Predictors of willingness to receive updated 2023-2024 COVID-19 booster vaccines among a convenience sample in Minnesota

OBJECTIVES

To determine factors associated with intention to receive recommended COVID-19 booster vaccines in 2023-2024.

METHODS

A cross-sectional study of 1,256 individuals at Minnesota State and County fairs was conducted to assess their intention to receive a COVID-19 booster vaccine in the coming year if recommended. The association between booster intention and multiple factors believed to influence willingness to receive the vaccine, including perceived vaccine safety, perceived risk of COVID-19, public health knowledge, fear of future pandemics, and political affiliation, were analyzed using ordinal logistic regression and adjusted odds ratios (aOR).

RESULTS

Intention to receive a COVID-19 booster vaccine was high among our participants with 56% reporting they were extremely likely to receive the vaccine this year and another 15% reporting that they were likely to do the same. A strong association with getting a booster vaccine was found between perceived vaccine safety (aOR: 15.3, 95% CI: 10.6-22.2), perceived COVID-19 risk (aOR: 3.5, 95% CI: 2.4-5.1), pandemic fear (aOR: 3.4, 95% CI: 2.4-4.8), public health knowledge (aOR: 1.3, 95% CI: 0.9-1.8), and democrat political affiliation (aOR: 2.8, 95%CI: 1.8-4.4).

CONCLUSIONS

Our study emphasizes the importance of perceived vaccine safety as a predictor of intention to accept COVID-19 vaccines and highlights the continued need to effectively communicate with the public about the safety of vaccines.

Increasing the accessibility to internet-based cognitive behavioural therapy for depression: A single-blind randomized controlled trial of condensed versus full-text versions

Background

Research shows that internet-based cognitive behavioural therapy (iCBT) is an effective treatment for depression. However, little is known about how the length of the text material in iCBT affects outcomes.

Objective

The aim of this study was to test whether a condensed iCBT version for depression would be non-inferior to the existing full-text version in reducing depressive symptoms at post-treatment. We also wanted to test non-inferiority for secondary outcomes and explore reading speed and ADHD symptoms as potential moderators.

Method

A single-blind randomized controlled trial was conducted (N = 267) comparing two versions of guided iCBT for depression; full-text (around 60,000 words) and condensed (around 30,000 words, with the option to listen to the text). Estimated between-group effect sizes and their confidence intervals for depression, anxiety and quality of life, were compared to a pre-determined non-inferiority margin (ES = 0.4). Moderation analyses of reading speed and ADHD symptoms were conducted.

Results

The condensed version of iCBT was non-inferior to the full-text version on post-treatment measures for depressive symptoms (95 % CI = -0.42-0.24), anxiety symptoms (95 % CI = -0.24-0.32), and quality of life (95 % CI = -0.09-0.49). Non-inferiority was inconclusive for depressive symptoms at the one-year follow-up (95 % CI = -0.60-0.47). There was no significant moderation effects of reading speed (p = 0.06) or ADHD symptoms (p = 0.11) on depressive symptoms.

Conclusion

These results indicate that a condensed version of iCBT for depression is as effective at treating depression as the full-text version. By shortening texts, iCBT may be made available to more people. Due to unequal dropout rates between the groups, these results are preliminary and need to be replicated.

An intersectional analysis of sociodemographic disparities in Covid-19 vaccination: A nationwide register-based study in Sweden

BACKGROUND

Studies on sociodemographic disparities in Covid-19 vaccination uptake in the general population are still limited and mostly focused on older adults. This study examined sociodemographic differences in Covid-19 vaccination uptake in the total Swedish population aged 18-64 years.

METHODS

National Swedish register data within the SCIFI-PEARL project were used to cross-sectionally investigate sociodemographic differences in Covid-19 vaccination among Swedish adults aged 18-64 years (n = 5,987,189) by 12 October 2021. Using logistic regression models, analyses were adjusted for sociodemographic factors, region of residence, history of Covid-19, and comorbidities. An intersectional analysis approach including several cross-classified subgroups was used to further address the complexity of sociodemographic disparities in vaccination uptake.

FINDINGS

By 12 October 2021, 76·0% of the Swedish population 18-64 years old had received at least two doses of Covid-19 vaccine, an additional 5·5% had received only one dose, and 18·5% were non-vaccinated. Non-vaccinated individuals were, compared to vaccinated, more often younger, male, had a lower income, were not gainfully employed, and/or were born outside Sweden. The social patterning for vaccine dose two was similar, but weaker, than for dose one. After multivariable adjustments, findings remained but were attenuated indicating the need to consider different sociodemographic factors simultaneously. The intersectional analysis showed a large variation in vaccine uptake ranging from 32% to 96% in cross-classified subgroups, reflecting considerable sociodemographic heterogeneity in vaccination coverage.

INTERPRETATION

Our study, addressing the entire Swedish population aged 18-64 years, showed broad sociodemographic disparities in Covid-19 vaccine uptake but also wide heterogeneities in coverage. The intersectional analysis approach indicates that focusing on specific sociodemographic factors in isolation and group average risks without considering the heterogeneity within such groups will risk missing the full variability of vaccine coverage.

FUNDING

SciLifeLab / Knut & Alice Wallenberg Foundation, Swedish Research Council, Swedish government ALF agreement, FORMAS.

POS0434 A NOVEL TARGET FOR TREATMENT OF INFLAMMATORY JOINT DISEASES

Background

A significant number of patients with inflammatory joint disorders do not respond or experience a waning effect to currently available pharmaceuticals, which emphasizes a high medical need for new efficacious drugs operating through novel targets and modes of action. One unexplored novel target is Bile Salt-Stimulated Lipase (BSSL).

We have shown that patients with rheumatoid arthritis (RA), psoriasis arthritis (PsA), and juvenile idiopathic arthritis (JIA) have increased BSSL plasma levels compared to healthy controls, and that these levels correlate with disease activity scores. Moreover, conventional BSSL knockout mice are protected from developing disease in several recognized in vivo arthritis models and antibodies targeting BSSL prevent or mitigate arthritis in rodent models1.

