Exposure to residential traffic and trajectories of unhealthy ageing: results from a nationally-representative cohort of older adults

BACKGROUND

Traffic exposure has been associated with biomarkers of increased biological ageing, age-related chronic morbidities, and increased respiratory, cardiovascular, and all-cause mortality. Whether it is associated with functional impairments and unhealthy ageing trajectories is unknown.

METHODS

Nationally representative population-based cohort with 3,126 community-dwelling individuals aged ≥60 years who contributed 8,291 biannual visits over a 10 year period. Unhealthy ageing was estimated with a deficit accumulation index (DAI) based on the number and severity of 52 health deficits, including 22 objectively-measured impairments in physical and cognitive functioning. Differences in DAI at each follow-up across quintiles of residential traffic density (RTD) at 50 and 100 meters, and closest distance to a petrol station, were estimated using flexible marginal structural models with inverse probability of censoring weights. Models were adjusted for sociodemographic and time-varying lifestyle factors, social deprivation index at the census tract and residential exposure to natural spaces.

RESULTS

At baseline, the mean (SD) age and DAI score of the participants were 69.0 (6.6) years and 17.02 (11.0) %, and 54.0% were women. The median (IQR) RTD at 50 and 100 meters were 77 (31-467) and 509 (182-1802) vehicles/day, and the mean (SD) distance to the nearest petrol station of 962 (1317) meters. The average increase in DAI (95%CI) for participants in quintiles Q2-Q5 (vs Q1) of RTD at 50 meters was of 1.51 (0.50, 2.53), 0.98 (-0.05, 2.01), 2.20 (1.18, 3.21) and 1.98 (0.90, 3.05), respectively. Consistent findings were observed at 100 meters. By domains, most of the deficits accumulated with increased RTD were of a functional nature, although RTD at 50 meters was also associated with worse self-reported health, increased vitality problems and higher incidence of chronic morbidities. Living closer to a petrol station was associated with a higher incidence of functional impairments and chronic morbidities.

CONCLUSIONS

Exposure to nearby residential traffic is associated with accelerated trajectories of unhealthy ageing. Diminishing traffic pollution should become a priority intervention for adding healthy years to life in the old age.

Toenails as biomarker of exposure to essential trace metals: A review

Health problems associated with essential trace metals can result from both inadequate (i.e., low intake) and excessive exposures (i.e., from environmental and/or occupational source). Thus, measuring the exposure level is a real challenge for epidemiologists. Among non-invasive biomarkers that intend to measure long-term exposure to essential trace metals, the toenail is probably the biological matrix with the greatest potential. This systematic review collects the current evidence regarding the validity of toenail clippings as exposure biomarker for trace metals such as boron, cobalt, copper, iron, manganese, molybdenum, selenium, silicon, vanadium and zinc. Special attention was paid to the time-window of exposure reflected by the toenail, the intraindividual variability in exposure levels over time in this matrix, and the relationship of toenail with other biomarkers, personal characteristics and environmental sources. Our search identified 139 papers, with selenium and zinc being the most studied elements. The variability among studies suggests that toenail levels may reflect different degrees of exposure and probably correspond to exposures occurred 3-12 months before sampling (i.e., for manganese/selenium). Few studies assessed the reproducibility of results over time and, for samples obtained 1-6 years apart, the correlation coefficient were between 0.26 and 0.66. Trace metal levels in toenails did not correlate well with those in the blood and urine and showed low-moderate correlation with those in the hair and fingernails. Available data suggests that for some elements (Se, Mn, Zn) toenail concentrations reflect long-term external exposures in fairly reproducible levels, while for other metals, this association has not yet been assessed. Among dietary factors, only toenail selenium showed clear associations with the intake of supplements or specific foods. The toenail levels could also represent occupational exposure, for instance, Mn exposure in welders. The scarcity of information on other essential trace elements, together with the great heterogeneity among studies makes the validation of the usage of toenails as biomarkers of exposure to these elements difficult. Standardization of sample collection, quality control, analytical techniques and reporting procedures might facilitate further research focused on the clear understanding of the significance of essential levels in this promising matrix and would enhance its utility in epidemiological research.

