Endothelial CaSR is involved in the induction of atherosclerosis by promoting cell adhesion and local inflammation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Humboldt foundation

Background

Calcium-Sensing Receptor (CaSR) is a cell surface G-protein coupled receptor that senses calcium in the extracellular environment. This receptor is widely studied in mineral homeostasis due to its presence in varied calcitropic tissues. However, CaSR is also present on the surface of vascular and hematopoietic cells and recent studies suggest that this receptor can also have pathological consequences related to cardiovascular diseases, like atherosclerosis. Since endothelial cells are crucial players in atherogenesis, we aimed to investigate which role endothelial CaSR plays in the development and progression of atherosclerosis.

Methods

We cross-bred CaSRflox/flox Apoe-/- mice with BmxCreERT2 Apoe-/- (endothelial cell specific Cre driver) mice to obtain tamoxifen-inducible mice which have an endothelial cell specific deletion of CaSR. The mice were then fed with a high fat diet (HFD) for 4 or 12 weeks, reflecting early and late atherosclerosis, respectively. We used histological and immuno-fluorescent stainings to analyse the atherosclerotic lesion size and its cellular and acellular composition. Systemic effects on leukocytes were evaluated using flow-cytometry, while intra-vital microscopy was used to study leukocyte adhesion to activated endothelium in-vivo. Further mechanistic studies were performed in human coronary artery endothelial cells (HCAECs) in-vitro.

Results

Endothelial CaSR deficiency in mice resulted in significantly smaller lesion size in early atherosclerotic stages (4 weeks HFD), whereas late atherosclerotic lesions (12 weeks HFD) were not affected by the lack of endothelial CaSR. Moreover, the phenotype of atherosclerotic plaques, characterized by macrophage, smooth muscle cell, collagen and necrotic core content remained unaltered between wild-type and endothelial cell specific CaSR knockout mice. Interestingly, leukocyte adhesion in-vivo, especially neutrophil adhesion, was significantly reduced in endothelial cell CaSR deficient mice. In line with this, overexpression of CaSR in HCAECs in-vitro increased the production of inflammatory cytokines and expression of adhesion molecules ICAM and VCAM.

Conclusion

Our results indicate that while endothelial cell specific CaSR is involved in the induction of atherosclerosis, it does not play a major role in its progression. CaSR has a major influence on endothelium-leukocyte interaction and endothelial inflammation. The increased expression of ICAM/VCAM suggest that CaSR mainly mediates such adhesive effects by modulating integrin expression. Thereby this study highlights that CaSR plays a crucial role in atherosclerosis development, rendering it a novel, so far unexplored therapeutic target.

Environmental impacts of innovative dairy farming systems aiming at improved internal nutrient cycling: A multi-scale assessment

Several dairy farms in the Netherlands aim at reducing environmental impacts by improving the internal nutrient cycle (INC) on their farm by optimizing the use of available on-farm resources. This study evaluates the environmental performance of selected INC farms in the Northern Friesian Woodlands in comparison to regular benchmark farms using a Life Cycle Assessment. Regular farms were selected on the basis of comparability in terms of milk production per farm and per hectare, soil type and drainage conditions. In addition, the environmental impacts of INC farming at landscape level were evaluated with the integrated modelling system INITIATOR, using spatially explicit input data on animal numbers, land use, agricultural management, meteorology and soil, assuming that all farms practised the principle of INC farming. Impact categories used at both farm and landscape levels were global warming potential, acidification potential and eutrophication potential. Additional farm level indicators were land occupation and non-renewable energy use, and furthermore all farm level indicators were also expressed per kg fat and protein corrected milk. Results showed that both on-farm and off-farm non-renewable energy use was significantly lower at INC farms as compared with regular farms. Although nearly all other environmental impacts were numerically lower, both on-farm and off-farm, differences were not statistically significant. Nitrogen losses to air and water decreased by on average 5 to 10% when INC farming would be implemented for the whole region. The impact of INC farming on the global warming potential and eutrophication potential was, however, almost negligible (<2%) at regional level. This was due to a negligible impact on the methane emissions and on the surplus and thereby on the soil accumulation and losses of phosphorus to water at INC farms, illustrating the focus of these farms on closing the nitrogen cycle.

Assessment of disease activity by patients with juvenile idiopathic arthritis and the parents compared to the assessment by pediatric rheumatologists

BACKGROUND

Self assessment of arthritis is important for recognition of disease activity and early initiation of therapy. Proper interpretation of physical symptoms is necessary for this. The purpose was to investigate the assessment by patients and parents of disease activity in juvenile idiopathic arthritis (JIA) and to compare their assessments to rheumatologists' assessments.

METHODS

Patients and parents assessed 69 joints on a paper homunculus and marked each joint with a different color according to presumed presence of disease: active disease (AD), doubt, and non-active disease (NAD). Their assessments were compared to the rheumatologists' assessments. If patients and/or parents marked an inflamed joint, it counted as AD. Pain, functional impairment, and disease duration were analyzed to differentiate more precise between true and false positive and true and false negative assessments.

RESULTS

We collected assessments of 113 patients and/or parents. AD was assessed 54 times, 33 of which were true positives. NAD was assessed 23 times, 22 of which were true negatives. Doubt was expressed 36 times, 9 of which were assessed by the rheumatologist as AD. Sensitivity and specificity of AD was 0.77 and 0.31. Pain and functional impairment scored highest in AD, intermediate in doubt, and lowest in NAD.

CONCLUSION

Patients and/or parents seldom missed arthritis but frequently overestimated disease activity. Pain, functional impairment, disease duration, gender, and age did not differentiate between true and false positives for. Patients perceived JIA as active if they experienced pain and functional impairment. To reduce overestimation of the presence of AD we need to improve their understanding of disease activity by teaching them to distinguish between primary symptoms of JIA and symptoms like pain and functional impairment.

