (e.g. inpatient hospital care). For those patients who experienced an exacerbation during the trial (irrespective of treatment group), resource use was increased during the periods when an exacerbation was reported when compared with the periods before or after an exacerbation. The proportion of cases attending the physician doubled and with a trip to the Emergency Room (ER) increased approximately ninefold during the reporting period in which the exacerbation occurred compared with the previous month. This study has shown that use of an IVRS, even in elderly patients, is an effective means of gathering RU data over long periods. The study findings suggest that the advent of effective therapeutic interventions, particularly any with the ability to minimize exacerbations and limit disease progression, could impact on the health care services used and potentially reduce associated costs.

Modifications to the hand-held Gene Gun: improvements for in vitro biolistic transfection of organotypic neuronal tissue

Transfection and subsequent expression of DNA in living neuronal tissue is problematic and no technique has emerged that is completely non-damaging, efficient and reproducible. The Bio-Rad hand-held Gene Gun has overcome some of these problems by exploiting a biolistic method in which small gold particles carrying plasmid DNA are propelled into neurons whilst causing minimal detectable cell damage. In its current configuration, however, the Bio-Rad Gene Gun is optimised for transfecting cells in dispersed cultures, and therefore delivers particles superficially over a relatively wide area. Here we report modifications to the Bio-Rad Gene Gun that both enhance its accuracy by restricting its target area, and increase the depth penetration achieved by gold particles, thereby allowing smaller and deeper tissues to be transfected. These alterations make the modified Gene Gun more applicable for in vitro transfection of organotypic cultures and enhance its potential utility for in vivo gene delivery. Moreover, the modified configuration operates successfully at lower gas pressures, thereby reducing even further the degree of cell damage incurred during transfection.

The nonuniform distribution of the GABA(A) receptor alpha 1 subunit influences inhibitory synaptic transmission to motoneurons within a motor nucleus

Using immunohistochemistry we studied the distribution of GABA(A) and glycine receptor alpha1 subunits in the rat hypoglossal nucleus during postnatal development. In the neonate [postnatal day (P) 1-3] and adult nucleus (P28-30), GABA(A) receptor alpha1 subunit labeling was relatively modest. However, in the juvenile nucleus (P9-13), labeling was strong in the ventrolateral region and moderate in the dorsal region. Glycine receptor alpha1 subunit labeling was strong and uniform in the juvenile and adult nucleus and absent in the neonate nucleus. GABA and glycine neurotransmitter labeling was uniform throughout the neonatal and juvenile nucleus. To study the functional consequences of this regional differential GABA(A) receptor alpha1 subunit distribution, we voltage clamped juvenile hypoglossal motoneurons (HMs) from the ventrolateral and dorsal regions and recorded spontaneous miniature IPSCs (mIPSCs). Pure GABAergic events had slower decay times than glycinergic events. Although pure GABAergic and glycinergic decay times did not differ depending on HM location, the decays of mixed mIPSCs from ventrolateral HMs, recorded without GABA(A) and glycine receptor antagonists, had significantly slower decays than mIPSCs from dorsal HMs. Focally applied GABA and glycine onto outside-out patches revealed that the GABAergic to glycinergic peak current amplitude ratio was larger for patches from ventrolateral HMs compared with dorsal HMs. Dual component mIPSCs, presumably caused by co-release of GABA and glycine, were recorded more frequently in the ventrolateral nucleus. These data suggest that the number of synapses using GABA(A) receptor-mediated transmission is greater on ventrolateral HMs than dorsal HMs, demonstrating a nonuniformity of synaptic function within a defined motor nucleus.

Alzheimer's disease and other dementia in nursing homes: levels of management and cost

OBJECTIVE

To estimate comparative management levels and the annual cost of caring for a nursing home resident with and without dementia.

METHOD

Data from the 1995 Massachusetts Medicaid nursing home database were used to examine residents with Alzheimer's disease, other types of dementia, and no dementia to determine care and dependency levels. Massachusetts Medicaid 1997 per-diem rates for each of 10 designated management levels were applied accordingly to residents in each level to estimate annual care costs. Costs from this analysis are reported in 1997 U.S. dollars.

RESULTS

Of the 49,724 nursing home residents identified, 26.4% had a documented diagnosis of dementia. On average, a resident with dementia requires 229 more hours of care annually than one without dementia, resulting in a mean additional cost of $3,865 per patient with dementia per year.

CONCLUSIONS

Dementia increases the care needs and cost of caring for a nursing home resident.

Diabetes in Canada: direct medical costs of major macrovascular complications

OBJECTIVES

To estimate direct medical costs of managing major macrovascular complications in diabetic patients.

METHODS

Costs were estimated for acute myocardial infarction (AMI) and ischemic stroke by applying unit costs to typical resource use profiles. Data were obtained from many Canadian sources, including the Ontario Case Cost Project, provincial physician and laboratory fee schedules, provincial formularies, government reports, and peer-reviewed literature. For each complication, the event costs per patient are those associated with resource use specific to the acute episode and any subsequent care occurring in the first year. State costs are the annual costs per patient of continued management. All costs are expressed in 1996 Canadian dollars.

RESULTS

Acute hospital care accounts for approximately half of the first year management costs ($15,125) of AMI. Given the greater need for postacute care, acute hospital care has less impact (28%) on event costs for stroke ($31,076). The state costs for AMI and stroke are $1544 and $8141 per patient, respectively.

CONCLUSIONS

Macrovascular complications of diabetes potentially represent a substantial burden to Canada's health care system. As new therapies emerge that may reduce the incidence of some diabetic complications, decision makers will need information to make critical decisions regarding how to spend limited health care dollars. Published literature lacks Canadian-specific cost estimates that may be readily translated into patient-level cost inputs for an economic model. This paper provides two key pieces of the many needed to understand the scope of the economic burden of diabetes and its complications for Canada.

Clinical practice guidelines and the cost of care. A growing alliance

Healthcare policy, medical practice, and cost of care are no longer considered distinct entities. Each is an integral factor in determining not only what, but how, patient care will be delivered. Clinical practice guidelines are the lynchpin that connects them. This paper addresses the various components of the clinical practice guideline--cost alliance.

OBJECTIVE

To examine the bidirectional influence of choice of care on costs and of cost of care on decision making.

METHODS

The literature was used to identify cost-related factors that influence development of guidelines and change in physician practice behavior. In a MEDLINE search with modifiers to the keywords "clinical practice guidelines," particular attention was paid to identifying surveys of practitioners. An analysis, prompted by a recently published guideline, of treating penetrating intraperitoneal colon injuries by different surgical approaches (primary repair versus diverting colostomy) exemplified how implementation of a guideline can affect the cost of care. Inpatient cost estimates, adjusted for medical inflation and cost-to-charge ratios and reported in 1999 U.S. dollars, were developed using data from 1996 and 1997 discharge databases from California and Massachusetts.

