The association of bullying with suicide ideation and attempt among adolescents with different dimensions of sexual orientation

Introduction

Sexual minority youth are at increased risk for bullying and suicide, but they are heterogeneous in their sexual orientation dimensions (attraction, behavior and identity).

Objective

To compare the association of bullying and suicide parameters between (1) heterosexually identified students without same-sex attractions or behaviors (2) heterosexually identified students with same-sex attractions or behaviors and (3) non-heterosexually identified students.

Methods

The Quebec Youth Risk Behavior Survey was a self-report questionnaire given to 1852 students 14–18 years old.

Results

The heterosexually identified students without same-sex attraction or behavior, and no bullying, was our reference group. When these students had bullying, the likelihood of suicidal ideation was double, but their likelihood of suicide attempts was the same. For non-heterosexually identified students, those with no bullying were twice as likely, and those with bullying were four times as likely to have suicidal ideation. When these students had no bullying, they were not more likely to have suicide attempts, but they were almost three times as likely when they had bullying. Heterosexually identified students with same-sex attraction or behavior were never more likely on any of the suicide measures.

Conclusion

This study was the first to show that adolescents with a non-heterosexual identity will have a disproportionately greater likelihood in their suicide parameters when subject to bullying, than heterosexually identified students with or without same-sex attraction or behavior, suggesting that these latter two dimensions were non-contributory to suicide risk. The significance of identity as a predictor of suicidal ideation and behavior will be discussed.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Identification of factors associated with diagnostic error in primary care

Background

Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason’s taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed.

Methods

Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician’s initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified.

Discussion

This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

Total and bioavailable arsenic concentration in arid soils and its uptake by native plants from the pre-Andean zones in Chile

Arsenic is the most important contaminant of the environment in northern Chile. Soil samples and plant organs from three native plant species, Pluchea absinthioides, Atriplex atacamensis and Lupinus microcarpus, were collected from arid zones in order to determine the total and bioavailable arsenic concentrations in soils and to assess the bioconcentration factor (BCF) and transport index (Ti) of arsenic in the plants. Total arsenic concentrations in soils (pH 8.3-8.5) where A. atacamensis and P. absinthioides were collected, reached levels considered to be contaminated (54.3 ± 15.4 and 52.9 ± 9.9 mg kg⁻¹, respectively), and these values were approximately ten times higher than in soils (pH 7.6) where L. microcarpus was collected. Bioavailable arsenic ranged from 0.18 to 0.42% of total arsenic concentration. In the three plant species, arsenic concentration in leaves were significantly (p ≤ 0.05) higher than in roots. L. microcarpus showed the highest arsenic concentration in its leaves (9.7 ± 1.6 mg kg⁻¹) and higher values of BCF (1.8) and Ti (6.1), indicating that this species has a greater capacity to accumulate and translocate the metalloid to the leaf than do the other species.

As2O3-induced oxidative stress and cycle progression in a human intestinal epithelial cell line (Caco-2)

Foods and drinking water are the main routes for human exposure to inorganic arsenic, the intestinal epithelium being the first barrier against such exogenous toxicants. The present study evaluates the effect of As(III) (0.5-25 microM) upon Caco-2 cells as an intestinal epithelia model. Cell viability, intracellular formation of reactive oxygen species (ROS), mitochondrial membrane potential (Deltapsim) changes, and cell cycle distribution in exposed cultures were evaluated. The intracellular production of ROS was seen to increase in a non-dose dependent manner at all concentrations tested, with impairment of cell mitochondrial enzyme function secondary to a loss of Deltapsim. Concentrations between 0.5 and 5 microM induce cell cycle transition from phase G1 to phase S, with no significant alteration in the proportion of cells in phase G2. These data suggest that As(III) could induce intestinal oxidative stress-cytotoxicity at mitochondrial functional level, and affect cell cycle progression. The data presented in this work may also suggest the impairment of essential survival processes in Caco-2 cells, induced after exposure to As(III) (1-25 microM). Oxidative stress and alteration of mitochondrial functionality could be early indicators of arsenic-induced cytotoxicity, with the resulting abnormal progression of the cell cycle.

Bioaccessibility and transport by Caco-2 cells of organoarsenical species present in seafood

Organoarsenical standards and raw and cooked seafood (DORM-2, sole, and Greenland halibut) were subjected to in vitro gastrointestinal digestion to estimate arsenic bioaccessibility (maximum soluble concentration in gastrointestinal medium). The in vitro digestion did not modify the chemical form of the organoarsenic species standards. In seafood, bioaccessibility was 67.5-100% for arsenobetaine (AB), 30% for dimethylarsinic acid (DMA), 45% for tetramethylarsonium ion (TETRA), and >50% for trimethylarsine oxide (TMAO). Cooking induced no changes in bioaccessible contents. In addition, transport by Caco-2 cells, an intestinal epithelia model, was evaluated from organoarsenical standards and DORM-2. For standards, transport ranged from 1.7% for AB to 15.5% for TETRA. In DORM-2, transport was observed for only AB (12%), with far higher efficiency than in the case of the standard solution, thus illustrating the interest of using whole foods for studying bioavailability.