Quantitative simulation tools to analyze up- and downstream interactions of soil and water conservation measures: supporting policy making in the Green Water Credits program of Kenya

Upstream soil and water conservation measures in catchments can have positive impact both upstream in terms of less erosion and higher crop yields, but also downstream by less sediment flow into reservoirs and increased groundwater recharge. Green Water Credits (GWC) schemes are being developed to encourage upstream farmers to invest in soil and water conservation practices which will positively effect upstream and downstream water availability. Quantitative information on water and sediment fluxes is crucial as a basis for such financial schemes. A pilot design project in the large and strategically important Upper-Tana Basin in Kenya has the objective to develop a methodological framework for this purpose. The essence of the methodology is the integration and use of a collection of public domain tools and datasets: the so-called Green water and Blue water Assessment Toolkit (GBAT). This toolkit was applied in order to study different options to implement GWC in agricultural rainfed land for the pilot study. Impact of vegetative contour strips, mulching, and tied ridges were determined for: (i) three upstream key indicators: soil loss, crop transpiration and soil evaporation, and (ii) two downstream indicators: sediment inflow in reservoirs and groundwater recharge. All effects were compared with a baseline scenario of average conditions. Thus, not only actual land management was considered but also potential benefits of changed land use practices. Results of the simulations indicate that especially applying contour strips or tied ridges significantly reduces soil losses and increases groundwater recharge in the catchment. The model was used to build spatial expressions of the proposed management practices in order to assess their effectiveness. The developed procedure allows exploring the effects of soil conservation measures in a catchment to support the implementation of GWC.

Impact of wind turbine sound on annoyance, self-reported sleep disturbance and psychological distress

PURPOSE OF THE RESEARCH

The present government in the Netherlands intends to realize a substantial growth of wind energy before 2020, both onshore and offshore. Wind turbines, when positioned in the neighborhood of residents may cause visual annoyance and noise annoyance. Studies on other environmental sound sources, such as railway, road traffic, industry and aircraft noise show that (long-term) exposure to sound can have negative effects other than annoyance from noise. This study aims to elucidate the relation between exposure to the sound of wind turbines and annoyance, self-reported sleep disturbance and psychological distress of people that live in their vicinity. Data were gathered by questionnaire that was sent by mail to a representative sample of residents of the Netherlands living in the vicinity of wind turbines

PRINCIPAL RESULTS

A dose-response relationship was found between immission levels of wind turbine sound and selfreported noise annoyance. Sound exposure was also related to sleep disturbance and psychological distress among those who reported that they could hear the sound, however not directly but with noise annoyance acting as a mediator. Respondents living in areas with other background sounds were less affected than respondents in quiet areas.

MAJOR CONCLUSIONS

People living in the vicinity of wind turbines are at risk of being annoyed by the noise, an adverse effect in itself. Noise annoyance in turn could lead to sleep disturbance and psychological distress. No direct effects of wind turbine noise on sleep disturbance or psychological stress has been demonstrated, which means that residents, who do not hear the sound, or do not feel disturbed, are not adversely affected.

Five-year follow-up of oral functioning and quality of life in patients with oral cancer with implant-retained mandibular overdentures

BACKGROUND

The purpose of this prospective study was to assess the quality of life (QOL) and oral functioning of patients with oral cancer up to 5 years after prosthodontic rehabilitation with mandibular implant-retained overdentures.

METHODS

Fifty patients who had received implants during ablative surgery were evaluated by standardized questionnaires before and after oncological and prosthetic treatment.

RESULTS

In 20 of 24 surviving patients, the dentures were functional after 5 years. In these survivors, oral function remained unchanged during this period. In the 6 patients with concurrent comorbidity, global health and QOL had deteriorated, while in the patients without comorbidity, global health and QOL were very high. Five-year survivors had a higher global health and better oral functioning at the 1-year evaluation than nonsurvivors.

CONCLUSION

Oral function and denture satisfaction were high and did not change over time for survivors. Deterioration in overall global health and QOL was associated with concurrent comorbidity.

Support behavior and relationship satisfaction in couples dealing with diabetes: main and moderating effects

This study examined associations between support behavior, i.e. active engagement and protective buffering, and relationship satisfaction in both patients with diabetes and their partners. Active engagement refers to supportive behavior characterized by involving one's partner in discussions, asking how the other feels, and problem solving strategies. Protective buffering refers to less supportive behavior characterized by denying fears and worries, and by pretending everything is fine. Furthermore, we examined whether there were interactive effects of these two support behaviors on patients' and partners' relationship satisfaction. At baseline (T1), 205 couples rated to which degree they received active engagement and protective buffering from their partners, and completed a measure of relationship satisfaction. At three follow-up assessments, couples were asked to fill out the same measures. Using dyadic data analytic approaches, we found relationship satisfaction to be positively associated with active engagement, and negatively with protective buffering, in both patients and partners. Moreover, we found a moderating effect, in that the negative association between protective buffering and relationship satisfaction was only present when levels of active engagement were relatively low. Again, these results were found for patients as well as their partners. We were able to replicate the T1 results at the other three assessment points. Our findings illustrate the need to consider adequate and less adequate support behaviors simultaneously, and to study the effects on both patients and partners.

Promoting physical activity in children with juvenile idiopathic arthritis through an internet-based program: results of a pilot randomized controlled trial

OBJECTIVE

Patients with juvenile idiopathic arthritis (JIA) are less physically active than healthy peers. Therefore, we developed an Internet-based intervention to improve physical activity (PA). The aim of this study was to examine the effectiveness of the program in improving PA.

METHODS

PA was determined by activity-related energy expenditure, PA level, time spent on moderate to vigorous PA, and the number of days with > or =1 hour of moderate to vigorous activity, and was assessed with a 7-day activity diary. Aerobic exercise capacity was assessed by means of a Bruce treadmill test and was recorded as maximum endurance time. Disease activity was assessed by using the JIA core set. Adherence was electronically monitored.

RESULTS

Of 59 patients, 33 eligible patients were included and randomized in an intervention (n = 17, mean +/- SD age 10.6 +/- 1.5 years) or control waiting-list group (n = 16, mean +/- SD age 10.8 +/- 1.4 years). All patients completed baseline and T1 testing. PA significantly improved in both groups. Maximum endurance time significantly improved in the intervention group but not in the control group. In a subgroup analysis for patients with low PA (intervention: n = 7, control: n = 5), PA improved in the intervention group but not in the control group. The intervention was safe, feasible, and showed a good adherence.

CONCLUSION

An Internet-based program for children with JIA ages 8-12 years directed at promoting PA in daily life effectively improves PA in those patients with low PA levels. It is also able to improve endurance and it is safe, feasible, and has good adherence.

