Comorbid neurotrauma increases neurodegenerative-relevant cognitive, motor, and autonomic dysfunction in patients with REM sleep behavior disorder: A substudy of the North American Prodromal Synucleinopathy Consortium

STUDY OBJECTIVES

Rapid eye movement (REM) sleep behavior disorder (RBD) is strongly associated with phenoconversion to an overt synucleinopathy, e.g., Parkinson's disease (PD), Lewy Body Dementia (LBD), and related disorders. Comorbid traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) - henceforth "neurotrauma" (NT) - increase the odds of RBD by ~2.5-fold and is associated with an increased rate of service-connected PD in Veterans. Thus, RBD and NT are both independently associated with PD; however, it is unclear how NT influences neurological function in patients with RBD.

METHODS

Participants ≥18 years with overnight-polysomnogram-confirmed RBD were enrolled between 8/2018 to 4/2021 through the North American Prodromal Synucleinopathy (NAPS) Consortium. Standardized assessments for RBD, TBI, and PTSD history, as well as cognitive, motor, sensory and autonomic function were completed. This cross-sectional analysis compared cases (n=24; RBD+NT) to controls (n=96; RBD), matched for age (~60 years), sex (15% female), and years of education (~15 years).

RESULTS

RBD+NT reported earlier RBD symptom onset (37.5±11.9 vs. 52.2±15.1 years of age) and a more severe RBD phenotype. Similarly, RBD+NT reported more severe anxiety and depression, greater frequency of hypertension, and significantly worse cognitive, motor, and autonomic function compared to RBD. No differences in olfaction or color vision were observed.

CONCLUSION

This cross-sectional, matched case:control study shows individuals with RBD+NT have significantly worse neurological measures related to common features of an overt synucleinopathy. Confirmatory longitudinal studies are ongoing; however, these results suggest RBD+NT may be associated with more advanced neurological symptoms related to an evolving neurodegenerative process.

Vascular disease risk factors in multiple sclerosis: Effect on metabolism and brain volumes

BACKGROUND

Vascular disease risk factors (VDRF) such as hypertension, hyperlipidemia, obesity, diabetes and heart disease likely play a role in disease progression in people with multiple sclerosis (PwMS) (Marrie, Rudick et al. 2010). Studies exploring the mechanistic connection between vascular disease and MS disease progression are scant. We hypothesized that phosphate energy metabolism impairment in PwMS with VDRFs (VDRF+) will be greater compared to PwMS without VDRFs (VDRF-) and is related to increased brain atrophy in VDRF+. To test this hypothesis, we planned to study the differences in the high energy phosphate (HEP) metabolites in cerebral gray matter as assessed by 31P magnetic resonance spectroscopic imaging (MRSI) and MRI brain volumetric in the VDRF+ and VDRF- PwMS at four different timepoints over a 3 yearlong period using a 7T MR system. We present here the results from the cross-sectional evaluation of HEP metabolites and brain volumes. We also evaluated the differences in clinical impairment, blood metabolic biomarkers and quality of life in VDRF+ and VDRF- PwMS in this cohort.

METHODS

Group differences in high energy phosphate metabolites were assessed from a volume of interest in the occipital region using linear mixed models. Brain parenchymal and white matter lesion volumes were determined from MR anatomic images. We present here the cross-sectional analysis of the baseline data collected as part of a longitudinal 3 yearlong study where we obtained baseline and subsequent 6-monthly clinical and laboratory data and annual 7T MRI volumetric and 31P MR spectroscopic imaging (MRSI) data on 52 PwMS with and without VDRF. Key clinical and laboratory outcomes included: body mass index (BMI), waist and thigh circumferences and disability [Expanded Disability Status Scale (EDSS)], safety (complete blood count with differential, complete metabolic), lipid panel including total cholesterol and HbA1C. We analyzed clinical and laboratory data for the group differences using student's t or χ2 test. We investigated relationship between phosphate metabolites and VDRF using mixed effect linear regression.

RESULTS

Complete MRI data were available for 29 VDRF+, age 56.3 (6.8) years [mean (SD)] (83% female), and 23 VDRF-, age 52.5 (7.5) years (57% female) individuals with MS. The mean value of normalized adenosine triphosphate (ATP) (calculated as the ratio of ATP to total phosphate signal in a voxel) was decreased by 4.5% (p < .05) in VDRF+ compared to VDRF- MS group. White matter lesion (WML) volume fraction in VDRF+ individuals {0.007 (0.007)} was more than doubled compared to VDRF- participants {0.003 (0.006), p= .02}.

CONCLUSIONS

We found significantly lower brain ATP and higher inorganic phosphate (Pi) in those PwMS with VDRFs compared to those without. ATP depletion may reflect mitochondrial dysfunction. Ongoing longitudinal data analysis from this study, not presented here, will evaluate the relationship of phosphate metabolites, brain atrophy and disease progression in PwMS with and without vascular disease.

252 Non-Invasive Quantification of Human Brain Lactate Concentrations Across Sleep-Wake Cycles

Introduction

Cellular mechanisms underlying changes in small animal brain lactate concentrations have been investigated for more than 70 years and report sharp reductions in lactate (12-35%) during sleep or anesthesia relative to wakefulness. The goal of this study was to investigate alterations in human cerebral lactate concentrations across sleep-wake cycles. Toward this goal, we developed a novel non-invasive methodology, quantified changes in human cerebral lactate during sleep stages, and investigated potential mechanisms associated with changes in lactate.

