Hearing outcome of early postnatal exposure to hypoxia in Sprague-Dawley rats

Objective: To determine the effect of experimentally induced hypoxia, in the first 10 days of life, on physiological hearing in a Sprague-Dawley rat model. Methods: A prospective, controlled animal study was carried out using 22 male rat pups. The rats in the hypoxic group (n = 12) were reared in hypoxia for the first 10 days of life, and subsequently reared in normoxia, while those in the control group (n = 10) were reared in normoxia for the duration of the experiment. Hearing was assessed using auditory brainstem response testing at approximately 72 days of age. Results: The hypoxia group had higher auditory brainstem response thresholds for all frequencies tested (more pronounced at 16 kHz), compared with controls. Wave I-V inter-peak latencies were more prolonged in the hypoxic rats, while both groups had similar wave I latencies. Conclusion: Chronic postnatal hypoxia induced permanent hearing loss in this Sprague-Dawley rat model. Prolonged wave I-V inter-peak latencies suggested functional abnormality in the central auditory pathway.

Virus and Antibody Diagnostics for Swine Samples of the Dominican Republic Collected in Regions Near the Border to Haiti

The Dominican Republic (DR) and Haiti share the island of Hispaniola, and reportable transboundary animal diseases have been introduced between the two countries historically. Outbreaks of severe teschovirus encephalomyelitis in pigs began occurring in Haiti in February 2009, and a field and laboratort study in April 2010 indicated that the teschovirus disease is prevalent in many regions in Haiti including areas near the border with DR and that other viral disease agents, including CSF virus (CSFV), porcine circovirus type 2 (PCV-2), porcine reproductive and respiratory syndrome virus (PRRSV), and swine influenza virus (SIV), are present in the swine population in these regions. The purpose of this study was to evaluate the introduction of teschovirus encephalomyelitis from Haiti to DR and to identify the other viral disease agents present in the swine population in regions of DR near the border with Haiti. Six of 7 brains and 6 of 7 spinal cords collected from pigs with central nervous system (CNS) signs were positive in reverse transcription-polymerase chain reaction for PTV. Genome sequencing on the Dominican PTV and phylogenetic analysis on the polyprotein of PTV strains indicate that the sequence of the Dominican PTV is 99.1% identical to the Haitian isolate and closely related to other PTV-1 strains in the world. Among 109 serum samples tested, 65 (59.6%) were positive for antibodies to PCV-2, and 51 (46.8%) were positive for antibodies to CSFV. Fifty-four of the 109 serum samples were tested for antibodies to other agents. Among the 54 samples, 20 (37.0%) were seropositive to PTV-1, 17 (31.5%) tested seropositive to SIV H3N2, 12 (22.2%) were seropositive to SIV H1N1, and 1 (1.9%) was seropositive to PRRSV.

Ongoing in vivo studies with cytoskeletal drugs in tau transgenic mice

Most drug discovery efforts for Alzheimer's disease (AD) have focused on prevention or clearance of beta-amyloid (Abeta) fibrils or oligomers, with far less attention to prevention of tau abnormalities that lead to neurofibrillary tangles (NFTs). Much evidence now indicates that Abeta multimers can trigger neurodegenerative changes that involve formation of dystrophic neurites and cytoskeletal collapse, possibly due loss of microtubule (MT) stabilization by the tau protein. We have found that several MT-stabilizing agents such as Taxol significantly enhanced neuronal survival in the presence of Abeta and identified agents that enter the brain, a necessity for in vivo testing in animal models of tau pathology. Studies were designed to test two agents in the tau mutant (JNPL3) mouse that develops severe motor deficits at about seven months of age, accompanied by neuropathological markers of tau pathology. In addition to using motor performance tests through the planned period of drug administration, we designed a simple appetitive memory test that required a reduction in ad lib food intake. Although the neurochemical data are still being analyzed, we were surprised to find that all of the JNPL3 mice, whether receiving the drug or not, developed no signs of motor impairment up to 10 months of age. This is considerably beyond the age at which free-fed mice survived and suggests that the food restriction alone may have delayed the pathological process. A study is ongoing with free-fed mice to determine if the drug interventions do have any beneficial effects in these mutant mice.

Curdlan and other bacterial (1→3)-β-d-glucans

Three structural classes of (1-->3)-beta-D-glucans are encountered in some important soil-dwelling, plant-associated or human pathogenic bacteria. Linear (1-->3)-beta-glucans and side-chain-branched (1-->3,1-->2)-beta-glucans are major constituents of capsular materials, with roles in bacterial aggregation, virulence and carbohydrate storage. Cyclic (1-->3,1-->6)-beta-glucans are predominantly periplasmic, serving in osmotic adaptation. Curdlan, the linear (1-->3)-beta-glucan from Agrobacterium, has unique rheological and thermal gelling properties, with applications in the food industry and other sectors. This review includes information on the structure, properties and molecular genetics of the bacterial (1-->3)-beta-glucans, together with an overview of the physiology and biotechnology of curdlan production and applications of this biopolymer and its derivatives.

Worry about ovarian cancer risk and use of ovarian cancer screening by women at risk for ovarian cancer

OBJECTIVE

This study examined reports of perceived risk of ovarian cancer, worry, and screening use in a large sample of women. While screening for asymptomatic women is not generally recommended, in 1994 a consensus conference concluded that women with multiple affected relatives are at high risk for ovarian cancer and should be encouraged to participate in screening. The consensus report also suggested that women with a single affected first-degree relative are at elevated risk and while these women were not encouraged to get screening it was suggested that they may choose to pursue screening outside of a randomized trial [NIH Consensus Conference. JAMA 1995;273(6) 491-7].