Organoarsenical species contents in cooked seafood

The organoarsenical species arsenobetaine (AB), arsenocholine (AC), tetramethylarsonium ion (TMA+), dimethylarsinic acid (DMA), and monomethylarsonic acid (MMA) were determined in 64 cooked seafood products (fish, bivalves, squid, crustaceans) included in a Total Diet Study carried out in the Basque Country (Spain). For cooking, various treatments were employed (grilling, roasting, baking, stewing, boiling, steaming, microwaving). The results obtained show that in cooked seafood AB is the major species, followed by DMA and TMA+. AC and MMA are minor species. The results in cooked seafood were compared with the arsenic species contents obtained for the same product raw. After cooking there was an increase in DMA for sardines and bivalves and an increase or appearance of TMA+ for meagrim, anchovy, Atlantic horse mackerel, and sardine. The data provided add to the very scant information available about organoarsenical species contents in cooked seafood.

Muraglitazar, a dual (α/γ) PPAR activator: A randomized, double-blind, placebo-controlled, 24-week monotherapy trial in adult patients with type 2 diabetes

BACKGROUND

Peroxisome proliferator-activated receptors (PPARs) present a therapeutic target, and simultaneous activation of PPAR-alpha and PPAR-gamma may provide improvements in glycemic control and dyslipidemia in patients with type 2 diabetes.

OBJECTIVE

The goal of this study was to evaluate the efficacy and safety of muraglitazar, a dual (alpha/gamma) PPAR activator, in adult patients with type 2 diabetes whose disease was inadequately controlled by diet and exercise.

METHODS

This was a randomized, double-blind, placebo-controlled, parallel-group, multicenter, 24-week monotherapy study in drug-naive, type 2 diabetes patients with inadequate glycemic control. Men and women aged 18 to 70 years with a body mass index < or =41 kg/m(2) and serum triglyceride levels < or =600 mg/dL were eligible for study participation. The study included double-blind and open-label treatment phases. Patients with glycosylated hemoglobin (HbA(1c)) levels > or =7.0% and < or =10.0% at screening were enrolled in the double-blind treatment phase. These patients received treatment with muraglitazar 2.5 mg, muraglitazar 5 mg, or placebo. Patients with HbA(1c) levels >10.0% and < or =12.0% who met all other study criteria were eligible for enrollment in a 24-week, open-label evaluation of muraglitazar 5 mg. The primary end point was the mean change from baseline in HbA(1c) levels after 24 weeks of treatment.

RESULTS

A total of 340 patients (179 men, 161 women) participated in the double-blind treatment phase of the study. Patients had mean baseline HbA(1c) levels of 7.9% to 8.0%. Monotherapy with muraglitazar 2.5 and 5 mg significantly reduced HbA(1c) levels (-1.05% and -1.23%, respectively) compared with placebo (-0.32%; P < 0.001). At week 24, 58%, 72%, and 30% of the patients receiving muraglitazar 2.5 mg, muraglitazar 5 mg, and placebo, respectively, achieved the American Diabetes Association-recommended HbA(1c) goal of <7.0%. Fasting plasma glucose, free fatty acids, and fasting plasma insulin levels significantly decreased during muraglitazar treatment (P < 0.001), suggesting an increase in insulin sensitivity. Muraglitazar 2.5 and 5 mg provided improvements from baseline in triglyceride (-18% and -27%), high-density lipoprotein (HDL) cholesterol (10% and 16%), apolipoprotein B (-7% and -12%), and non-HDL cholesterol levels (-3% and -5%) (P < 0.05 vs placebo for each). In a parallel, open-label cohort of 109 drug-naive patients (56 men, 53 women; mean baseline HbA(1c) level, 10.6%), muraglitazar 5 mg decreased the overall mean HbA(1c) level from baseline by 2.62% (last observation carried forward) and by 3.49% in the 62 patients completing 24 weeks of study. Changes in lipid parameters during open-label treatment were similar to those observed during double-blind treatment. Muraglitazar was generally well tolerated. Edema-related adverse events of mild to moderate severity occurred in 8% to 11% of patients in all groups. Mean changes from baseline weight in the double-blind treatment groups were 1.1 kg for muraglitazar 2.5 mg, 2.1 kg for muraglitazar 5 mg, and -0.8 kg for placebo (P < 0.001); there was a mean 2.9-kg increase in the open-label muraglitazar 5-mg group.