Methods

Nine subjects (four females, five males; 21-27 y-o, mean age 24.2 ±2) were sleep deprived overnight, and underwent (5:45~11:00 am) experiments combining simultaneous MR-spectroscopy (MRS) and polysomnography (PSG) in a 3 T MR instrument using a 64-channel head/neck coil. A single voxel MRS (1H-MRS) acquired signals from a volume of interest (12~24 cm3) for every 7.5-s for 88~180-min. Lactate signal intensity was determined from each 7.5-s spectrum, normalized to corresponding water signal, and averaged over 30-s for each PSG epochs. Artifact corrected PSG data were scored for each 30-s epoch using the standard criteria and classified into one of four stages: W, N1, N2 and N3. Group mean lactate levels were quantified using LCModel. Three subjects returned for lactate diffusivity measurements using diffusion-sensitized PRESS MRS sequence.

Results

Compared to W, group mean lactate levels within each sleep stage showed a reduction of [4.9 ± 4.9] % in N1, [10.4 ± 5.2] % in N2, and [24.0 ± 5.8] % in N3. We observed a significant decrease in lactate apparent diffusion coefficient (ADC) accompanied by reduced brain lactate in sleep compared to wake (P&lt;0.002). There were no differences in ADC values between wake and sleep for H2O, NAA, tCr, or Cho.

Conclusion

This is the first in-vivo report of alterations in human brain lactate concentrations across sleep-wake cycles. Observed decline in lactate levels during sleep compared to wakefulness is consistent with, and extends results from invasive small animal brain studies first reported more than 70 years ago, and support the notion of altered lactate metabolism and/or increased glymphatic activity in sleeping human brain.

Support (if any)

The Paul. G. Allen Family Foundation funded the study.

Structural Neural Correlates of Impaired Postural Control in People with Secondary Progressive Multiple Sclerosis

BACKGROUND

Secondary progressive multiple sclerosis (SPMS) is characterized by worsening of postural control and brain atrophy. However, little is known about postural deficits and their neuroanatomical correlates in this population. We aimed to determine the neuroanatomical correlates of postural deficits in people with SPMS and whether posture control deteriorates concomitantly with the brain and spinal cord atrophy in 2 years in SPMS.

METHODS

This study is a post hoc analysis of data from 27 people with SPMS (mean ± SE age, 58.6 ± 1.1 years). Participants had magnetic resonance imaging (MRI) of the brain and cervical spinal cord followed by sway testing using inertial sensors during standing with eyes open (EO) and eyes closed without (EC) and with (ECC) a cognitive task. Partial correlations investigated relationships between postural control and MRI measures at baseline and 2 years.

RESULTS

At baseline, sway measures were inversely related to cortical thickness and cord cross-sectional area (CSA) during the EO task but only to cord CSA with EC (P < .05). After 2 years, the percentage change in sway amplitude and dispersion during EO tasks significantly related to the percentage decline in cord CSA (P < .01).

CONCLUSIONS

Cortical and spinal cord inputs are essential for regulation of postural control during standing with EO in SPMS. Without visual input, people with SPMS preferentially rely on somatosensory inputs from the spinal cord for maintaining postural control. Postural deficits related to cord atrophy over 2 years, suggesting that postural control may be a surrogate marker of disease progression in people with SPMS.

Multisite reliability and repeatability of an advanced brain MRI protocol

BACKGROUND

MRI is the imaging modality of choice for diagnosis and intervention assessment in neurological disease. Its full potential has not been realized due in part to challenges in harmonizing advanced techniques across multiple sites.

PURPOSE

To develop a method for the assessment of reliability and repeatability of advanced multisite-multisession neuroimaging studies and specifically to assess the reliability of an advanced MRI protocol, including multiband fMRI and diffusion tensor MRI, in a multisite setting.

STUDY TYPE

Prospective.

POPULATION

Twice repeated measurement of a single subject with stable relapsing-remitting multiple sclerosis (MS) at seven institutions.

FIELD STRENGTH/SEQUENCE

A 3 T MRI protocol included higher spatial resolution anatomical scans, a variable flip-angle longitudinal relaxation rate constant (R₁ ≡ 1/T₁ ) measurement, quantitative magnetization transfer imaging, diffusion tensor imaging, and a resting-state fMRI (rsFMRI) series.

ASSESSMENT

Multiple methods of assessing intrasite repeatability and intersite reliability were evaluated for imaging metrics derived from each sequence.

STATISTICAL TESTS

Student's t-test, Pearson's r, and intraclass correlation coefficient (ICC) (2,1) were employed to assess repeatability and reliability. Two new statistical metrics are introduced that frame reliability and repeatability in the respective units of the measurements themselves.

RESULTS

Intrasite repeatability was excellent for quantitative R₁ , magnetization transfer ratio (MTR), and diffusion-weighted imaging (DWI) based metrics (r > 0.95). rsFMRI metrics were less repeatable (r = 0.8). Intersite reliability was excellent for R₁ , MTR, and DWI (ICC >0.9), and moderate for rsFMRI metrics (ICC∼0.4).

DATA CONCLUSION

From most reliable to least, using a new reliability metric introduced here, MTR > R₁ > DWI > rsFMRI; for repeatability, MTR > DWI > R₁ > rsFMRI. A graphical method for at-a-glance assessment of reliability and repeatability, effect sizes, and outlier identification in multisite-multisession neuroimaging studies is introduced.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:878-888.

Unit Leadership and Climates for Evidence-Based Practice Implementation in Acute Care: A Cross-Sectional Descriptive Study

PURPOSE

The purposes of this study were to (a) describe nurse manager (NM) leadership behaviors for evidence-based practice, NM evidence-based practice competencies, and unit climates for evidence-based practice implementation in acute care, and (b) test for differences in NMs' and staff nurses' (RNs') perceptions.

DESIGN

A multisite cross-sectional design was used to collect data from a sample of 24 NMs and 553 RNs from 24 adult medical-surgical units in seven U.S. community hospitals.

METHODS

Responses were collected using electronic questionnaires, inclusive of the Nurse Manager Evidence-Based Practice Competency Scale (NM only), Implementation Leadership Scale, and Implementation Climate Scale. E-mail reminders and gift card lottery drawings encouraged response. Descriptive statistics described total and subscale scores by role. Differences in perceptions were evaluated using independent t-tests with Bonferroni correction (α = .05).