We have further shown that BSSL is secreted from activated granulocytes, binds to monocytes and stimulates their migration in vitro. With that knowledge, we developed a humanized anti-BSSL antibody (SOL-116) that blocks BSSL from binding to monocytes and we are now evaluating SOL-116 as candidate drug for treatment of chronic inflammatory joint diseases, including RA, PsA and JIA in man.

Objectives

The aim of the present study was to characterize SOL-116’s biological activity in vitro and verify the therapeutic efficacy in the pristane induced arthritis (PIA) rat model.

Methods

The affinity of SOL-116 to human, mouse and rat BSSL was measured by surface plasmon resonance biosensor technology. The epitope on human BSSL was mapped by hydrogen deuterium exchange mass spectrometry (HDX-MS) and confirmed by crystallization of SOL-116 Fab-fragments with human BSSL. For efficacy evaluation, arthritis was induced in DA rats by administration of pristane. SOL-116 at three different doses (10, 30 and 90 mg/kg) or vehicle control were administered subcutaneously on day 5, 10 and 15 after disease induction. Disease activity was evaluated daily from day 7 in a blinded fashion using a macroscopic scoring system of the four limbs. To gain knowledge about the mechanism of action, the effect of SOL-116 on BSSL induced cell migration was evaluated using a transwell migration assay.

Results

SOL-116 binds to human, mouse, and rat BSSL, although a single amino acid deviation in the BSSL epitope results in approximately 80-fold lower affinity to rodent compared to human BSSL protein. In the efficacy validation study, treatment with highest dose SOL-116 (90 mg/kg) significantly mitigated disease severity in the PIA rats (Figure 1A). The relatively high doses of SOL-116 were chosen to compensate the low affinity for rat BSSL. A decrease in disease severity was also seen with SOL-116 at 30 mg/kg and 10 mg/kg, indicating a dose response, albeit not statistically significant. The plasma concentration of SOL-116 at day 19 correlated significantly to the arthritis score (Figure 1B). Mechanistic studies show that BSSL stimulates migration of CD14+ monocytes, and that SOL-116 prevents this effect in a dose dependent manner.

Figure 1.

Arthritis development and SOL-116 exposure in rats following pristane injection. (A) Animals treated with SOL-116 (90 mg/kg) show significantly lower disease severity compared to vehicle treated animals. Results are presented as mean ± SEM. (B) Plasma concentration of SOL-116 at day 19 in animals treated with 90 mg/kg correlates to disease severity.

Conclusion

The present study verifies that BSSL plays an important role in inflammation and that SOL-116 is a promising biologic drug candidate for novel treatment of chronic inflammatory joint diseases.

References

[1]Lindquist S, Andersson EL, Lundberg L, Hernell O. Bile salt-stimulated lipase plays an unexpected role in arthritis development in rodents. PLoS One. 2012;7(10):e47006.

Acknowledgements

The authors are grateful to Mrs. Eva-Lotta Andersson for excellent technical assistance.

Disclosure of Interests

Susanne Lindquist Shareholder of: Lipum AB, Umeå, Sweden, Grant/research support from: Lipum AB, Employee of: Lipum AB, Helena Persson: None declared, Annette Roos: None declared, Lennart Lundberg Shareholder of: Lipum AB, Consultant of: Lipum AB, Grant/research support from: Lipum AB, Employee of: Lipum AB, Olle Hernell Shareholder of: Lipum AB, Consultant of: Lipum AB, Grant/research support from: Lipum AB, Employee of: Lipum AB.

Protonated and Cationic Helium Clusters

Protonated rare gas clusters have previously been shown to display markably different structures compared to their pure, cationic counterparts. Here, we have performed high-resolution mass spectrometry measurements of protonated and pristine clusters of He containing up to 50 atoms. We identify notable differences between the magic numbers present in the two types of clusters, but in contrast to heavier rare gas clusters, neither the protonated nor pure clusters exhibit signs of icosahedral symmetries. These findings are discussed in light of results from heavier rare gases and previous theoretical work on protonated helium.

Determination of Crude Protein in Animal Feed, Forage, Grain, and Oilseeds by Using Block Digestion with a Copper Catalyst and Steam Distillation into Boric Acid: Collaborative Study

A collaborative study was conducted to evaluate the repeatability and reproducibility of an extension of AOAC Official Method 991.20, Nitrogen (Crude) in Milk, to animal feed, forage (plant tissue), grain, and oilseed materials. Test portions are digested in an aluminum block at 420°C in sulfuric acid with potassium sulfate and a copper catalyst. Digests are cooled and diluted, and concentrated sodium hydroxide is added to neutralize the acid and make the digest basic; the liberated ammonia is distilled by using steam distillation. The liberated ammonia is trapped in a weak boric acid solution and titrated with a stronger standardized acid, hydrochloric acid; colorimetric endpoint detection is used. Fourteen blind samples were sent to 13 collaborators in the United States, Denmark, Sweden, Germany, and the United Kingdom. Recoveries of nitrogen from lysine, tryptophan, and acetanilide were 86.8, 98.8, and 100.1%, respectively. The within-laboratory relative standard deviation (RSDr, repeatability) ranged from 0.40 to 2.38% for crude protein. The among-laboratories (including within-) relative standard deviation (RSDR, reproducibility) ranged from 0.44 to 2.38%. It is recommended that the method be adopted First Action by AOAC INTERNATIONAL. A lower concentration (1% H3BO3) of trapping solution was compared with the concentration specified in the original protocol (4% H3BO3) and was found comparable for use in an automatic titration system in which titration begins automatically as soon as distillation starts. The Study Directors recommend that 1% H3BO3 as an optional alternative to 4% boric acid trapping solution be allowed for automatic titrators that titrate throughout the distillation.