CONCLUSION

In this study, 24 weeks of treatment with muraglitazar 2.5 or 5 mg was an effective treatment option for these patients with type 2 diabetes whose disease was inadequately controlled with diet and exercise.

Influence of a mine tailing accident near Doñana National Park (Spain) on heavy metals and arsenic accumulation in 14 species of waterfowl (1998 to 2000)

This article presents the impact on waterbirds in Doñana National Park (Spain) of an accidental release of 5 million m3 acid waste produced by the processing of pyrite ore. Heavy metals (zinc, copper, cadmium, and lead) and arsenic were measured in several soft tissues (liver, kidney, and muscle) taken from 14 waterfowl species collected between April 1998 and May 2000. The main source of copper and zinc found in the waterfowl species examined was the spill waste, whereas cadmium, lead, and arsenic could also came from other sources. Kidney was the primary organ for cadmium and lead accumulation, whereas liver accumulated the most zinc and copper. Arsenic was concentrated in both muscle and liver tissue. The degree of contamination of the area where the birds lived, their age, their sex their size, and the time since the spill were found to have less influence than species and trophic level on the accumulation of metal in organs and tissues. Four species (Anser anser, Ciconia ciconia, Larus ridibundus, and Porphyrio porphyrio) were found to have the highest levels of the 5 elements.

Use of near-infrared spectroscopy for determining the total arsenic content in prostrate amaranth

The potential of near infrared spectroscopy (NIRS) for determining the total arsenic (As) content in the prostrate amaranth (Amaranthus blitoides S. Watson) was assessed. Seventy-four samples belonging to this species, were harvested at different maturity stages along the polluted area, and then were scanned by NIRS. Their As reference values were obtained by atomic absorption spectrometry and they were regressed against different spectral transformations using modified partial least square (MPLS) regression. First derivative transformation equation of the raw optical data, previously standardized by standard normal variate (SNV) and De-trending (DT) transformations, resulted in a coefficient of determination (r(2)) in the external validation of 0.63, indicative of equations that can be used for a correct separation of the samples into low, medium and high groups. The standard deviation to standard error of prediction ratio (RPD) and range to standard error of prediction ratio (RER) for the first derivative equation were similar to those obtained for other trace metal calibrations reported in NIRS reflectance. Major cell components such as chlorophyll, lipids, starch and proteins were used by MPLS for modeling the equations. The use of NIRS for the determination of the As content in A. blitoides plants offers an important saving of time and cost of analysis.

Estimation of arsenic bioaccessibility in edible seaweed by an in vitro digestion method

The aim of this study was to examine the bioaccessibility (maximum soluble concentration in gastrointestinal medium) of total (AsT) and inorganic (AsI) arsenic contents and the effect on them of cooking edible seaweed, a food of great interest because of its high As content. An in vitro gastrointestinal digestion (pepsin, pH 2, and pancreatin-bile extract, pH 7) was applied to obtain the mineral soluble fraction of three seaweeds (Hizikia fusiforme, Porphyra sp., and Enteromorpha sp.). AsT was determined by dry-ashing flow injection hydride generation atomic absorption spectrometry. AsI was determined by acid digestion, solvent extraction, and flow injection hydride generation atomic absorption spectrometry. The bioaccessibility of AsI increased significantly after cooking, attaining 73% in Porphyra sp. and 88% in H. fusiforme. For cooked H. fusiforme, the AsI attained in the bioaccessible fraction was 26 microg g(-1) seaweed, a concentration that is a warning of the toxicological risk of this food.

Heavy metal, total arsenic, and inorganic arsenic contents of algae food products

The total arsenic, inorganic arsenic, lead, cadmium, and mercury contents of 18 algae food products currently on sale in Spain were determined. The suitability of the analytical methodologies for this type of matrix was confirmed by evaluating their analytical characteristics. The concentration ranges found for each contaminant, expressed in milligrams per kilogram of dry weight, were as follows: total arsenic, 2.3-141; inorganic arsenic, 0.15-88; lead, < 0.05-1.33; cadmium, 0.03-1.9; and mercury, 0.004-0.04. There is currently no legislation in Spain regarding contaminants in algae food products, but some of the samples analyzed revealed Cd and inorganic As levels higher than those permitted by legislation in other countries. Given the high concentrations of inorganic As found in Hizikia fusiforme, a daily consumption of 1.7 g of the product would reach the Provisional Tolerable Weekly Intake recommended by the WHO for an average body weight of 68 kg. A more comprehensive study of the contents and toxicological implications of the inorganic As present in the algae food products currently sold in Spain may be necessary, which might then be the basis for the introduction of specific sales restrictions.