METHODS

A total of 3257 women participated in this research by completing a mailed survey on ovarian cancer risk, worry, and use of screening. One hundred forty-two of these women were at high risk for this disease due to a strong family history. An additional 144 women were at elevated risk due to a single first-degree affected relative with ovarian cancer.

RESULTS

Family history did predict perceived risk, difficulties due to worry, and use of ovarian cancer screening. However, the group of women most likely to report high levels of perceived risk and to have received screening for ovarian cancer were women with a single affected relative rather than those at high risk, for whom screening is recommended.

CONCLUSIONS

These results suggest that many women need additional education about ovarian cancer risk. Most women overestimated their risk for this disease. Some average-risk women get screening although it is not recommended outside of randomized trials, and a significant percentage of women at high risk fail to get recommended screening.

Trans-10, cis-12 conjugated linoleic acid increases fatty acid oxidation in 3T3-L1 preadipocytes

The purpose of this study was to examine the effect of 0-50 micromol/L trans-10, cis-12 conjugated linoleic acid (CLA) and cis-9, trans-11 CLA isomers on lipid and glucose metabolism in cultures of differentiating 3T3-L1 preadipocytes. Specifically, we investigated the effects of 6 d of CLA treatment on the following: 1) (14)C-glucose and (14)C-oleic acid incorporation and esterification into lipid; 2) (14)C-glucose and (14)C-fatty acid oxidation; and 3) basal and isoproterenol-stimulated lipolysis. Trans-10, cis-12 CLA supplementation (25 and 50 micromol/L) increased both (14)C-glucose and (14)C-oleic acid incorporation into the cellular lipid fraction, which was primarily triglyceride (TG), compared with bovine serum albumin (BSA) controls. Although glucose oxidation ((14)C-glucose to (14)C-CO(2)) was unaffected by CLA supplementation, oleic acid oxidation ((14)C-oleic acid to (14)C-CO(2)) was increased by approximately 55% in the presence of 50 micromol/L trans-10, cis-12 CLA compared with BSA controls. In contrast, 50 micromol/L linoleic acid (LA) and cis-9, trans-11 CLA-treated cultures had approximately 50% lower CO(2) production from (14)C-oleic acid compared with control cultures after 6 d of fatty acid exposure. Finally, 50 micromol/L trans-10, cis-12 CLA modestly increased basal, but not isoproterenol-stimulated lipolysis compared with control cultures. Thus, the TG-lowering actions of trans-10, cis-12 CLA in cultures of 3T3-L1 preadipocytes may be via increased fatty acid oxidation, which exceeded its stimulatory effects on glucose and oleic acid incorporation into lipid.

Trans-10,cis-12 conjugated linoleic acid reduces triglyceride content while differentially affecting peroxisome proliferator activated receptor gamma2 and aP2 expression in 3T3-L1 preadipocytes

A series of experiments was conducted using 3T3-L1 preadipocytes as the cell model to determine: (i) whether the triglyceride (TG)-lowering effects of a crude mixture of conjugated linoleic acid (CLA) isomers were due to a specific isomer of CLA and the timing of treatment, (ii) if CLA reduced TG content by inhibiting a key regulator of adipogenesis, (iii) if CLA incorporated into either neutral lipid or phospholipid cell fractions, and (iv) whether the effects of CLA treatment were reversible. Trans-10,cis-12 CLA reduced TG content, whereas the cis-9,trans-11 isomer increased TG content compared to vehicle [bovine serum albumin (BSA)] controls. Treatment with 50 microM trans-10,cis-12 CLA during the entire 6 d of differentiation reduced TG content to a greater extent than treatment during either the first 3 d or last 3 d of differentiation. Trans-10,cis-12 CLA treatment of preadipocyte cultures for 48 h increased peroxisome proliferator activated receptor gamma2 (PPARgamma2) protein expression compared to cultures treated with linoleic acid (LA) or the BSA controls. CLA had no effect on adipose P2 (aP2), a fatty acid-binding protein regulated by PPARgamma2. Both the cis-9,trans-11 and the trans-10,cis-12 isomers of CLA were incorporated into neutral lipids and phospholipids. However, cis-9,trans-11 CLA levels were one- to twofold higher than trans-10,cis-12 CLA levels. Moreover, trans-10,cis-12 CLA treatment reduced cis-11 18:1 concentrations in both neutral lipids and phospholipids while increasing cis-9 18:1 and 18:2 concentrations. Palmitoleic acid (16:1) levels were also lower in the neutral lipid fraction of cultures treated with trans-10,cis-12 CLA. Supplementing trans-10,cis-12 CLA-treated cultures (50 microM) with increasing levels of LA resulted in a dose-dependent increase in TG content compared to cultures treated with 50 microM CLA alone. LA supplementation also prevented some of the morphological changes associated with trans-10,cis-12 CLA treatment as seen with scanning electron microscopy. Treatment with 50 microM trans-10,cis-12 CLA for 6 d decreased PPARgamma2 levels, and supplementation of CLA-treated cultures with LA increased PPARgamma2 levels compared with cultures treated with CLA alone. Taken together, these data indicate that in cultures of 3T3-L1 preadipocytes: (i) trans-10,cis-12 CLA is the TG-lowering isomer of CLA, and its effects are dependent on dose, duration of treatment, and the amount of LA in the cultures; (ii) trans-10,cis-12 CLA treatment alters the monounsaturated fatty acid profile of neutral- and phospholipids of the cultures; and (iii) although acute (2-d) trans-10,cis-12 CLA treatment increased PPARgamma2 protein levels, chronic (6-d) treatment decreased PPARgamma2 levels.

