The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection

OBJECTIVE

To validate and refine two sets of candidate criteria for the classification/diagnosis of axial spondyloarthritis (SpA).

METHODS

All Assessment of SpondyloArthritis international Society (ASAS) members were invited to include consecutively new patients with chronic (> or =3 months) back pain of unknown origin that began before 45 years of age. The candidate criteria were first tested in the entire cohort of 649 patients from 25 centres, and then refined in a random selection of 40% of cases and thereafter validated in the remaining 60%.

RESULTS

Upon diagnostic work-up, axial SpA was diagnosed in 60.2% of the cohort. Of these, 70% did not fulfil modified New York criteria and, therefore, were classified as having "non-radiographic" axial SpA. Refinement of the candidate criteria resulted in new ASAS classification criteria that are defined as: the presence of sacroiliitis by radiography or by magnetic resonance imaging (MRI) plus at least one SpA feature ("imaging arm") or the presence of HLA-B27 plus at least two SpA features ("clinical arm"). The sensitivity and specificity of the entire set of the new criteria were 82.9% and 84.4%, and for the imaging arm alone 66.2% and 97.3%, respectively. The specificity of the new criteria was much better than that of the European Spondylarthropathy Study Group criteria modified for MRI (sensitivity 85.1%, specificity 65.1%) and slightly better than that of the modified Amor criteria (sensitivity 82.9, specificity 77.5%).

CONCLUSION

The new ASAS classification criteria for axial SpA can reliably classify patients for clinical studies and may help rheumatologists in clinical practice in diagnosing axial SpA in those with chronic back pain.

TRIAL REGISTRATION NUMBER

NCT00328068.

The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal

OBJECTIVE

Non-radiographic axial spondyloarthritis (SpA) is characterised by a lack of definitive radiographic sacroiliitis and is considered an early stage of ankylosing spondylitis. The objective of this study was to develop candidate classification criteria for axial SpA that include patients with but also without radiographic sacroiliitis.

METHODS

Seventy-one patients with possible axial SpA, most of whom were lacking definite radiographic sacroiliitis, were reviewed as "paper patients" by 20 experts from the Assessment of SpondyloArthritis international Society (ASAS). Unequivocally classifiable patients were identified based on the aggregate expert opinion in conjunction with the expert-reported level of certainty of their judgement. Draft criteria for axial SpA were formulated and tested using classifiable patients.

RESULTS

Active sacroiliitis on magnetic resonance imaging (MRI) (odds ratio 45, 95% CI 5.3 to 383; p<0.001) was strongly associated with the classification of axial SpA. The knowledge of MRI findings led to a change in the classification of 21.1% of patients. According to the first set of candidate criteria (sensitivity 97.1%; specificity 94.7%) a patient with chronic back pain is classified as axial SpA in the presence of sacroiliitis by MRI or x rays in conjunction with one SpA feature or, if sacroilitiis is absent, in the presence of at least three SpA features. In a second set of candidate criteria, inflammatory back pain is obligatory in the clinical arm (sensitivity 86.1%; specificity 94.7%).

CONCLUSION

The ASAS group has developed candidate criteria for the classification of axial SpA that include patients without radiographic sacroiliitis. The candidate criteria need to be validated in an independent international study.

2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis

This first update of the ASAS/EULAR recommendations on the management of ankylosing spondylitis (AS) is based on the original paper, a systematic review of existing recommendations and the literature since 2005 and the discussion and agreement among 21 international experts, 2 patients and 2 physiotherapists in a meeting in February 2010. Each original bullet point was discussed in detail and reworded if necessary. Decisions on new recommendations were made - if necessary after voting. The strength of the recommendations (SOR) was scored on an 11-point numerical rating scale after the meeting by email. These recommendations apply to patients of all ages that fulfill the modified NY criteria for AS, independent of extra-articular manifestations, and they take into account all drug and non-drug interventions related to AS. Four overarching principles were introduced, implying that one bullet has been moved to this section. There are now 11 bullet points including 2 new ones, one related to extra-articular manifestations and one to changes in the disease course. With a mean score of 9.1 (range 8-10) the SOR was generally very good.