FINDINGS

23 NMs and 287 RNs responded (95.8% and 51.9% response rates, respectively). NMs reported they were "somewhat competent" in evidence-based practice (M = 1.62 [SD = 0.5]; 0-3 scale). NMs and RNs perceived leadership behaviors (NM: M = 2.73 [SD = 0.46]; RN: M = 2.88 [SD = 0.78]; 0-4 scale) and unit climates for evidence-based practice implementation (NM: M = 2.16 [SD = 0.67]; RN: M = 2.24 [SD = 0.74]; 0-4 scale) as evident to a "moderate extent." RN and NM perceptions differed significantly on the Proactive (p = .01) and Knowledgeable (p < .001) leadership subscales.

CONCLUSIONS

Evidence-based practice competencies and leadership behaviors of NMs, and unit climates for evidence-based practice were modest at best and interventions are needed. To close the research to practice gap, future studies should investigate the interplay between social dynamic context factors and implementation strategies to promote uptake of evidence-based practices.

CLINICAL RELEVANCE

Critical attention is needed to build organizational capacity for evidence-based practices through development of unit leadership and climate for evidence-based practice to accelerate routine use of evidence-based practices for improving care delivery and patient outcomes. The three instruments described herein provide a foundation for nurse leaders to assess these dynamic context factors and design interventions or programs where there is opportunity for improvement.

Lipoic acid in secondary progressive MS: A randomized controlled pilot trial

Objective:

To determine whether lipoic acid (LA), an endogenously produced antioxidant, slowed the whole-brain atrophy rate and was safe in secondary progressive MS (SPMS).

Methods:

Patients with SPMS aged 40–70 years enrolled in a single center, 2-year, double-blind, randomized trial of daily oral 1,200 mg LA vs placebo. Primary outcome was change in annualized percent change brain volume (PCBV). Secondary outcomes were changes in rates of atrophy of segmented brain, spinal cord, and retinal substructures, disability, quality of life, and safety. Intention-to-treat analysis used linear mixed models.

Results:

Participation occurred between May 2, 2011, and August 14, 2015. Study arms of LA (n = 27) and placebo (n = 24) were matched with mean age of 58.5 (SD 5.9) years, 61% women, mean disease duration of 29.6 (SD 9.5) years, and median Expanded Disability Status Score of 6.0 (interquartile range 1.75). After 2 years, the annualized PCBV was significantly less in the LA arm compared with placebo (−0.21 [standard error of the coefficient estimate (SEE) 0.14] vs −0.65 [SEE 0.10], 95% confidence interval [CI] 0.157–0.727, p = 0.002). Improved Timed 25-Foot Walk was almost but not significantly better in the LA than in the control group (−0.535 [SEE 0.358] vs 0.137 [SEE 0.247], 95% CI −1.37 to 0.03, p = 0.06). Significantly more gastrointestinal upset and fewer falls occurred in LA patients. Unexpected renal failure (n = 1) and glomerulonephritis (n = 1) occurred in the LA cohort. Compliance, measured by pill counts, was 87%.

Conclusions:

LA demonstrated a 68% reduction in annualized PCBV and suggested a clinical benefit in SPMS while maintaining favorable safety, tolerability, and compliance over 2 years.

ClinicalTrials.gov identifier:

NCT01188811.

Classification of evidence:

This study provides Class I evidence that for patients with SPMS, LA reduces the rate of brain atrophy.

P4-15-02: Clinical and Epidemiological Correlates of Elevated Distress Thermometer Scores in Breast Cancer Patients

Objectives: Distress is prevalent in breast cancer patients and can be detrimental to quality of life, performance status, treatment adherence, and satisfaction with medical care. The National Comprehensive Cancer Network (NCCN) developed the Distress Thermometer (DT) as a quick and efficient self-assessment tool for screening distress in cancer patients. While surveys estimate that between 20–40% of patients with cancer have significant levels of distress, fewer than 10% are identified and treated. Given time and monetary constraints, it is important to refine screening criteria to identify patients with elevated risk for distress. In this study, we identify clinical and epidemiological factors that are associated with an increased likelihood of elevated DT scores (≥4 and ≥7) in breast cancer patients.

Methods: We assessed 229 consecutive female patients with the DT at their initial consultation for breast cancer at the Huntsman Cancer Hospital between September 2007 and December 2008. The DT screening tool measures a global level of distress using a visual analogue scale from 0–10 in the shape of a thermometer, with zero identified as “No Distress” and ten labeled as “Extreme Distress.” The DT screening tool also includes a checklist of common emotional, family, physical, practical, and spiritual concerns with instructions for the paitent to indicate which of those concerns contributed to the distress they experienced within the past week. We chose a score ≥4 as our cutoff for a positive screen for “distress” and a score ≥7 as our cutoff for a positive screen for “extreme distress/depression” based on previous studies. Variables included in the analyses were: age, employment status, race/ethnicity, personal history of depression, family history of breast cancer, marital status, estrogen and progesterone receptor status, stage of cancer, time since diagnosis, and recurrence. Descriptive statistics and logistic regression models were used to determine associations between DT and patient data. Results: Emotional and physical concerns were associated with scores ≥4 and scores ≥7. Spiritual concerns were significantly associated with patients reporting scores ≥7. Patients who were non-Caucasian, unemployed, had a prior history of depression, who presented for recurrent disease, or who had been recently diagnosed had a higher likelihood of scores ≥4 and scores ≥7.

Conclusions: The likelihood of scoring ≥4 and ≥7 on the DT screening tool is highest during the first 30 days after receiving a breast cancer diagnosis. Four groups of patients should be targeted for aggressive screening: patients with a prior diagnosis of depression, patients presenting with recurrent disease, unemployed patients, and non-Caucasian patients. Interventions should address physical, emotional and spiritual concerns.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-15-02.