Response to noise from modern wind farms in The Netherlands

The increasing number and size of wind farms call for more data on human response to wind turbine noise, so that a generalized dose-response relationship can be modeled and possible adverse health effects avoided. This paper reports the results of a 2007 field study in The Netherlands with 725 respondents. A dose-response relationship between calculated A-weighted sound pressure levels and reported perception and annoyance was found. Wind turbine noise was more annoying than transportation noise or industrial noise at comparable levels, possibly due to specific sound properties such as a "swishing" quality, temporal variability, and lack of nighttime abatement. High turbine visibility enhances negative response, and having wind turbines visible from the dwelling significantly increased the risk of annoyance. Annoyance was strongly correlated with a negative attitude toward the visual impact of wind turbines on the landscape. The study further demonstrates that people who benefit economically from wind turbines have a significantly decreased risk of annoyance, despite exposure to similar sound levels. Response to wind turbine noise was similar to that found in Sweden so the dose-response relationship should be generalizable.

A whole-farm strategy to reduce environmental impacts of nitrogen

Dutch regulations for ammonia emission require farmers to inject slurry into the soil (shallow) or to apply it in narrow bands at the surface. For one commercial dairy farm in the Netherlands it was hypothesized that its alternative farming strategy, including low-protein feeding and surface spreading, could be an equally effective tool for ammonia emission abatement. The overall objective of the research was to investigate how management at this farm is related to nitrogen (N) losses to the environment, including groundwater and surface water. Gaseous emission of ammonia and greenhouse gasses from the naturally ventilated stables were 8.1 and 3.1 kg yr(-1) AU(-1) on average using the internal tracer (SF(6))-ratio method. Measurements on volatilization of ammonia from slurry application to the field using an integrated horizontal flux method and the micrometeorological mass balance method yielded relatively low values of ammonia emissions per ha (3.5-10.9 kg NH(3)-N ha(-1)). The mean nitrate concentration in the upper ground water was 6.7 mg L(-1) for 2004 and 3.0 mg L(-1) for 2005, and the half-year summer means of N in surface water were 2.3 mg N L(-1) and 3.4 mg N L(-1) for 2004 and 2005, respectively. Using a nutrient budget model for this farm, partly based on these findings, it was found that the calculated ammonia loss per ton milk (range 5.3-7.5 kg N Mg(-1)) is comparable with the estimated ammonia loss of a conventional farm that applies animal slurry using prescribed technologies.

[The influence of the pharmaceutical industry in patient organisations]

Most patient organisations have no objection to sponsoring by the pharmaceutical industry. Only 5% of all organisations are against sponsoring. When patient organisations were asked whether or not their activities could continue without sponsoring, 42% answered no, 6% yes, and 52% felt that they might continue, but restricted. In a report of the public health inspector on the subject, transparency is considered to be a remedy for the entanglement between patient organisations and the pharmaceutical industry. However, the authors doubt that this is effective. The government should provide sufficient support for patient organisations so that they can become independent from the industry.

Prosthodontic rehabilitation of oral function in head-neck cancer patients with dental implants placed simultaneously during ablative tumour surgery: an assessment of treatment outcomes and quality of life

The aim of this prospective study was to assess treatment outcome and impact on quality of life of prosthodontic rehabilitation with implant-retained prostheses in head-neck cancer patients. Fifty patients were evaluated by standardized questionnaires and clinical assessment. All received the implants during ablative tumour surgery in native bone in the interforaminal area. About two-thirds of the patients (n=31) needed radiotherapy post-surgery. Both in irradiated and non-irradiated bone two implants were lost 18-24 months after installation. Peri-implant tissues had a healthy appearance. No cases of osteoradionecrosis occurred. In 15 patients no functional implant-retained lower dentures could be made for various reasons. The other 35 patients all functioned well, with an improvement in quality of life. Major improvement was observed in the non-irradiated patients. In the irradiated patients, less improvement in many functional items was observed, while items related to the oral sequelae of radiotherapy did not improve. Similar to the quality-of-life assessments, denture satisfaction was improved and tended to be higher in non-irradiated than irradiated patients. Implant-retained lower dentures can substantially improve the quality of life related to oral functioning and denture satisfaction in head-neck cancer patients. This effect is greater in non-irradiated than irradiated cancer patients.

Quality of life related to oral function in edentulous head and neck cancer patients posttreatment

PURPOSE

Surgical treatment of malignancies in the oral cavity and subsequent radiotherapy often result in an oral condition unfavorable for prosthodontic rehabilitation. This study assessed the quality of life related to oral function in edentulous head and neck cancer patients following oncology treatment of malignancies in the lower region of the oral cavity.

MATERIALS AND METHODS

Patients treated between 1990 and 2000 with surgery and radiotherapy for a squamous cell carcinoma in the oral cavity who were edentulous in the mandible and had been treated with a conventional, non-implant-retained denture received an invitation for a clinical check-up (clinical assessment, questionnaires regarding oral function and quality of life).

RESULTS

Sixty-seven of the 84 patients who fulfilled the inclusion criteria were willing to participate in the study. The mean irradiation dosage that these patients had received in the oral region was 61.8 +/- 5.4 Gy. Half of the patients (n=33) were not very satisfied with their prostheses; they wore their mandibular prostheses at most a few hours per day. It was concluded from the clinical assessment that two thirds of the patients (n 4) could benefit from an implant-retained mandibular denture. Analyses of the questionnaires revealed no significant associations between functional assessments, quality of life, and parameters such as size of the primary tumor, location of the primary tumor, and different treatment regimes. Despite cancer treatment, the patients reported a rather good general quality of life.

CONCLUSIONS

Sequelae resulting from radiotherapy probably dominate oral function and quality of life after oncology treatment. In two thirds of the patients, improvement of oral function and related quality of life would be expected with the use of an implant-retained mandibular denture.

Assessment of severity of hand eczema: discrepancies between patient- and physician-rated scores

BACKGROUND

In clinical practice or trials on hand eczema the severity of this disease can be 'measured' in different ways: by means of a physician-rated clinical severity score, a patient-rated clinical severity score or by an indicator of the burden of disease. We assume that the patient-rated severity score corresponds more with the (change in) burden of disease than with the physician-rated severity score.