GADD45 induction of a G2/M cell cycle checkpoint

G1/S and G2/M cell cycle checkpoints maintain genomic stability in eukaryotes in response to genotoxic stress. We report here both genetic and functional evidence of a Gadd45-mediated G2/M checkpoint in human and murine cells. Increased expression of Gadd45 via microinjection of an expression vector into primary human fibroblasts arrests the cells at the G2/M boundary with a phenotype of MPM2 immunopositivity, 4n DNA content and, in 15% of the cells, centrosome separation. The Gadd45-mediated G2/M arrest depends on wild-type p53, because no arrest was observed either in p53-null Li-Fraumeni fibroblasts or in normal fibroblasts coexpressed with p53 mutants. Increased expression of cyclin B1 and Cdc25C inhibited the Gadd45-mediated G2/M arrest in human fibroblasts, indicating that the mechanism of Gadd45-mediated G2/M checkpoint is at least in part through modulation of the activity of the G2-specific kinase, cyclin B1/p34(cdc2). Genetic and physiological evidence of a Gadd45-mediated G2/M checkpoint was obtained by using GADD45-deficient human or murine cells. Human cells with endogenous Gadd45 expression reduced by antisense GADD45 expression have an impaired G2/M checkpoint after exposure to either ultraviolet radiation or methyl methanesulfonate but are still able to undergo G2 arrest after ionizing radiation. Lymphocytes from gadd45-knockout mice (gadd45 -/-) also retained a G2/M checkpoint initiated by ionizing radiation and failed to arrest at G2/M after exposure to ultraviolet radiation. Therefore, the mammalian genome is protected by a multiplicity of G2/M checkpoints in response to specific types of DNA damage.

ASAS/EULAR recommendations for the management of ankylosing spondylitis

OBJECTIVE

To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism.

METHODS

Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise.

RESULTS

The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

How to diagnose axial spondyloarthritis early

BACKGROUND

Chronic low back pain (LBP), the leading symptom of ankylosing spondylitis (AS) and undifferentiated axial spondyloarthritis (SpA), precedes the development of radiographic sacroiliitis, sometimes by many years.

OBJECTIVE

To assign disease probabilities and to develop an algorithm to help in the early diagnosis of axial SpA.

METHODS

Axial SpA comprises AS and undifferentiated SpA with predominant axial involvement. Clinical features include inflammatory back pain (IBP), alternating buttock pain, enthesitis, arthritis, dactylitis, acute anterior uveitis, a positive family history, psoriasis, inflammatory bowel disease, and good response to NSAIDs. Associated laboratory findings include raised acute phase reactions, HLA-B27 association, and abnormalities on skeletal imaging. Sensitivities, specificities, and likelihood ratios (LRs) of these parameters were determined from published studies. A 5% prevalence of axial SpA among patients with chronic LBP was used. The probability of the presence of axial SpA, depending on the presence or absence of the above clinical features of SpA, was determined. A probability of > or = 90% was used to make a diagnosis of axial SpA.

RESULTS

The presence of inflammatory back pain features increased the probability of axial SpA from the background 5% prevalence to 14%. The presence of 2-3 SpA features was necessary to increase the probability of axial SpA to 90%. The highest LRs were obtained for HLA-B27 and MRI. Diagnostic algorithms to be used in daily practice were suggested.

CONCLUSIONS

This approach can help clinicians to diagnose with a high degree of confidence axial SpA at an early stage in patients with IBP who lack radiographic sacroiliitis.

Self-emulsifying drug delivery systems (SEDDS) of coenzyme Q10: formulation development and bioavailability assessment

The goals of our investigations are to develop and characterize self-emulsifying drug delivery systems (SEDDS) of coenzyme Q10 (CoQ10), using polyglycolyzed glycerides (PGG) as emulsifiers and to evaluate their bioavailability in dogs. Solubility of CoQ10 was determined in various oils and surfactants. SEDDS consisted of oil, a surfactant and a cosurfactant. Four types of self-emulsifying formulations were prepared using two oils (Myvacet 9-45 and Captex-200), two emulsifiers (Labrafac CM-10 and Labrasol) and a cosurfactant (lauroglycol). In all the formulations, the level of CoQ10 was fixed at 5.66% w/w of the vehicle. The in vitro self-emulsification properties and droplet size analysis of these formulations upon their addition to water under mild agitation conditions were studied. Pseudo-ternary phase diagrams were constructed identifying the efficient self-emulsification region. From these studies, an optimized formulation was selected and its bioavailability was compared with a powder formulation in dogs. Medium chain oils and Myvacet 9-45 provided higher solubility than long chain oils. Efficient and better self-emulsification processes were observed for the systems containing Labrafac CM-10 than formulations containing Labrasol. Addition of a cosurfactant improved the spontaneity of self-emulsification. From these studies, an optimized formulation consisting of Myvacet 9-45 (40%), Labrasol (50%) and lauroglycol (10%) was selected for its bioavailability assessment. A two-fold increase in the bioavailability was observed for the self-emulsifying system compared to a powder formulation. SEDDS have improved the bioavailability of CoQ10 significantly. The data suggest the potential use of SEDDS to provide an efficient way of improving oral absorption of lipophilic drugs.