Alterations in redox homeostasis and prostaglandins impair endothelial-dependent vasodilation in euglycemic autoimmune nonobese diabetic mice

We report herein the novel observation that alterations in oxidant/antioxidant balance are evident and cause vascular dysfunction in aortae of prediabetic nonobese-diabetic mice (NOD). We found that nitrotyrosine, a biochemical marker of oxidant stress, was higher in the NOD aortae when compared to age-matched non-autoimmune BALB/c controls or the diabetes-resistant NOD congenic strain, NOD.Lc7. The oxidant stress was localized to the intimal and medial layers, and endothelium-dependent relaxation to acetylcholine was decreased in isolated aortic rings from NOD mice. Inhibition of nitric oxide synthesis caused an endothelium-dependent contraction, and treatment with either a selective thromboxane A2/prostaglandin H2 receptor antagonist or a non-isozyme-specific cyclooxygenase inhibitor reversed this effect. Aortic rings from NOD.Lc7 did not display the paradoxical vasoconstriction. Furthermore, the vascular dysfunction was caused by oxidative stress, as treatment with a superoxide dismutase mimetic in vivo or with native antioxidant enzymes ex vivo inhibited the tissue oxidant stress and restored endothelium-dependent relaxation. Endothelial function was also restored by the inhibitors of NAD(P)H oxidase, diphenylene iodonium or apocynin. Our studies indicate that an oxidant stress that occurs prior to the onset of diabetes in this mouse model contributes to endothelial dysfunction independently of overt diabetes.

Effects of age, menopause, and comorbidities on neurological function of the female genitalia

The aim of this study was to investigate the effects of age, menopause, and comorbidities on neurological function of the female genitalia using a noninvasive, validated technique. In all, 58 consecutive women were enrolled in the study. Biothesiometry was performed at five genital sites and one peripheral site with S2 dermatome distribution. Kruskal-Wallis one-way ANOVA on ranks was used to evaluate the relationship between age and vibratory sensation. Bivariate and regressional analyses were performed to evaluate the effects of age, menopause and comorbidities on genital sensation. The mean age was 44.6+14.8 y (range 20-78 y). Vibration thresholds increased with advancing age at all six sites. Multilinear regression analysis indicated that menopause and increasing age negatively affect sensation. History of herniated lumbar disc, vaginal delivery, and diabetes variably affected genital sensation. There is a significant increase in vibration thresholds (indicating worsening neurological function) in women as they age and undergo menopause. Biothesiometry is a technique for evaluating genital neurological function in women with coexisting morbidities.

Role for oxidative stress in the regeneration of islet beta cells?

In the nonobese diabetic (NOD) mouse model of type 1 diabetes, we have found that there are increased markers of oxidative stress in islet beta cells in prediabetic animals when compared with control strains. Treatment of these mice with a superoxide dismutase (SOD) mimetic can markedly reduce the level of nitrotyrosine found in islets. In a diabetes-resistant NOD congenic mouse, the NOD.Lc7 mouse, we found increased beta cell proliferation and decreased apoptosis in islets. There are also lower levels of nitrotyrosine in islets of NOD.Lc7 mice than in NOD mice, suggesting that NOD.Lc7 islets are less susceptible to oxidative damage. We hypothesize that there may be a link between the ability of islet cells to regenerate and their resistance to oxidative stress.

Role for Oxidative Stress in the Regeneration of Islet Beta Cells?

In the nonobese diabetic (NOD) mouse model of type 1 diabetes, we have found that there are increased markers of oxidative stress in islet beta cells in prediabetic animals when compared with control strains. Treatment of these mice with a superoxide dismutase (SOD) mimetic can markedly reduce the level of nitrotyrosine found in islets. In a diabetes-resistant NOD congenic mouse, the NOD.Lc7 mouse, we found increased beta cell proliferation and decreased apoptosis in islets. There are also lower levels of nitrotyrosine in islets of NOD.Lc7 mice than in NOD mice, suggesting that NOD.Lc7 islets are less susceptible to oxidative damage. We hypothesize that there may be a link between the ability of islet cells to regenerate and their resistance to oxidative stress.

Oxidative Stress in Type 1 Diabetes

We have been investigating the effects of preventing oxidative stress on pathogenesis and complications of type 1 diabetes in the NOD mouse model. Our studies have shown that damage caused by oxidative stress is higher in islets and vascular tissue of NOD mice than in nonautoimmune controls or a diabetes-resistant NOD mouse. In addition, phagocytic function and cytokine production by macrophages are aberrant in the NOD. We have demonstrated that treatment of prediabetic NOD mice for 2 weeks with a metalloporphyrin superoxide dismutase (SOD) mimetic results in marked reduction of oxidative stress in islets and vascular tissue and a reversal of macrophage defects.

Genetic Variation Among Isolates of the Web Blight Pathogen of Common Bean Based on PCR-RFLP of the ITS-rDNA Region

Variability of 45 isolates of Rhizoctonia solani (teleomorph Thanatephorus cucumeris) causing web blight (WB) of common bean, Phaseolus vulgaris, was examined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis of the internal transcribed spacer regions (ITS1 and ITS2) and the 5.8S subunit (5.8S) of the nuclear ribosomal DNA repeat (ITS-5.8S-rDNA). Isolates were collected from diseased bean leaves from Argentina, Costa Rica, Cuba, Dominican Republic, Honduras, Panama, and Puerto Rico. These WB isolates belong to AG-1 and AG-2 based on anastomosis reaction. Isolates of AG-1 that cause WB were separated into three distinct groups of RFLP patterns from enzymatic digestion of a 740-bp PCR fragment. Microsclerotia-producing isolates (<1 mm) were differentiated from macrosclerotia-producing isolates (5 to 20 mm) based on PCR-RFLP patterns even though they are placed in the same AG1-1B subgroup by anastomosis reaction. WB isolates of AG-2 were separated into two distinct PCR-RFLP groups as previously reported. AG-1 macrosclerotial-producing isolates were the most virulent, whereas isolates of AG-2 were the least virulent. Genetic variability of the WB pathogen may have influenced the failure or success of management practices implemented in the past in Latin America.