Liquid Chromatographic Determination of Residual Nitrite/Nitrate in Foods: NMKL Collaborative Study

Nitrite and nitrate are used as additives in the food industry to provide color and taste and to control undesirable gas and flavor production by anaerobic bacteria by virtue of their antimicrobial properties. The analytical method that has been widely used to determine nitrite and nitrate involves the use of toxic cadmium. In response to a request from the Nordic Committee on Food Analysis, a study was performed to obtain an alternative chromatographic method to determine residual nitrite and nitrate in meat products. The study was done in 3 stages: (1) comparative evaluation of the performance of 3 liquid chromatographic methods, (2) internal validation of the selected ion chromatographic method, and (3) a collaborative study in which 17 laboratories from European countries participated. Furthermore, the applicability of the method to matrixes other than meat and meat products was demonstrated. The results of the collaborative study show that the European Prestandard prENV 12014-4 is well suited for the determination of nitrite and nitrate in different foods (e.g., meat products, vegetables, baby food, and cheese). The limits of detection for nitrite and nitrate ions are 1 and 10 mg/kg, respectively. Recoveries of residual nitrite/nitrate ranged from 96 to 108%. Repeatability and reproducibility were satisfactory.

Hydrogenated Gold Clusters from Helium Nanodroplets: Cluster Ionization and Affinities for Protons and Hydrogen Molecules

We report the mass spectrometric detection of hydrogenated gold clusters ionized by electron transfer and proton transfer. The cations appear after the pickup of hydrogen molecules and gold atoms by helium nanodroplets (HNDs) near zero K and subsequent exposure to electron impact. We focus on the size distributions of the gold cluster cations and their hydrogen content, the electron energy dependence of the ion yield, patterns of hydrogenated gold cluster cation stability, and the presence of "magic" clusters. Ab initio molecular orbital calculations were performed to provide insight into ionization energies and proton affinities of gold clusters as well as into molecular hydrogen affinities of the ionized and protonated gold cluster cations.

Electron Attachment and Electron Ionization of Formic Acid Clusters Embedded in Helium Nanodroplets

We report the results of an experimental study of electron ionization of large helium nanodroplets doped with formic acid (FA). Several homologous series of cluster anions are observed, including [FA_n-H]^-, undissociated FA_n^-, and these ions complexed with one or more H₂O. Some major features resemble those observed upon sputtering of frozen FA films but they differ significantly from results obtained by electron attachment to bare FA clusters in the gas phase. The FA_n^- and (H₂O)[FA_n-H]^- series show abrupt onsets above n = 2 and 5, respectively. A prominent resonance in the anion yield occurs at 22.5 eV due to the formation of an intermediate He^-*. Also observed are homologous series of [FA-H]^- or [FA₂-H]^- complexed with helium. The cation chemistry is dominated by the production of protonated formic acid clusters, [FA_nH]⁺, but various other homologous cluster ion series are observed as well. Graphical Abstract.

Granulocyte Elastase, β-Thromboglobulin, and C3D during Acetate or Bicarbonate Hemodialysis with Hemophan® Compared to a Cellulose Acetate Membrane

Twenty-two patients were dialysed in a cross-over design using Hemophan® or cellulose acetate membranes. The dialysate buffer was acetate (n = 12) or bicarbonate (n = 10). Blood was sampled at 0, 15, 60 and 180 min and mean values were adjusted for changes in total protein in each sample. At 15 min during dialysis a decrease in leukocytes and platelets occurred with both membranes, irrespective of the buffer (Wilcoxon, p < 0.006). During dialysis, increases were found in granulocyte elastase inhibitor complex (E-α1-PI), β-thromboglobulin and C3d. β2-microgrobulin was not significantly changed in blood after dialysis with Hemophan® or cellulose acetate membranes with bicarbonate buffer. Side effects were more pronounced at 180 min during dialysis with bicarbonate in patients using cellulose acetate than with Hemophan® (p = 0.021, n = 8). Hemophan® seemed to be more favourable than cellulose acetate membranes in regard to leukopenia and E- α1-PI. The dialysate buffer may also alter membrane biocompatibility.

Backdiffusion or Bicarbonate May Stimulate Complement Activation during Haemodialysis with Low-Flux Membranes

Backdiffusion of dialysate during haemodialysis with low-flux membranes and the use of bicarbonate dialysatebase, may increase the risk for contamination. The influence on the complement system was studied by altering the flux of acetate or bicarbonate dialysate base across the membrane. Eight patients were dialysed with a transmembrane pressure of 100 mm Hg (group I) during the first 60 min to standardize the ultrafiltration (UF) and acetate as dialysate. In eight other patients (group II) the UF was “set at zero” ml during the first 60 min using an FCM 10-1 monitor (Gambro) and bicarbonate as base. The groups were dialysed three times on two hollow-fiber membranes made of Hemophan® and cellulose acetate (CA). Blood samples were taken at 0, 15, 60 and 180 min, and analysed for plasma protein, haematocrit and complement C3d. In group II there was a reduction in plasma protein concentration at 15 and 60 min (p<0.002) for Hemophan and at 60 min (p<0.01) using CA. C3d was increased at 15 min for both filters (p<0.03). The reduction of protein in group II was followed by changes in the haematocrit, indicating a backdiffusion of dialysate, which may contribute to the concomittant increase in C3d.

Aggressive Posterior Retinopathy of Prematurity Is Associated with Multiple Infectious Episodes and Thrombocytopenia

BACKGROUND

The most severe form of rapidly progressing retinopathy of prematurity (ROP) is termed aggressive posterior ROP (APROP). APROP frequently causes severe visual impairment in affected preterm infants despite timely and appropriate laser treatment.

OBJECTIVES

We investigated the postnatal characteristics associated with APROP development in a national Swedish cohort.

METHODS

This retrospective, 1:1 matched case-control study included all infants that developed APROP in zone 1 (n = 9) between 2008 and 2012. Control infants, matched for gestational age and birth weight, developed ROP no worse than stage 2 (n = 9). We retrieved data from medical records on infant birth characteristics, postnatal morbidities, and blood analyses from birth to the first ROP treatment. Infectious episodes included sepsis, C-reactive protein ≥10 mg/l, and other clinical signs of infection that required antibiotic treatment. A platelet count <100 × 109/l was considered to be thrombocytopenia.