New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS)

OBJECTIVE

Inflammatory back pain (IBP) is an important clinical symptom in patients with axial spondyloarthritis (SpA), and relevant for classification and diagnosis. In the present report, a new approach for the development of IBP classification criteria is discussed.

METHODS

Rheumatologists (n = 13) who are experts in SpA took part in a 2-day international workshop to investigate 20 patients with back pain and possible SpA. Each expert documented the presence/absence of clinical parameters typical for IBP, and judged whether IBP was considered present or absent based on the received information. This expert judgement was used as the dependent variable in a logistic regression analysis in order to identify those individual IBP parameters that contributed best to a diagnosis of IBP. The new set of IBP criteria was validated in a separate cohort of patients (n = 648).

RESULTS

Five parameters best explained IBP according to the experts. These were: (1) improvement with exercise (odds ratio (OR) 23.1); (2) pain at night (OR 20.4); (3) insidious onset (OR 12.7); (4) age at onset <40 years (OR 9.9); and (5) no improvement with rest (OR 7.7). If at least four out of these five parameters were fulfilled, the criteria had a sensitivity of 77.0% and specificity of 91.7% in the patients participating in the workshop, and 79.6% and 72.4%, respectively, in the validation cohort.

CONCLUSION

This new approach with real patients defines a set of IBP definition criteria using overall expert judgement on IBP as the gold standard. The IBP experts' criteria are robust, easy to apply and have good face validity.

Invited review: effects of milk ration on solid feed intake, weaning, and performance in dairy heifers

A feeding regimen that allows a smooth transition from milk to solid feed is vital for successful heifer-rearing programs. In the past, research efforts have focused on the development of feeding methods that allow early weaning, perhaps because the risk of disease is highest during the milk feeding stage. To encourage early intake of calf starter, conventional feeding programs have limited the supply of milk (often to 10% of BW at birth). However, dairy calves provided free access to milk will typically consume more than twice this amount. We critically review the available literature examining the relationship between milk feeding method, solid feed consumption, and rumen development in young dairy calves and identify areas where new work is required. We conclude that milk-fed dairy calves can safely ingest milk at approximately 20% of body weight (BW)/d, and greater milk consumption supports greater BW gain, improved feed efficiency, reduced incidence of disease, and greater opportunity to express natural behaviors, which in combination suggest improved welfare. Method of weaning greatly influences feed consumption, rumen development, and growth check in calves provided higher amounts of milk. Gradual weaning encourages starter intake during the preweaning period, and both weaning age and duration of weaning influence this consumption. Increased solid feed consumption during the weaning process contributes to rumen development, permitting higher starter intake and BW gain after weaning. Growth factors in milk may also enhance the growth and maturation of the gastrointestinal tract, but more research is required to understand the role of these factors. Greater nutrient supply through increased amount of milk appears to improve immune function and long-term performance of heifer calves; for example, reducing the age at first breeding and increasing first-lactation milk yield, but more research is needed to confirm these effects.

Nanoparticle technology for drug delivery across the blood-brain barrier

Nanoparticles (NP) are solid colloidal particles ranging in size from 1 to 1000 nm that are utilized as drug delivery agents. The use of NPs to deliver drugs to the brain across the blood-brain barrier (BBB) may provide a significant advantage to current strategies. The primary advantage of NP carrier technology is that NPs mask the blood-brain barrier limiting characteristics of the therapeutic drug molecule. Furthermore, this system may slow drug release in the brain, decreasing peripheral toxicity. This review evaluates previous strategies of brain drug delivery, discusses NP transport across the BBB, and describes primary methods of NP preparation and characterization. Further, influencing manufacturing factors (type of polymers and surfactants, NP size, and the drug molecule) are detailed in relation to movement of the drug delivery agent across the BBB. Currently, reports evaluating NPs for brain delivery have studied anesthetic and chemotherapeutic agents. These studies are reviewed for efficacy and mechanisms of transport. Physiological factors such as phagocytic activity of the reticuloendothelial system and protein opsonization may limit the amount of brain delivered drug and methods to avoid these issues are also discussed. NP technology appears to have significant promise in delivering therapeutic molecules across the BBB.

Positron emission tomography scanning in the evaluation of hepatocellular carcinoma

BACKGROUND/AIMS

18F-fluorodeoxyglucose uptake allows estimation of glucose metabolism by tumor cells using positron emission tomography (PET). We evaluated the role of PET imaging in the diagnosis of hepatocellular carcinoma.

METHODS

PET images were collected after intravenous injection of 8-12 mCi of 18F-FDG in 20 patients with hepatocellular carcinoma (HCC). PET tumor activity level was assessed on a scale of 1 to 4 compared to normal liver tissue. The PET score was compared with abdominal computerized tomography (CT) scan results and between tumors of different grades and differentiation.