Handling missing data in nursing research with multiple imputation

BACKGROUND

In the data analysis phase of research, missing values present a challenge to nurse investigators. Common approaches for addressing missing data generally include complete-case analysis, available-case analysis, and single-value imputation methods. These methods have been the subject of increasing criticism with respect to their tendency to underestimate standard errors, overstate statistical significance, and introduce bias.

OBJECTIVES

This article reviews the limitations of standard approaches for handling missing data, and suggests multiple imputation is a useful method for nursing research.

METHOD

Secondary analysis was conducted to examine the effect of a public policy on the health of women using a data set that had a large degree and complex patterns of missing data.

DISCUSSION

In the example, accommodation of the incomplete data was critical to making valid inferences; however, complete-case, available-case, or single imputation could not be defended as an adequate method for dealing with the missing data patterns. Alternative methods for dealing with incomplete data were sought, and a multiple imputation approach was selected given the missing data pattern. Nurse researchers confronting similar complex patterns of missing data may find multiple imputation a useful procedure for conducting data analysis and avoiding the bias associated with other methods of handling missing data.

Trans-10, cis-12, but not cis-9, trans-11, conjugated linoleic acid attenuates lipogenesis in primary cultures of stromal vascular cells from human adipose tissue

We have previously shown that both a commercially available mixture of conjugated linoleic acid (CLA) isomers and the trans-10, cis-12 isomer of CLA reduced the triglyceride (TG) content and induced apoptosis in differentiating cultures of murine 3T3-L1 preadipocytes. However, the influence of CLA isomers on differentiating human (pre)adipocytes is unknown. Therefore, we conducted a series of studies using primary cultures of stromal vascular cells isolated from human adipose tissue to determine: 1) the influence of seeding density and thiazolidinedione (TZD) concentration on TG content; 2) the chronic dose response of cis-9, trans-11 CLA vs. trans-10, cis-12 CLA on TG content; 3) whether chronic linoleic acid supplementation could rescue the TG content of CLA-treated cultures; and 4) whether trans-10, cis-12-mediated reduction in cellular TG was due to decreased lipogenesis and/or increased lipolysis. In expt. 1, the TG content [micromol/(L x 10(6) cells)] increased as both seeding density and TZD concentration increased. For example, cultures seeded at 4 x 10(4) cells/cm(2) and supplemented with 10 micromol/L BRL 49653 had 10-fold more TG than similarly seeded cultures without BRL 49653. In expt. 2, TG content decreased as the level of trans-10, cis-12 CLA increased from 1 to 10 micromol/L, whereas the TG content increased with increasing concentrations of either linoleic acid or cis-9, trans-11 CLA. In expt. 3, linoleic acid supplementation restored the TG content of cultures treated with trans-10, cis-12 CLA compared with cultures treated with CLA alone, suggesting that attenuation of TG content by CLA is reversible. In expt. 4, glucose incorporation into total lipid decreased with increasing levels of trans-10, cis-12 CLA, whereas neither CLA isomer acutely affected lipolysis. These data suggest that the reported antiobesity actions of a supplement containing a crude mixture of CLA isomers given to humans may be due to inhibition of lipogenesis by the trans-10, cis-12 isomer.

Design issues for conducting cost-effectiveness analyses alongside clinical trials

In response to rising demands for timely economic data on new medical technologies, cost-effectiveness studies are increasingly being conducted alongside clinical trials. Because of the historical differences in perspective and methods between cost-effectiveness studies and clinical trials, the design phase of these hybrid trials requires special consideration. Cost-effectiveness studies require more comprehensive evaluations of outcomes than the endpoints typically measured in clinical trials. Often, these comprehensive outcome measures (such as quality of life) prove useful for interpreting the other endpoints measured in the trial, as well as for estimating the cost-effectiveness of the intervention. In this manuscript, we discuss several aspects related to the design of joint clinical/economic trials, including study perspective, hypothesis testing, sample size estimation, and methods for collecting cost and outcome data. We also discuss issues that may limit the external validity of the cost-effectiveness results of these trials. Many potential threats to external validity can be successfully addressed if they are identified and accounted for in the design phase of the study.

Linoleic acid partially restores the triglyceride content of conjugated linoleic acid-treated cultures of 3T3-L1 preadipocytes