Cyanide ingestion: preventing the cascade

Patients with cyanide exposure present a rare and unique challenge to the critical care nurse. The following article assists the critical care nurse and advanced practice nurse in understanding the pathophysiology of cyanide exposure, assessment of signs and symptoms, and antidotal and supportive therapies. In addition, a case review of nursing care for a patient exposed to cyanide is discussed.

Outpatient use of left ventricular assist devices: nursing, technical, and educational considerations

Improvements in technology and in the selection, care, and treatment of patients have led to wider clinical use of mechanical circulatory support. Considerable progress has been made with the use of left ventricular assist devices. Patients are currently maintained in outpatient facilities until a donor heart becomes available; recently, left ventricular assist devices have started to be used as permanent implants. This article outlines the steps that are taken to prepare the patient, the patient's family, and the medical staff for discharge from the hospital of a patient supported with a left ventricular assist device. Extensive technical and clinical training of the primary caregiver and the patient is required to prepare for discharge from the hospital. Data are rapidly accumulating that show that left ventricular assist devices are safe and efficacious for outpatient use. Similar success is expected in clinical trials of permanent left ventricular assist devices, suggesting that many more patients will benefit from this technology in the future.

Outpatient use of left ventricular assist devices: nursing, technical, and educational considerations

Improvements in technology and in the selection, care, and treatment of patients have led to wider clinical use of mechanical circulatory support. Considerable progress has been made with the use of left ventricular assist devices. Patients are currently maintained in outpatient facilities until a donor heart becomes available; recently, left ventricular assist devices have started to be used as permanent implants. This article outlines the steps that are taken to prepare the patient, the patient's family, and the medical staff for discharge from the hospital of a patient supported with a left ventricular assist device. Extensive technical and clinical training of the primary caregiver and the patient is required to prepare for discharge from the hospital. Data are rapidly accumulating that show that left ventricular assist devices are safe and efficacious for outpatient use. Similar success is expected in clinical trials of permanent left ventricular assist devices, suggesting that many more patients will benefit from this technology in the future.

Exercise mode and gender comparisons of energy expenditure at self-selected intensities

The purpose of this study was to compare oxygen consumption (VO2) and energy expenditure after 20 min of self-selected submaximal exercise for four modes of exercise. Eighteen subjects (9 male and 9 female) first completed a test of VO2max during treadmill running. On separate days, subjects then completed 20 min submaximal treadmill running (TR), simulated cross-country skiing (XC), cycle ergometry (CE), and aerobic riding (AR) exercise. Total VO2 and energy expenditure were significantly higher for TR than all other modes for both males and females (43.6 +/- 10.4, 39.1 +/- 9.7, 36.1 +/- 7.6, 28.4 +/- 6.1 LO2, for TR, XC, CE, and AR, respectively, P < 0.0001). For males and females, heart rate was similar during TR and XC and lower during CE and AR (154.8 +/- 14.2, 152 +/- 13.1, 143.4 +/- 14.9, and 126.2 +/- 12.0 beats.min-1 for TR, XC, CE, and AR, respectively, P < 0.0001). Compared with females, males had significantly greater VO2 (P < 0.005) and energy expenditure (P < 0.004), while females had higher heart rates (P < 0.003). Ratings of perceived exertion (RPE) were not different between TR, XC, and CE, but were significantly lower during AR (13.4 +/- 1.3, 13.6 +/- 0.8, 13.2 +/- 0.9, and 12.6 +/- 1.0 for TR, XC, CE, and AR, respectively, P < 0.003). TR elicited the greatest VO2 and energy expenditure during self-selected exercise despite and RPE similar to XC and CE. Therefore, treadmill exercise may be the modality of choice for individuals seeking to improve cardiorespiratory endurance and expend a larger number of kjoules.

Housing costs for adults who are mentally ill and formerly homeless

The goal of this study was to evaluate the costs, under two different housing conditions, to the state mental health agency of caring for adults who are homeless and mentally ill. One hundred and twelve clients of the Massachusetts Department of Mental Health, living in psychiatric shelters, were randomly assigned to one of two housing types: Evolving Consumer Households or Independent Living apartments. For the next 18 months each client was followed so that the cost of treatment, case management, and housing could be collected and compared. The authors found that treatment and case management costs did not vary by housing type, but housing costs were significantly higher for those assigned to Evolving Consumer Households. Regardless of original housing assignment, treatment costs were lower for clients who remained where they were originally placed. The authors conclude that providing support for clients that increases housing stability reduces their need for treatment and that independent living arrangements may be a more cost-effective policy choice.

Milk-alkali syndrome induced by 1,25(OH)2D in a patient with hypoparathyroidism

Milk-alkali syndrome was first described 70 years ago in the context of the treatment of peptic ulcer disease with large amounts of calcium and alkali. Although with current ulcer therapy (H-2 blockers, omeprazole, and sucralfate), the frequency of milk-alkali syndrome has decreased significantly, the classic triad of hypercalcemia, alkalosis, and renal impairment remains the hallmark of the syndrome. Milk-alkali syndrome can present serious and occasionally life-threatening illness unless diagnosed and treated appropriately. This article presents a patient with hypoparathyroidism who was treated with calcium carbonate and calcitriol resulting in two admissions to the hospital for milk-alkali syndrome. The patient was successfully treated with intravenous pamidronate on his first admission and with hydrocortisone on the second. This illustrates intravenous pamidronate as a valuable therapeutic tool when milk-alkali syndrome presents as hypercalcemic emergency.