RESULTS

The results showed that a substantial savings in hospital costs was achieved when a primary repair surgical technique, as advocated by the guideline, was used. The effect of cost influences on the development of clinical practice guidelines was established by demonstrating the cyclical effect between usual and customary practices, guideline implementation, changing practice patterns, and the economic considerations influencing the process.

CONCLUSIONS

A growing, albeit uneasy, alliance between costs and clinical practice guidelines is evident.

Intracellular pathways regulating ciliary beating of rat brain ependymal cells

1. The mammalian brain ventricles are lined with ciliated ependymal cells. As yet little is known about the mechanisms by which neurotransmitters regulate cilia beat frequency (CBF). 2. Application of 5-HT to ependymal cells in cultured rat brainstem slices caused CBF to increase. 5-HT had an EC50 of 30 microM and at 100 microM attained a near-maximal CBF increase of 52.7 +/- 4.1 % (mean +/- s.d.) (n = 8). 3. Bathing slices in Ca2+-free solution markedly reduced the 5-HT-mediated increase in CBF. Fluorescence measurements revealed that 5-HT caused a marked transient elevation in cytosolic Ca2+ ([Ca2+]c) that then slowly decreased to a plateau level. Analysis showed that the [Ca2+]c transient was due to release of Ca2+ from inositol 1,4,5-trisphosphate (IP3)-sensitive stores; the plateau was probably due to extracellular Ca2+ influx through Ca2+ release-activated Ca2+ (CRAC) channels. 4. Application of ATP caused a sustained decrease in CBF. ATP had an EC50 of about 50 microM and 100 microM ATP resulted in a maximal 57.5 +/- 6.5 % (n = 12) decrease in CBF. The ATP-induced decrease in CBF was unaffected by lowering extracellular [Ca2+], and no changes in [Ca2+]c were observed. Exposure of ependymal cells to forskolin caused a decrease in CBF. Ciliated ependymal cells loaded with caged cAMP exhibited a 54.3 +/- 7.5 % (n = 9) decrease in CBF following uncaging. These results suggest that ATP reduces CBF by a Ca2+-independent cAMP-mediated pathway. 5. Application of 5-HT and adenosine-5'-O-3-thiotriphosphate (ATP-gamma-S) to acutely isolated ciliated ependymal cells resulted in CBF responses similar to those of ependymal cells in cultured slices suggesting that these neurotransmitters act directly on these cells. 6. The opposite response of ciliated ependymal cells to 5-HT and ATP provides a novel mechanism for their active involvement in central nervous system signalling.

Economic analysis of initial HIV treatment. Efavirenz- versus indinavir-containing triple therapy

OBJECTIVE

To compare the clinical and economic outcomes associated with triple therapy containing efavirenz or indinavir and 2 nucleoside reverse transcriptase inhibitors (NRTIs; zidovudine and lamivudine) in HIV-positive patients.

DESIGN AND SETTING

An economic model based on viral load and CD4+ cell counts to predict long term outcomes such as progression to AIDS and AIDS-related death was developed and then analysed using data from a randomised clinical trial. Cost estimates from the healthcare system perspective were based on data from 6 state, all-payor databases, the AIDS Cost and Services Utilisation Study, and other literature. Analyses were carried out for time horizons between 5 and 15 years.

PATIENTS AND INTERVENTIONS

HIV-positive patients with limited exposure to NRTIs. Initial regimens consisted of efavirenz or indinavir, each combined with 2 NRTIs. A maximum of 2 switches to other regimens was permitted.

MAIN OUTCOME MEASURES AND RESULTS

The efavirenz-containing triple therapy regimen was predicted to prolong survival at a savings of up to 10,923 US dollars (1998 values) relative to initial therapy with the indinavir-containing regimen. Patients who receive efavirenz are expected to have 11% greater survival at 5 years and fewer treatment failures (28 vs 52%, at 2 years). Overall, the economic and health benefits predicted for the efavirenz-containing regimen were robust to reasonable variation in key parameters.

CONCLUSIONS

The superior clinical trial outcomes for efavirenz-containing regimens should translate into substantial economic and health benefits.

Point-of-care testing

Is POCT worth integrating into a facility? Despite its promise of speed and convenience, this technology requires careful evaluation of potential benefits, disadvantages, and challenges to the existing system. If the pros outweigh the cons, a step-by-step approach can ease the process of implementing a POCT program.

Developmental changes in the modulation of synaptic glycine receptors by ethanol

During postnatal motoneuron development, the glycine receptor (GlyR) alpha subunit changes from alpha2 (fetal) to alpha1 (adult). To study the effect this change has on ethanol potentiation of GlyR currents in hypoglossal motoneurons (HMs), we placed neurons into two groups: neonate [postnatal day 1 to 3 (P1-3)], primarily expressing alpha2, and juvenile (P9-13), primarily expressing alpha1. We found that glycinergic spontaneous miniature inhibitory postsynaptic currents (mIPSCs) in neonate HMs are less sensitive to ethanol than in juveniles. Thirty millimolar ethanol increased the amplitude of juvenile mIPSCs but did not significantly change neonatal mIPSCs. However, 100 mM ethanol increased the amplitudes of both neonate and juvenile mIPSCs. There was a significant difference between age groups in the average ethanol-induced increase in mIPSC amplitude for 10, 30, 50, and 100 mM ethanol. In both age groups ethanol increased the frequency of glycinergic mIPSCs, but there was no difference in the amount of frequency increase between age groups. Ethanol (100 mM) also potentiated evoked IPSCs (eIPSCs) in both neonate and juvenile HMs. As we observed for mIPSCs, 30 mM ethanol increased the amplitude of juvenile eIPSCs, but had no significant effect on eIPSCs in neonate HMs. Ethanol also potentiated currents induced by exogenously applied glycine in both neonate and juvenile HMs. These results suggest that ethanol directly modulates the GlyR. To investigate possible mechanisms for this, we analyzed the time course of mIPSCs and single-channel conductance of the GlyR in the presence and absence of ethanol. We found that ethanol did not significantly change the time course of mIPSCs. We also determined that ethanol did not significantly change the single-channel conductance of synaptic GlyRs, as estimated by nonstationary noise analysis of mIPSCs. We conclude that the adult form of the native GlyR is more sensitive to ethanol than the fetal form. Further, enhancement of GlyR currents involves mechanisms other than an increase in the single-channel conductance or factors that alter the decay kinetics.