RESULTS

All APROP cases postnatally developed at least two infectious episodes, one in the first month and one around the time of ROP diagnosis. All APROP cases exhibited thrombocytopenia in the first month, and 6/9 exhibited thrombocytopenia around the time of ROP diagnosis. Compared to the controls, APROP cases more frequently developed necrotizing enterocolitis (8/9 vs. 1/9; p < 0.01) and sepsis (9/9 vs. 3/9; p < 0.01), and they had significantly lower median platelet counts (90 × 109/l, range 4-459, vs. 158 × 109/l, range 20-500; p < 0.001).

CONCLUSION

Multiple infectious episodes and thrombocytopenia, particularly around the time of ROP diagnosis, were associated with APROP development.

Haemostatic biomarkers are associated with long-term recurrent vascular events after ischaemic stroke

Ischaemic stroke patients continue to be at risk for recurrent vascular events for many years. Predictors of long-term prognosis are needed. It was the objective of this study to investigate levels of four haemostatic proteins as long-term predictors of recurrent vascular events after ischaemic stroke. We prospectively followed 548 ischaemic stroke patients, 18-69 years, and registered recurrent vascular events. Plasma levels of tissue-type plasminogen activator (t-PA), von Willebrand factor (VWF), fibrinogen and thrombin activatable fibrinolysis inhibitor activation peptide (TAFI-AP) were measured three months after index stroke. Cox regression models were used to assess associations to outcomes for single biomarkers and for a combined biomarker measure. For single biomarkers significantly associated with any of the outcomes, we performed subanalyses stratified for age, sex, diabetes and atherosclerosis. During 5,637 person-years of follow-up, we registered 74 vascular deaths, 90 recurrent strokes and 62 coronary events. Levels of t-PA, VWF and fibrinogen were significantly associated with vascular death and coronary events. After adjustment, the association between t-PA and vascular death remained (HR per 1 SD increase in plasma level 1.27, 95 % CI 1.00-1.61, p=0.047). The combined effect of t-PA, VWF and fibrinogen was associated with coronary events (adjusted HR 1.35, 1.02-1.80, p=0.04). In non-diabetic patients, an association with coronary events was seen for VWF levels (adjusted HR 2.23, 1.45-3.43, p<0.01). In conclusion, plasma levels of haemostatic factors were associated with vascular death and coronary events, but not with recurrent stroke. Our results suggest that the predictive value of biomarkers differ by specific outcome measure and subgroup of patients.

BATLS/BARTS training in Lithuania

OBJECTIVE

In order to train medical personnel properly for future international missions the Lithuanian Armed Forces decided to adopt BATLS/BARTS as a basic course for military pre-hospital trauma care. This decision was based upon the increasing Lithuanian participation in international missions as a part of multinational units. Another important reason was the personal experience of the course concept acquired in Sweden in 2001 by five Lithuanian medical officers.

METHODS

Similar to the way BATLS/BARTS was introduced in Sweden, a regular Swedish course (as given in Sweden for own units prior to international missions) was given in Lithuania. The faculty consisted of three experienced instructors from Sweden, and the two Lithuanian medical officers who had previously taken the BATLS course and the BATLS instructor course in Sweden.

RESULTS

Two BATLS/BARTS courses have been given in Kaunas, Lithuania. A total number of eight medical officers, nine military nurses, five medics, three civilian doctors and four medical students have taken the course. Some of these (four medical officers, two military nurses and two medics) have later been deployed to Afghanistan, Iraq and Kosovo, where the Lithuanian units have been collaborating with British, Danish, Polish and Czech-Slovakian units.

CONCLUSION

As international missions become multinational, it is essential there is full confidence in the level of training and preparedness among all units working together. One way to achieve this is through bi- or multinational training as described in this paper.

Minimized weight gain between hemodialysis contributes to a reduced risk of death

The risk of death is higher in dialysis patients compared to age matched healthy subjects, the main reason being cardiovascular. This prospective study investigated if the extent of ultrafiltration was of importance for the outcome.

MATERIAL AND METHODS

88 hemodialysis patients were included and followed prospectively. The outcome was registered in regard to death, acute myocardial infarction or coronary vascular intervention. The extent of ultrafiltration needed at dialysis was calculated as a mean during the observation period as were other variables. The mean extent of ultrafiltration was compared for patients who had survived without end-points (group 1, n=53) versus those who reached any end-point during the period (group 2, n=35).

RESULTS

In total, 40% of the patients reached end-point during the observation period. There was no difference at baseline between the groups in regard to age, prevalence of diabetes mellitus or history of previous cardiovascular disease, KT/V, residual renal function ultrafiltration need, C-reactive protein, s-albumin, cholesterol, LDL-cholesterol, HDL-cholesterol, appetite or wellbeing, while triglyceride was lower in group 2 (p=0.035). The observation period for group 1 was at a mean 24.7 months (SD13.1) and for those in group 2 at a mean 13.8 (+/-11.7 months, p<0.001). Patients representing group 1 at 24 and 30 months had less need of ultrafiltration than those in group 2. Thus, the need of ultrafiltration was about 27% lower at 24 months (for 29 persons in group 1: 3.63+/-1.93 weight% versus 4.97+/-1.70 weight% for 9 patients from group 2, p=0.046) and 46% at 30 months (for 18 from group 1: 3.48+/-1.95 versus 6.45+/-1.55 for 3 from group 2, p=0.030). C-reactive protein did not differ significantly between the groups during the period.

CONCLUSION

After a prolonged period of 24 months the extent of ultrafiltration need seems to be important for the outcome of the patients. Thereby those with higher need of ultrafiltration had worse prognosis. It seems important to motivate patients to reduce the extent of fluid intake between dialysis to prolong survival.

Safety and efficacy of atorvastatin in patients with severe renal dysfunction

OBJECTIVE

To investigate the efficacy and safety of a daily dose of 10 mg of atorvastatin in patients with chronic kidney disease (CKD) stages 4 and 5 and a glomerular filtration rate of <30 ml/min.