RESULTS

Of the 20 patients studied, 11 (55%) had positive PET scans (PET score: 3 or 4) while nine (45%) were negative (PET score: 1 or 2). CT scan was positive in 18 patients (90%) and negative in two (10%). PET, however, revealed metastases in three patients that were not seen on CT. On pathological review, well-differentiated and low-grade tumors had lower PET scores. Comparison of the well-differentiated with the moderately- and poorly-differentiated tumors revealed a statistically significant difference. No statistical significance was observed between the moderately- and poorly-differentiated tumors or between different tumor grades and PET scores.

CONCLUSIONS

The sensitivity of PET in diagnosis of HCC was 55% compared to 90% for CT scanning, although only PET detected some tumors (including distant metastases). Well-differentiated and low tumor grades had lower activity on PET and correspondingly lower PET scores. PET imaging may help assess tumor differentiation and may be useful in the diagnosis and staging and prognostication of HCC as an adjunct to CT.

Primary structure of four allatostatins: neuropeptide inhibitors of juvenile hormone synthesis

Four neuropeptides that inhibit juvenile hormone synthesis by the corpora allata have been isolated from brains of the virgin female cockroach Diploptera punctata. These allatostatins are 8-13 amino acids long, are amidated, and show sequence similarity, including a 3-amino acid sequence at the C-terminal end that is common to all four peptides. The peptide sequences are as follows: allatostatin 1, Ala-Pro-Ser-Gly-Ala-Gln-Arg-Leu-Tyr-Gly-Phe-Gly-Leu-NH2; allatostatin 2, Gly-Asp-Gly-Arg-Leu-Tyr-Ala-Phe-Gly-Leu-NH2; allatostatin 3, Gly-Gly-Ser-Leu-Tyr-Ser-Phe-Gly-Leu-NH2; and allatostatin 4, Asp-Arg-Leu-Tyr-Ser-Phe-Gly-Leu-NH2. An in vitro bioassay of the synthesized allatostatins showed greater than 40% inhibition of juvenile hormone synthesis by corpora allata of virgin females with 10(-9) M allatostatin 1, 10(-8) M allatostatins 2 and 4, and 7 X 10(-7) M allatostatin 3. Inhibition by allatostatins 1-4 was reversible. In addition, allatostatin 1 inhibited juvenile hormone synthesis by corpora allata from mated females and last-instar larvae of D. punctata and corpora allata of adult female Periplaneta americana.

Invited review: Transitioning from milk to solid feed in dairy heifers

Calves are born with a physically and metabolically underdeveloped rumen and initially rely on milk to meet nutrient demands for maintenance and growth. Initiation of solid feed consumption, acquisition of anaerobic microbes, establishment of rumen fermentation, expansion of rumen in volume, differentiation and growth of papillae, development of absorption and metabolic pathways, maturation of salivary apparatus and development of rumination behavior are all needed as the calf shifts from dependence on milk to solid feed. In nature and some production systems (e.g., most beef calves), young ruminants obtain nutrients from milk and fresh forages. In intensive dairying, calves are typically fed restricted amounts of milk and weaned onto starter feeds. Here we review the empirical work on the role of feeding and management during the transition from milk to solid feed in establishing the rumen ecosystem, rumen fermentation, rumen development, rumination behavior, and growth of dairy calves. In recent years, several studies have illustrated the benefits of feeding more milk and group rearing of dairy calves to take advantage of social facilitation (e.g., housing with peers or dam), and this review also examines the role of solid feed on rumen development and growth of calves fed large quantities of milk and reared under different housing situations. We conclude that the provision of high-starch and low-fiber starter feeds may negatively affect rumen development and that forage supplementation is beneficial for promoting development of the gut and rumination behavior in young calves. It is important to note that both the physical form of starter diets and their nutritional composition affect various aspects of development in calves. Further research is warranted to identify an optimal balance between physically effective fiber and readily degradable carbohydrates in starter diets to support development of a healthy gut and rumen, rumination behavior, and growth in young calves.

The SAPHO syndrome

The occurrence of musculoskeletal manifestations (including synovitis, chest wall arthro-osteitis and multifocal aseptic osteomyelitis) in association with severe acne, palmoplantar pustulosis and perhaps with some presentations of psoriasis, have been described by many authors in the past 30 years. These different multifaceted descriptions have been designated by a variety of terms. More recently, a possible link between these conditions and spondarthritides has also been underlined by a slightly increased prevalence of HLA-B27 and occasional occurrences of sacroiliitis, chronic inflammatory bowel disease and possibly psoriasis. An acronym, the SAPHO syndrome (which stands for Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis) is proposed for this group of diseases because of the similarity of musculoskeletal manifestations in patients with severe acne and pustulosis. The clinical, epidemiological, pathophysiological, immunogenetic and diagnostic aspects, as well as the management of this syndrome, are reviewed.