The circadian cycle of mPER clock gene products in the suprachiasmatic nucleus of the siberian hamster encodes both daily and seasonal time

The circadian clock in the hypothalamic suprachiasmatic nuclei (SCN) regulates the pattern of melatonin secretion from the pineal gland such that the duration of release reflects the length of the night. This seasonally specific endocrine cue mediates annual timing in photoperiodic mammals. The aim of this study was to investigate how changes in photoperiod influence the cyclic expression of recently identified clock gene products (mPER and mTIM) in the SCN of a highly seasonal mammal, the Siberian hamster (Phodopus sungorus). Immunocytochemical studies indicate that the abundance of both mPER1 and mPER2 (but not mTIM) in the SCN exhibits very pronounced, synchronous daily cycles, peaking approximately 12 h after lights-on. These rhythms are circadian in nature as they continue approximately under free-running conditions. Their circadian waveform is modulated by photoperiod such that the phase of peak mPER expression is prolonged under long photoperiods. mPER1 protein is also expressed in the pars tuberalis of Siberian hamsters. In hamsters adapted to long days, the expression of mPER1 is elevated at the start of the light phase. In contrast, there is no clear elevation in mPER1 levels in the pars tuberalis of hamsters held on short photoperiods. These results indicate that core elements of the circadian clockwork are sensitive to seasonal time, and that encoding and decoding of seasonal information may be mediated by the actions of these transcriptional modulators.

Probing the structure of rotavirus NSP4: a short sequence at the extreme C terminus mediates binding to the inner capsid particle

The rotavirus nonstructural glycoprotein NSP4 functions as the receptor for the inner capsid particle (ICP) which buds into the lumen of the endoplasmic reticulum during virus maturation. The structure of the cytoplasmic domain of NSP4 from rotavirus strain SA11 has been investigated by using limited proteolysis and mass spectrometry. Digestion with trypsin and V8 protease reveals a C-terminal protease-sensitive region that is 28 amino acids long. The minimal sequence requirements for receptor function have been defined by constructing fusions with glutathione S-transferase and assessing their ability to bind ICPs. These experiments demonstrate that 17 to 20 amino acids from the extreme C terminus are necessary and sufficient for ICP binding and that this binding is cooperative. These observations are consistent with a model for the structure of the NSP4 cytoplasmic region in which four flexible regions of 28 amino acids are presented by a protease-resistant coiled-coil tetramerization domain, with only the last approximately 20 amino acids of each peptide interacting with the surface binding sites on the ICP.

Analysis of clock proteins in mouse SCN demonstrates phylogenetic divergence of the circadian clockwork and resetting mechanisms

The circadian clock in the suprachiasmatic nuclei (SCN) is comprised of a cell-autonomous, autoregulatory transcriptional/translational feedback loop. Its molecular components include three period and two cryptochrome genes. We describe circadian patterns of expression of mPER2 and mPER3 in the mouse SCN that are synchronous to those for mPER1, mCRY1, and mCRY2. Coimmunoprecipitation experiments demonstrate in vivo associations of the SCN mPER proteins with each other and with the mCRY proteins, and of mCRY proteins with mTIM, but no mPER/mTIM interactions. Examination of the effects of weak and strong resetting light pulses on SCN clock proteins highlights a central role for mPER1 in photic entrainment, with no acute light effects on either the mCRY or mTIM proteins. These clock protein interactions and photic responses in mice are divergent from those described in Drosophila.

Economic assessment of troglitazone as an adjunct to sulfonylurea therapy in the treatment of type 2 diabetes

OBJECTIVE

To assess the economic efficiency of adding troglitazone to sulfonylurea therapy to improve glycemic control.

BACKGROUND

Despite the high prevalence of type 2 diabetes, existing treatment strategies often fail. New oral agents give a wider segment of the population with type 2 diabetes hope of achieving near-normal blood-glucose levels. Troglitazone, a novel chemical entity, is one promising new agent.

METHODS

We conducted an economic analysis based on glycemic-control data from a randomized clinical trial comparing troglitazone with placebo, each added to glyburide. A patient simulation model was used to translate these data to long-term outcomes associated with diabetes. Patients had poorly controlled type 2 diabetes mellitus despite glyburide therapy. Risk functions of developing and progressing through nephropathy, retinopathy, neuropathy, hypoglycemia, and macrovascular disease were developed from the Diabetes Control and Complications Trial and large epidemiologic studies. Cost estimates were based on data from 5 states, all payor databases, surveys, and literature. The main outcomes of the model were cost-consequences, number of patients developing each type of complication, mean time to development of the complication, cost per life-year gained (LYG), and cost per quality-adjusted life-year.

RESULTS

The model predicts that for every 1000 patients treated with troglitazone, the improved glycemic control could mean that 95 to 140 fewer patients would experience one of the most severe diabetic complications (eg, blindness, end-stage renal disease, amputation), which may increase life expectancy by 2.0 years. These benefits are obtained at an additional $2100 per LYG (undiscounted). The ratio remains <$50,000 per LYG for most variations in input.

CONCLUSIONS

The clinical trial demonstrated that troglitazone + glyburide improves glycemic control compared with glyburide alone. Based on these results, the model estimates fewer diabetic complications at a cost well below accepted cost-effective thresholds.

Disruption of the substance P receptor (neurokinin-1) gene does not prevent upregulation of preprotachykinin-A mRNA in the spinal cord of mice following peripheral inflammation

The neuropeptide substance P is thought to play an important role in nociception, although the function of the peptide remains controversial. Following peripheral inflammation there is a pronounced upregulation of substance P expression both in sensory neurons and in postsynaptic neurons within the spinal cord. We have examined the levels of expression of mRNA encoding substance P and dynorphin following the development of inflammatory hyperalgesia in mice in which the substance P receptor gene, also known as the neurokinin-1 receptor gene, has been disrupted by homologous recombination. We show that inflammatory hyperalgesia following injection of complete Freund's adjuvant develops normally in animals that lack the neurokinin-1 receptor and that expression of mRNAs encoding substance P and the neuropeptide dynorphin are upregulated regardless of the genotype of the mouse. This suggests that substance P activity is not required for the development and maintenance of inflammatory hyperalgesia and that the upregulation of substance P expression is mediated by neurotransmitters other than substance P.

Cotransmission of GABA and glycine to brain stem motoneurons

Using whole cell patch-clamp recording in a rat brain stem slice preparation, we found that gamma-aminobutyric acid (GABA) and glycine act as cotransmitters to hypoglossal motoneurons (HMs). Focal application of GABA and glycine onto a single HM revealed that GABAA and glycine receptors are present on the same neuron. To demonstrate that HMs receive both GABAergic and glycinergic synaptic inputs, we simultaneously recorded GABAA- and glycine-receptor-mediated spontaneous miniature inhibitory postsynaptic currents (mIPSCs) in single HMs. GABAergic and glycinergic mIPSCs were differentiated based on their kinetics and modulation by pentobarbital. Specifically, GABAA-receptor-mediated events decayed more slowly than glycine-receptor-mediated events. GABAergic response decay kinetics were prolonged by pentobarbital, whereas glycinergic response decay kinetics remained unchanged. The distinct kinetics of the glycine- and GABAA-receptor-mediated synaptic events allowed us to record dual component mIPSCs, mIPSCs that are mediated by both receptor types. These data suggest that GABA and glycine are colocalized in the same presynaptic vesicle and are coreleased from presynaptic terminals opposed to motoneurons.