OBJECTIVES

To demonstrate how physicians and patients differ in their assessment of the severity of hand eczema as seen in a physician-rated severity score, patient-rated severity score and a burden of disease questionnaire.

METHODS

We used data from an open-label randomized controlled trial which was set up in two university hospital dermatology departments in the Netherlands, specializing in hand eczema. One hundred and fifty-eight patients with moderate to severe chronic hand eczema were included. The main outcome measures were the physician-rated severity score, based on five visible aspects of hand eczema (desquamation, erythema, vesicles, infiltration, fissures), the patient-rated severity score (a self-rating scale), a burden of disease questionnaire (the Dermatology Life Quality Index, DLQI) and the correlations between these parameters, both at inclusion and over time.

RESULTS

Only desquamation and infiltration were significantly correlated with patient-rated severity score. Patient-rated severity score correlated with seven of 10 DLQI items, but it did not correlate with the items regarding influence on clothes worn, impairment of sporting activities, and problems associated with treatment of the skin. The majority of patients showed improvement in all parameters after treatment. However, the improvement in patient-rated severity score was not clearly correlated with changes in physician-rated severity score. Except for DLQI item 1 (itch, soreness, pain, stinging), none of the changes in burden of disease was correlated with changes in patient-rated severity score. For each DLQI item, change over time correlated weakly with decreases in several, but not all, components of the physician-rated severity score.

CONCLUSIONS

Disease severity can be expressed by different scores; these scores are not clearly correlated, and measure different aspects. Patient satisfaction is not guaranteed when treatment is focused solely on the visible aspects of hand eczema. Instead, burden of disease has a greater impact.

Recall bias did not affect perceived magnitude of change in health-related functional status

BACKGROUND AND OBJECTIVE

It was hypothesized that within an invasively treated group and within a group that improved in angina pectoris no difference in effect size would occur between prospective and retrospective measures. Furthermore, it was hypothesized that assessment of perceived change at post-test may be invalid because of recall bias and present-state bias.

STUDY DESIGN AND SETTING

Effect sizes (as standardized response means) were used as indicators of magnitude of change. Linear structural equation analysis (with LISREL) was used to investigate the relationship between the estimates of recall accuracy and retrospectively assessed change.

RESULTS

No significant differences were found between prospective and retrospective measures of change over time in health-related functional status. Recall bias was not associated with retrospective measurement of change within a 12-week interval. An expected present-state effect was found in a structural equation model.

CONCLUSION

Prospective and retrospective indices of magnitude of change were similar between groups receiving treatment of known efficacy. Recall bias seems to be an acceptable risk in short-term follow-up studies.

Improving self-management in insulin-treated adults participating in diabetes education. The role of overprotection by the partner

AIMS

To examine the role of overprotection by the partner--i.e. excessive protection, unnecessary help, excessive praise for accomplishments, or attempts to restrict activities as a consequence of underestimating the patient's capabilities--in changes in patient self-management in the context of diabetes education.

METHODS

Sixty-seven insulin-treated patients with a partner completed questionnaires on admission to a Multidisciplinary Intensive Education Programme (MIEP) and 3 months after completing the core module of MIEP. Factors assessed were overprotection by their partner and three aspects of diabetes self-management, namely internal locus of control, diabetes-related distress and HbA1c. Regression analyses were used to test the independent associations of patient sex, baseline overprotection and the interaction between sex and overprotection with diabetes self-management at the follow-up stage, controlling for the baseline value of the dependent variable.

RESULTS

The increase in internal locus of control and decrease in HbA1c were both significantly less for female patients who perceived their partner to be rather overprotective than for female patients who did not perceive their partner to be overprotective. The more patients, both male and female, perceived their partner to be overprotective, the less their diabetes-related distress decreased.

CONCLUSIONS

Overprotection by the partner showed a negative association with improvement in diabetes self-management, especially for female patients. Thus, an intervention programme with the aim of reducing overprotection by the partner, or the perception of this, may enhance self-management in patients participating in diabetes education.

One-year follow-up effects of diabetes rehabilitation for patients with prolonged self-management difficulties

The aim of this study is to determine effects and the role of facilitators of empowerment of a Multidisciplinary Intensive Education Programme (MIEP) for diabetic patients with prolonged self-management difficulties. Glycemic control (HbA1c), health-related quality of life (HR-QoL) and facilitators of empowerment (health locus of control and coping) were measured in 99 participants of MIEP at baseline (T0), 3 (T1) and 12 months (T2) follow-up and in 231 non-referred consecutive outpatients. HbA1c improved at T2, although initial improvement was partially lost. Patients improved in most HR-QoL domains, without any relapse at T2. At T2, participants no longer differed from the average outpatients in any outcome. Initially, the HbA1c of men and women improved equally, but at T2 women consolidated improvement, whereas men relapsed. After MIEP, patients became more empowered (both at T1 and T2), explaining additional variance in HR-QoL improvement. The aim of MIEP to empower patients, rather than trying to solve problems for them seems effective.

Cost and benefits of a multidisciplinary intensive diabetes education programme

OBJECTIVES

To determine the cost and benefits of an intensive diabetes education programme for patients with prolonged self-management problems and to determine the inclusion criteria for optimal outcomes.

METHODS

Sixty-one participants of a multidisciplinary intensive diabetes education programme (MIDEP) were measured before they started the intervention (T0), and at 1-year follow-up (T1). Data on glycaemic control (HbA1c), diabetes-related distress (PAID) and costs were obtained. Changes over time were analysed and means at T0 and T1 were compared to a reference group of 230 non-referred consecutive outpatients. The number needed to treat (NNT), that is, the number of patients to be treated to achieve one successful case, was calculated for different baseline values of HbA1c and PAID to determine optimal inclusion criteria.

RESULTS

Diabetes-related costs decreased significantly and participants improved significantly in HbA1c and diabetes-related distress following MIDEP. HbA1c and distress reached the levels of the reference group. The T1 costs remained higher than in the reference group, but the reduction in costs outweighed the intervention costs. Including patients with baseline HbA1c>or=8.0% and/or PAID scores>or=40 would improve the NNT to achieve clinically relevant outcomes, while 76% of the patients matched these inclusion criteria.

CONCLUSIONS

MIDEP is effective in improving glycaemic control and diabetes-related distress for patients with prolonged self-management difficulties. Besides the immediate reduction in costs found in the present study, improved glycaemic control may reduce future costs of diabetic complications. Stricter inclusion criteria with respect to HbA1c and PAID scores may further improve the programme's efficiency.