One-year study of felodipine or placebo for stage 1 isolated systolic hypertension

Asubstantial number of older hypertensive patients have stage 1 isolated systolic hypertension (systolic blood pressure between 140 and 159 mm Hg and diastolic blood pressure <90 mm Hg), but there are currently no data showing that drug treatment is effective, safe, and/or beneficial. To compare the effects of active treatment compared with placebo on blood pressure, left ventricular hypertrophy, and quality of life among older stage 1 isolated systolic hypertensive patients, a randomized, double-blind, parallel-group, multicenter clinical trial comparing felodipine (2.5, 5, or 10 mg once daily) and matching placebo was performed in 171 patients (49% male, average age 66+/-7 years, with 49% white and 30% Hispanic) with a baseline blood pressure of 149+/-7/83+/-6 mm Hg. During 52 weeks of treatment, patients randomized to active treatment achieved significantly lower blood pressures (137.0+/-11.7/80.2+/-7.6 mm Hg for extended-release felodipine versus 147.5+/-16.0/83.5+/-9.7 mm Hg for placebo, P<0.01 for each), a reduced incidence of left ventricular hypertrophy (7% for extended release felodipine versus 24% for placebo, P<0.04), and improved quality of life (change in Psychological General Well-Being index, 3.0+/-6.8 for extended-release felodipine versus -0.8+/-10.3 for placebo, P<0.01) versus baseline. There were no clinically significant differences between treatments in tolerability or adverse effects. Stage 1 isolated systolic hypertension can be effectively and safely treated pharmacologically. Treatment reduced progression to the higher stages of hypertension, reduced the incidence of left ventricular hypertrophy, and improved an overall measure of the quality of life. Larger and longer studies will be needed to document any long-term reduction in cardiovascular event rates associated with treating stage 1 systolic hypertension.

Arsenic in cooked seafood products: study on the effect of cooking on total and inorganic arsenic contents

Total and inorganic arsenic contents were analyzed in cooked seafood products consumed in Spain during the period July 1997-June 1998: hake, meagrim, small hake, anchovy, Atlantic horse mackerel, sardine, bivalves, crustaceans, squid, and salted cod. Various cooking treatments were used (grilling, roasting, baking, stewing, boiling, steaming, and microwaving). The results obtained were compared statistically with those found previously in the same products raw, and they showed that after cooking there was a significant increase in the concentration of total arsenic for salted cod and bivalves, and in the concentration of inorganic arsenic for bivalves and squid. The mean content of inorganic arsenic was significantly higher in bivalves than in any other type of seafood. For the Spanish population, the mean intake of total arsenic estimated on the basis of the results obtained in this study is 245 microg/day. The intake of inorganic arsenic (2.3 microg/day) represents 1.7% of the World Health Organization provisional tolerable weekly intake (PTWI), leaving an ample safety margin for this population, which has a very high consumption of seafood.

Effect of cooking temperatures on chemical changes in species of organic arsenic in seafood

The concentrations of arsenobetaine (AB), tetramethylarsonium ion (TMA(+)), and trimethylarsine oxide (TMAO) were determined in samples of sole, dory, hake, and sardine, raw and after being subjected to cooking processes--baking, frying, and grilling--at various temperatures. In all cases, the temperature attained inside the product during the cooking process was measured. The arsenic species extracted from the samples with methanol/water were separated by means of a column switching technique between a PRP-X100 column and a PRP-X200 column. AB was detected by hydride generation atomic absorption spectrometry, whereas TMA(+) and TMAO were detected by hydride generation atomic fluorescence spectrometry. The results obtained showed that, in all of the types of seafood studied, TMA(+) appeared after cooking, possibly because heating facilitates decarboxylation of AB to TMA(+).

Kinetic study of transformations of arsenic species during heat treatment

The combination of temperatures and pH levels applied in domestic or industrial cooking and in the sterilization of seafood might cause the transformation of certain species of arsenic into other more toxic species, which could pose a risk to the consumer. To clarify the effect of the temperatures traditionally used in cooking or sterilization on the stability of the various species of arsenic, a kinetic study was carried out, using standards of arsenobetaine (AB), dimethylarsinic acid (DMA), monomethylarsonic acid (MMA), trimethylarsine oxide (TMAO), tetramethylarsonium ion (TMA(+)), and arsenocholine (AC) heated at different temperatures (85--190 degrees C) and for different treatment times. Various pH levels (4.5, 5.5, 6.5, and 8.0) were applied during the heating process. The results obtained indicated that there were no transformations of arsenic species after temperature treatments up to 120 degrees C. However, when temperatures between 150 and 190 degrees C were used, a partial decomposition of AB was achieved, producing TMAO at 150 degrees C and TMAO and TMA(+) at temperatures of 160 degrees C or above, in proportions that varied according to the temperature and duration of the heat treatment.