Use of mental health services by formerly homeless adults residing in group and independent housing

OBJECTIVE

The study examined patterns of mental health service use among 112 formerly homeless mentally ill adults to determine whether clients in a staffed group living situation would need fewer types of services or lesser amounts of some services than those living independently in single apartments.

METHODS

Clients in the Boston McKinney demonstration project were randomly assigned to two housing types: individual apartments or a group living situation designed to teach residents to manage the house and their own affairs with minimal staff presence. The types and amounts of services these clients used during an 18-month period were documented and compared.

RESULTS

Service use by all clients was heavy, especially use of inpatient psychiatric services. It did not differ by housing type. The large majority of clients in both housing types were able to remain housed and avoid homelessness. Clients who did not stay in assigned housing for the duration of the study had higher levels of inpatient service use, including detoxification and substance abuse treatment.

CONCLUSIONS

When homeless mentally ill adults are provided permanent housing and accessible mental health treatment and specialized social services, they are likely to avoid unstable housing patterns, which are associated with higher use of inpatient services.

Travel Illness and the Family Practitioner: A Retrospective Assessment of Travel-Induced Illness in General Practice and the Effect of a Travel Illness Clinic

As the recognition of the discipline of Travel Medicine grows with increased international travel, an examination of both the value of pretravel advice as well as the general practitioner's role in preparation for, care during, and diagnosis and treatment after travel is necessary. This study was conducted to determine the incidence of travel-related illness in a typical urban population in Scotland and to examine the efficacy of our pretravel clinic related to reduction of illness, preparedness of our patients for travel, and the effects of our travel clinic on the workload generated by the returning ill in our practice. In this retrospective study, 1568 patients, presenting within a 1-year period from 1992-1993 at a medical practice and 100 patients at a travel clinic were studied. Their morbidity rates and, therefore, the effect of the travel clinic on prophylaxis and pretravel advice were determined. In the practice sample, 42% of travelers became ill while abroad, with 48% of ill travelers returning to consult their family doctor at home. Travelers to Africa and Asia were shown to have the highest rates of illness. Travel clinic attendees were more likely to be traveling to high-risk destinations, but were better prepared, experiencing a significantly lower rate of illness during travel (22%). Clinic attendees were less likely to consult their doctor on return home, preferring instead to resolve their illness by self-medication. The results suggest that travel clinics significantly reduce the morbidity of illness for travelers and that the burden on general practices could be reduced with the pretravel advice and prophylaxis that travel clinics can provide.

CSF, sagittal sinus, and jugular venous pressures during desflurane or isoflurane anesthesia in dogs

Previous studies to determine whether desflurane increases cerebrospinal fluid (CSF) pressure are inconclusive because none have included all of the following: multiple doses of desflurane, administration for at least several hours, examination at normo- and hypocapnia, a concurrent comparison group, direct measurement of both intra- and extracranial CSF pressures, and measurement of venous pressures that influence CSF pressure. The present study was designed to determine whether CSF pressure increases during 4.0 h desflurane anesthesia using a study design that included the above elements. Catheters were placed in the lateral cerebral ventricle, cisterna magna, sagittal sinus, and jugular vein of 12 dogs anesthetized with thiopental 12 mg.kg-1.h-1 and halothane 0.5 to 0.8%. Catheter pressures were measured, and the CSF-sagittal sinus pressure gradient and slope of the gradient to CSF pressure relationship were determined during control conditions. Then, 6 dogs were anesthetized with desflurane and 6 dogs were anesthetized with isoflurane, and the same values were determined for 1.0 h at each of four experimental conditions: 0.5 and 1.0 minimum alveolar concentration (MAC) during normocapnia (PaCO2 35-39 mm Hg) and 0.5 and 1.0 MAC during hypocapnia (PaCO2 20-24 mm Hg). CSF and sagittal sinus pressures, but not jugular venous pressure, increased with both desflurane and isoflurane. The greater increase of CSF pressure with 4.0 h desflurane (to 40.2 +/- 12.7 cm H2O) than with 4.0 h isoflurane (to 26.2 +/- 11.5 cm H2O) was attributable to an increase of CSF pressure that was greater during 2.0 h desflurane and normocapnia than during 2.0 h isoflurane and normocapnia, and to an increase of CSF pressure during 2.0 h desflurane and hypocapnia that was similar to that during 2.0 h isoflurane and hypocapnia. The greater increase of CSF pressure during desflurane may have resulted, in part, from increased CSF volume as indicated by a positive CSF-sagittal sinus pressure gradient (in contrast, there was little or no CSF-sagittal sinus pressure gradient during isoflurane) and a steeper slope of the gradient to CSF pressure relationship.

Effect of mannitol on cerebrospinal fluid dynamics and brain tissue edema

Mannitol is used widely to decrease intracranial pressure (ICP); however, the mechanism by which this effect occurs is unclear. This study was designed to examine the effects of mannitol on cerebrospinal fluid (CSF) formation rate (Vf), resistance to reabsorption of CSF (Ra), and brain tissue water content (BTWC). Eighteen New Zealand White rabbits were allocated into one of three groups and studied at baseline and at two sequential doses of 20% mannitol: 0.75 g/kg followed by 4.4 mg.kg-1.min-1, and 2.0 g/kg (1.25 g/kg added to the initial dose of 0.75 g/kg) followed by 8.6 mg.kg-1.min-1. In Group 1, closed ventriculocisternal perfusion (VCP) was performed to determine changes in ICP due to mannitol. In Group 2, the increase in CSF osmolality due to mannitol was determined. In Group 3, mock CSF was used for open VCP to determine Vf and Ra. At the conclusion of each study, brain tissue samples were taken for determination of BTWC. Mannitol increased CSF and plasma osmolality. Ra was increased by 104% with the low dose of mannitol and not significantly changed by the high dose. Mannitol decreased BTWC, Vf (by 49% with the high dose), ICP, and hematocrit. The authors conclude that two of the mechanisms contributing to decreased ICP with mannitol are: 1) decreased CSF volume as indicated by decreased Vf, and 2) decreased brain tissue volume as indicated by decreased BTWC.