Clinical characteristics of persistent lone atrial fibrillation in the RACE study

In the RAte Control versus Electrical cardioversion for persistent atrial fibrillation (RACE) study, 522 patients were randomized to either rate or rhythm control therapy. Lone atrial fibrillation (AF) was present in 89 patients. Demographics, cardiovascular mortality and morbidity, and quality of life were compared between patients with lone AF and those with underlying structural heart disease. Patients with lone AF were significantly younger (65 +/- 10 vs 69 +/- 8 years) and had fewer complaints of fatigue (p = 0.01) and dyspnea (p = 0.005). With lone AF, quality-of-life scores were higher on almost all 8 Medical Outcomes Study Short-Form health survey questionnaire subscales, and comparable to healthy, age- and gender-matched controls. Mean follow-up was 2.3 +/- 0.6 years. Cardiovascular end points occurred in 9 patients with lone AF (10%), consisting of death (all bleedings) 3%, thromboembolic complications in 3%, nonfatal bleeding in 2%, and pacemaker implantation in 2%, but no heart failure and severe adverse effects due to antiarrhythmic drugs occurred. End points occurred in 95 patients (22%) with underlying diseases. Heart failure and severe adverse effects from drugs did not occur in patients with lone AF in this study. Despite the absence of demonstrable cardiovascular and cerebrovascular disease, lone AF is associated with bleeding and thromboembolism.

Do diabetologists recognise self-management problems in their patients?

OBJECTIVE

The aim of this study was to determine whether diabetologists recognise patients' needs for additional intensive multidisciplinary care due to glycaemic and diabetes-related psychosocial difficulties.

RESEARCH DESIGN AND METHODS

We compared 114 participants in a diabetes intervention programme with 201 as yet non-referred outpatients, of whom 54 outpatients were considered eligible for the intervention by their diabetologists; thus, 147 outpatients were considered non-eligible.

RESULTS

Analysis revealed that the eligible patients had poorer glycaemic control but all other parameters were similar to non-eligible patients. Significantly, 22 (15%) of the 147 non-eligible patients clearly had diabetes distress and could potentially benefit from the intervention.

CONCLUSION

The results suggest that in regular care, patients' needs with respect to glycaemic control are recognised by their diabetologists, but patients with high psychosocial diabetes-related distress are often overlooked, though they also may be in need of additional care. Integrated monitoring of diabetes-related distress in outpatients could improve this area of diabetes care.

Diabetes rehabilitation: development and first results of a Multidisciplinary Intensive Education Program for patients with prolonged self-management difficulties

For a number of diabetes patients regular care may be insufficient. A Multidisciplinary Intensive Education Program (MIEP), based on the empowerment approach, has been developed to help patients obtain their treatment goals (adequate self-management, glycemic control and quality of life). The aim of this pilot study is to determine the effects of MIEP and it's mechanisms of influence. MIEP consisted of 12 days group-sessions and individual counseling. At baseline and 3-months follow-up, blood-glucose (HbA1c), quality of life, health locus of control, distress, and knowledge were obtained (N = 51). Paired T-tests and regression analyses were conducted. HbA1c, and knowledge improved significantly, patients rated themselves healthier and were more internal and less powerful others oriented. Baseline scores explained effects in HbA1c, and quality of life. Locus of control significantly contributed in effects on quality of life. MIEP benefited patients with prolonged self-management difficulties, and this form of care seems to complement regular care.

Lebensqualit�t bei Patienten mit berufsbedingten Handekzemen

In recent years quality of life has been studied in a growing number of different dermatological diseases. Internationally validated questionnaires such the RAND-36 (identical to the SF-36) do not contain enough questions which are relevant for skin diseases. There is no publication on quality of life issues in occupational skin diseases, and only one short report gives data on quality of life in hand eczema. The widely used skin specific instrument DLQI has only 2 questions that indirectly refer to employment issues. A quality of life questionnaire on occupational skin diseases (mostly hand eczema) should ideally include questions on work-related impairment of both physical functioning and interaction with colleagues.

Satisfaction and psychosocial aspects of patients with an extremely resorbed mandible treated with implant-retained overdentures. A prospective, comparative study

The objective of the present report was to study the effect of implant treatment on subjective parameters in edentulous patients with an extremely resorbed mandible. Three different treatment modalities to support an overdenture were compared: transmandibular implant according to Bosker, augmentation of the mandible followed by four endosseous implants, and the insertion of four short endosseous implants. Sixty patients [50 women and 10 men, mean (+/- SD) age 59 (+/- 11) years] met the inclusion criteria and were assigned in one of the three treatment groups. Before treatment and 12 months after placement of the new overdentures, denture satisfaction, psychosocial aspects and experiences during the surgical phase were assessed with a battery of questionnaires. After 1 year, 58 patients were available for evaluation: one patient had died, and one patient had moved out of the region. There was a significant improvement of patient satisfaction and psychosocial functioning in all three treatment groups. At the 1-year evaluation, differences amongst the three groups were not significant. However, in terms of discomfort and pain during the surgical phase as well as the length of this phase (at least 6 months), the augmentation using an autologous bone graft from the iliac crest followed by inserting four endosseous implants 3 months later appeared the least favorite option of the three modalities studied.

Rate control versus electrical cardioversion for atrial fibrillation: A randomised comparison of two treatment strategies concerning morbidity, mortality, quality of life and cost-benefit - the RACE study design

BACKGROUND

Persistent atrial fibrillation (AF) does not terminate spontaneously and may cause left ventricular dysfunction and thromboembolic complications. For restoration of sinus rhythm electrical cardioversion (ECV) is most effective. However, AF frequently relapses, necessitating re-ECV and institution of potentially harmful antiarrhythmic drugs. If AF is accepted, rate control and prevention of thromboembolic complications using negative chronotropic drugs and warfarin is pursued. It is our hypothesis that rate control therapy is not inferior to ECV therapy in preventing morbidity and mortality.