Pre- and Postweaning Performance of Holstein Female Calves Fed Milk Through Step-Down and Conventional Methods

Milk consumption, dry feed intake, body weight (BW) gain, occurrence of diarrhea, and selected blood metabolites were studied in female Holstein calves fed milk either through conventional or step-down (STEP) methods. In conventional method, the calves (n = 20) were fed colostrum and then milk at the rate of 10% of BW for the entire period of 45 d. In STEP method, the calves (n = 20) were given colostrum and then milk for 25 d at the rate of 20% of BW, which was reduced (between d 26 to 30) to 10% of BW for the remaining 15 d. The calves fed through conventional and STEP methods were weaned gradually by diluting milk with water between d 46 and 50. Feed intake and BW of the calves were monitored until 90 d of age. The STEP calves consumed 92.3, 19.4, and 62.4% more milk than conventionally fed calves during pre-STEP (d 1 to 30), post-STEP (d 31 to 50), and preweaning (d 1 to 50) periods, respectively. Consumption of starter and hay were greater during the pre-STEP period and lesser during the post-STEP and postweaning (d 51 to 90) periods in calves provided milk using conventional method compared with STEP-fed calves. Body weight gain, dry matter intake, and feed efficiency of calves were greater in those on the STEP method than on the conventional method. Lesser blood glucose and greater blood urea nitrogen at weaning (d 50) and postweaning (d 60) possibly indicated a better functioning rumen in calves fed milk through The STEP method than those fed conventionally. Occurrence of diarrhea was higher during wk 3 and 4 of age in calves fed milk through conventional method compared with STEP-fed calves. In conclusion, STEP milk feeding may prevent the problems of depressed solid feed intake associated with ad libitum milk feeding and of poor BW gain with conventional milk feeding in dairy calves.

Identification of a novel GC-rich 113-nucleotide region to complete the circular, single-stranded DNA genome of TT virus, the first human circovirus

The sequence data (H. Okamoto et al., Hepatol. Res. 10:1-16, 1998) of a newly discovered single-stranded DNA virus, TT virus (TTV), showed that it did not have the terminal structure typical of a parvovirus. Elucidation of the complete genome structure was necessary to understand the nature of TTV. We obtained a 1.0-kb amplified product from serum samples of four TTV carriers by an inverted, nested long PCR targeted for nucleotides (nt) 3025 to 3739 and 1 to 216 of TTV. The sequence of a clone obtained from serum sample TA278 was compared with those registered in GenBank. The complete circular TTV genome contained a novel sequence of 113 nt (nt 3740 to 3852 [=0]) in between the known 3'- and 5'-end arms, forming a 117-nt GC-rich stretch (GC content, 90.6% at nt 3736 to 3852). We found a 36-nt stretch (nt 3816 to 3851) with an 80.6% similarity to chicken anemia virus (CAV) (nt 2237 to 2272 of M55918), a vertebrate circovirus. A putative SP-1 site was located at nt 3834 to 3839, followed by a TATA box at nt 85 to 90, the first initiation codon of a putative VP2 at nt 107 to 109, the termination codon of a putative VP1 at nt 2899 to 2901, and a poly(A) signal at nt 3073 to 3078. The arrangement was similar to that of CAV. Furthermore, several AP-2 and ATF/CREB binding sites and an NF-kappaB site were arranged around the GC-rich region in both TTV and CAV. The data suggested that TTV is circular and similar to CAV in its genomic organization, implying that TTV is the first human circovirus.

Hay intake improves performance and rumen development of calves fed higher quantities of milk

Research to date has suggested that access to forage before weaning can limit rumen development in calves, but no research has yet addressed the role of forage for calves fed higher quantities of milk. This study compared performance and rumen development of calves provided high volumes (equivalent to approximately 20% of calf birth weight) of milk with and without access to hay. At d 3 of age, individually housed calves were randomly assigned to treatment (either ad libitum access to chopped grass hay or no forage; n=15 calves per treatment, 10 heifers, and 5 bulls). All calves were provided ad libitum access to water and starter throughout the study. All calves were offered 8L of milk/d from a nipple bottle from d 3 to 35, 4 L/d from d 36 to 53, and 2L/d until weaning at d 56. Solid feed intake and growth parameters were monitored from d 3 to 70. At d 70, males from both treatments were slaughtered to measure rumen development parameters. Overall dry matter (DM) intake from solid feed did not differ between treatments before wk 5. However, during wk 6 to 10, calves fed forage consumed more total DM (starter plus hay) than did calves fed no forage. Hip and wither height, heart girth, and body barrel at d 3, 56, and 70 did not differ between treatments. Reticulorumen weight was heavier in calves fed hay versus those fed only starter (12.77±1.29 vs. 7.99±0.69 kg with digesta; 1.89±0.05 vs.1.60±0.09 kg without digesta). Body weight without digesta was similar in calves fed forage or no forage. Mean rumen pH was higher in calves fed hay compared with those fed no forage (5.49±0.08 vs. 5.06±0.04). In conclusion, provision of chopped hay to calves fed high volumes of milk can promote solid feed DM intake and rumen development without affecting BW gain.