Leukotriene B4 receptor transgenic mice reveal novel protective roles for lipoxins and aspirin-triggered lipoxins in reperfusion

Polymorphonuclear neutrophil (PMN) activation is pivotal in acute inflammation and injury from reperfusion. To elucidate components controlling PMNs in vivo, we prepared novel transgenic mice with the human leukotriene (LT) B4 receptor (BLTR) for functional characterization. Overexpression of BLTR in leukocytes dramatically increased PMN trafficking to skin microabscesses and lungs after ischemia-reperfusion, whereas mice deficient in 5-lipoxygenase (5-LO) showed diminished PMN accumulation in reperfused lungs. Hence, both BLTR expression and LT biosynthesis are critical for PMN infiltration in reperfusion-initiated second-organ injury. Also, in BLTR transgenic mice, 5-LO expression and product formation were selectively increased in exudates, demonstrating that receptor overexpression amplifies proinflammatory circuits. Endogenous lipoxin (LX) A4 was produced in ischemic lungs and elevated by reperfusion. Because LXA4 and aspirin-triggered 15-epimeric LXA4 (ATL) selectively regulate leukocyte responses, they were tested in BLTR transgenic mice. Despite excessive PMN recruitment in BLTR transgenic mice, intravenous injection of ATL sharply diminished reperfusion-initiated PMN trafficking to remote organs, and topical application of LX was protective in acute dermal inflammation. These results demonstrate a direct role for BLTR with positive feedback, involving BLTR and 5-LO signaling in controlling PMNs. Moreover, LXA4 and ATL counter BLTR-amplified networks, revealing a novel protective role for LX and ATL in stress responses that has applications in perioperative medicine.

Local and systemic delivery of a stable aspirin-triggered lipoxin prevents neutrophil recruitment in vivo

Aspirin (ASA) triggers a switch in the biosynthesis of lipid mediators, inhibiting prostanoid production and initiating 15-epi-lipoxin generation through the acetylation of cyclooxygenase II. These aspirin-triggered lipoxins (ATL) may mediate some of ASA's beneficial actions and therefore are of interest in the search for novel antiinflammatories that could manifest fewer unwanted side effects. Here, we report that design modifications to native ATL structure prolong its biostability in vivo. In mouse whole blood, ATL analogs protected at carbon 15 [15(R/S)-methyl-lipoxin A4 (ATLa1)] and the omega end [15-epi-16-(para-fluoro)-phenoxy-LXA4 (ATLa2)] were recoverable to approximately 90 and 100% at 3 hr, respectively, compared with a approximately 40% loss of native lipoxin A4. ATLa2 retains bioactivity and, at levels as low as approximately 24 nmol/mouse, potently inhibited tumor necrosis factor-alpha-induced leukocyte recruitment into the dorsal air pouch. Inhibition was evident by either local intra-air pouch delivery (approximately 77% inhibition) or systemic delivery by intravenous injection (approximately 85% inhibition) and proved more potent than local delivery of ASA. Rank order for inhibiting polymorphonuclear leukocyte infiltration was: ATLa2 (10 micrograms, i.v.) approximately ATLa2 (10 micrograms, local) approximately dexamethasone (10 micrograms, local) >ASA (1.0 mg, local). Applied topically to mouse ear skin, ATLa2 also inhibited polymorphonuclear leukocyte infiltration induced by leukotriene B4 (approximately 78% inhibition) or phorbol ester (approximately 49% inhibition), which initiates endogenous chemokine production. These results indicate that this fluorinated analog of natural aspirin-triggered lipoxin A4 is bioavailable by either local or systemic delivery routes and is a more potent and precise inhibitor of neutrophil accumulation than is ASA.

Migraine therapy: development and testing of a patient preference questionnaire

OBJECTIVES

To develop and test a patient preference questionnaire in migraine.

METHODS

A user-friendly, self-administered questionnaire was developed to assess the relative importance of aspects of migraine therapy to patients. It was tested in a convenience sample of 66 migraineurs. The questionnaire has five sections: patient preference, migraine history, demographics, usual behavior during an attack, and migraine impact on cognition and functionality. It employs a special reverse-ranking technique to quantify preferences.

RESULTS

Sixty-six migraineurs participated: 86% were women, 53% had not consulted their doctor about migraine in the previous year; and only 51% took prescribed medication, the majority (52%) at the start of a migraine. "A medication that can be taken any time during a migraine attack" was ranked most important by 20% of the migraineurs, one that decreases pain from the unbearable level in 30 minutes by 17%, and one that relieves pain completely within 2 hours by 15%. Not being able to think or concentrate with severe symptoms was reported by 71%. Optional activities were impeded by migraine in 83% of subjects, but required activities in only 60%.

CONCLUSIONS

The patient preference questionnaire is readily completed by subjects and reveals that the dimensions of relief preferred by patients can be addressed by a self-report questionnaire.

Direct medical costs of complications resulting from type 2 diabetes in the U.S

OBJECTIVE

To estimate direct medical costs of managing the complications of type 2 diabetes.

RESEARCH DESIGN AND METHODS

Costs were estimated for 15 diabetic complications by applying unit costs to typical resource-use profiles. Resource used and unit costs were estimated from many sources, including acute care discharge databases, clinical guidelines, government reports, fee schedules, and peer-reviewed literature. For each complication, the event costs are those associated with resource use that is specific to the acute episode and any subsequent care occurring in the 1st year. State costs are the annual costs of continued management. All costs are expressed in 1996 U.S. dollars.

RESULTS

As expected, the more severe or debilitating events, such as acute myocardial infarction ($27,630 event cost; $2,185 state cost), generate a greater financial burden than do early-stage complications, such as microalbuminuria ($62 event cost; $14 state cost). Yet, complications that are initially relatively low in cost (e.g., microalbuminuria) can progress to more costly advanced stages (e.g., end-stage renal disease, $53,659 state cost); therefore, minor complications should also be considered in any economic analysis of diabetes.

CONCLUSIONS

The recent literature has lacked cost estimates that may be readily translated into patient-level cost inputs for an economic model. Emerging therapies that may reduce the incidence of some diabetic complications will need to be scrutinized economically in today's cost-conscious environment. The cost estimates from this study provide one piece of the economic analysis needed to evaluate these new interventional therapies.