We have previously demonstrated that a crude mixture of commercially available conjugated linoleic acid (CLA) isomers suppressed triglyceride (TG) content and induced apoptosis in post-confluent cultures of murine 3T3-L1 preadipocytes. Furthermore, we found that 100 &mgr;M of trans-10, cis-12 isomer of CLA had a greater TG-lowering and apoptotic effect than the crude mixture of CLA isomers. Therefore, the purpose of this study was to: 1) compare the potencies of the two main isomers found in the crude mixture of CLA isomers, e.g. cis-9, trans-11 (41%) and trans-10, cis-12 (44%); and 2) determine if the TG-reducing actions of CLA could be attenuated by the addition of increasing levels of linoleic acid to the cultures. Preadipocyte differentiation was assessed on day 7 of the differentiation protocol by measuring TG content (per 10(6) cells), cell size, and lipid staining. In experiment 1, post-confluent cultures of 3T3-L1 preadipocytes treated for the first 6 d of differentiation with 100 &mgr;M of a crude mixture of CLA isomers or 44 &mgr;M of trans-10, cis-12 CLA had less TG content than all other cultures. In contrast, cultures supplemented with 41 &mgr;M of the cis-9, trans-11 CLA isomer had the same amount of TG as the BSA controls. In experiment 2, post-confluent cultures of 3T3-L1 preadipocytes treated for the first 6 d of differentiation with 50 &mgr;M trans-10, cis-12 CLA had less TG content and a greater number of smaller cells (10-12.5 microns) compared to all other treatments. CLA-treated cultures supplemented with increasing levels of linoleic acid (50-200 &mgr;M) had greater TG contents and greater numbers of larger cells (15-20 microns) than cultures treated with 50 &mgr;M of the trans-10, cis-12 CLA isomer alone. These data demonstrate that: 1) the TG-lowering effects of the crude mixture of CLA isomers is due almost exclusively to the trans-10, cis-12 isomer; and 2) linoleic acid partially reverses CLA's attenuation of TG content, suggesting that these unsaturated fatty acids may compete for incorporation into TG or phospholipid-derived eicosanoids that regulate preadipocyte differentiation.

Relationship between underlying renal disease and renal transplantation outcome

The purpose of this study is to better characterize graft and patient survival posttransplantation by examining survival according to underlying renal disease for all first-time renal allograft recipients in the United Network for Organ Sharing (UNOS) registry. From 1987 through 1996, the UNOS registry collected data on 23,838 living and 67,183 cadaveric renal transplantations. This investigation included all patients undergoing their first renal transplantation for whom the underlying cause of renal failure could be identified and categorized. Gross 1- and 3-year patient and graft survival according to underlying renal disease are included. In addition, a Cox proportional hazards model was created to analyze the effect of underlying disease on graft and patient survival after adjusting for comorbid conditions, demographics, and type of renal transplant (living versus cadaveric). The association between underlying disease and graft and patient survival is shown. Amyloidosis, sickle cell anemia, scleroderma, and radiation nephritis are associated with poor graft and patient survival. The risk ratio for patient mortality was more than twice that for immunoglobulin A nephropathy for a number of conditions, including analgesic nephropathy, amyloidosis, and both forms of diabetes mellitus.

Factors influencing serum CA125II levels in healthy postmenopausal women

Our objective was to identify factors that correlate with CA125 concentrations in healthy postmenopausal women and to introduce recommendations for reporting and interpreting individual CA125 assay results. We analyzed repeated serum CA125 levels, as measured by the CA125II assay, in 18,748 postmenopausal women who participated in the ST: Bartholomew's/Royal London Hospital Ovarian Cancer screening trial from 1986 to 1994 and were not diagnosed with ovarian cancer during the 12-year follow-up period. We found that race is a substantial predictor of normal levels of CA125, with average CA125II concentration from African (median, 9.0; 95% range, 4.0-26.0 units/ml) and Asian women (median, 13.0; range, 5.9-33.3 units/ml) lower than that in Caucasian women (median, 14.2; range, 6.0-41.0 units/ml; P < 0.001). Women with a hysterectomy have lower CA125II values (median, 13.6; range 5.5-39.0 units/ml; P < 0.001), and women with a prior cancer diagnosis other than ovarian cancer have higher levels of CA125 II (median, 16.0; range, 6.0-49.0 units/ml; P < 0.003). Regular smoking and caffeine consumption decrease CA125 levels (P < 0.001). A woman's age, age at menarche, age at menopause, and history of a previous ovarian cyst (P < 0.05) are also predictive of baseline CA125 levels. Parity, history of hormone replacement therapy or unilateral oopherectomy, and previous use of oral contraceptives or talcum powder are not significant predictors of CA125 concentrations (P > 0.05). We concluded that clinically significant differences in individual patient characteristics need to be reflected in the screening algorithms that use CA125II so that designed performance characteristics (sensitivity and specificity) are maintained in practice.

Race, ethnicity, and the health care system: public perceptions and experiences

To assess the public's perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities--many were unaware that blacks fare worse than whites on measures such as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

A diet containing food rich in soluble and insoluble fiber improves glycemic control and reduces hyperlipidemia among patients with type 2 diabetes mellitus

The clinical significance of fiber on metabolic control among people with type 2 diabetes is debatable. Patients with type 2 diabetes who consumed a diet containing food naturally rich in fiber (e.g., 50 g fiber/day, 50% soluble) for 6 weeks had significant improvements in glycemic control and lipid panels when compared with patients who consumed a diet with moderate amounts of fiber (e.g., 25 g fiber/day, 50% soluble). Whether this high intake of fiber-rich food, especially fruits, can be maintained, tolerated without side effects or micronutrient deficiencies, and affordable for longer than 6 weeks in people with type 2 diabetes remains to be determined.