It is possible to change clozapine by another neuroleptic

It is well known that when we have a schizophrenic patient who do not respond to two batches of neuroleptics at full dosage for more than six month, it may be wise to try with clozpine which is believed to be one of the best neuroleptics we have but with two main handicaps: it can produce leucopenia which can be fatal and epileptic seizures as well. We do think that in many cases, clozapine has been used too soon in the treatment of the schizophrenic patient, before we can really talk of a resistant patient. To prove that we have changed the clozapine treatment of four chronically ill schizophrenic patients admitted to a home for the chronically mentally ill. Two patients were changed from clozapine 400 mg/day to paliperidone 15 mg/day along two months time. They both improved in mental clarity and ability of thinking. Another patient were changed from 600 mg/day to 27 mg/day of paliperidone. That patient worsened a little bit mainly with hostility and social avoidance but it was mandatory to change neuroleptic because he had had two seizures and had low levels of platelets and therefore he was at risk of developing leukopenia. The fourth one was taking 300 mg of clozapine and was changed to 12 mg of paliperidone. We got no change in the clinical outcome.

Discussion

We discuss the different explanations for the results we got.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Preclinical evidence implicating corticotropin-releasing factor signaling in ethanol consumption and neuroadaptation

The results of many studies support the influence of the corticotropin-releasing factor (CRF) system on ethanol (EtOH) consumption and EtOH-induced neuroadaptations that are critical in the addiction process. This review summarizes the preclinical data in this area after first providing an overview of the components of the CRF system. This complex system involves hypothalamic and extra-hypothalamic mechanisms that play a role in the central and peripheral consequences of stressors, including EtOH and other drugs of abuse. In addition, several endogenous ligands and targets make up this system and show differences in their involvement in EtOH drinking and in the effects of chronic or repeated EtOH treatment. In general, genetic and pharmacological approaches paint a consistent picture of the importance of CRF signaling via type 1 CRF receptors (CRF(1)) in EtOH-induced neuroadaptations that result in higher levels of intake, encourage alcohol seeking during abstinence and alter EtOH sensitivity. Furthermore, genetic findings in rodents, non-human primates and humans have provided some evidence of associations of genetic polymorphisms in CRF-related genes with EtOH drinking, although additional data are needed. These results suggest that CRF(1) antagonists have potential as pharmacotherapeutics for alcohol use disorders. However, given the broad and important role of these receptors in adaptation to environmental and other challenges, full antagonist effects may be too profound and consideration should be given to treatments with modulatory effects.

IYCr2014: Online activities in Spain to attract and involve everyone

New technologies offer an emerging framework to spread scientific knowledge. New sites based on different platforms (blogs, websites, youtube channels, etc.) are born everyday with an informative and educational spirit. The success of such proposals lies in an increasingly growing interest of the general publicusing these tools as an easy, convenient and funnyway to share information. These technologies contribute to spread and promote the participation in the IYCr2014 activities by supporting all the activities organized under the IYCr2014 [1,2] in Spain,accessing an ever wider audience through the network. First, we have created an own website: www.iycr2014.info where all the information about the different activities (national and international) of the IYCr2014 are being posted. This website has a TV channel available where some events (workshops, exhibitions, conferences, activities for school children or public engagement events) are broadcasted. Both, website and TV channel, are being supported by means of the most popular social networks: facebook and tweeter. Besides, some of our actions are designed by the use of different network tools. As selected running activities, we shall present the Massive Open Online Course (MOOC) [3] about crystallization and crystallography. This course is builtby using an accessible language andwas thought to support Crystallization in the School Project. A second example is the Mobile application to the project: Sands of the world. This very complex project needs worldwide collaboration to collect samples of sand from as many beaches as possible around the world. A third application is the Online development of competitions such as The most relevant molecule in SpanishCrystallography and The Round Robin-Crystal phase identification. Acknowledgements: Financial support from Ministerio de Economía y Competitividad de España (MAT2010-15094, Factoría de Cristalización – Consolider Ingenio 2010) Figure: QR codes of the website (left) and the MOOC (right)

Zinc alpha-2 glycoprotein is implicated in dyslipidaemia in HIV-1-infected patients treated with antiretroviral drugs

OBJECTIVES

Treated HIV-1-infected patients with lipodystrophy often develop insulin resistance and proatherogenic dyslipidaemia. Zinc alpha-2 glycoprotein (ZAG) is a recently characterized adipokine which has been shown to be involved in the development of obesity and metabolic syndrome in uninfected subjects. We assessed the relationship between circulating ZAG levels and metabolic derangements in HIV-1-infected patients receiving antiretroviral drugs.

