[Effects of dose of erythropoiesis stimulating agents on cardiovascular outcomes, quality of life and costs of haemodialysis. the clinical evaluation of the DOSe of erythropoietins (C.E. DOSE) Trial]

BACKGROUND

Anaemia is a risk factor for death, adverse cardiovascular outcomes and poor quality of life in patients with chronic kidney disease (CKD). Erythropoietin Stimulating Agents (ESA) are the most used treatment option. In observational studies, higher haemoglobin (Hb) levels (around 11-13 g/dL) are associated with improved survival and quality of life compared to Hb levels around 9-10 g/dL. Randomized studies found that targeting higher Hb levels with ESA causes an increased risk of death, mainly due to adverse cardiovascular outcomes. It is possible that this is mediated by ESA dose rather than haemoglobin concentration, although this hypothesis has never been formally tested.

METHODS

We present the protocol of the Clinical Evaluation of the Dose of Erythropoietins (C.E. DOSE) trial, which will assess the benefits and harms of a high versus a low ESA dose therapeutic strategy for the management of anaemia of end stage kidney disease (ESKD). This is a randomized, prospective open label blinded end-point (PROBE) design trial due to enroll 900 haemodialysis patients. Patients will be randomized 1:1 to 4000 UI/week i. v. versus 18000 UI/week i. v. of epoetin alfa, beta or any other epoetin in equivalent doses. The primary outcome of the trial is a composite of cardiovascular events. In addition, quality of life and costs of these two strategies will be assessed. The study has been approved and funded by the Italian Agency of Drugs (Agenzia Italiana del Farmaco (AIFA)) within the 2006 funding plan for independent research on drugs (registered at www.clinicaltrials.gov (NCT00827021)).

Inactivation of swmA results in the loss of an outer cell layer in a swimming synechococcus strain

The mechanism of nonflagellar swimming of marine unicellular cyanobacteria remains poorly understood. SwmA is an abundant cell surface-associated 130-kDa glycoprotein that is required for the generation of thrust in Synechococcus sp. strain WH8102. Ultrastructural comparisons of wild-type cells to a mutant strain in which the gene encoding SwmA has been insertionally inactivated reveal that the mutant lacks a layer external to the outer membrane. Cryofixation and freeze-substitution are required for the preservation of this external layer. Freeze fracturing and etching reveal that this additional layer is an S-layer. How the S-layer might function in motility remains elusive; however, this work describes an ultrastructural component required for this unique type of swimming. In addition, the work presented here describes the envelope structure of a model swimming cyanobacterium.

Making health care decisions without a prognosis: life in a brain trauma unit

When the author's daughter was hit by a car and remained unconscious for seven months, she found that there were certain factors where traditional ethical theory was not sufficiently nuanced to guide her practical decision making in regard to her daughter's health care. This article concentrates on three of those factors. They are: (1) no reliable prognosis can be offered for many brain-injured individuals; (2) a patient's age and the relationship between the patient and the caregiver affect the context of caring; and (3) there are severe difficulties in obtaining and sustaining chronic care and accessing scarce resources.

[Role of iron deficiency in erythropoietin sensitivity in dialysis patients with elevated C-reactive protein]

BACKGROUND

Chronic inflammation is a well-known cause of hyporesponsiveness of the bone marrow to erythropoietin (Epo). Factors which contribute to Epo resistance in the presence of inflammation include inhibition of erythroid precursor proliferation and functional iron deficiency induced by inflammatory cytokines. The specific role of iron deficiency in this clinical context, however, has not yet been clarified.

METHODS

Our dialysis population consisted of 200 patients, from which 163 (91 males, mean age 67 +/- 12 years) who had been in dialysis for at least 4 (mean 62.4 +/- 71) months were selected for further study. Two groups were defined on the basis of C-reactive protein (CRP) concentrations: Group A (normal CRP < 5 mg/L; 78 patients) and Group B (elevated CRP > 15 mg/L; 43 patients). The remaining 42 patients with CRP in the range of 5 to 15 mg/L were excluded from the study.