Total and inorganic arsenic in fresh and processed fish products

Total arsenic and inorganic arsenic contents were determined in 153 samples of seafood products consumed in the Basque Country (Spain): fish (white fish and blue fish), mollusks, crustaceans, and preserved fish. White fish presented higher levels of total arsenic and lower levels of inorganic arsenic than the blue fish, indicating possible differences in the metabolization of inorganic arsenic. For total arsenic, 66% of the samples exceeded the maximum permitted level by the strictest international legislation in seafood products [1 microg g(-)(1), wet weight (ww)]. The levels of inorganic arsenic were considerably lower than the maximum authorized in New Zealand (2 microg g(-)(1), ww), the only country with legislation for inorganic arsenic in fish and fish products. It is recommended that legislation based on levels of inorganic arsenic should be established.

Accumulation of heavy metals and As in wetland birds in the area around Doñana National Park affected by the Aznalcollar toxic spill

The impact of the spill from the mine in Aznalcollar (Seville, Spain) on waterfowl in the Doñana National Park is assessed. The concentrations of Cu, Pb, Cd, Zn nd As in the liver and eggs of 16 species of waterfowl found dead in the Park between April and November 1998 were determined. The highest levels were found for Zn, followed by Cu, Pb, Cd and As. The main parameters related to the accumulation of these elements in the waterfowl studied were species and trophic level. The other variables studied--distance from the spill, days of exposure, sex, size, and age--are important, although this depends on the element studied. Zn and Cu from the spill have entered the food chain of the aquatic birds studied, but Cd, Pb and As have not. There is currently no evidence to suggest that the trace element concentrations measured have reached toxic levels.

Trace elements in blood collected from birds feeding in the area around Doñana National Park affected by the toxic spill from the Aznacóllar mine

A long-term monitoring plan was established to study if bird populations around Doñana National Park were affected by the toxic spill from the Aznalcóllar mine. The concentrations of Zn, Pb, As, Cu, Sb, Co, Tl and Cd in the blood of 11 bird species feeding in the area were determined. The parameters which most affect the accumulation of trace elements in the birds studied are, firstly, species and secondly, trophic position, sex, days of exposure and weight. In some individuals, Zn and Cu occurred at higher levels than the reference values for contaminated areas. Concentrations of Pb and Cd in a considerable number of individuals were higher than those found in birds from uncontaminated areas. The present data, together with the lack of data on blood metal concentration prior to the spill, do not offer any conclusive evidence of the influence of the spill on avian blood metal concentrations.

Total and inorganic arsenic in the fauna of the Guadalquivir estuary: environmental and human health implications

To evaluate the impact on fauna of the release of toxic waste from the tailings dam operated by the Boliden Apirsa S.L company at Aznalcóllar, Seville (Spain) a study was carried out of total and inorganic arsenic contents in 164 samples from six different estuary species, including molluscs, crustaceans and fish, collected at six sampling stations distributed along the estuary and mouth of the River Guadalquivir. The contents found, expressed in micrograms per gram wet weight, were as follows. Total arsenic: Crassostrea angulata--giant cupped oyster (2.44 +/- 0.45); Scrobicularia plana--peppery furrow (2.50 +/- 0.73); Palaemon longirostris--delta prawn (1.33 +/- 0.54); Uca tangeri--AfroEuropean fiddler crab (1.76 +/- 0.08); Melicertus kerathurus--shrimp (3.60 +/- 1.92); and Liza ramada--mullet (0.65 +/- 0.38). Inorganic arsenic: C. angulata (0.09 +/- 0.02); S. plana (0.38 +/- 0.23); P. longirostris (0.04 +/- 0.01); U. tangeri (0.22 +/- 0.03); M. kerathurus (0.03 +/- 0.01); and L. ramada (0.03 +/- 0.03). The levels of total As are comparable to those obtained by other authors. With respect to inorganic arsenic, only S. plana and U. tangeri present high levels of inorganic arsenic. This may be due to the fact that these organisms live in estuary sediments, reservoirs of inorganic arsenic, and ingest particles of sediments during feeding. Because of the lack of information for this area concerning previous levels of total and inorganic arsenic in the species analysed, it was not possible to establish the impact on the fauna of the River Guadalquivir estuary of the toxic spill resulting from the failure of the mine tailings dam at Aznalcóllar. With respect to the implications to human health as a result of consumption of species from the Guadalquivir estuary, only with the species Scrobicularia plana, as a high consumption of this mollusc might, in some cases, exceed the maximum tolerable intake for inorganic arsenic indicated by the FAO/WHO. Consumption of the liver of L. ramada does not appear to present problems to human health.