METHODS

RACE (RAte Control versus Electrical cardioversion for atrial fibrillation) is a randomised comparison of serial ECV therapy (repeat ECV as soon as possible after a relapse and institution of an antiarrhythmic drug: sotalol, class IC drug and amiodarone) and rate control therapy (resting heart rate <100 bpm using digitalis, calcium channel blockers and/or β-blockers) in patients with persistent AF. Morbidity (heart failure, side effects of drugs, thromboembolic complications, bleeding and pacemaker implantation), mortality, quality of life and cost-effectiveness are primary and secondary endpoints. Included are patients with a recurrence of persistent AF, present episode <1 year and a maximum of two previous successful ECVs during the last two years. This study is a multicentre study in 31 centres throughout the Netherlands. All 520 patients have now been included. Follow-up is two years. The results are expected this year.

How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating?

Some clinical trials perform repeated measurement over time and estimate clinically relevant change in an instrument's score with global ratings of perceived change or so-called transition questions. The conceptual and methodological difficulties in estimating the magnitude of clinically relevant change over time in health-related functional status (HRFS) are discussed. This paper investigates the concordance between the amount of serially assessed change with effect size estimates (the researcher's perspective) and global ratings of perceived change (the patient's perspective). A total of 217 patients who were scheduled for diagnostic examination were included, and the Minnesota Living with Heart Failure Questionnaire, extended with MOS-20 items, was assessed before and after medical intervention (percutaneous transluminal coronary angioplasty, coronary artery bypass grafting or pharmaco-therapy). Global questions were applied to assess perceived change over time for every item from domains of physical and emotional functioning and used as the external criterion of relevant change in the analysis of items. Global questions corresponding with overall change in these domains were used in the comparison of change in physical and emotional functioning scales. Two effect size indices were used: (i) ES (mean change/SDpooled) and (ii) ES (mean change/SDchange). A method is described to calculate a value indicating the extent of discordance between the researcher's interpretation of magnitude of change and the external criterion (the patient's perspective). Findings suggest that effect size (ES) (mean change/SDpooled) was in keeping with the magnitude of change indicated by patients' judgements, or their category of subjective meaning, for all scales. Furthermore, in cases in which the magnitude of change estimated with the SRM (mean change/SDchange) was not confirmed empirically by the external criterion ratings, the discordance could be interpreted as a trivial discordance.

Psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q)

OBJECTIVE

To evaluate the psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q) in patients with atrial fibrillation.

DESIGN

A prospective study of the patients who underwent DC electrical cardioversion.

SETTING

Clinics of cardiology and thoracic surgery of the University Hospital in Groningen, the Netherlands.

MAIN OUTCOME MEASURES

The disease-specific MLHF-Q and generic measures of quality of life were administered. The sensitivity to change over time was tested with effect sizes (ES). Internal consistency of MLHF-Q scales was estimated with Cronbach's alpha. To evaluate the construct validity multitrait-multimethod analysis was applied. The 'known group validity' was evaluated by the comparison of mean scores and effect sizes between two groups of the New York Heart Association (NYHA) classification (NYHA I versus II-III). Stability of MLHF-Q scales was estimated in a subgroup of patients who remained stable. Perfect congruence analysis and factor analysis were applied to confirm the a priori determined structure.

RESULTS

Cronbach's alpha was > or = 0.80 of the MLHF-Q scales. Perfect congruence analysis (PCA) showed that the results resemble quite well the a priori assumed factor structure. Multitrait-multimethod analysis showed convergent validity coefficients ranging from 0.59 to 0.73 (physical impairment dimension) and 0.39 to 0.69 (emotional dimension). The magnitude of change can be interpreted as medium (ES = 0.50). The results of a 'test-retest' analysis in a stable group can be valued as satisfactory for the MLHF-Q scales (Pearson's r > 0.60). The physical dimension and the overall score of the MLHF-Q discriminated significantly between the NYHA I and II-III groups (p < 0.001) with large effect sizes (ES > 1.0).

Estrogen receptor-alpha protein localization in the testis of the rainbow trout (Oncorhynchus mykiss) during different stages of the reproductive cycle

Estrogen receptor-alpha (ER-alpha) is important for male reproduction in mammals; however, no information is available on ER-alpha protein distribution in the testes of fishes. The cellular localization of the rainbow trout (Oncorhynchus mykiss) ER-alpha (rtER-alpha) protein, throughout the annual reproductive cycle was determined in this study. An antibody was designed based on a 15-amino acid sequence from the D-domain of the rtER-alpha, and its specificity was confirmed using Western blot analysis. Immunohistochemical analysis revealed rtER-alpha protein to be present only in the testicular interstitium, at every stage of the annual reproductive cycle. The localization of rtER-alpha protein in the interstitial fibroblasts, the Leydig cell precursor in the rainbow trout, suggests a role for estrogens in the differentiation of these precursor cells into mature Leydig cells. This is the first study to report the cellular localization of an estrogen receptor protein in the testis of any fish species.

Morphological analysis of endocytosis in efferent ductules of estrogen receptor-alpha knockout male mouse

Lack of estrogen receptor (ER) results in fluid accumulation and dilation of the efferent ductules, suggesting that the role of estrogen and ER in the male reproductive tract is related to fluid reabsorption in the ductules. In the present study, endocytosis of the nonciliated cells of the efferent ductules was compared morphologically between wild type (WT) and estrogen receptor-alpha knockout (alpha ERKO) male mice. The epithelial cells lining the WT efferent ductules were tall columnar in shape, whereas those of the alpha ERKO were low columnar. Immunocytochemically, the nonciliated cells of both genotypes showed positive reactions of sulfated glycoprotein-2, but the reaction products were reduced in amount in the alpha ERKO. Electron microscopy revealed that the nonciliated cells of the WT had numerous organelles for endocytosis such as coated pits and vesicles, tubules, endosomes, multivesicular bodies and lysosomes in the apical cytoplasm. These organelles were less developed in the nonciliated cells of the alpha ERKO. Morphometric analysis indicated that there was a significant reduction in area of endocytotic apparatus in the nonciliated cells of the alpha ERKO compared with that of the WT. A tracer study using gold particles demonstrated that the nonciliated cells of both WT and alpha ERKO efferent ductules were capable of taking up luminal contents. These results suggest that reabsorption of the luminal contents via endocytosis takes place in the efferent ductules but is greatly reduced in amount in the absence of ER alpha.