RESULTS

Erythropoietin dose and the parameter EpoDose/hemoglobin (Hb) were both greater in Group B (dose: 150 +/- 65 vs. 106 +/- 56 U/kg, p<0.001; EpoDose/Hb: 14.0 +/- 6 vs. 9.8 +/- 6, p<0.001. The two groups were stratified on the basis of transferrin saturation (tSAT) greater or less than 20%: A1 (tSAT > 20%, n = 52), A2 (tSAT < 20%, n = 26), B1 (tSAT > 20%, n = 19) and B2 (tSAT < 20%, n = 24). Erythropoietin dose and EpoDose/Hb were lower in A1 compared to A2 (dose: 96 +/- 52 vs. 124 +/- 6 U/kg, p<0.05; EpoDose/Hb: 8.4 +/- 5 vs. 12.4 +/- 7, p < 0.05), whereas in the B subgroups the variables were equally elevated (dose: 151 +/- 71 vs 142 +/- 59 U/kg, ns; EpoDose/Hb: 14.4 +/- 7 vs. 13.6 +/- 6, ns). Patients in subgroups A2 and B2 were treated with intravenous Fe gluconate 31 mg after each dialysis session for 6 months. Erythropoietin dose and EpoDose/Hb were significantly reduced only in subgroup A2 with normal CRP (dose: from 126 +/- 55 to 95 +/- 52 U/kg, p < 0.05; EpoDose/Hb: from 12.4 +/- 7 to 8.4 +/- 5, p < 0.05), whereas no improvement was observed in subgroup B2 with elevated CRP (dose: from 142 +/- 59 to 151 +/- 65 U/kg, ns; EpoDose/Hb: from 13.6 +/- 6 to 14.4 +/- 7, ns).

CONCLUSIONS

Our data demonstrate that dialysis patients with CRP greater than 15 mg/L require an erythropoietin dose approximately 40% higher than patients with normal CRP, both in the presence and absence of iron deficiency. Iron therapy in patients with normal CRP and tSAT < 20% significantly improved the response to erythropoietin, but was completely ineffective in patients with increased CRP. These results suggest that functional iron deficiency plays a marginal role in resistance to erythropoietin observed in patients with elevated CRP concentrations.

Law, ethical codes, and the report of the CSSP survey on ethics policies. Council of Scientific Society Presidents

Recently, the Council of Scientific Society Presidents (CSSP) collected data from its member organizations regarding codes of ethics. To better understand why such a survey would be undertaken, this paper begins by examining what is meant by ethics and highlights some distinctions between law and ethics. It then discusses codes of ethics, stressing their purposes and functions. Finally, it looks at the results of the CSSP survey and evaluates how various organizations formulate and implement their codes.

Altered membrane proteins and permeability correlate with cardiac dysfunction in cardiomyopathic hamsters

A mutation in the delta-sarcoglycan (SG) gene with absence of delta-SG protein in the heart has been identified in the BIO14.6 cardiomyopathic (CM) hamster, but how the defective gene leads to myocardial degeneration and dysfunction is unknown. We correlated left ventricular (LV) function with increased sarcolemmal membrane permeability and investigated the LV distribution of the dystrophin-dystroglycan complex in BIO14.6 CM hamsters. On echocardiography at 5 wk of age, the CM hamsters showed a mildly enlarged diastolic dimension (LVDD) with decreased LV percent fractional shortening (%FS), and at 9 wk further enlargement of LVDD with reduction of %FS was observed. The percent area of myocardium exhibiting increased membrane permeability or membrane rupture, assessed by Evans blue dye (EBD) staining and wheat germ agglutinin, was greater at 9 than at 5 wk. In areas not stained by EBD, immunostaining of dystrophin was detected in CM hamsters at sarcolemma and T tubules, as expected, but it was also abnormally expressed at the intercalated discs; in addition, the expression of beta-dystroglycan was significantly reduced compared with control hearts. As previously described, alpha-SG was completely deficient in CM hearts compared with control hearts. In myocardial areas showing increased sarcolemmal permeability, neither dystrophin nor beta-dystroglycan could be identified by immunolabeling. Thus, together with the known loss of delta-SG and other SGs, abnormal distribution of dystrophin and reduction of beta-dystroglycan are associated with increased sarcolemmal permeability followed by cell rupture, which correlates with early progressive cardiac dysfunction in the BIO14.6 CM hamster.

Criminal prosecution of child sexual abuse cases

To describe the outcome of prosecuting alleged intrafamilial/caretaker child sexual abuse, the authors evaluated charts for 1986-1988 at La Rabida Children's Hospital and Research Center in Chicago, plus police records for Area V, Chicago for 1986-1987. The state's attorney's office provided data on outcome of legal proceedings. Of 451 allegations, 324 (72%) were formally designated as probable sexual abuse cases, and 269 (83%) alleged perpetrators were identified. Complaints (77 felonies, 29 misdemeanors, and 30 juvenile charges) were initiated by the police for preliminary hearings against 136 (51%) persons. Of the felony charges, 66 (85.7%) resulted in indictments, and 11 (14.3%) in dismissal of charges by judge or grand jury. Thirty-two (48.5%) of those indicted pleaded guilty, 24 (36%) went to trial; 16 (67%) were found guilty, and 8 (12%) had charges dismissed. Therefore, of the 77 felony complaints initiated, 48 (62%) ended in convictions and 29 (38%) in dismissals or not-guilty verdicts. Only 24 (5%) of the original allegations resulted in trials. Although 30% of allegations and 51% of alleged perpetrators ended up in court, only 17% of the original 451 allegations were prosecuted for a felony. For felony indictments, 36% of victims appeared in court. Forty-three of 48 persons found guilty served time (mean sentencing time, 6.8 years). The mean time from initial hearing to final disposition was 321 days and was significantly longer if the accused either went to trial (501 vs. 236 days) or was found guilty or pleaded guilty (353 vs. 254 days for not-guilty verdicts). The authors conclude that very few children (5%) have to appear as witnesses in court, as most cases are resolved by plea bargaining, and that resolution by trial can take 12 to 16 months.