METHODS

Plasma ZAG levels were assessed in 222 individuals: 166 HIV-1-infected patients treated with antiretroviral drugs (77 with lipodystrophy and 89 without lipodystrophy) and 56 uninfected controls. Plasma ZAG levels were assessed by enzyme-linked immunosorbent assay (ELISA) and were correlated with fat distribution abnormalities and metabolic parameters.

RESULTS

HIV-1-infected patients had lower plasma ZAG levels compared with uninfected controls (P < 0.001). No differences were found in ZAG plasma levels according to the presence of lipodystrophy, components of the metabolic syndrome or type of antiretroviral treatment regimen. Circulating ZAG levels were strongly determined by high-density lipoprotein cholesterol (HDLc) in men (B = 0.644; P < 0.001) and showed a positive correlation with total cholesterol (r = 0.312; P < 0.001) and HDLc (r = 0.216; P = 0.005).

CONCLUSIONS

HIV-1-infected patients have lower plasma ZAG levels than uninfected controls. In infected patients, plasma ZAG levels are in close relationship with total cholesterol and HDLc.

Mercury, lead and cadmium in human milk in relation to diet, lifestyle habits and sociodemographic variables in Madrid (Spain)

BACKGROUND

Although breastfeeding is the ideal way of nurturing infants, it can be a source of exposure to toxicants. This study reports the concentration of Hg, Pb and Cd in breast milk from a sample of women drawn from the general population of the Madrid Region, and explores the association between metal levels and socio-demographic factors, lifestyle habits, diet and environmental exposures, including tobacco smoke, exposure at home and occupational exposures.

METHODS

Breast milk was obtained from 100 women (20 mL) at around the third week postpartum. Pb, Cd and Hg levels were determined using Atomic Absorption Spectrometry. Metal levels were log-transformed due to non-normal distribution. Their association with the variables collected by questionnaire was assessed using linear regression models. Separate models were fitted for Hg, Pb and Cd, using univariate linear regression in a first step. Secondly, multivariate linear regression models were adjusted introducing potential confounders specific for each metal. Finally, a test for trend was performed in order to evaluate possible dose-response relationships between metal levels and changes in variables categories.

RESULTS

Geometric mean Hg, Pb and Cd content in milk were 0.53 μg L(-1), 15.56 μg L(-1), and 1.31 μg L(-1), respectively. Decreases in Hg levels in older women and in those with a previous history of pregnancies and lactations suggested clearance of this metal over lifetime, though differences were not statistically significant, probably due to limited sample size. Lead concentrations increased with greater exposure to motor vehicle traffic and higher potato consumption. Increased Cd levels were associated with type of lactation and tended to increase with tobacco smoking.

CONCLUSIONS

Surveillance for the presence of heavy metals in human milk is needed. Smoking and dietary habits are the main factors linked to heavy metal levels in breast milk. Our results reinforce the need to strengthen national food safety programs and to further promote avoidance of unhealthy behaviors such as smoking during pregnancy.