Structural growth, rumen development, and metabolic and immune responses of Holstein male calves fed milk through step-down and conventional methods

Structural growth, feed consumption, rumen development, metabolic response, and immune response were studied in Holstein calves fed milk through either a conventional method or a step-down (STEP) method. In the conventional method, calves (n = 20) were fed colostrum and then milk at a rate of 10% of their BW for the entire period of 44 d. In the STEP method, calves (n = 20) were given colostrum and then milk at a rate of 20% of their BW for 23 d, which was reduced (between d 24 to 28) to 10% of their BW for the remaining 16 d. The calves on both methods were weaned gradually by diluting milk with water between d 45 and 49. After weaning, feed consumption, structural growth, and body weight gain were monitored until calves were 63 d of age. At d 63, twelve calves (6/treatment) were euthanized and rumen papillae length, papillae width, rumen wall thickness, and emptied forestomach weight were recorded. At wk 4, 7, and 9, ruminal contents were collected to enumerate rumen metabolites. The STEP-fed calves consumed a greater amount of milk than conventionally fed calves during the pre-STEP (d 1 to 28), post-STEP (d 29 to 49), and preweaning (d 1 to 49) periods. Consumption of starter and hay was greater during the pre-STEP period and lesser during the post-STEP and postweaning (d 50 to 63) periods in calves on the conventional method than on the STEP method. Body weight gain and structural growth measurements of calves were greater on the STEP method than on the conventional method. A hypophagic condition caused by greater milk consumption depressed solid feed intake of STEP-fed calves during the pre-STEP period, and a hyperphagic response caused by a reduced nutrient supply from milk triggered their consumption of solid feed during the post-STEP and postweaning periods. Ruminal pH and concentrations of ammonia, total volatile fatty acids, acetate, propionate, butyrate, and plasma beta-hydroxybutyrate were higher in calves on the STEP method and at weaning and postweaning (d 63) were lower in calves on the conventional method. Emptied weight of the forestomach, rumen wall thickness, papillae length, papillae width, and papillae concentration were higher in calves on the STEP method than in those on the conventional method. Blood glucose was lower, and blood urea nitrogen and beta-hydroxybutyrate at weaning and postweaning were higher in STEP-fed calves. Serum IgG, IgA, and triglycerides for 1, 2, and 3 wk of age were higher in calves on the STEP method than in those on the conventional method. In conclusion, greater feed consumption, BW gain, and structural growth, and a more metabolically and physically developed rumen were observed in calves on the STEP method than in those on the conventional method.

An omega-3 polyunsaturated fatty acid concentrate administered for one year decreased triglycerides in simvastatin treated patients with coronary heart disease and persisting hypertriglyceridaemia

BACKGROUND

Omega-3 fatty acids, such as those present in fish oil, have been reported to prolong life in myocardial infarction survivors. These fatty acids can decrease serum triglyceride concentrations, but so far the doses used in trials examining their effects on coronary end points have had only minimal triglyceride lowering effects.

OBJECTIVE

To examine the triglyceride lowering effectiveness, safety, and tolerability of Omacor, a concentrate of omega-3, long chain, polyunsaturated fatty acids from fish oil (84% of the total as opposed to an average of 35% in fish oil) over one year in patients with established coronary heart disease (CHD) and persisting hypertriglyceridaemia, despite receiving simvastatin in doses similar to those employed in the Scandinavian simvastatin survival study.

SUBJECTS AND METHODS

59 patients with CHD, receiving simvastatin 10-40 mg daily with serum triglycerides > 2.3 mmol/l, were randomised to receive Omacor 2 g twice a day or placebo for 24 weeks in a double blind trial. Forty six patients accepted the offer of active treatment for a further 24 weeks in an open phase of the trial.

RESULTS

There was a sustained significant decrease in serum triglycerides by 20-30% (p < 0.005) and in very low density lipoprotein (VLDL) cholesterol by 30-40% (p < 0.005) in patients receiving active Omacor at three, six, and 12 months compared either to baseline or placebo. Omacor did not have any deleterious effect on low density or high density lipoprotein cholesterol or on biochemical and haematological safety tests. There was no adverse effect on glycaemic control in patients with diabetes, who showed a decrease in serum triglyceride, which was at least as great as in non-diabetic patients. One patient receiving placebo died of acute myocardial infarction. Three patients withdrew from the trial (two on placebo and one on active treatment). Omacor was generally well tolerated.