Interdisciplinary evaluations of alleged sexual abuse cases

Children who are alleged to have been sexually abused often go through gruelling interrogations to relate their experiences to adults and, even then, most are not viewed as reliable sources of information. The Victim Sensitive Interviewing Program (VSIP) was initiated to decrease the number of interviews endured by a child who allegedly had been sexually abused. The program brought together the disciplines involved in the evaluation of these cases: hospital-based social worker and pediatrician, state child protective agency worker, police, and assistant state's attorney. This team established a protocol for an investigative interview to be conducted by a team member. Pre-VSIP sexual abuse evaluations from 1985 and 1986 (38) were compared with VSIP evaluations (226) from 1987 and 1988. There was no significant difference between the two groups in relation to gender or age of victim, physical symptoms, physical findings, sexually transmitted diseases present, age of perpetrator, or length of stay in hospital. However, there were significant differences between the two groups in (1) number of interviews, 11% pre-VSIP vs 79% VSIP receiving only one interview (P less than .001); (2) number of interviewers, 24% pre-VSIP vs 88% VSIP were interviewed by only one interviewer (P less than .001); (3) indicated cases of sexual abuse, 68% pre-VSIP vs 88% VSIP (P less than .006); (4) identification of the perpetrator, 71% pre-VSIP vs 85% VSIP (P less than .035); and (5) charges pressed if perpetrator identified, 33% pre-VSIP vs 60% VSIP (P less than .010). It is concluded that interdisciplinary evaluations of alleged sexual abuse in children not only decreased the number of interviews a child must undergo but also increased the likelihood of indicated cases, identification of the perpetrator, and charges being pressed. Therefore, it is strongly recommended that interdisciplinary teams be formed to assess alleged sexual abuse in children.

Three-dimensional pattern of enkephalin-like immunoreactivity in the caudate nucleus of the cat

Recent anatomical investigations of the mammalian neostriatum have uncovered discrete neurochemical zones characterized by low levels of AChE and high levels of enkephalin-like immunoreactivity (ELI) compared with the surrounding neostriatal tissue. These regions, termed striosomes, which appear as patches in individual sections, have been associated with specific afferent and efferent pathways that differ from those of the surrounding neostriatal tissue. In the present study, the 3-dimensional distribution of these enkephalin-rich compartments in the caudate nucleus of the adult cat was investigated using computer-assisted 3-dimensional reconstruction techniques. Series consisting of coronal, sagittal, and horizontal tissue sections were obtained. In individual sections, discrete patches of intense enkephalin-like immunoreactivity appeared against a lighter-staining background. Three-dimensional reconstructions revealed that these patches overlapped across sections to form a highly inter-connected structure within the head and body of the caudate nucleus. Several structural features were evident in these reconstructions that appeared to be similar across animals. One consistent pattern was the formation of enkephalin-labeled finger-like structures radiating from the ventricular edge diagonally across the width of the nucleus. Smaller crossbridges were seen connecting the fingers, which often resulted in the formation of claws or rings of enkephalin-like immunoreactivity. These elements appear to align across planes to form a lattice-like structure outlining continuous regions of matrix. This structure may provide a basis for the orderly interaction between the patch and matrix compartments.

Procedural learning in a patient with amnesia due to hypoxia

It has been claimed that procedural learning on a broad range of perceptuomotor and cognitive tasks is normal in amnesic patients whose severe deficits in acquiring declarative knowledge can be well documented. To evaluate the generality of this proposition we studied procedural learning on three different tasks in an amnesic patient who displayed no signs of intellectual deterioration including problem-solving difficulty. The patient showed normal improvement in learning to read transformed script and normal within-session improvement on a mirror-reading task. However, his retention of the mirror-reading skill from one day to the next was impaired, and he learned the Tower of Hanoi puzzle more slowly than normal. This patient's performance demonstrates that even amnesics without problem-solving difficulties do not perform normally on all tasks that are said to measure procedural learning. In the absence of a clear operational definition of procedural learning the usefulness of the concept remains heuristic.