Altered nociception, analgesia and aggression in mice lacking the receptor for substance P

The peptide neurotransmitter substance P modulates sensitivity to pain by activating the neurokinin-1 (NK-1) receptor, which is expressed by discrete populations of neurons throughout the central nervous system. Substance P is synthesized by small-diameter sensory 'pain' fibres, and release of the peptide into the dorsal horn of the spinal cord following intense peripheral stimulation promotes central hyperexcitability and increased sensitivity to pain. However, despite the availability of specific NK-1 antagonists, the function of substance P in the perception of pain remains unclear. Here we investigate the effect of disrupting the gene encoding the NK-1 receptor in mice. We found that the mutant mice were healthy and fertile, but the characteristic amplification ('wind up') and intensity coding of nociceptive reflexes was absent. Although substance P did not mediate the signalling of acute pain or hyperalgesia, it was essential for the full development of stress-induced analgesia and for an aggressive response to territorial challenge, demonstrating that the peptide plays an unexpected role in the adaptive response to stress.

A Schwann cell mitogen accompanying regeneration of motor neurons

Motor neurons are the only adult mammalian neurons of the central nervous system to regenerate following injury. This ability is dependent on the environment of the peripheral nerve and an intrinsic capacity of motor neurons for regrowth. We report here the identification, using a technique known as messenger RNA differential display, of an extracellular signalling molecule, previously described as the pancreatic secreted protein Reg-2, that is expressed solely in regenerating and developing rat motor and sensory neurons. Axon-stimulated Schwann cell proliferation is necessary for successful regeneration, and we show that Reg-2 is a potent Schwann cell mitogen in vitro. In vivo, Reg-2 protein is transported along regrowing axons and inhibition of Reg-2 signalling significantly retards the regeneration of Reg-2-containing axons. During development, Reg-2 production by motor and sensory neurons is regulated by contact with peripheral targets. Strong candidates for peripheral factors regulating Reg-2 production are cytokines of the LIF/CNTF family, because Reg-2 is not expressed in developing motor or sensory neurons of mice carrying a targeted disruption of the LIF receptor gene, a common component of the receptor complexes for all of the LIF/CNTF family.

NMDA and non-NMDA receptors are co-localized at excitatory synapses of rat hypoglossal motoneurons

We used whole-cell patch clamp recordings in a rat brainstem slice preparation to characterize the properties of miniature excitatory postsynaptic currents (mEPSCs) in hypoglossal motoneurons. The distinct kinetic characteristics of N-methyl-D-aspartate (NMDA) and non-NMDA receptor-mediated synaptic responses allowed us to study dual component mEPSCs mediated by the two receptor types. Using this approach, NMDA and non-NMDA receptors were found to be co-localized at the same synaptic locations. In addition, some sites contain only NMDA receptors since a large proportion of mEPSCs were apparently mediated by NMDA receptors only. Furthermore, the amplitudes of pharmacologically isolated NMDA receptor-mediated mEPSCs were highly variable in individual cells and their decay kinetics were modulated by membrane potential.

Quantitative analysis of firing properties of pyramidal neurons from layer 5 of rat sensorimotor cortex

Quantitative aspects of repetitive firing evoked by injected current steps and ramps were studied in layer 5 pyramidal neurons in brain slices of rat sensorimotor cortex to answer the following questions. Do the tonic firing properties of burst-firing and regular-spiking (nonbursting) neurons differ significantly? Does burst firing denote a discrete class of neurons or represent a continuum of firing properties? Is firing rate during the burst of action potentials related to stimulus amplitude? What aspect of the stimulus might the initial firing rate code? How stable are a neuron's firing properties over time? All recorded neurons fired tonically to a long-lasting current above a minimum value, and the tonic firing properties of most neurons were quite similar irrespective of their initial response to a current step. Only a group of high-resistance neurons had significantly different tonic firing properties. When slow current ramps (rising between 0.5 and approximately 20 nA/s) were applied, the relation between firing rate and current during the ramp was very similar to the relation between tonic firing rate and current obtained from long-lasting current steps. Low-resistance cells exhibited three distinct initial responses to a current step: fast adaptation, high-threshold bursts, and low-threshold bursts, observed in 54, 28, and 10% of recorded cells, respectively. High-resistance cells exhibited a distinctive slow adaptation of firing rate. Slowly adapting, fast-adapting (FA), and high-threshold burster (HTB) neurons exhibited no adaptation near the minimum current that evoked repetitive firing (I(o)). FA and HTB cells exhibited two-spike adaptation to a fina tonic firing rate during currents up to 1.6 times I(o). Only a higher current (2.1 times I(o)) evoked a burst in HTB cells, whereas a burst was evoked at I(o) in the low-threshold burster cells. In most cells analyzed, the initial firing rate, whatever its nature, increased monotonically with current step amplitude. The response to fast current ramps indicated that firing rate during adaptation or bursting may code rate of change of current. Repeated measurements during long-duration impalements indicated that both transient and tonic firing properties are stable over time. We discuss how the different tonic firing properties of large and small pyramidal neurons could be more important functionally than the different transient responses (burst/nonburst) of the large neurons. We conclude that the large neurons would perform a better linear transduction of time-varying synaptic current that reaches their somata. We compare the responses evoked by somatically injected current with those evoked by dendritic glutamate iontophoresis in previous studies.

Effects of albumin on the disposition of morphine and morphine-3-glucuronide in the rat isolated perfused liver

1. The effect of albumin on the disposition of morphine and hepatically generated morphine-3-glucuronide (M3G) was investigated in the single-pass rat isolated perfused liver. 2. Using a balanced cross-over design, each of 10 livers was perfused at 30 mL/min with medium containing 2.7 mumol/L morphine in the presence and absence of 10 g/L bovine serum albumin (BSA). 3. Both bile flow rate and hepatic oxygen consumption were significantly higher (P < 0.005) when BSA was present in the perfusion medium, suggestive of a change in the functional performance of the perfused liver. 4. The binding of morphine and M3G was negligible in both BSA-free and -containing perfusate. 5. Outflow perfusate contained both morphine and M3G, while the metabolite but not morphine was found in bile. The recovery of the administered morphine was approximately 100% and was not altered (P > 0.05) by the presence or absence of BSA. 6. The fraction of morphine escaping heptic extraction in the absence of BSA (mean +/- SD; 0.41 +/- 0.14) was not altered significantly (P > 0.05) by the presence of the protein in perfusate (0.35 +/- 0.13), indicating no change in the intrinsic clearance or morphine despite the difference in oxygen consumption. 7. The fraction of hepatically generated M3G excreted in bile was significantly higher (P < 0.005) when BSA was present in the perfusate than when it was not (0.44 +/- 0.14 vs 0.38 +/- 0.16, respectively). 8. The results are consistent with the concept that BSA modifies the ability of solutes, including M3G, to move through the paracellular pathway from the canalicular to the vascular space. 9. It is concluded that because albumin may modify not only the unbound fraction of a ligand in perfusate, but also the functional performance of the liver, care is needed in the interpretation of studies examining the influence of the protein on the hepatic disposition of drugs and their metabolites.