Comparing the clastogenic potential of atrazine with caffeine using Chinese hamster ovary (CHO) cells

The agronomically important herbicide atrazine has been reported to cause damage to animal chromosomes at levels of atrazine found contaminating drinking water supplies. While documenting potential chromosome damage is important it is equally important to compare the damage with the potential consequences of compounds readily found in our food and water supply. In this study atrazine and caffeine, a ubiquitous food additive, were compared at equal levels and at real exposure levels for their ability to damage animals chromosomes in cell culture. Nuclei and chromosomes from treated and control cells were analyzed by flow cytometry. At extremely low levels, atrazine was found to be a more potent clastogen. Caffeine had no effect on the chromosomes at the lower levels. Both chemicals were genotoxic at the potential exposure levels with caffeine being more disruptive than atrazine. Atrazine appears to be a more potent damaging agent than caffeine at similar levels of exposure; however, the levels of caffeine one is exposed to during everyday life appears to be more damaging on the endpoints analyzed in this study than the levels of atrazine found contaminating water supplies. The advantages and limitations of whole cell clasotgenicity are also presented in light of these results.

High incidence of a male-specific genetic marker in phenotypic female chinook salmon from the Columbia River

Numerous populations of anadromous salmonids in the northwestern United States have been declining for many years, resulting in Endangered Species Act listings and in some cases extinction. The degradation of river ecosystems has been proposed as one of the major reasons for the inability of salmon to maintain their populations. However, the specific factors interfering with the reproduction and survival of salmon during the freshwater phase of their life cycle have not been fully described. This study was initiated to determine the incidence of phenotypic sex reversal in wild, fall chinook salmon (Oncorhynchus tshawytcha) that returned to spawn in the Columbia River. Fish were sampled at different locations within this watershed to determine whether they were faithfully expressing their genotype. We report a high incidence (84%) of a genetic marker for the Y chromosome in phenotypic females sampled from the wild, which was not observed in female fish raised in hatcheries. It appears likely that female salmon with a male genotype have been sex reversed, creating the potential for an abnormal YY genotype in the wild that would produce all-male offspring and alter sex ratios significantly.

[Regional differences in prehospital time delay for patients with acute myocardial infarction; Rotterdam and Groningen, 1990-1995]

OBJECTIVE

To describe pre-hospital delay times in patients with acute myocardial infarction (AMI) in two regions in the Netherlands: Groningen (a region with high mortality for coronary heart disease (CHD)) and Rotterdam (a region with low CHD mortality).

DESIGN

Descriptive.

METHOD

The pre-hospital treatment delay of AMI patients in Rotterdam in 1990-1991 versus 1993-1995 was compared and also compared between Groningen en Rotterdam (1993-1995). In each region 3 hospitals participated (1 academic, 2 regional). The data were collected with a structured interview within 7 days after onset of symptoms in hospitalized AMI patients (n = 924) or by interviewing relatives of deceased patients (n = 40). The median patient, general practitioner (GP) and ambulance delays were calculated.

RESULTS

Total median pre-hospital delay was 2.5 hours (5-95-percentile: 50 min-36 hours). Median patient delay time was shorter in Groningen than in Rotterdam (respectively 30 and 45 min) and the same applied to doctor delay times (respectively 38 and 72 min). In Rotterdam doctor delay time decreased by 23 min between 1990-1991 and 1993-1995. Median ambulance delay was 30 min in Rotterdam and 35 min in Groningen. Total pre-hospital delay times of self referred patients were 32-78 min shorter than those of patients who consulted a GP before admission.

CONCLUSION

Reduction of pre-hospital delay in Rotterdam between 1990-1991 and 1993-1995 was due to faster decision time by the GP. The short pre-hospital treatment delay in Groningen in hospitalized patients suggests that relatively more AMI patients die outside hospital which may contribute to the high CHD mortality in this region.

Morphologic changes in efferent ductules and epididymis in estrogen receptor-alpha knockout mice

Estrogen has been shown to have an important role in fluid reabsorption in efferent ductules of the testis. Our previous study of the estrogen receptor-alpha knockout mouse (ERKO) showed that the efferent ductules and rete testis were primary targets of estrogen receptor function. In the present study, a more comprehensive evaluation of the ERKO male reproductive tract was performed to determine the severity of effects in efferent ductules as well as the epididymis. The following observations were found in ERKO males: 1) blind-ending efferent ductules were more prevalent in ERKO than in wild type (WT) tissues; 2) glycogen-containing cells were observed at the rete testis-efferent ductule junction; 3) the tubular diameters of the efferent ductules and initial segment epididymides were dilated; 4) efferent ductules were dilated between 130 to 300% over wild type ductules; 5) efferent ductule epithelial height was reduced nearly 50%; 6) microvilli of nonciliated cells of efferent ductules were 64% shorter in length; 7) cilia were reduced in number; 8) initial segment epithelium was displaced into regions adjacent to the rete testis and in short segments of the common region of efferent ductule; 9) apical, narrow, and clear cells of the epididymis also were abnormal in some regions; 10) in the corpus and cauda regions, sperm granulomas were noted in one third of the ERKO males. In conclusion, the entire reproductive tract is affected in ERKO males. The cells showing the greatest effects were estrogen receptor-positive cells. It appears that in the ERKO mouse there are developmental anomalies that must be considered separately from adult dysfunctional changes in the male reproductive tract.

Longer pre-hospital delay in acute myocardial infarction in women because of longer doctor decision time

STUDY OBJECTIVE

To measure the pre-hospital delay times in patients with proven acute myocardial infarction (AMI) and to identify possibilities for reduction of treatment delay.

DESIGN

Descriptive three centre study.

SETTING

One university teaching hospital and two regional hospitals in Groningen, the Netherlands.

PATIENTS

400 consecutive confirmed AMI patients, age below 75 years, admitted to coronary care departments.

MAIN RESULTS

Mean age was 59 years and 78% of patients were men. Within two hours after onset of symptoms half of the patients with AMI arrived at the hospital. Patient, doctor, and ambulance delay times (median values) were 30, 38, and 35 minutes respectively. Calling the personal general practitioner (GP) or the locum tenens and whether or not the AMI occurred during a weekend or on a working day had no consequences for pre-hospital delay times. At night patients waited longer before calling a GP than in the daytime. There was a positive correlation between patient and doctor delay. Twenty two per cent of AMI patients waited two hours or more before calling a GP. Total pre-hospital delay times differed between men and women. Longer doctor delay in women (36 minutes for men and 52 minutes for women) was caused by displacement of specific symptoms, in particular in women. AMI patients who were alone during onset of symptoms showed higher patients delay (72 compared with 23 minutes).