Comparison of two strategies for intensifying antihypertensive treatment: low-dose combination (enalapril + felodipine ER) versus increased dose of monotherapy (enalapril). LEVEL (Lexxel vs Enalapril) Study Group

To compare two popular strategies for intensifying treatment for hypertension, a double-blind, randomized, prospective, parallel-group, and partial crossover study was done. After 2 weeks of placebo run-in (baseline) and 3 weeks of 5 mg enalapril once daily, 217 patients were randomized to 6 weeks of treatment with either a low-dose combination therapy (5 mg enalapril + 5 mg felodipine ER once daily, Lexxel, Astra Merck, Inc.), or a higher dose of monotherapy (10 mg enalapril once daily, Vasotec, Merck & Co., Inc.). The group randomized to the combination had significantly greater reductions in sitting systolic/diastolic blood pressure (BP)--14.2/10.6 mm Hg compared with baseline versus 9.6/7.4 mm Hg (P < .05/.01)--as well as a greater percentage of patients having achieved either diastolic BP < 90 mm Hg or a decline of at least 10 mm Hg (responders), 59% v 41% (P < .01). When patients originally taking 10 mg enalapril were crossed over to the combination therapy for a further 6 weeks, there was a further BP reduction and increase in response rate, with loss of significant differences compared with those treated continuously with the combination for the entire 12 weeks. The greater BP-lowering efficacy of the combination was independent of age, gender, and race. There were no significant differences in tolerability between the regimens. These data support the hypothesis that in patients who do not achieve goal BP reduction with a low dose of an antihypertensive agent, a combination of two drugs with complementary mechanisms of action is more effective than increasing the dose of the first agent.

Optimization of the solubilization, extraction and determination of inorganic arsenic [As(III) + (As(V)] in seafood products by acid digestion, solvent extraction and hydride generation atomic absorption spectrometry

A method for the selective quantitative determination of inorganic arsenic [As(III) + As(V)] in seafood was developed. In order to do so, various procedures for the solubilization and extraction of inorganic arsenic quoted in the literature were tested. None provided satisfactory recoveries for As(III) and As(V) in real samples. Consequently, a methodology was developed which included solubilization with HCl and subsequent extraction with chloroform. The arsenic was solubilized in 9 mol l-1 hydrochloric acid. After reduction by hydrobromic acid and hydrazine sulfate, the inorganic arsenic was extracted into chloroform, back-extracted into 1 mol l-1 HCl, dry-ashed, and quantified by hydride generation-atomic absorption spectrometry (HG-AAS). The analytical features of the method are as follows: detection limit, 3.07 ng g-1 As (fresh mass); precision (RSD), 4.0%; recovery, As(III) 99%, As(V) 96%. In the optimized conditions, other arsenic species--dimethylarsinic acid (DMA), arsenobetaine (AB), arsenocholine (AC) and tetramethylarsonium-ion (TMA+)--were not co-extracted. However, different percentages of minor species were extracted with chloroform: monomethylarsonic acid (MMA) 100%, and trimethylarsine oxide (TMAO) 3-10%. Real samples and reference materials of seafood (DORM-1, DORM-2, TORT-2, CRM-278 and SRM-1566a) were analyzed. The analysis of DORM-1 provided an inorganic arsenic value of 124 +/- 4 ng g-1 As, dry mass (dm), which is very close to the value obtained by other authors using high performance liquid chromatography-inductively coupled plasma-mass spectrometry (HPLC-ICP-MS) and ionic chromatography-hydride generation-atomic absorption spectrometry (IC-HG-AAS).

Arsenic speciation in manufactured seafood products

The literature on the speciation of arsenic (As) in seafoods was critically reviewed. Most research has been directed toward fresh seafood products with few papers dealing with As speciation in manufactured seafoods. Predictions concerning As species made on the basis of fresh seafood products cannot be extrapolated to manufactured seafoods. Therefore, due to the numerous species of As, the scarcity of data concerning their presence in foods, the transformations each species may undergo during industrial processing and cooking, and the lack of legislation on permitted As levels in seafood products, As species in manufactured seafood products need to be determined and quantified.