The cytoplasmic tail of NSP4, the endoplasmic reticulum-localized non-structural glycoprotein of rotavirus, contains distinct virus binding and coiled coil domains

The final steps in the assembly of rotavirus occur in the lumen of the endoplasmic reticulum (ER). Targeting of the immature inner capsid particle (ICP) to this compartment is mediated by the cytoplasmic tail of NSP4, a non-structural virus glycoprotein located in the ER membrane. To delineate structural and functional features of NSP4, soluble fragments of the cytoplasmic tail have been expressed and purified. Our analysis combines a functional assay for ICP binding with biochemical and CD spectroscopic studies to examine the secondary and quaternary structure. The ICP-binding domain is located within the C-terminal 20 amino acids of the polypeptide. A second region, distinct from this receptor domain, adopts an alpha-helical coiled coil structure and mediates the oligomerization of the virus binding domains into a homotetramer. The domain organization of the cytoplasmic fragments of NSP4 suggests a novel structure for an icosahedral virus receptor protein in which C-terminal binding sites for immature rotavirus particles are connected to an alpha-helical coiled coil stalk which projects from the ER membrane.

The disposition of morphine and morphine-3-glucuronide in the isolated perfused rat liver: effects of altered perfusate flow rate

The rat single-pass isolated perfused liver preparation was used to study the effects of altered perfusate flow rate on the hepatic disposition of morphine and its polar metabolite morphine-3-glucuronide (M3G). Using a balanced, cross-over design, livers of female Sprague-Dawley rats (n = 6) were perfused at 15 and 30 mL min-1 with erythrocyte- and protein-free perfusion medium containing a constant concentration of morphine (2.7 microM). After reaching steady-state, inflow and outflow perfusate and bile samples were collected and morphine and M3G were measured by HPLC. Doubling of perfusate flow rate was associated with a significant increase (P < 0.05) in the availability of morphine (mean +/- s.d. of 0.19 +/- 0.06 at 15 mL min-1 and 0.29 +/- 0.08 at 30 mL min-1). The magnitude of the change in morphine availability was consistent with the predictions of the well-stirred model of hepatic elimination. The fate of hepatically generated M3G was assessed by the biliary extraction ratio of M3G; alterations in perfusate flow rate had no significant effect on this ratio (mean +/- s.d. of 0.49 +/- 0.14 at a perfusate flow rate of 15 mL min-1 and 0.47 +/- 0.22 at 30 mL min-1). A physiologically-based mathematical model, in which the vascular and intracellular spaces of the liver were represented by two well-mixed compartments, was utilized to derive an equation for the biliary extraction ratio of M3G. According to the model, the value of this extraction ratio will become insensitive to changes in perfusate flow rate when the permeability for M3G of the membrane separating the intracellular and vascular compartments is low compared with perfusate flow rate. Hence, the experimental results are consistent with the concept that the hepatic sinusoidal membrane represents a diffusional barrier to M3G.

Quinoxapeptins: novel chromodepsipeptide inhibitors of HIV-1 and HIV-2 reverse transcriptase. I. The producing organism and biological activity

Quinoxapeptin A and B are novel chromodepsipeptides which were isolated from a nocardioform actinomycete with indeterminant morphology. Quinoxapeptins A and B are potent inhibitors of HIV-1 and HIV-2 reverse transcriptase and almost equally active against two single mutants forms as well as a double mutant form of HIV-1 reverse transcriptase. Quinoxapeptin A and B are specific inhibitors of HIV-1 and HIV-2 reverse transcriptase because they did not inhibit human DNA polymerase alpha, beta, gamma and delta. Quinoxapeptin A and B are structurally similar to luzopeptin A which was also active against HIV-1 and HIV-2 reverse transcriptase.

Pharmacology of L-744,453, a novel nonpeptidyl endothelin antagonist

L-744,453 ((+/-)3-[4-(1-carboxy-1-(3,4-methylenedioxyphenyl)methoxy)-3,5-diprop ylphenyl methyl]-3H-imidazo[4,5-c]pyridine) is an endothelin (ET) receptor antagonist from a new structural class, the dipropyl-alpha-phenoxyphenylacetic acid derivatives. L-744,453 competitively and reversibly inhibits [125I]-ET-1 binding to Chinese Hamster Ovary cells expressing cloned human ET receptors (K(i)s: hET(A)=4.3 nM; hET(B)=232 nM), and is selective for endothelin receptors compared to other peptide receptors. It is an antagonist of ET-1 stimulated phosphatidyl inositol hydrolysis in rat uterine slices (IC50=220 nM) and exhibits no agonist activity. This compound also inhibits ET-1 stimulated contraction of rat aortic rings with a K(b) value of 50 nM. L-744,453 protects against ET-1 induced lethality in mice after i.v. (AD50=13 mg/kg i.v.) or oral administration. This compound also antagonizes ET-1 induced increases in diastolic blood pressure in conscious normotensive rats (AD50=0.67 mg/kg i.v.) and anesthetized ferrets (AD50=1.6 mg/kg i.v.). L-744,453 is a potent, selective, orally active endothelin antagonist which may be useful in elucidating the role of endothelin in normal and pathophysiological states.

The cost of treating heart valve related complications

BACKGROUND AND AIM OF THE STUDY

Heart valve replacement can result in serious complications. Therefore, it is important in decision making regarding the choice of valves to know the cost of such complications.

METHODS

Complications were defined according to guidelines proposed by the Society of Thoracic Surgeons. They included valve thrombosis, embolism, hemorrhage due to anticoagulation, non-structural dysfunction, structural deterioration and endocarditis. The costs of the pre-admission assessment, acute inpatient stay, inpatient physician fees, post-discharge and out-patient physician fees were estimated for each complication to determine the average total cost in 1995 US dollars. Cost inputs were obtained from existing Massachusetts databases and Medicare fee schedules.

RESULTS

The costs of managing valve thrombosis, endocarditis and non-structural dysfunction were all estimated to exceed $30,000 for a single event. The costs of acute management of embolism and anticoagulant-related hemorrhage were between $8,000 and $11,500. However, it is of note that managing the sequelae of an embolism was calculated to be greater than $70,000 over 15 years. The greatest contributor to the average cost of treating a complication was determined to be the in-patient facility cost.

CONCLUSIONS

Complications related to heart valve replacement can be very costly to manage in both the short term and the long term.