CONCLUSION

Omacor was found to be a safe and effective means of lowering serum triglycerides over one year in patients with CHD and combined hyperlipidaemia, whose triglycerides remained elevated despite simvastatin treatment.

Nitric oxide and penile erection: is erectile dysfunction another manifestation of vascular disease?

There is convincing evidence that the prevalence of erectile dysfunction is increased among men with ischaemic heart disease. This association may be attributed to the fact that both erectile dysfunction and ischaemic heart disease share similar risk factors (e.g. hypertension, dyslipidaemia, diabetes and smoking). Nitric oxide (NO) activity is adversely affected, in penile and vascular tissue, by these risk factors. It is therefore not surprising that a defect in NO activity is thought to play a role in the pathogenesis of both erectile dysfunction and ischaemic heart disease. We consider this evidence and propose that defective NO activity provides a unifying explanation for the association between these two conditions. Further research in this area may improve our understanding of the pathogenesis of cardiovascular diseases as a whole.

The corrosion behaviour of Ti-6Al-4V, Ti-6Al-7Nb and Ti-13Nb-13Zr in protein solutions

Ti alloys are used in orthopaedic applications owing to their appropriate mechanical properties and their excellent corrosion resistance. The release of titanium and the other alloying elements into the surrounding tissue has been reported due either to passive corrosion or accelerating processes such as wear. Since the passive layer can be broken down in certain circumstances by wear it is important to study the ability of these alloys to repassivate in biological environments, in particular in the presence of proteins, and evaluate how the repassivated surface may vary from the original surface. In this study we investigated the ability of Ti-6Al-4V, Ti-6Al-7Nb and Ti-13Nb-13Zr to repassivate in phosphate buffered saline (PBS), bovine albumin solutions in PBS and 10% foetal calf serum in PBS at different pH values and at different albumin concentrations. It was found that an increase in pH had a greater effect on the corrosion behaviour of Ti-6Al-4V and Ti-6Al-7Nb than on Ti-13Nb-13Zr in PBS and that the addition of protein to the PBS reduced the influence of pH on the corrosion behaviour of all the alloys. The effect of the corrosion and repassivation was investigated by measuring changes in the surface hardness of the alloys and it was found that corrosion reduced the hardness of the surface oxides of all the alloys. In PBS the reduction was smallest for Ti-6Al-4V and largest for Ti-13Nb- 3Zr and that corrosion in protein solutions further reduced the hardness of the surface oxides. This effect was greater for Ti-6Al-4V and Ti-6Al-7Nb than for Ti-13Nb-13Zr. In conclusion, proteins in the environment appear to interact with the repassivation process at the surface of these alloys and influence the resulting surface properties.

The prevalence of cardiac valvular insufficiency assessed by transthoracic echocardiography in obese patients treated with appetite-suppressant drugs

BACKGROUND

After case reports of cardiac-valve abnormalities related to the use of appetite suppressants were published, we undertook a study to determine the prevalence of the problem using transthoracic echocardiography.

METHODS

We examined patients who had taken dexfenfluramine alone, dexfenfluramine and phentermine, or fenfluramine and phentermine for various periods. We enrolled obese patients who had taken or were taking these agents during open-label trials from January 1994 through August 1997. We also recruited subjects who had not taken appetite suppressants and who were matched to the patients for sex, height, and pretreatment age and body-mass index. The presence of cardiac-valve abnormalities, defined by the Food and Drug Administration and Centers for Disease Control and Prevention as at least mild aortic-valve or moderate mitral-valve insufficiency, was determined independently by at least two cardiologists. Multivariate logistic-regression analysis was used to identify factors associated with cardiac-valve abnormalities.

RESULTS

Echocardiograms were available for 257 patients and 239 control subjects. The association between the use of any appetite suppressant and cardiac-valve abnormalities was analyzed in a final matched group of 233 pairs of patients and controls. A total of 1.3 percent of the controls (3 of 233) and 22.7 percent of the patients (53 of 233) met the case definition for cardiac-valve abnormalities (odds ratio, 22.6; 95 percent confidence interval, 7.1 to 114.2; P<0.001). The odds ratio for such cardiac-valve abnormalities was 12.7 (95 percent confidence interval, 2.9 to 56.4) with the use of dexfenfluramine alone, 24.5 (5.9 to 102.2) with the use of dexfenfluramine and phentermine, and 26.3 (7.9 to 87.1) with the use of fenfluramine and phentermine.

CONCLUSIONS

Obese patients who took fenfluramine and phentermine, dexfenfluramine alone, or dexfenfluramine and phentermine had a significantly higher prevalence of cardiac valvular insufficiency than a matched group of control subjects.