Parameter solicitation for planning cost effectiveness studies with dichotomous outcomes

When economic endpoints are included alongside clinical effectiveness measures in randomized clinical trials (RCT), they are summarized together by the incremental cost effectiveness ratio (ICER). Adding economic endpoints to an RCT complicates the planning of experiments because investigators must now solicit their beliefs about costs, but even more challenging, they must also specify their association with effectiveness. Solicitation of correlations between costs and effects can be unintuitive, and so potentially highly inaccurate. This is unfortunate because power is highly sensitive to the association between costs and effects. Mis-specification in this association may lead to substantially underpowered or overpowered studies. We show that when clinical effectiveness measures are dichotomous, specification of the correlation between costs and effects can be avoided by instead describing their association with a mixture model. This representation leads to simple and highly intuitive parameter specifications. It may also be used to generate realistic raw data that can be used to evaluate experiment power with simulation. We give particular attention to evaluating and interpreting power when Fieller's theorem method (FTM) is used to calculate confidence for, and test hypotheses about, the ICER. Data from a previously published clinical trial are used to demonstrate the use of this new method to calculate sample size for a cost effectiveness study.

Conjugated linoleic acid suppresses triglyceride accumulation and induces apoptosis in 3T3-L1 preadipocytes

Four sets of experiments were conducted to examine the influence of conjugated linoleic acid (CLA) isomers during proliferation and differentiation of cultures of 3T3-L1 preadipocytes using physiological culturing conditions. Cultures treated with either albumin [bovine serum albumin (BSA) vehicle] or linoleic acid (LA) served as controls. For the proliferation study (Expt.1), cells were cultured in media containing a crude mixture of CLA isomers or pure LA at 0, 10, 50, or 200 microM for 4 d. Preadipocyte proliferation (cell number, 3H-thymidine incorporation into DNA) decreased as the level of CLA increased in the cultures. In contrast, LA had no impact on DNA synthesis. In Experiment 2a, postconfluent cultures were grown in media containing a crude mixture of CLA isomers or LA at 0, 10, 50, or 200 microM for the next 6 d. Postconfluent cultures supplemented with 50-200 microM CLA had less triglyceride (TG) and were smaller in size than cultures supplemented with similar amounts of LA. In Experiment 2b, postconfluent cultures supplemented with 200 microM of a crude mixture of CLA isomers or LA were harvested on days 1, 3, 6, or 9. Differences in TG content of cultures supplemented with 200 microM CLA compared to control and LA-supplemented cultures became apparent after 3 d of culture. Experiments 3a and 3b examined whether the fatty acid vehicle (BSA vs. ethanol) or the vitamin E status (+/-0.2 mM alpha-tocopherol) of the cultures altered CLA's impact on preadipocyte TG content. In Experiment 3a, ethanol-treated cultures had more TG than non-ethanol-treated cultures regardless of the fatty acid treatment. In Experiment 3b, cultures treated with 100 microM of either a crude mixture of CLA or the trans-10,cis-12 CLA isomer without supplemental vitamin E for 6 d had less TG than CLA-treated cultures containing vitamin E. In Experiment 4, postconfluent cultures were grown in media containing 100 microM LA or either a crude mixture of CLA isomers or the trans-10,cis-12 CLA isomer for 24-96 h to assess CLA's influence on the cell cycle and indices of apoptosis. Cultures treated with 100 microM CLA for 24-96 h had more apoptotic cells than BSA- or LA-treated cultures. Furthermore, cultures treated for 48 h with CLA had fewer cells in the S-phase than control cultures. The effects of the trans-10,cis-12 CLA isomer were more pronounced than those of the crude mixture of CLA isomers. These data suggest that CLA may exert its antiobesity effects by inhibiting proliferation, attenuating TG content, and/or inducing apoptosis in (pre)adipocytes.

Simulation modeling of outcomes and cost effectiveness

Modeling will continue to be used to address important issues in clinical practice and health policy issues that have not been adequately studied with high-quality clinical trials. The apparent ad hoc nature of models belies the methodologic rigor that is applied to create the best models in cancer prevention and care. Models have progressed from simple decision trees to extremely complex microsimulation analyses, yet all are built using a logical process based on objective evaluation of the path between intervention and outcome. The best modelers take great care to justify both the structure and content of the model and then test their assumptions using a comprehensive process of sensitivity analysis and model validation. Like clinical trials, models sometimes produce results that are later found to be invalid as other data become available. When weighing the value of models in health care decision making, it is reasonable to consider the alternatives. In the absence of data, clinical policy decisions are often based on the recommendations of expert opinion panels or on poorly defined notions of the standard of care or medical necessity. Because such decision making rarely entails the rigorous process of data collection, synthesis, and testing that is the core of well-conducted modeling, it is usually not possible for external audiences to examine the assumptions and data that were used to derive the decisions. One of the modeler's most challenging tasks is to make the structure and content of the model transparent to the intended audience. The purpose of this article is to clarify the process of modeling, so that readers of models are more knowledgeable about their uses, strengths, and limitations.

beta3 subunit is present in different nicotinic receptor subtypes in chick retina

Although the neuronal nicotinic beta3 subunit was cloned several years ago, it has only recently been shown to form heteromeric channels when associated with other nicotinic subunits, and very little information is available concerning its assembly in the native nicotinic receptors of the nervous system. Using subunit-specific antibodies and immunoprecipitation experiments, we have identified the retina as being the chick central nervous system (CNS) area that expresses the highest level of the beta3 subunit. Sequential immunopurification experiments showed that there are at least two populations of beta3-containing receptors in chick retina: in one, the beta3 subunit is associated with the alpha6 and beta4 subunits; in the other more heterogeneous population, the beta3 subunit is associated with the alpha2, alpha3, alpha4, beta2 and beta4 subunits. Both of these receptor populations bind [3H]epibatidine and a number of nicotinic receptor agonists with high affinity (nM) and nicotinic receptor antagonists with a lower affinity (microM). The greatest pharmacological difference between the two populations is the affinity for the alpha-conotoxin MII, which inhibits binding to alpha6-containing receptors and not that to beta3-containing receptors. We also searched for the presence of the beta3 subunit associated with the alpha-bungarotoxin binding subunits alpha7 and/or alpha8 in retina and chick brain. Immunoprecipitation studies using anti-beta3 antibodies did not detect any specific alpha-bungarotoxin labeled receptors, thus, indicating that the beta3 subunit is not present in the alpha-bungarotoxin receptors of these areas.