MATERIAL AND METHODS

This was an open, prospective, randomized study. A total of 143 patients were included: 73 were controls and 70 were prescribed 10 mg/day of atorvastatin. As efficacy variables, total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglyceride levels were determined at the start of the study and at 1, 3, 6, 12, 18, 24, 30 and 36 months.

RESULTS

The follow-up period was a mean of 20+/-14.4 months (range 1-36 months) for those on atorvastatin versus 22+/-12.7 months (range 0.5-36 months) for the controls. Compared with baseline values, patients treated with atorvastatin had significantly lower concentrations of total cholesterol at Month 36 (5.8 vs 4.4 mmol/l; -23%; p<0.001), of LDL cholesterol at Month 36 (3.6 vs 2.2 mmol/l; -35%; p<0.001) and of triglycerides at Months 24 (2.5 vs 1.9 mmol/l) and 36 (2.5 vs 1.8 mmol/l). The controls had significantly reduced levels of total cholesterol at Month 36 (p<0.21) and of LDL cholesterol at Months 30 and 36. Compared with the controls, the atorvastatin group had lower levels of total cholesterol and LDL cholesterol at Months 1-30. Fifteen patients (21%) stopped taking their medication as they could not tolerate the side-effects, the most frequent complaints being gastrointestinal discomfort and headache.

CONCLUSION

Although the medication caused no severe adverse events, we recommend caution when using atorvastatin for severe CKD patients until further evidence of its safety and efficacy is verified.

Heroin impurity profiling. A harmonization study for retrospective comparisons

Three laboratories present a harmonised system for the retrospective comparison of south west Asian heroin. It consists of an improved gas chromatographic (GC) profiling method and a computerised data retrieval. The investigations of the GC were necessary with a view to improve the reproducibility of the system. The necessity of a strict quality control is emphasized. The peaks of the GC profile were investigated for abundance, intensity, GC behaviour (reproducibility) and correlations; 16 of them were selected for describing the heroin profile in the database. The results from intra-lab profile comparisons are reported. The reproducibility of the analysis was good and the variation between the samples was large, thus, allowing conclusions with a high degree of certainty. The criteria of similarity were defined. The system is successfully running in all three labs. In connection with inter-laboratory comparison, the aspects of method harmonisation and standardisation are discussed. It appeared that the GC method is a very subtile one, urging for a strict standardisation between the three labs. Despite a long cooperation between three well-equipped and experienced labs, a more or less serious loss of reproducibility was noticed in the inter-lab results in comparison with the intra-lab results. The loss could for the greater part be attributed to the (limits of the) GC technique; a number of compounds, necessary for making the discrimination between samples, showed difficult chromatographic behaviour, leading to insufficient inter-lab reproducibility. Using the actual variables, improvements in performance can hardly be expected in the near future. The loss of reproducibilty implies that the number of false positive matches in a database search increases. This may strongly reduce the value of a relatively large, international database. The study shows that so far, the best option for international comparison is the analysis in a central laboratory. The idea of local determination at a large number of national labs and the use of a common database is not a realistic aim for this type of analysis.

Health-related quality of life in patients with psoriasis and atopic dermatitis measured with SF-36, DLQI and a subjective measure of disease activity

The impact of skin diseases on health-related quality of life is considerable. It is important to quantify the patient's perspective of the severity of their disease. Health-related quality of life was measured in 366 patients with skin diseases attending the dermatology outpatient clinic in Uppsala, Sweden, from November 1996 to December 1997, with 1 generic (SF-36) and 1 disease-specific (DLQI) health-related quality of life instrument, and a subjective measure of disease activity. The SF-36 mean scores were below those of the age- and gender-matched general population in Sweden. No difference in health-related quality of life was found between men and women or between patients with atopic dermatitis and psoriatic patients. However, patients with psoriatic arthritis had significantly poorer health-related quality of life than both patients with atopic dermatitis and psoriatic patients. The estimated correlations between the instruments were in the expected direction and mostly significant. The results confirm that skin diseases have an adverse impact on patients' health-related quality of life.

Quality of life, health-state utilities and willingness to pay in patients with psoriasis and atopic eczema

Skin diseases have been shown to have a significant adverse impact on the health-related quality of life of patients that may be underestimated by objective assessments of clinical severity. The main aim of this study was to measure the health-state utilities on a scale between 0 (dead) and 1 (full health) of patients with psoriasis and atopic eczema, and to measure the willingness to pay for a cure for psoriasis and atopic eczema. A second aim was to analyse how these measures are related to different dimensions of health-related quality of life, as measured by general and disease-specific quality of life instruments and a subjective measure of disability activity. This study was based on data from a questionnaire administered to, and interviews conducted with, 366 patients with psoriasis and atopic eczema aged 17-73 years, attending the dermatology outpatient clinic in Uppsala, Sweden from November 1996 to December 1997. The survey included: a rating scale question, a time trade-off question, a standard gamble question, a dichotomous choice willingness to pay question, a bidding-game willingness to pay question, a generic quality of life instrument (SF-36), a disease-specific quality of life instrument (the Dermatology Life Quality Index) and a subjective measure of disease activity (on a visual analogue scale). The mean health-state utility was 0.69 (rating scale), 0.88 (time trade-off) and 0.97 (standard gamble) for patients with psoriasis. The corresponding health-state utilities for patients with atopic eczema were 0.73, 0.93 and 0.98. On average, patients were willing to pay between 1253 and 1956 Swedish crowns (SEK) per month for a psoriasis cure and between SEK 960 and 1083 per month for an atopic eczema cure ($1 = SEK 8.25 and pound1 = SEK 13.23). The health-state utilities were related to SF-36, the Dermatology Life Quality Index and disease activity in the expected direction and the correlations were strongest for rating scale and weakest for standard gamble. The willingness to pay was correlated with the Dermatology Life Quality Index and disease activity, but not with SF-36. The study indicates that it is feasible to measure health-state utilities and willingness to pay in this patient population, and the sizeable willingness to pay suggests that skin diseases are associated with substantial reductions in quality of life.