Bileaflet valve replacement: complications and costs

A meta-analysis of the available literature on the CarboMedics and St. Jude Medical valves was conducted to compare their clinical performance. Frequency of valve-related complications for aortic, mitral, and double-valve replacements served as a measure of performance. An economic model was created to estimate the economic impact of valve-related complications. Overall, fewer events occurred with the St. Jude Medical valve than with the CarboMedics valve. As a result, use of the St. Jude Medical valve is expected to save up to $13,201 over 10 years.

Pharmacology of L-754,142, a highly potent, orally active, nonpeptidyl endothelin antagonist

L-754,142, (-)-N-(4-iso-propylbenzenesulfonyl)-alpha-(4-carboxyl-2-n-propy lphenoxy)-3,4- methylenedioxyphenylacetamide, is a potent nonpeptidyl endothelin antagonist (e.g., Ki: cloned human ETA = 0.062 nM: cloned human ETB = 2.25 nM), with high specificity for endothelin receptors. In vitro, L-754,142 is a potent antagonist of ET-1-induced phosphatidyl inositol hydrolysis in Chinese hamster ovary cells expressing cloned human endothelin receptors (IC50: hETA = 0.35 nM; hETB = 26 nM) and of ET-1 induced contractions in rabbit iliac artery rings (pA2 = 7.74) and rat aortic rings (pA2 = 8.7). In vivo, L-754,142 is a potent and specific antagonist of exogenously administered ET-1 or big ET-1, L-754,142 fully protects against ET-1-induced lethality in mice (AD50 = 0.26 mg/kg i.v.). The pressor response to big ET-1 in the anesthetized ferret is blocked by this compound with an ED50 value of 0.019 mg/kg i.v. L-754,142 also blocks the pressor response to big ET-1 in the conscious rat with ED50 values of 0.30 mg/kg i.v. and 0.56 mg/kg p.o. The duration of action of L-754,142 in this rat model is more than 12 hr after an oral dose of 3 mg/kg. In summary, L-754,142 is a potent, orally active ET antagonist with a long duration of action in several in vivo models.

Conventional patterns of human intestinal proliferation in a severe-combined immunodeficient xenograft model

The present work describes the pattern of human intestinal proliferation in an immunodeficient murine xenograft model, which we have shown to closely mimic cell division in normal paediatric gut. Cellular proliferation was measured using a double-label technique combining MIB-1 immunohistochemistry and [3H]thymidine autoradiography, to critically compare values for the tissue growth fraction (G1, G2, S- and M-phase cells) and DNA synthesizing (S-phase) cells in xenograft epithelium, lamina propria, muscularis externa and intraepithelial lymphocytes. The MIB-1 monoclonal antibody (which recognises the cell-cycle dependent nuclear antigen Ki-67) specifically labelled proliferating human cells within the xenografts and did not cross-react with dividing murine cells. This was confirmed using ultrastructural in situ hybridisation with human- and mouse-specific DNA probes to identify the genetic origin of proliferating cells. In general, we found a good tissue correlation between MIB-1 and [3H]thymidine labelling, the only exception being an apparent dysregulation of Ki-67 antigen expression in regenerating xenograft epithelium. In developed xenograft intestine, the highest levels of proliferation were consistently recorded within the crypt epithelium, where 15.7%-26.7% of cells were actively cycling and S-phase occupied approximately half of the cell cycle. The frequency distribution of proliferating epithelial cells within small and large intestinal xenograft crypts was clearly tissue-specific, showing typical patterns of cell division. Therefore, the presence of functional pluripotent epithelial stem cells and conventional spatio-temporal patterns in cellular proliferation, migration, de-cycling, lineage commitment and cytodifferentiation now makes this an attractive experimental model with which to study human intestinal crypt responses to various types of tissue manipulation, e.g. cytotoxic, radiotherapeutic, dietary, endocrine and gene-targeting therapy.

Characterization of the human oxytocin receptor stably expressed in 293 human embryonic kidney cells

The human oxytocin (OT) receptor was stably expressed in 293 embryonic kidney cells (293/OTR), characterized pharmacologically and compared to human uterine myometrial receptors. The cloned receptor is expressed at a reasonably high density (0.82 fmole/microgram protein) and exhibits high affinity for [3H]OT (Kd = 0.32nM), similar to the value found in human myometrial tissue. The rank-order of potency for various antagonist and agonist ligands from several structural classes is also similar between the cloned and native receptor, as seen in a comparison of their inhibitory constants for [3H]OT binding. Agonist affinity at the cloned OT receptor is decreased by guanine nucleotide analogs, demonstrating functional G-protein-coupling. The OT receptor in 293 cells, like in human myometrium, is also coupled to the inositol phosphate pathway. In 293/OTR cells, OT stimulates inositol phosphate accumulation with an EC50 = 4.1 nM, an effect blocked by a potent and selective OT antagonist, L-366,948. Additionally, the cloned receptor in 293 cells desensitizes to high concentrations of OT, similar to the desensitization in myometrial tissue and also described for several other G-protein-coupled receptors. These results illustrate the utility of the 293 cell line for expressing human OT receptors in an environment quite comparable to the native myometrial tissue.

Impaired cell volume regulation in intestinal crypt epithelia of cystic fibrosis mice

Cystic fibrosis is a disease characterized by abnormalities in the epithelia of the lungs, intestine, salivary and sweat glands, liver, and reproductive systems, often as a result of inadequate hydration of their secretions. The primary defect in cystic fibrosis is the altered activity of a cAMP-activated Cl- channel, the cystic fibrosis transmembrane conductance regulator (CFTR) channel. However, it is not clear how a defect in the CFTR Cl- channel function leads to the observed pathological changes. Although much is known about the structural properties and regulation of the CFTR, little is known of its relationship to cellular functions other than the cAMP-dependent Cl- secretion. Here we report that cell volume regulation after hypotonic challenge is also defective in intestinal crypt epithelial cells isolated from CFTR -/- mutant mice. Moreover, the impairment of the regulatory volume decrease in CFTR -/- crypts appears to be related to the inability of a K+ conductance to provide a pathway for the exit of this cation during the volume adjustments. This provides evidence that the lack of CFTR protein may have additional consequences for the cellular function other than the abnormal cAMP-mediated Cl- secretion.