Prednisone withdrawal in kidney transplant recipients on cyclosporine and mycophenolate mofetil--a prospective randomized study. Steroid Withdrawal Study Group

BACKGROUND

Prospective randomized trials have shown a reduced rate of acute rejection (AR) in mycophenolate mofetil-treated kidney transplant recipients. We hypothesized that this increased protection from AR could allow successful prednisone (P) withdrawal in cyclosporine/mycophenolate mofetil/P-treated recipients.

METHODS

A multicenter, prospective, randomized, double-blind trial of P withdrawal at 3 months post-transplant was initiated. Entry criteria were: primary transplant, adult, no AR by 90 days, mycophenolate mofetil dose > or =2 g/day, cyclosporine dose = 5-15 mg/kg/ day, P dose = 10-15 mg/day. Study participants were randomized to have P tapered over 8 weeks (beginning at 3 months posttransplant) to 0 vs. 10 mg/day. Prestudy power analysis determined 500 recipients should be randomized for 80% statistical power to test equivalence of the primary endpoint, AR, or treatment failure at 1 year posttransplant. By design, the study was to be stopped if interim data precluded reaching equivalence. An established data safety monitoring board monitored the study.

RESULTS

After 266 patients were enrolled, the patient enrollment was stopped (after safety monitoring board review) because of excess rejection in the P withdrawal group. The Kaplan-Meier estimate of the cumulative incidence of rejection or treatment failure within 1 year posttransplant (+/-95% confidence interval) for the maintenance group was 9.8% (4.4%; treatment failure, 14.9%); for the withdrawal group, 30.8% (21.0%; 39.3%). Treatment differences in the distribution of time to event were highly significant (P = 0.0007). Of note, risk was higher in blacks (39.6%) versus nonblacks (16.0%) (P<0.001). At 1 year post-transplant, there was no difference between groups in patient or graft survival. For the patients with functioning grafts at 6 months posttransplant, withdrawal patients had lower cholesterol (P = 0.0005), had higher creatinine (P = 0.03), and were less likely to use antihypertensives (P = 0.001). These differences persist to 1 yr posttransplant.

CONCLUSIONS

We conclude that for recipients on cyclosporine/mycophenolate mofetil/P with no AR at 90 days, the chance of developing subsequent AR is small; if P is tapered and withdrawn, the risk increases (but the majority remain free of acute and chronic rejection). After withdrawal, the risk of AR is different for blacks versus nonblacks. Withdrawal patients had a lower cholesterol level and less need for antihypertensives.

Opposing actions of dehydroepiandrosterone and corticosterone in rats

The purpose of this study was to determine the impact of dehydroepiandrosterone (DHEA) and corticosterone (CORT) treatment, using implants as a route of administration, on specific hormones, metabolites, and enzymes involved in energy metabolism. Sixty male Sprague-Dawley rats, 325 g initial weight, were implanted subcutaneously for 3 weeks with time-release pellets containing either DHEA or CORT at doses of 0, 10, 25, 50, or 100 mg in this 2 x 5 factorial experiment. In general, body weights and food intakes decreased as the level of steroid hormones increased. In contrast to DHEA treatment, rats receiving the 50- and 100-mg doses of CORT had lighter thymus glands and spleens and heavier epididymal and retroperitoneal fat pads than their controls. Rats treated with 100 mg of DHEA had lowered serum levels of triglycerides and lipid hydroperoxides whereas rats treated with 100 mg of CORT had higher levels of these blood lipids compared to their respective controls. In contrast to DHEA treatment, there was a dose-dependent increase in liver lipid content and the specific activities of the hepatic lipogenic enzymes glucose-6-phosphate dehydrogenase, malic enzyme, and fatty acid synthase in response to CORT treatment. Rats treated with 100 mg of DHEA had higher serum levels of IGF-1 than control rats. Conversely, rats treated with 100 mg of CORT had lower serum levels of IGF-1 and higher serum levels of testosterone, progesterone, and insulin than their controls. These data demonstrate the lipogenic actions of corticosterone in rats. Conversely, DHEA treatment reduced serum and hepatic lipids. Furthermore, these data suggest that using implants instead of bolus injections of steroids may be a more physiological approach for studying the influence of these steroids on lipid metabolism.