Maternal distress and congenital malformations: do mothers of malformed fetuses have more problems?

As compared with 580 randomly chosen pregnant women without malformed offspring. 161 women with malformed offspring at the index pregnancy had a more frequent history of previous multiple offspring deaths and somewhat increased maternal age but were not different on social class, marital or cohabitation status or parity. As compared with demographically similar reproducing women (n = 54) interviewed, malformation cases (n = 98) reported having had significantly more strong stress before identification of the malformation, as well as a clear tendency toward less appropriate timing of the pregnancy. Women with malformed offspring represent a psychosocially vulnerable group and should receive special clinical and personal support.

The relationship between health-state utilities and the SF-12 in a general population

It would be a major advance if quality-of-life instruments could be translated into health-state utilities. The aim with this study was to investigate the relationship between the SF-12 and health-state utilities, based on responses to a postal questionnaire sent to a random sample of 8,000 inhabitants, aged 20-84 years, in the general population. The questionnaire included the SF-12, a rating-scale (RS) question, and a time-tradeoff (TTO) question; the response rate was 68%. Age, gender, and the 12 items of the SF-12 were used as explanatory variables in a linear regression analysis of the health-state utilities. The regression models explained about 50% of the variance in the RS answers and about 25% of the variance in the TTO answers. Most of the SF-12 items were related to the health-state utilities in the expected ways, with especially strong results for the RS method. The results suggest that the SF-12 can be converted to health-state utilities, but that further work is needed to reliably estimate the conversion function.

The impact of over-the-counter availability of nasal sprays on sales, prescribing, and physician visits

OBJECTIVE

The aim was to study changes in sales and prescribing of nasal decongestants containing oxymetazoline or xylometazoline, changes in number of physician visits for rhinitis and sinusitis, and changes in public expenditures for physician visits due to the switch of these drugs from prescription to over-the-counter status in Sweden in 1989.

DESIGN

Retrospective registry study using the local sales statistics on medicines in the municipality of Tierp from The National Corporation of Swedish Pharmacies and the individual-based computerised registry in Tierp based on health care utilisation and drug use from the Centre for Primary Care. Analyses were carried out during the time period 1988-1995.

SETTING

The Swedish community of Tierp with about 20,000 inhabitants.

SUBJECTS

The population of Tierp.

MAIN OUTCOME MEASURE

Sales of nasal decongestants and dispensed prescriptions of nasal decongestants, physician visits for rhinitis and sinusitis, and public expenditures for these.

RESULTS

Sales of nasal sprays increased, while sales of nasal drops decreased. The number of dispensed prescriptions as well as physician visits decreased. The public expenditures estimated for physician visits decreased as well.

CONCLUSION

This study shows an increase in sales of nasal decongestants and a significant decrease in prescribing of nasal decongestants and the number of physician visits for rhinitis and sinusitis as well as the public expenditures estimated for these, after the switch from prescription to over-the counter status of nasal sprays in 1989.

A note on validating Wagstaff and van Doorslaer's health measure in the analysis of inequalities in health

The aim of this note is to validate Wagstaff and van Doorslaer's approach of constructing a continuous health measure to be used in the analysis of inequalities in health. We calculate health concentration indices for Uppsala County in Sweden based on three different health status measures: health measured according to the WvD approach based on a self-assessed categorical health measure, health measured by the rating scale method, and health measured by the time trade-off method. The concentration index does not differ significantly for the three health status measures, and our results thus support the validity of the WvD method.

Effects of user charges on the use of prescription medicines in different socio-economic groups

This study examined the sensitivity towards increases in user charges for different types of drugs and among different socio-economic groups. It was based on responses by 2008 consumers of prescription drugs to a self-administered postal questionnaire sent to a random sample of 8000 inhabitants in Uppsala County in Sweden. The questionnaire included a question about whether the respondents would use fewer prescription drugs if the user charges increased by a specific amount. The increase in user charges was varied between 9 and 150% in five different subsamples. Logistic regression analysis was used to estimate the probability that a respondent would reduce consumption of prescription drugs as a function of the size of the user charges increase, socio-economic characteristics and the type of drug used. Results showed that the price sensitivity decreased with increasing age, income, education and self-rated health status. Price sensitivity was highest for antitussives and lowest for climacteric drugs. If the user charges doubled, 40% of antitussives users would reduce their consumption whereas only 11% of climacteric drugs users would reduce their consumption. It is concluded that sensitivity to increases in user charges varied greatly between different types of drugs and between socio-economic groups. The young, those with poor health status, low education and low income are most likely to decrease consumption of prescription drugs when user charges increase.

Naturally occurring variants of human milk bile salt-stimulated lipase

Analysis of milk samples from a number of lactating women revealed molecular variants of bile salt-stimulated lipase (BSSL) of both lower and higher molecular mass than that commonly occurring. In contrast to previous observations, we report on individuals having only a variant of lower mass, both one of lower and one of common mass, or both one of lower and one of higher mass of the lipase. From two individuals we purified the lower molecular mass BSSL variant and characterized it. The amount of lipase in the milk of these two individuals was considerably less than average (mean of 10 women with BSSL of the most common molecular mass). The BSSL variant of lower mass showed the same bile salt activation, pH dependency, temperature stability as those most commonly occurring. We could localize the difference in mass to the large O-glycosylated repeat sequence close to the C-terminus of the protein. With respect to all characteristics studied, the BSSL variant of higher mass was also similar to that most commonly ocurring. Again, the difference in mass could be localized to the repeat region of the protein. Hence, it appears as if the repeat region, normally carrying 16 repeats of 11 amino acids each, varies in size between individuals.