The HPV response is different with constant pressure vs constant flow perfusion

Hypoxic pulmonary vasoconstriction (HPV) may be manifest in one of two ways: either an increase in the pulmonary artery pressure, or flow diversion away from the portion of the pulmonary bed with reduced conductance. We tested the hypothesis that the magnitude of the HPV response differs under conditions of constant flow perfusion, where pulmonary artery pressure (Ppa) rises during hypoxia, vs conditions of constant pressure perfusion, where Ppa remains constant and flow (Q) is diverted away from the lungs during hypoxia. In isolated, perfused rabbit lungs, the HPV response to four levels of hypoxia (12, 6, 3 and 0% oxygen) was of greater magnitude and more sustained under conditions of constant pressure perfusion as compared to constant flow perfusion. The possible significance of these findings as they relate to interpretation of studies in both the perinatal and mature pulmonary circulation is discussed.

A 24-year follow-up of California narcotics addicts

OBJECTIVE

This study examined longitudinal patterns of narcotics use, other substance use, criminal involvement, morbidity, and mortality among narcotics addicts.

DESIGN

A 24-year follow-up study. Data were obtained from admission records and two face-to-face interviews conducted in 1974-1975 and 1985-1986.

PARTICIPANTS

Five hundred eighty-one narcotics addicts admitted to the California Civil Addict Program during the years 1962 through 1964.

RESULTS

Most of this sample initiated narcotics use before age 20 years and had a mean age at program admission of 25.4 years. In 1974-1975, 13.8% of the sample died and 28.6% tested negative for opiates. Corresponding rates in 1985-1986 were 27.7% and 25.0%, respectively. Substance use and criminal involvement remained high among this sample into their late 40s. In any given year during the 10 years prior to the 1985-1986 interview, less than 10% of the sample participated in community-based treatment programs such as methadone maintenance. Disability, long periods of heavy alcohol use, heavy criminal involvement, and tobacco use were among the strongest correlates of mortality.

CONCLUSIONS

The results suggest that the eventual cessation of narcotics use is a very slow process, unlikely to occur for some addicts, especially if they have not ceased use by their late 30s.

Characterization of myocardial extracellular ATP receptors by photoaffinity labelling and functional assays

Extracellular ATP receptors in rat ventricular myocytes were investigated through intact cell photolabelling followed by protein isolation. 8-Azido-ATP (8Az-ATP) was used for labelling under specific conditions determined by parallel functional studies. In those studies ATP-induced cytosolic Ca2+ transients were irreversibly and specifically inhibited by UV-photolyzed 8Az-ATP, but not by 2-azido-ATP (2Az-ATP), even in the presence of high concentrations of phosphonucleotides not affecting myocardial ATP receptors. Under those conditions background labelling is minimized and radioactive 8Az-ATP specifically labels a band of 45-48 kDa on a SDS gel. Labelling under the above conditions in the presence of ATP gamma S or 2-methylthio-ATP (2-meSATP), which are distinct for two functionally different cardiac ATP receptors, shows two different proteins within the same band consistent with the possible labelling of these two receptors.

Anatomy of the renal innervation: intrarenal aspects and ganglia of origin

The intrinsic innervation of the kidney is described based on studies using ultrastructural, fluorescent, immunocytochemical, and autoradiographic techniques. The efferent sympathetic innervation reaches all the segments of the renal vasculature and to a much lesser extent the tubular nephron. The afferent renal nerves are localized predominantly in the pelvic region, the major vessels, and the corticomedullary connective tissue. The pathways of the renal innervation to the corresponding ganglia, as reported from observations resulting from the combination of axonal transport labeling and immunocytochemical methods, are presented. In the rat the ganglia of origin of the sympathetic efferent innervation include T13-L1 ipsilateral and contralateral paravertebral ganglia and the prevertebral superior mesenteric and celiac ganglia. The sensory afferent innervation presents a different segmental distribution of the dorsal root ganglia for the right and left kidney. For the left kidney, the corresponding ganglia extend from T8 to L2 with the greatest numbers in T12 and T13. For the right kidney, ganglia as high as T6 and as low as L2 harbor neurons innervating the kidney. Current knowledge of the anatomical bases of the function of the renal nerves is discussed.

Amrinone reduces pulmonary vascular resistance elevated by U46619 in isolated perfused lungs

The effects of amrinone on pulmonary vascular resistance (PVR) were studied in an isolated, perfused rabbit lung model where all the major determinants of PVR were controlled. In this preparation, the alveolar oxygen and carbon dioxide tensions, vascular pH and vascular oxygen and carbon dioxide tensions, and zonal conditions of the lung and phasic variations of pulmonary artery pressures could be precisely measured and controlled. Measurements of PVR were made by a complete determination of the pulmonary pressure-flow curve and determination of the PVR under identical flow conditions for all studies. This approach allowed a more precise determination of the primary effects of amrinone on normal and elevated PVR than has been previously possible. We found that amrinone in final concentrations of either 4 or 8 micrograms/ml had no effect on basal PVR and no effect on lung water weight to dry ratios. When PVR was elevated by the addition of the thromboxane A2 mimetic U46619, amrinone reduced the PVR by 27% at a final concentration of 4 micrograms/ml and by 74% at a final concentration of 8 micrograms/ml. We conclude that in the doses tested, amrinone has no effects on basal PVR but is able to reduce elevated PVR in a dose-dependent manner. These results are the first to demonstrate clearly that amrinone has the ability to reduce elevated pulmonary vascular tone through a direct mechanism and not through secondary effects on other determinants of PVR such as left atrial pressure (Pla), increased cardiac output with resultant vascular recruitment, or increases in mixed venous oxygen tension. The possible implications for the clinical use of amrinone in situations of elevated PVR are discussed.