Relationship between event rates and treatment effects in clinical site differences within multicenter trials: an example from primary Pneumocystis carinii prophylaxis

The results of multicenter clinical trials may differ across participating clinical sites. We present a diagnostic approach for evaluating this diversity that emphasizes the relationship between the observed event rates and treatment effects. We use as an example a trial of sequential strategies of Pneumocystis prophylaxis in human immunodeficiency virus infection with 842 patients randomly allocated to start prophylaxis with trimethoprim/sulfamethoxazole, dapsone, or pentamidine. Prophylaxis failure rates varied significantly across the 30 clinical sites (0-30.3%, p = 0.002 by Fisher's exact test) with prominent variability in the pentamidine arm (0-63.6%). Starting with oral regimens was better than starting with pentamidine in sites with high rates of events, whereas the three strategies had more similar efficacy in other sites. Sites enrolling fewer patients had lower event rates and had more patients who withdrew prematurely or were lost to follow-up. In a hierarchical regression model adjusting for random measurement error in the observed event rates, starting with trimethoprim/sulfamethoxazole was predicted to be increasingly better than starting with aerosolized pentamidine as the risk of prophylaxis failure increased (p = 0.01), reducing the risk of failure by 47% when the failure rate of pentamidine was 30%, whereas the two regimens were predicted to be equivalent when the failure rate was 17%. Differences in event rates could reflect a combination of heterogeneity in diagnosis, administration of treatments, and disease risk in patients across sites. The evaluation of clinical site differences with a systematic approach focusing on event rates may give further insight in the interpretation of the results of multicenter trials beyond an average treatment effect.

Are we making progress with emergency contraception? Recent findings on American adults and health professionals

OBJECTIVES

To determine how awareness of and practices and attitudes toward emergency contraceptive pills (ECPs) have progressed among the American public and US health professionals.

METHODS

In 1997, we conducted two nationally representative telephone surveys of Americans and health professionals of their knowledge, attitudes, and practices on ECPs and compared the findings to previous surveys.

RESULTS

66% of women and 51% of men 18 to 44 years old had heard of ECPs, up from 61% of women and 45% of men the same age in 1994. Only 1% of women surveyed reported having ever used this method, reflecting no change from 1994. Only 11% of women knew enough about ECPs to be able to use them. Americans named media as the primary source of information about ECPs. The proportion of physicians who had prescribed ECPs at least once in the preceding year increased significantly in 1997: 85% of obstetrician/gynecologists and 50% of family physicians compared to 69% and 34% in 1995. Almost all health professionals considered ECPs to be safe (99%) and effective (100%), yet relatively few discussed this option with their patients, and even fewer commonly prescribed it.

CONCLUSION

Ongoing efforts are needed to improve awareness among the general public and to encourage health professionals to discuss and offer ECPs more widely.

Missed opportunities: teenagers and emergency contraception

OBJECTIVE

To determine American teenagers' awareness of and knowledge about emergency contraceptive pills and their likelihood to use them.

METHODS

We conducted a nationally representative telephone survey between March 28, 1996, and May 5, 1996, of 1510 teenagers (757 girls and 753 boys), aged 12 to 18 years, living in the continental United States in households with telephones. The sample overrepresented African American, Latino, and low-income teenagers. The error attributable to sampling and other random effects for the total sample is +/-3 percentage points at the 95% confidence level.

RESULTS

Of the 1510 teenagers, only about one quarter (23%) were aware that "anything" could be done after unprotected sex to prevent pregnancy. Slightly more (28%) had heard of "morning-after pills" or emergency contraceptive pills. Of the 423 teenagers who had heard of emergency contraceptive pills, one third (32%) did not know that a prescription is necessary to obtain them, and three quarters (78%) underestimated how long after unprotected intercourse the emergency contraceptive pill regimen could be initiated. Only 9% knew that emergency contraceptive pills are effective as long as 72 hours after unprotected sex. After being told about the option of emergency contraceptive pills, two thirds (67%) of teenaged girls said that they would be likely to use emergency contraceptive pills. Among the 66% of teenaged girls who had not previously heard of emergency contraceptive pills, 64% said that they would be likely to use them.

CONCLUSIONS

Emergency contraceptive pills have great potential as a tool for reducing unplanned pregnancies among teenaged girls in the United States. Few teenaged girls were aware that this option exists. Once informed, teenaged girls reported being very interested in taking emergency contraceptive pills if needed.

Dehydroepiandrosterone attenuates preadipocyte growth in primary cultures of stromal-vascular cells

The purpose of this study was to determine whether the antiobesity actions of dehydroepiandrosterone (DHEA) are due to an influence on preadipocyte proliferation and/or differentiation in primary cultures of pig and rat stromal-vascular (SV) cells. Pig SV cells were isolated from dorsal subcutaneous adipose tissue of 7-day-old pigs. For the proliferation assays, pig SV cells were grown for 4 days in plating medium containing DHEA at 0, 15, 50, or 150 microM. For the differentiation assays, pig SV cells were grown in plating medium for 3 days and then switched to a serum-free medium containing DHEA at 0, 15, 50, or 150 microM for the next 6 days. Rat SV cells were isolated from inguinal fat pads of 5-wk-old male rats. Rat SV cells were exposed to DHEA at 0, 5, 25, or 75 microM during proliferation. For the differentiation assays, rat SV cells were grown for 8 days in a serum-free medium containing DHEA at 0, 5, 25, or 75 microM. Preadipocyte differentiation [lipid staining, glycerol-3-phosphate dehydrogenase (GPDH) activity] and proliferation (preadipocyte-specific antigen staining) decreased with increasing levels of DHEA in cultures of pig SV cells. In cultures of rat SV cells, preadipocyte differentiation (lipid staining, GPDH activity) and proliferation ([3H]thymidine incorporation) were decreased in the 25 and 75 microM DHEA groups compared with the control and 5 microM DHEA groups. The level of expression of CCAAT enhancer binding protein-alpha, a master regulator of adipogenesis, in cultures of pig SV cells treated with 150 microM DHEA was 38% of control cultures. These data support the hypothesis that DHEA directly attenuates adipogenesis via attenuation of preadipocyte proliferation and differentiation.