Conjoint corrosion and wear in titanium alloys

When considering titanium alloys for orthopaedic applications it is important to examine the conjoint action of corrosion and wear. In this study we investigate the corrosion and wear behaviour of Ti-6Al-4V, Ti-6Al-7Nb and Ti-13Nb-13Zr in phosphate buffered saline (PBS), bovine albumin solutions in PBS and 10% foetal calf serum solutions in PBS. The tests were performed under four different conditions to evaluate the influence of wear on the corrosion and corrosion on the wear behaviour as follows: corrosion without wear, wear-accelerated corrosion, wear in a non-corrosive environment and wear in a corrosive environment. The corrosion behaviour was investigated using cyclic polarisation studies to measure the ability of the surface to repassivate following breakdown of the passive layer. The properties of the repassivated layer were evaluated by measuring changes in the surface hardness of the alloys. The amount of wear that had occurred was assessed from weight changes and measurement of the depth of the wear scar. It was found that in the presence of wear without corrosion the wear behaviour of Ti-13Nb-13Zr was greater than that of Ti-6Al-7Nb or Ti-6Al-4V and that in the presence of proteins the wear of all three alloys is reduced. In the presence of corrosion without wear Ti-13Nb-13Zr was more corrosion resistant than Ti-6Al-7Nb which was more corrosion resistant than Ti-6Al-4V without proteins whereas in the presence of protein the corrosion resistance of Ti-13Nb-13Zr and Ti-6Al-7Nb was reduced and that of Ti-6Al-4V increased. In the presence of corrosion and wear the corrosion resistance of Ti-13Nb-13Zr is higher than that of Ti-6Al-7Nb or Ti-6Al-4V in PBS but in the presence of proteins the corrosion resistance of Ti-13Nb-13Zr and Ti-6Al-7Nb are very similar but higher than that of Ti-6Al-4V. The wear of Ti-13Nb-13Zr is lower than that of Ti-6Al-7Nb and Ti-6Al-4V with or without the presence of proteins in a corrosive environment. Therefore the overall degradation when both corrosion and wear processes are occurring is lowest for Ti-13Nb-13Zr and highest for Ti-6Al-4V and the presence of proteins reduces the degradation of all three alloys.

HLA-B27 and its subtypes in world populations

Twenty-five years ago, HLA-B27 was recognized as a new HLA specificity. It is present throughout Eurasia but is virtually absent among the genetically unmixed native populations of South America, the Bantus and Sans (Bushmen) of equatorial and southern Africa, and the aborigines of Australia. B27 is a serologically determined specificity that encompasses nine different allotypes (subtypes), B*2701 to B*2709. Ankylosing spondylitis or related spondyloarthropathies thus far have been documented in individuals with any of the following five subtypes: B*2701, B*2702, B*2704, B*2705, or B*2707.

Feasibility of outpatient management of fever in cancer patients with low-risk neutropenia: results of a prospective randomized trial

PURPOSE

We recently demonstrated the efficacy of single-agent oral ofloxacin in the management of hospitalized neutropenic febrile patients. Ofloxacin was particularly effective in patients with short duration of neutropenia and fever of undetermined origin. These results prompted us to study the feasibility of outpatient management of neutropenic febrile patients who are otherwise at low risk of morbidity and mortality.

PATIENTS AND METHODS

This multi-institutional, prospective, randomized trial included 182 low-risk neutropenic febrile episodes. After an initial work-up for fever, patients were randomized to receive oral ofloxacin 400 mg immediately and twice daily thereafter in the hospital or as outpatients. Close monitoring and follow-up were carried out in all patients. Those who failed to respond and remained febrile were given parenteral antibiotics. Nonresponding outpatients were admitted to the hospital for parenteral therapy.

RESULTS

One hundred sixty-nine episodes were evaluable. The hospital and outpatient treatment groups had comparable clinical characteristics. Pyrexias of undetermined origin (PUO) comprised 69% of episodes managed in hospital and 73% of episodes treated outside. The success rate with PUO was similar with inpatient and outpatient management. Patients with clinical and microbiologic infections fared less well than those with PUO. Overall, 78% of inpatient and 77% of outpatient fevers resolved with no modification of the initial treatment. Twenty-one percent of patients originally assigned to outside management required hospitalization. Mortality was 2% among inpatients and 4% among outpatients. One early death in a nonhospitalized patient underscores the need for close monitoring and surveillance in these cases.

CONCLUSIONS

Outpatient management of low-risk neutropenic febrile patients with ofloxacin is as effective as inpatient management with the same agent. This approach should be limited to the subset of patients with low-risk factors who are not otherwise on quinolone prophylaxis.