Some analyses of forgetting of pictorial material in amnesic and demented patients

Three experiments evaluating the rate of forgetting of pictorial stimuli in amnesic, demented, and normal control subjects are reported. When prolonged exposures of pictorial material were used to equate recognition performance after a 10-min delay, alcoholic Korsakoff (AK) patients and patients with Huntington's Disease (HD) demonstrated normal rates of forgetting over a 1-week period. In addition to replicating previous findings with AK patients, these results are consistent with recent suggestions that retrieval, not storage, deficiencies characterize the HD patients' memory problems. The second experiment explored whether the AK and HD patients learned as much about the features of the pictorial stimuli as did the normal subjects. After the subjects viewed a series of pictorial stimuli, recognition was assessed 10 min later using the whole pictures, isolated main features of the pictures, or isolated peripheral features of the pictures. The results showed that, with prolonged exposure times, the two patient groups did not differ from the normal control group in terms of the features of the stimuli they analyzed and remembered. The third experiment evaluated the rate of forgetting of pictorial material of two groups ("young" and "old") of normal subjects, one group ("old") having viewed each picture for 1 s and the other group ("young") for .5 s. Although the two groups did not differ in recognition performance 10 min after presentation, the young subjects who viewed each picture for .5 s showed more rapid forgetting over a 1-week period. This finding indicates that similar recognition scores do not necessarily signify equal learning under all exposure conditions.

An assessment of verbal recall, recognition and fluency abilities in patients with Huntington's disease

Two investigations concerned with the memory deficits of patients with Huntington's Disease (HD) were performed. In the first experiment, early and advanced HD patients showed superior recognition memory than did alcoholic Korsakoff patients on modified recall and recognition forms of the Rey Auditory Verbal Learning Test. In contrast, on a letter fluency test (FAS) requiring the patients to search their semantic memories, both HD groups produced fewer correct words and perseveration errors than did the alcoholic Korsakoff group. In the second experiment, HD patients and Korsakoff patients were compared in their and recognition of short passages. While the HD and Korsakoff patients were equally impaired on recall tests, the HD patients evidenced significantly better recognition memory than did the amnesic group. As on the fluency test, the prose of the Korsakoff patients was characterized by intrusion (i.e., perseverative) errors. The results of the two experiments indicate that HD and Korsakoff patients' memory deficits are related to deficiencies in retrieval and an increased sensitivity to proactive interference, respectively.

Memory disorders associated with Huntington's disease: verbal recall, verbal recognition and procedural memory

Two experiments were conducted to evaluate the hypothesis that the memory disorders of Huntington's Disease (HD) patients are characterized by deficiencies in both retrieval mechanisms and the acquisition of procedural (skill-based) information. In the first study, verbal recall and recognition tests were administered to HD patients, amnesics and normal control (NC) subjects. Although the two patient groups were impaired relative to NC subjects on both recall and recognition of word lists, the performance of the HD patients was superior to that of the amnesics on the recognition test. In the second experiment early HD (EHD), advanced HD (AHD), amnesic and NC subjects were compared in the acquisition of the 'Tower of Hanoi' puzzle. Both the NC subjects and EHD patients acquired the solution of this puzzle after repeated trials, whereas the AHD and amnesic patients evidenced little improvement. However, on a recognition test assessing memory for facts about the puzzle, both the EHD and AHD patients were superior to the amnesic subjects. These results are consistent with the retrieval hypothesis but are equivocal with regard to the HD patients' proposed deficit in skill learning. Since the 'Tower' puzzle may rely heavily on both problem solving and skill learning capabilities, it may be of limited value in searching for double dissociations between patient groups and the acquisition of skill-based and data-based knowledge.

Dissociations between skill learning and verbal recognition in amnesia and dementia

Patients with Huntington's disease (HD), patients with alcoholic Korsakoff's syndrome, and normal control subjects were compared on tests of skill learning (mirror reading) and verbal recognition. Like previously reported results, the patients with Korsakoff's syndrome acquired the mirror-reading skill at a normal rate but were severely impaired in their recognition of the words used on the mirror-reading task. In contrast to the amnesic patients, the demented patients with HD were retarded in their ability to acquire this skill but showed normal verbal recognition. Besides emphasizing substantial differences in the anterograde substantial differences in the anterograde memory disorders of these two patient populations, the results suggest that the memory disorder of patients with HD may appear much more severe when recall rather than recognition test paradigms are employed. This failure of recall by the patients with HD may be due to an inability to generate strategies necessary to search their short- and long-term memories.