The skeletonized body: suicidal inhalation of motorbike exhaust

An adolescent boy who was being treated for psychiatric illness went missing. The body was discovered a year later, and he appeared to have committed suicide by inhaling the exhaust fumes from his motorbike. This report highlights the procedure used for the identification of his skeletonized body and the unusual nature of the source of exhaust fumes.

Silver acetate mouth spray as an aid in smoking cessation: results of a double-blind trial

BACKGROUND

We studied the use of an aversive technique to improve the outcome of smoking-cessation efforts. We hypothesized that a silver acetate mouth spray, which produces a strong aversive taste when cigarettes are smoked, would increase the quit rate among smokers.

METHODS

Our study was a double-blind, placebo-controlled trial that was carried out in a private family practice office in an urban area. We studied 42 smokers, who were recruited by advertisement and who were motivated to quit by self-report. They were randomly assigned active spray or placebo spray; all were given a written list of behavioral suggestions. The spray was to be used every 2 hours for 3 weeks during which time the subjects were to keep diaries of cigarette smoking and spray use. Biochemical measures (salivary thiocyanate and cotinine) were recorded at entry, at 3 weeks, and at 3 months.

RESULTS

Thirty smokers completed the study. No differences were found between the two groups in quit rate or number of cigarettes smoked.

CONCLUSIONS

Silver acetate aversive spray did not increase quit rate among motivated smokers.

Parathyroid hormone, ionised calcium, and potentially interacting variables in plasma of an Old World primate

Bone turnover and calcium homeostasis in man can only be modelled validly in Old World nonhuman primates. In order to interpret the models it is necessary to establish endocrine and biochemical parameters of bone mineral metabolism. This report is probably the first description of acute phase parathyroid responses to manipulations of blood ionised calcium, and of reference values for potentially interacting variables, in vervet monkeys. Plasma parathyroid hormone concentrations were measured in vervets under defined conditions, and ranges reported as normal for other nonhuman primates and man are summarised.

The electrophysiological effects of opioid receptor-selective antagonists on sheep Purkinje fibres

The cardiac electrophysiological effects of 16-methylcyprenorphine (M8008), nor-binaltorphimine (NBT) and naltrexone, which are relatively specific opioid antagonists for delta, kappa and mu receptors, respectively, were studied in paced (1.5 Hz) sheep Purkinje fibres in vitro. M8008 (1 ng ml-1-10 micrograms ml-1) caused a concentration-dependent reduction in the maximum rate of depolarisation of phase 0 (MRD) and in the action potential duration measured at 50% repolarisation, APD50. Neither NBT (10 ng ml-1-10 micrograms ml-1) nor naltrexone (1 ng ml-1-10 micrograms ml-1) produced any significant effect on the cardiac action potential. In the presence of a physiological salt solution modified to mimic some of the changes that occur during myocardial ischaemia (i.e. hypoxia, acidosis, hyperkalaemia), M8008 caused a more marked reduction in MRD and prolonged rather than shortened APD50. These results suggest that the reported antiarrhythmic activity of M8008, but not NBT or naltrexone, may be, at least in part, explained by a direct cardiac electrophysiological action.

Effects of selective opioid receptor agonists and antagonists during myocardial ischaemia

The antiarrhythmic activities of 16-methylcyprenorphine (M8008), nor-binaltorphimine (NBT) and naltrexone, which are relatively specific opioid receptor antagonists for delta, kappa and mu receptors, respectively, were examined during the 30 min following coronary artery occlusion in anaesthetised rats. The haemodynamic and electrocardiographic effects of the opioid receptor agonists [D-Ala2,D-Leu5]enkephalin (DADLE) (relatively selective for delta receptors), ICI-204448 (kappa) and glyol (mu) were also investigated over the 30-90 min post ligation period. When administered intravenously 5 min before ligation, M8008 (0.5 mg kg-1 and 2.5 mg kg-1) reduced the number of ventricular ectopic beats but had no effect on the incidence or duration of ventricular fibrillation. NBT and naltrexone were not antiarrhythmic at a dose of 0.5 mg kg-1 but at 2.5 mg kg-1 (a concentration at which both drugs block kappa receptors) the number of ventricular ectopic beats, the incidence of ventricular fibrillation and mortality were all reduced. All of the opioid receptor agonists caused a transient decrease in heart rate and in arterial blood pressure but none exhibited an arrhythmogenic effect. These studies suggest that the delta and kappa opioid receptor antagonists used may be antiarrhythmic as a result of blockade of the action of endogenously released peptides acting on these receptors or that they have a non-specific 'direct' antiarrhythmic action.

Aggressive early medical management by a specialist in physical medicine and rehabilitation: effect on lost time due to injuries in hospital employees

Musculoskeletal injuries to hospital workers are both common and costly. Little advice has been written on how to decrease losses after injury. In a tertiary care hospital with 2700 employees a specialist in physical medicine and rehabilitation evaluated injured employees who were out of work for more than 2 days. Physician management emphasized increasing patient investment in the problem, early assessment of delayed recovery, and effective communication with the employer. There were 61 injuries averaging 6.7 days off per injury. In a previous year, 52 injuries averaged 11.8 days. Employees out for more than 2 days with back pain and seen by the physiatrist (52%) averaged 11 days off per injury whereas others averaged 14.9 days. In this hospital, early management by a specialist resulted in a substantial decrease in time off because of injury.