Subunit G of the vacuolar proton pump. Molecular characterization and functional expression

The vacuolar type proton pump of clathrin-coated vesicles has a multisubunit ATP hydrolytic center that is peripheral to the membrane. Polypeptides present in this domain include the well characterized subunits A, B, C, D, E, and F; SFD, a dimer composed of 50- and 57-kDa polypeptides; and polypeptides termed G and H. Of these, subunits A, B, C, and E have been shown to be necessary but not sufficient for significant ATPase activity; in addition, either polypeptide G or H is also required for ATP hydrolysis (Xie, X.-S. (1996) J. Biol. Chem. 271, 30980-30985). In this study, the polypeptides G and H were purified and directly sequenced. Subsequent molecular analysis has revealed that these proteins are isoforms, which we designate G1 and G2. The cDNAs encoding the rat and bovine brain and chicken osteoclast forms of G1 have been cloned. The open reading frames of the rat and bovine clones encode hydrophilic proteins of 118 amino acids that differ at only five residues; bovine G1 has 36% identity with VMA10, a component of the proton channel of yeast. Northern blot analysis revealed a 1. 0-kilobase pair transcript encoding G1 in bovine brain, kidney, heart, and spleen. The cDNA encoding bovine polypeptide H was cloned and sequenced, revealing this protein to be 64% identical to G1, constituting isoform G2. In Northern blot analysis, a single 1. 7-kilobase pair transcript hybridized with a probe to G2 in brain, but not in heart, kidney, or spleen. An antibody against a bovine G1-specific domain reacts with V pump from bovine brain, kidney, and chromaffin granule, whereas an anti-G2 antibody reacts only with proton pump from brain. The bovine forms of G1 and G2 were subsequently expressed in Escherichia coli and Sf9 cells, respectively, and purified to homogeneity. Reconstitution of ATP hydrolysis was achieved by combination of recombinant subunits A, B, C, and E with either recombinant G1 or G2, demonstrating the role of these isoforms in pump function.

Recombinant human bile salt-stimulated lipase: an example of defective O-glycosylation of a protein produced in milk of transgenic mice

The expression of recombinant human bile salt-stimulated lipase (bssl) was targeted to the lactating mammary gland of transgenic mice. Expression of recombinant genes comprising bsslcDNA, or alternatively genomic bssl DNA, under control of regulatory elements derived from the murine whey acidic protein (wap) gene was achieved and evaluated. Constructs containing genomic bssl sequences mediated high levels (0.5-1 mg ml-1) of recombinant human BSSL in the milk. The recombinant BSSL produced was purified, biochemically characterized and compared to native BSSL and recombinant BSSL produced in mouse C127 and hamster CHO cells. Recombinant BSSL derived from transgenic mice showed a different migration and distribution after SDS-PAGE electrophoresis, lower apparent molecular mass on size-exclusion chromatography and no detectable interactions with a panel of lectins. These results indicate a significantly lower degree of O-glycosylation of recombinant BSSL in milk from transgenic mice than was found for the native enzyme or recombinant CHO- or C127 cell-produced BSSL. Despite these differences, mouse-milk-derived recombinant BSSL exhibited similar lipase activity, the same stability to low pH and similar sensitivity to elevated temperatures as the native enzyme. The observation that mouse-C127-cell-produced recombinant BSSL is heavily O-glycosylated makes species-related restrictions less attractive as an explanation for the reduced O-glycosylation.

Long-term experience of self-injection therapy with prostaglandin E1 for erectile dysfunction

A total of 42 evaluable patients 36-80 years old were treated with intracavernous injection of prostaglandin E1 for erectile dysfunction. They reported retrospectively via a questionnaire their long-term experience of this method. Twenty-four patients (57%) were after 46.9 months still using the technique, while 18 patients (43%) had abandoned the method after 21.4 months of use. No major complications were observed or reported.

Molecular cloning and characterization of the mouse carboxyl ester lipase gene and evidence for expression in the lactating mammary gland

DNA hybridization was used to isolate a 2.04-kb cDNA encoding carboxyl ester lipase (CEL) from a mouse lactating mammary gland, lambda gt10 cDNA library. The cDNA sequence translated into a protein of 599 amino acids, including 20 amino acids of a putative signal peptide. Comparison of the deduced amino acid sequence of the mouse CEL with CEL from five other species revealed that there is a high degree of homology between the different species. The mouse CEL gene was also isolated and found to span approximately 7.2 kb and to include 11 exons. This organization is similar to those of the recently reported human and rat CEL genes. We have also analyzed expression of the CEL gene in the mammary glands from other species by performing a Northern blot analysis with RNA from goat and cow. The results show that the gene is expressed in both species.

Recombinant human-milk bile-salt-stimulated lipase. Functional properties are retained in the absence of glycosylation and the unique proline-rich repeats

Human milk bile-salt-stimulated lipase ensures efficient utilization of milk lipid in breast-fed infants. The N-terminal two-thirds of the peptide chain is highly conserved and shows striking similarities to typical esterases. In contrast, the remaining C-terminal part consists of a unique sequence of 16 proline-rich O-glycosylated repeats of 11 residues each. Recently we could show, using recombinant lipase variants, that neither these repeats nor the single N-linked sugar chain are essential for catalytic efficiency. In the present study, we report on the lack of importance of glycosylation and the unique repeats for other important functional properties, i.e. bile-salt activation, heparin binding, heat stability, stability at low pH and resistance to proteolytic inactivation. Compared to native enzyme, recombinant full-length lipase produced in two mammalian cell lines differed slightly in glycosylation pattern with no effects on the functional properties. Moreover, a variant lacking all repeats and the C-terminal tail following the last repeat exhibited the same functional characteristics as purified native milk enzyme. Thus, the structural basis for all the typical and functionally important properties reside in the N-terminal conserved part, in spite of the fact that none of these properties are shared by typical esterases. We could however, demonstrate that the C-terminal repeats are responsible for the unusual behaviour of the enzyme in size-exclusion chromatography, resulting in a considerably higher than expected apparent molecular mass.