Evaluation of indapamide 1.25 mg once daily in elderly patients with mild to moderate hypertension

The objective of this study was to evaluate the safety and efficacy of indapamide 1.25 mg once daily as monotherapy in elderly patients (65 years and older) with mild to moderate essential hypertension. Two hundred and seventy-nine (279) elderly patients were enrolled in a washout period, during which patients received single-blind placebo for 4 weeks. Patients demonstrating supine diastolic pressures between 95 mm Hg and 114 mm Hg at the end of the 4-week placebo washout period were entered into the 8-week double-blind treatment period. Two hundred and four (204) patients qualified for the study and were randomized to the double-blind treatment; 103 patients received indapamide 1.25 mg and 101 patients received placebo for 8 weeks. Overall, 177 patients (92 indapamide and 85 placebo) completed the study. The primary efficacy criterion was the mean change in supine diastolic blood pressure (DBP) from double-blind baseline to the end of 8 weeks of therapy. By week 8 of the double-blind treatment period, indapamide 1.25 mg produced a statistically significant (P = 0.0037) decrease in supine DBP of 8.2 mm Hg compared to a decrease of 5.3 mm Hg produced in the placebo group. Additionally, indapamide 1.25 mg was statistically (P = 0.0028) more effective than placebo in reducing supine systolic BP (SBP) (-10.1 vs -4.2 mm Hg). The incidence of drug-related adverse events during the double-blind treatment period was similar between the two treatment groups. A low dose of indapamide, 1.25 mg, given once daily for 8 weeks was effective as monotherapy with respect to BP reduction in an elderly population with mild to moderate hypertension. Indapamide 1.25 mg was safe and generally well tolerated in this elderly patient population.

Trace element food toxicology: an old and ever-growing discipline

Food toxicology (FT) is an old science whose origins may go back to primitive humans. However, due to major environmental damage, daily market launches of new food products, and the analytical ability to detect ever small quantities of toxicants in foods, FT is also an ever-growing science with an enormous task ahead. With respect to trace elements, current research trends can be encompassed under the headings of detection, control, and toxicological evaluation. Under the heading detection, quality, sensitivity, speed, automation, and specificity for each food type are the characteristics currently sought when developing new methodologies. Under control, there is a great need for constant monitoring, on an international level, of the levels of trace elements present in foods; and for development and application of new methodologies to guarantee product and process safety. Under toxicological evaluation, information about the bioavailability of trace elements and consequently studies of the chemical species present in foods have top priority. The work still outstanding in the study of trace element FT is immense, because it is necessary to achieve a profound understanding of the toxicological characteristics of food products in relation to trace elements; to give information to food manufacturers that they can use to adapt their production so that it meets the requirements of international legislation and demands for quality and innocuousness on the part of the market and consumers; and to develop standards regulating the maximum content of trace elements, according to the content of the various species.

Arsenic content of Spanish cows' milk determined by dry ashing hydride generation atomic absorption spectrometry

The arsenic content of cows' milk consumed in Spain was determined. A procedure using dry ashing hydride generation atomic absorption spectrometry was developed for the purpose. Experimental conditions for the destruction of organic matter were established and an interference study was carried out. The method developed has a detection limit of 0.1 ng/g, a relative SD of 5%, and a recovery (mean +/- CSI) of 100 +/- 4%. The accuracy of the method was checked by analysis of a certified sample of IAEA milk powder (mean +/- CSI: certified, 4.85 +/- 0.32 ng/g; found, 5.04 +/- 0.81 ng/g). The proposed procedure was used to analyse cows' milk samples. The extremely low arsenic levels found do not present toxicological problems.

[The companion at the clinical interview]

OBJECTIVE

To discover how often patients attend a clinical interview with a companion; and to define this companion by the variables of age, gender, reason for the interview, the relationship (friend or relation) and his/her typology.

DESIGN

This was a descriptive, prospective study.

SETTING

The study was carried out in the Almanjayar and Cartuja Health Centres.

PATIENTS AND OTHER PARTICIPANTS

The 899 people who attended for a consultation during the last week of July, 1991, were included in the study.

MEASUREMENTS AND MAIN RESULTS

Companions were present in 39.15% of the clinical interviews. Patients under 20 and those with acute complaints were those who most commonly attended with a companion. 94% of the companions were family members: most commonly, the mother or the husband/wife. 18.7% of the companions caused conflict.

CONCLUSIONS

The companion can be seen as an important element of the health network as well as a social support. Companions with a collaborative attitude can be used to find out clinical data and family background during the interview; whereas difficult or sick companions require a particular approach to prevent their interfering with the development of the clinical interview.

[Efficacy of auditing in improving a Control Program of Pregnancy]

OBJECTIVE

To compare the results obtained in two successive audits to observe the effectiveness of this control method.

DESIGN

The care process followed by pregnant women attended in 1986-87 is compared with that in 1988.

LOCATION

Cartuja Health Centre (Granada).