Synthesis of a series of 4-(arylethynyl)-6-chloro-4-cyclopropyl-3,4-dihydroquinazolin-2(1H)-ones as novel non-nucleoside HIV-1 reverse transcriptase inhibitors

As part of an ongoing effort to prepare novel non-nucleoside inhibitors of human immunodeficiency virus type-1 (HIV-1) reverse transcriptase (RT), a series of 4-(arylethynyl)-6-chloro-4-cyclopropyl-3,4-dihydroquinazolin -2(1H)-ones 4aa-l has been prepared. Target compounds 4a-e were synthesized via addition of various 1-lithio-2-(aryl)alkyne nucleophiles to a 1-protected-4-cyclopropylquinazolin-2(1H)-one (7), followed by deprotection. The 3-methyl compound 4aa was prepared in an analogous manner, with the 3-alkylation performed prior to deprotection. Alternatively, the target compounds 4f-l were prepared by addition of 1-lithio-2-(trimethylsilyl)acetylene to 7, followed by deprotection and subsequent palladium-catalyzed coupling with various aryl halides. By incorporating an aryl group onto the end of the 4-acetylene functionality, the requirement for a metabolically labile 3-methyl group on the dihydroquinazolinone nucleus has been eliminated. A number of the target compounds were shown to be potent inhibitors of HIV-1 RT. Compound 4a, which had exhibited the most favorable overall biological profile, was resolved via a four-step procedure to provide the enantiomers 13a and 13b. Compound 13a having the (-)-4(S) configuration was shown to be the active enantiomer and was selected as a candidate for further investigation.

Metabolism of 3-[2-(benzoxazol-2-yl)ethyl]-5-ethyl-6-methylpyridin-2 (1H)-one (L-696,229), an HIV-1 reverse transcriptase inhibitor, by rat liver slices and in humans

Healthy subjects were administered single oral doses of 800 mg or 400 mg 3-[2-(benzoxazol-2-yl)ethyl]-5-ethyl-6-methylpyridin-2(1H)-o ne (L-696,229), a nonnucleoside inhibitor of the human immunodeficiency virus-type 1 (HIV-1) reverse transcriptase (RT). Plasma or urine samples were collected over a period of 48 hr. Pooled plasma (0.5-6 hr) and urine (0-24 hr) samples were analyzed by HPLC-UV and HIV-1 RT inhibition assay using poly rC.dG as a template primer. The parent compound and several common metabolites were detected in both samples. The metabolic profiles were also similar to those obtained from a rat liver slice incubation with [3H]L-696,229. The in vitro metabolites were identified by NMR and MS as 5 alpha-hydroxyethyl- (major), 5,6-dihydrodiol-, 6'-hydroxy-, 6-hydroxymethyl-, and 5-vinyl analogs, and a benzoxazole ring hydrolysis product. Most of the significant metabolites in human plasma and urine were found to be identical to the in vitro metabolites, as established by HPLC-UV and MS. Hydrolysis of the plasma and urine with beta-glucuronidase/sulfatase indicated the presence of significant amounts of conjugates of the parent compound and 5 alpha-hydroxyethyl metabolite. Most of the other primary metabolites were also present in conjugated forms, albeit in small quantities. In addition, two secondary metabolites were isolated and identified from the hydrolyzed urine as 5-acetyl-6'-hydroxy- and 5 alpha-hydroxyethyl-6-hydroxymethyl- analogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Altered renovascular resistance after spontaneous recovery from hemolytic uremic syndrome

Twenty-three patients were evaluated from 1-15 (mean 6) years after recovering from an episode of diarrhea-associated associated childhood hemolytic uremic syndrome (DA-HUS). All patients had received only conservative treatment; none had been given experimental, anti-coagulant, or immunological therapies. Follow-up studies included morphologic and duplex Doppler sonograms. Doppler sonography was used to determine the resistive index, a measure of renovascular resistance. Histories and physical examinations revealed no abnormalities. Results of laboratory studies, which included calculated glomerular filtration rates, were all within normal limits, except for one patient with minor urinary abnormalities. Renal sonograms showed no significant abnormalities of kidney length or parenchymal appearance. However, Doppler sonographic examinations revealed that the DA-HUS patients demonstrated less of a decrease in renovascular resistance with age than did the control group (p < 0.0002). After recovery, patients treated exclusively with conservative management during an acute episode of DA-HUS appeared to have an excellent long-term prognosis. Comparison of our results with those from other studies in which investigational therapies have been used during the acute phase of DA-HUS suggests that latent toxicities which cause long term sequelae may not have been appreciated previously. The clinical significance of the altered renal vascular resistance remains to be delineated.

Inactivation of the murine cftr gene abolishes cAMP-mediated but not Ca(2+)-mediated secretagogue-induced volume decrease in small-intestinal crypts

The cellular volume of crypts isolated from 2- to 3-week-old mouse small intestine has been measured to assess the capacity of the epithelial cells to respond to secretagogues. Vasoactive intestinal polypeptide (VIP) or carbachol, respectively cAMP- and calcium-mediated secretagogues, produced a reduction crypt volume attributed to KCl loss through channels activated by the agonists. Consistent with the participation of separate chloride channels, 4,4'-diisothiocyanatostilbene-2,2'-disulphonic acid (DIDS) blocked the carbachol- but not the VIP-induced volume decrease, whilst glibenclamide abolished the VIP effect without affecting the carbachol-induced volume decrease. Animals homozygous for a disrupted cftr gene, introduced by gene targeting, were also used as the source for crypt isolation. In these CFTR (-/-) crypts. VIP failed to elicit any reduction in cellular volume, while the response to carbachol was indistinguishable from that seen in crypts from age-matched control animals. These results are consistent with murine CFTR being a cAMP-activated chloride channel inhibited by glibenclamide and resistant to DIDS. A separate chloride conductance activated by calcium mobilization in small-intestinal crypts appears to be independent of CFTR.

Biotransformation of 5-chloro-3-phenylthioindole-2-carboxamide (L-734,005) in rhesus monkeys and rat liver microsomes to a potent HIV-1 reverse transcriptase inhibitor

Rhesus monkeys were dosed orally with 10 mg/kg 5-chloro-3-phenylthioindole-2-carboxamide (L-734,005), a nonnucleoside human immunodeficiency virus type 1 (HIV-1) reverse transcriptase inhibitor, in polyethylene glycol 300. Plasma samples from these monkeys demonstrated greater bioactivity in an HIV-1 reverse transcriptase inhibition assay than anticipated from the parent compound concentrations as determined by an HPLC-UV assay. One major and three minor metabolites, as well as the parent compound, were detected in the plasma. One of the minor metabolites was determined to be several-fold more active, and the major metabolite one-half as active as the parent compound in the inhibition assay. Identical metabolites were formed during an incubation of L-734,005 with rat liver microsomes. The most active minor metabolite was identified as a sulfone analog (L-737,126) of the parent compound by NMR and MS analyses. The less active major metabolite and two relatively inactive minor metabolites were similarly identified as the sulfoxide, 4-hydroxythiophenyl and 6-hydroxyindole analogs of L-734,005. The synthetic sulfone analog was highly potent against HIV-1, with a 95% inhibitory concentration of 3.0 nM for the spread of virus infection in a cell culture.