CONCLUSION

In hospital admitted patients younger than 75 years pre-hospital delay times are within acceptable limits. In some subgroups further reduction is attainable, for example in patient delay outside office hours and when patients are alone during onset of symptoms, in doctor delay in cases where women present with symptoms suggestive for AMI. Improvement of facilities for pre-hospital electrocardiographic diagnosis may facilitate decision making by GPs. Good opportunities for further reduction of treatment delay exist in shortening of hospital delay.

Immunohistochemical localization of somatostatin receptor sst2A in sarcoid granulomas

BACKGROUND

In a previous study, we demonstrated the presence of receptors for somatostatin, a neuropeptide with immunoregulatory properties, in the inflammatory lesions of patients suffering from sarcoidosis and other granulomatous diseases by in vivo somatostatin receptor scintigraphy and in vitro autoradiography. However, it was not possible to identify exactly which cell types expressed the somatostatin receptors and which subtype was expressed. In this study we used a polyclonal antiserum directed against the sst2A receptor to identify more accurately the sst2A-expressing cells in sarcoidosis and other granulomatous diseases.

DESIGN

Tissue biopsies from 12 patients with sarcoidosis, one patient with giant cell arteritis and one patient with Wegener's granulomatosis were studied by immunohistochemistry with the sst2A-specific antiserum. Two of the sarcoidosis patients were treated with the somatostatin analogue octreotide (100 microg t.i.d.).

RESULTS

Epithelioid cells, multinucleated giant cells and a subset of CD68+ macrophages stained positive for sst2A in 9 out of 12 of the sarcoid biopsies and in both non-sarcoid granuloma biopsies. Treatment with octreotide resulted in clinical improvement in one out of two treated patients.

CONCLUSION

The identification of somatostatin receptors on granuloma macrophages, epithelioid cells and giant cells, and the successful treatment of one patient with sarcoidosis with a somatostatin analogue, may offer new possibilities for treatment of granulomatous diseases.

Cost analysis of the treatment of severe spinal spasticity with a continuous intrathecal baclofen infusion system

OBJECTIVE

The purpose of our study was to analyse and evaluate the costs of continuous intrathecal baclofen administration as a modality in the treatment of severe spasticity in the Netherlands.

DESIGN

A cost analysis was conducted as part of a prospective, multicentre, multidisciplinary, randomised and placebo-controlled clinical trial. The study covered the period from December 1991 to September 1995. The data on medical consumption and costs were collected over a 3-year period from different sources: administrative databases of health insurance companies, hospital registries and a patient survey. These data were structured by means of a flowchart analysis of the medical decision-making by specialists and general practitioners (GPs). They included data on in- and outpatient care, home care and care in nursing homes. The cost analysis was conducted using data from 18 patients included in the trial and from 15 so-called 'match' patients. The latter group are patients with comparable diseases leading to spasticity and living in comparable circumstances. Next to absolute costs (direct and indirect) of care and treatment for the 2 groups of patients, cost differences between the 2 groups were considered (differential cost analysis).

SETTING

Per patient cost data, collected prospectively for 2 years during the phase of clinical evaluation, and retrospectively 1 year before implantation. The data were collected on patients from in- and outpatient care, home care and care in nursing home settings.

PATIENTS AND PARTICIPANTS

The trial patients (8 men) had a mean age of 46 years; 11 patients had multiple sclerosis and 7 patients had spinal cord injuries. The match patients (7 men) had a mean age of 48 years; 9 patients had multiple sclerosis and 6 patients had spinal cord injuries.

INTERVENTIONS

Trial patients were treated with a subcutaneously implanted programmable continuous infusion pump (SynchroMed, Medtronic), filled with baclofen (a muscle relaxant) to treat patients with chronic disabling spasticity who did not respond to a maximum dose of oral baclofen, dantrolene and tizanidine.

MAIN OUTCOME MEASURES AND RESULTS

An analysis of hospital stay between both groups showed a significant difference during the implantation year. The average number of hospital days per patient in the year in the treated group was 31.5 days and in the match group was 18.7 days. Significant cost differences between both groups in the year that started with pump implantation and the following year can be attributed mostly to the costs of implantation of the pump and related hospitalisation days. The total costs of patient selection, testing, implanting the pump and follow-up amounted to $US28,473 for the first year. Savings must be taken into consideration as well. The savings of direct costs were due to withdrawal of oral medication (estimated annual total of between $US1950 and $US2800 per patient). Indirect savings on employment and nursing home costs, amounted annually to $US1047 and $US5814, respectively. Scenarios make it possible to consider policy consequences. The case of 'extending' the indications for this treatment to a larger population has been calculated and visualised.

CONCLUSIONS

The costs of the therapy (continuous intrathecal infusion of baclofen) can be attributed mostly to implantation of the pump and related hospitalisation days. Savings originated from withdrawal of oral medication, job preservation and avoidance or delay of admission to a nursing home.

The cost of dental implants as compared to that of conventional strategies

The effectiveness of dental implants is widely studied, especially in terms of their clinical outcomes. However, from the policymaker's point of view, variables other than safety and efficacy, such as the costs and effectiveness of dental implants as compared to other treatment alternatives, are vital in decision making. This paper compares the costs of different treatment strategies in a randomized clinical trial in patients with resorbed mandibles and persistent problems with their conventional dentures: treatment with a mandibular overdenture on permucosal dental implants, an overdenture on a transmandibular implant, new dentures after preprosthetic surgery, and new dentures only. Data were gathered on an individual patient level to gain insight into specific cost episodes. Direct costs were subdivided into labor, material, technique, and overhead. Data concerning these components were gathered during the consecutive treatment phases in the first year. Results show that the resources used to treat a patient with an overdenture supported by a transmandibular implant are seven times those of a complete new set of dentures. Comparison of the cost ratio of an implant-retained overdenture supported by permucosal implants and conventional new prostheses proves less unfavorable: 1:3. New dentures after preprosthetic surgery are almost as expensive as treatment with permucosal implants.