PARTICIPANTS

Data referring to 20 markers with defined quality criteria are obtained by auditing clinical protocols.

METHODS AND MAIN RESULTS

The qualitative markers were compared to the comparison test of two proportions for separate samples and the quantitative markers with the of student for separate samples and equal variants. The quality index improved in 9 markers and worsened in 1; the remainder did not change. The results prove the effectiveness of quality control to improve care given in a Health Centre.

Double-blind, dose-response, placebo-controlled multicenter study of nisoldipine. A new second-generation calcium channel blocker in angina pectoris

BACKGROUND

Nisoldipine is a potent 1:4 dihydropyridine calcium channel antagonist, and doses of 5 or 10 mg administered either once or twice daily have been claimed to exert antianginal effects. There is, however, little information regarding the dose-response relation and whether the drug exerts any consistent effects throughout the dosing interval. In this placebo-controlled, parallel-design study, the dose-response relation of monotherapy with nisoldipine administered twice daily was studied in patients with stable angina pectoris.

METHODS AND RESULTS

Two hundred thirty-one patients received single-blind placebo for 2 weeks; of these, 185 patients who reproducibly stopped treadmill exercise because of angina of moderate severity and had greater than or equal to 1 mm ST segment depression during exercise and experienced an average of three episodes of anginal attacks per week were randomized in a double-blind manner to one of the four treatment groups: placebo (n = 48), nisoldipine 2.5 mg (n = 47), nisoldipine 5 mg (n = 44), or nisoldipine 10 mg (n = 46). Nisoldipine or placebo was administered twice daily for 4 weeks and symptom-limited exercise tests were repeated at 2 and 10-14 hours after the double-blind medication. One hundred sixty-eight patients completed the study and 181 patients were valid for efficacy analysis. Compared with double-blind placebo, there were marginally significant trends toward increases for time to onset of angina for the 10-mg-b.i.d. group (83 versus 108 seconds, p = 0.08), time to 1 mm ST segment depression for the 5-mg-b.i.d. group (54 versus 83 seconds, p = 0.08), and total exercise time for the 5- (30 versus 50 seconds, p = 0.10) and 10-mg-b.i.d. (30 versus 58 seconds, p = 0.06) groups at 2 hours after the dose (peak effect) after 4 weeks of therapy. At 10-14 hours after the dose (trough effect), no differences between placebo and any of the nisoldipine doses on any of the exercise parameters were found after 4 weeks of therapy. A subset analysis of patients who stopped exercise within 10 minutes because of angina of moderate severity during single-blind placebo therapy (n = 123) revealed significant increase in total exercise duration and time to 1 mm ST segment depression at 2 hours after the dose in the 5- and 10-mg-b.i.d. dose groups compared with double-blind placebo (p less than 0.04). No significant trough effects, however, were observed even in this subgroup after any of the doses of nisoldipine. The frequency of anginal attacks decreased by 44%, 41%, 30%, and 41% after twice-daily therapy with 2.5 mg, 5 mg, 10 mg nisoldipine, and placebo groups, respectively (p = NS, nisoldipine versus placebo). The incidence of adverse events (minor and major) was 43.8% in the placebo group and 42.6%, 45.5%, and 56.5% in the nisoldipine 2.5-, 5-, and 10-mg-b.i.d. groups, respectively (p = NS compared with placebo). However, four patients developed unstable angina while on nisoldipine therapy (two in the 2.5-mg, one in the 5-mg, and one in the 10-mg-b.i.d. group) and two patients died suddenly in the nisoldipine 10-mg-b.i.d. group.

CONCLUSIONS

Monotherapy with 2.5, 5, and 10 mg nisoldipine twice a day was not superior to placebo therapy in treating patients with angina pectoris, and the 10-mg-b.i.d. therapy resulted in a statistically insignificant but clinically important increase in the incidence of serious adverse events.

Safety and tolerability of metoprolol OROS in hypertension treatment

One hundred twenty-six patients with mild to moderate hypertension responsive to beta-adrenergic blocking agents--alone or in combination with other antihypertensive drugs--entered this open-label, multicenter study designed to evaluate the safety and tolerability of metoprolol OROS (metoprolol fumarate). Metoprolol OROS was given once daily for 14 weeks in doses ranging from 100 to 600 mg. Satisfactory blood pressure control was achieved by 85% of the patients at doses between 100 and 400 mg. Mean diastolic blood pressure was maintained at or below 90 mm Hg. Adverse reactions were experienced by 29% of the patients; most of these reactions were mild or moderate, and none was unexpected for treatment with a beta-blocker. Only three patients withdrew because of adverse reactions. The results of this study indicate that metoprolol OROS given once daily is safe and well tolerated.