Monoaminergic innervation of the rat kidney: a quantitative study

The sympathetic innervation of the renal tubules and vasculature was characterized by measuring the overlap of accumulations of autoradiographic grains (AAGs) on these structures in autoradiograms of kidney sections from rats injected with tritiated norepinephrine. AAG overlap was used as an indirect measure of the innervation of those structures. The renal vasculature showed x 4.5 more AAG overlap than observed on renal tubules. The greatest amount of AAG overlap occurred on afferent arterioles, followed by efferent arterioles, interlobular arteries, cortical capillaries, arcuate arteries, and renal veins. High concentration of AAGs occurred along the vascular bundles of the outer stripe. In the tubular nephron the proximal tubule had the greatest amount of AAG overlap, followed by the cortical thick ascending limb of Henle, the connecting tubule, the distal convoluted tubule, and the collecting duct. It was found that afferent arterioles had significantly higher mean density of AAG overlap than efferent arterioles for the superficial, midcortical, and juxtamedullary (vascular bundles excluded) renal cortex. There was consistently more AAG perimeter facing the interstitium than overlapping the vasculature. These observations, together with the ultrastructural distribution of synaptic vesicles in varicosities, suggest that the interstitium might be an additional pathway of neurotransmitter access to the effector structures.

Innervation of the renal proximal convoluted tubule of the rat

Experimental data suggest the proximal tubule as a major site of neurogenic influence on tubular function. The functional and anatomical axial heterogeneity of the proximal tubule prompted this study of the distribution of innervation sites along the early, mid, and late proximal convoluted tubule (PCT) of the rat. Serial section autoradiograms, with tritiated norepinephrine serving as a marker for monoaminergic nerves, were used in this study. Freehand clay models and graphic reconstructions of proximal tubules permitted a rough estimation of the location of the innervation sites along the PCT. In the subcapsular nephrons, the early PCT (first third) was devoid of innervation sites with most of the innervation occurring in the mid (middle third) and in the late (last third) PCT. Innervation sites were found in the early PCT in nephrons located deeper in the cortex. In juxtamedullary nephrons, innervation sites could be observed on the PCT as it left the glomerulus. This gradient of PCT innervation can be explained by the different tubulovascular relationships of nephrons at different levels of the cortex. The absence of innervation sites in the early PCT of subcapsular nephrons suggests that any influence of the renal nerves on the early PCT might be due to an effect of neurotransmitter released from renal nerves reaching the early PCT via the interstitium and/or capillaries.

Immunocytochemical localization of renin and kallikrein in the rat renal cortex

Immunocytochemical studies in the past, using alternate serial sections to localize individual antigens, concluded that there was no close relationship between renin- and kallikrein-containing structures in the rat kidney. We have investigated this relationship by simultaneously localizing renin and kallikrein in the same section using immunoperoxidase with two different chromogens. Analysis of serial kidney sections from three rats indicated that kallikrein-containing late distal tubular cells corresponded in their distribution to connecting tubule cells. They were observed in the proximity (less than 3 micrograms) of renin-containing JG cells in 66.6% of the superficial (N = 30), 46.6% of the midcortical (N = 15) and 26.7% of the juxtamedullary (N = 15) afferent arterioles surveyed. When traced through serial sections, 90% of the afferent arterioles from superficial glomeruli (N = 30), 86.7% of the afferent arterioles from midcortical glomeruli (N = 15) and 73.3% of those from juxtamedullary glomeruli (N = 15) came within 3 micrograms of a late distal tubule showing some kallikrein-positive cells. These cells were adjacent to the afferent arteriole in 67 to 80% of the arterioles surveyed. This spatial relationship suggests an anatomical basis for a possible interaction between the afferent arteriole, containing renin-positive JG cells, and kallikrein-positive late distal tubular cells.

Innervation of the late distal nephron: an autoradiographic and ultrastructural study

A study of the monoaminergic innervation of the cortical distal nephron beyond the thick ascending limb of Henle (TALH) was carried out by surveying nine autoradiograms, from three rats injected with exogenous tritiated norepinephrine, for overlapping of the tubule by accumulations of autoradiographic grains (AAGs). The largest number of the AAGs appeared on the late distal convoluted tubule-connecting tubule (LDCT-CNT) portion and the vast majority of the AAGs were related to the afferent arteriole. The distal convoluted tubule (DCT) and cortical collecting duct (CCD) showed half of their AAGs related to the efferent arterioles and capillary-interstitium although a substantial amount was associated with the afferent arterioles or arteries. Electron microscopy of reembedded autoradiograms demonstrated the presence of neuroeffector junctions with the CNT and CCD at sites of AAG overlap. The presence of adrenoceptors in the late distal nephron suggests the possibility of a local response of the nephron to the action of the adrenergic nerves shown in this study.

Innervation of the renal cortical tubules: a quantitative study

A quantitative assessment of the innervation of the different portions of the cortical tubular nephron in the rat was made using tritiated norepinephrine uptake to label monoaminergic nerves, followed by autoradiography. The proximal tubules (PT) showed the greatest number of innervated profiles (IPs) [i.e., tubular profiles overlapped by accumulations of autoradiographic grains (AAG)] followed by the thick ascending limb of Henle (TALH), the distal convoluted tubule (DCT), and the collecting duct (CD). However, the highest relative frequency of innervation (RFI), i.e., the ratio of the number of IPs to the total number of profiles surveyed, occurred in the TALH followed by the DCT and PT. The number of IPs of the CDs was too low to permit adequate statistical evaluation. The PT showed the largest number of AAGs facing the interstitium or in contact with capillaries, while the TALH had the highest number in contact with the efferent arteriole. The DCT showed a disproportionately high number of AAGs in contact with the afferent arteriole. Our results suggest that all portions of the cortical tubular nephron are under some degree of neural influence.