The prevalence of circulating anti-tubular basement membrane-antibody in renal diseases, and clinical observations

Anti-tubular basement membrane antibodies were determined by ELISA in 217 patients with different renal diseases. The assay for antibodies in serum was based on a 58 kD bovine tubular basement membrane antigen. Sera were studied from 69 patients with different forms of interstitial nephritis; 15 patients (10 women, 5 men) had anti-tubular basement membrane titers above the normal (compared with a reference group of healthy blood donors). Three patients are presented in greater detail. Thirty-four patients with pyelonephritis (confirmed by intravenous urogram) were investigated; one serum was positive. Sera from 114 patients with renal glomerular and/or vascular disease were studied; 12 had positive titers for tubular basement membrane and glomerular basement membrane or other kidney disease antibodies. This study supports the opinion that damage in the renal medulla can be caused by an autoimmune process. Circulating anti-TBM antibodies may be of value in the investigation of patients with tubulo-interstitial diseases but the cause and prognosis of this condition is, however, not known.

Backdiffusion or bicarbonate may stimulate complement activation during haemodialysis with low-flux membranes

Backdiffusion of dialysate during haemodialysis with low-flux membranes and the use of bicarbonate dialysatebase, may increase the risk for contamination. The influence on the complement system was studied by altering the flux of acetate or bicarbonate dialysate base across the membrane. Eight patients were dialysed with a transmembrane pressure of 100 mm Hg (group I) during the first 60 min to standardize the ultrafiltration (UF) and acetate as dialysate. In eight other patients (group II) the UF was "set at zero" ml during the first 60 min using an FCM 10-1 monitor (Gambro) and bicarbonate as base. The groups were dialysed three times on two hollow-fiber membranes made of Hemophan and cellulose acetate (CA). Blood samples were taken at 0, 15, 60 and 180 min, and analysed for plasma protein, haematocrit and complement C3d. In group II there was a reduction in plasma protein concentration at 15 and 60 min (p < 0.002) for Hemophan and at 60 min (p < 0.01) using CA. C3d was increased at 15 min for both filters (p < 0.03). The reduction of protein in group II was followed by changes in the haematocrit, indicating a backdiffusion of dialysate, which may contribute to the concomittant increase in C3d.

Recombinant human milk bile salt-stimulated lipase. Catalytic activity is retained in the absence of glycosylation and the unique proline-rich repeats

Human milk bile salt-stimulated lipase ensures efficient utilization of triacylglycerol by breast-fed infants. Cloning and sequencing of cDNA have revealed that the peptide chain consists of 722 amino acid residues showing only little homology to typical lipases. The sequence is identical to that of pancreatic carboxylic-ester hydrolase. The COOH-terminal part contains 16 proline-rich repeats of 11 residues with O-linked carbohydrate. The only N-linked sugar chain is situated close to the active-site serine. Using C127 cells and a bovine papilloma virus vector, high and stable expression of full-length lipase and of several variants, obtained by site-directed mutagenesis, was achieved. The produced proteins were purified and further characterized. Variants lacking all, or all but two, repeats were active with similar specific activity and the same bile salt dependence as the native milk enzyme. Changing the asparagine necessary for N-glycosylation gave the same principal results. Active recombinant full-length lipase was also produced in a bacterial system. We conclude that neither glycosylation (N- or O-linked) nor the proline-rich repeats are essential for catalytic activity or bile salt activation of human milk bile salt-stimulated lipase.

Circulatory basophilia in guinea pigs with delayed-type hypersensitivity. Topical antigenic provocation induces circulatory basophilia

Circulatory basophilia could be induced in inbred guinea pigs systematically immunized with ovalbumin and consequently provoked repeatedly with dissolved ovalbumin applied onto the mucosa of the nares or the outer eye. The degree of the increase in circulatory basophil granulocytes depended on the adjuvant used and was significantly more pronounced after immunization with Freund's complete adjuvant than with alhydrogel (Al(OH)3). The degree of basophilia was also dependent on the animal strain, but different in two strains selected for high-asthma trait.

Immunologically induced purulent anterior segment inflammation of the guinea pig eye

A single conjunctival application of ovalbumin to inbred guinea pigs (IMM/S 209) immunized with the same antigen in Freund's complete adjuvant provoked an acute purulent inflammation of the anterior segment of the eyes with a duration of up to 1 week. Intense conjunctival injection and chemosis were followed by a purulent discharge. A corneal haze was observed regularly, and a considerable proportion of the animals developed a pronounced pannus and corneal ulcers. Tear fluid cytology revealed a rapid increase in cell concentration, from the normal level (less than 10(8)/l) to greater than 10(11)/l. Seventy to 95% of the cells were polymorphonuclear leukocytes. Histological examination revealed an acute inflammatory reaction which radiated from the conjunctival fornices to the entire anterior segments of the eyes. The process was characterized by an intense oedema, vasodilation and perivascular aggregations of polymorphonuclear leukocytes, and to a lesser extent eosinophilic granulocytes which characteristically infiltrated and penetrated the epithelial layers. Neovascularization could be observed early after challenge in the stroma of all parts of the outer eye. Ulcerations of the conjunctival and corneal epithelia were observed frequently. After a number of reiterations of the antigenic challenge, a marked infiltration with lymphocytes and basophils/mast cells was observed, and significant scarring of the conjunctival mucosa developed. In several animals, a slight, but significant co-reaction of the contra-lateral, non-challenged eye was observed.

Genetic control of eosinophilia in guinea pig strains inbred for high or low bronchial allergic reactivity

Development of eosinophilia was studied in four strains of guinea pigs (gp), selectively bred for either high or low respiratory anaphylactic reactivity. One high-asthma strain (IMM/S 209) and one low-asthma strain (IMM/R 203) developed spontaneous high blood eosinophilia. The 2 other gp strains - one high-asthma strain (IMM/S 740) and one low-asthma strain (IMM/R 201-16) - maintained normal low levels of eosinophilic granulocytes (eos). The levels of eos in various tissues showed similar differences between the gp strains. Following immunization with ovalbumin/Al(OH)3 the levels of blood eos increased significantly only in gp of strain 209. The blood eos levels in gp of all 4 strains decreased significantly following immunization with ovalbumin in Freund's complete adjuvant (FCA).