Dissection of corticotropin-releasing factor system involvement in locomotor sensitivity to methamphetamine

Sensitivity to the euphoric and locomotor-activating effects of drugs of abuse may contribute to risk for excessive use and addiction. Repeated administration of psychostimulants such as methamphetamine (MA) can result in neuroadaptive consequences that manifest behaviorally as a progressive escalation of locomotor activation, termed psychomotor sensitization. The present studies addressed the involvement of specific components of the corticotropin-releasing factor (CRF) system in locomotor activation and psychomotor sensitization induced by MA (1, 2 mg/kg) by utilizing pharmacological approaches, as well as a series of genetic knockout (KO) mice, each deficient for a single component of the CRF system: CRF-R1, CRF-R2, CRF, or the CRF-related peptide Urocortin 1 (Ucn1). CRF-R1 KO mice did not differ from wild-type mice in sensitization to MA, and pharmacological blockade of CRF-R1 with CP-154,526 (15, 30 mg/kg) in DBA/2J mice did not selectively attenuate either the acquisition or expression of MA-induced sensitization. Deletion of either of the endogenous ligands of CRF-R1 (CRF, Ucn1) either enhanced or had no effect on MA-induced sensitization, providing further evidence against a role for CRF-R1 signaling. Interestingly, deletion of CRF-R2 attenuated MA-induced locomotor activation, elucidating a novel contribution of the CRF system to MA sensitivity, and suggesting the participation of the endogenous urocortin peptides Ucn2 and Ucn3. Immunohistochemistry for Fos was used to visualize neural activation underlying CRF-R2-dependent sensitivity to MA, identifying the basolateral and central nuclei of the amygdala as neural substrates involved in this response. Our results support further examination of CRF-R2 involvement in neural processes associated with MA addiction.

Ethanol intake and motor sensitization: the role of brain catalase activity in mice with different genotypes

The C57BL/6J strain of inbred mice shows a characteristic pattern of ethanol-induced behaviors: very weak acute locomotor stimulation, a lack of locomotor-sensitizing effect of ethanol, and a high level of ethanol intake. This strain has relatively low levels of activity of the ethanol metabolizing enzyme catalase, and it has been proposed that brain catalase plays a role in the modulation of some behavioral effects of ethanol. In the first study of the present paper, we investigated the effects of pharmacological manipulations of brain catalase activity on C57BL/6J mice in acute ethanol-induced locomotion and ethanol intake. Results indicated that the reduction in motor activity produced by ethanol was reversed by pretreatment with catalase potentiators and it was enhanced by catalase inhibitors. In addition, ethanol intake was highly correlated with brain catalase activity in mice treated with a catalase potentiator. In the second study, F1 hybrid mice (SWXB6) from the outbred Swiss-Webster mice and the inbred C57BL/6J mice were used. Basal brain catalase activity levels of F1 mice were intermediate between to those of the two progenitor genotypes. That profile of catalase activity was parallel to the acute-ethanol-induced locomotion and to repeated-ethanol-induced motor sensitization effects observed across the three types of mice. These data suggest that brain catalase activity modifications in the C57BL/6J strain change the pattern of several ethanol-related behaviors in this inbred mouse.

Reliability study of the European appropriateness evaluation protocol

OBJECTIVE

To help to co-ordinate and harmonize research on utilization review in Europe, the US Appropriateness Evaluation Protocol (f¿EP) was adapted for use in the European setting. The aim of this paper is to assess the reliability of the European version of the AEP (EU-AEP).

DESIGN

Nineteen English-language medical records were reviewed by a physician reviewer from each of six participating countries: Austria, France, Italy, Spain, Switzerland and the UK. Each of the six reviewers was asked to assess the appropriateness of the 19 admissions and 31 hospitalization days (19 admission days and 12 randomly selected days of hospital stay, excluding days of discharge) using the revised review instrument. To evaluate inter-rater reliability, the kappa statistic was used to measure overall and pair-wise agreement for the assessment of appropriateness of admission and of day of care, respectively.

RESULTS

For admission, the overall kappa statistic among the six reviewers was 0.64, with kappa values for each pair of reviewers in the range 0.46-0.86. For day of care, the kappa was 0.59, with pair-wise kappa coefficients in the range 0.25-0.95.

CONCLUSION

The observed agreement could be considered substantial, especially if the fact that medical records were hand-written in a language native to only one of the reviewers is considered. Besides all the study limitations, this finding provides at least preliminary support for the application of the EU-AEP as a reliable instrument in the European setting, including application in comparative studies involving two or more countries.

[Costs analysis of ambulatory blood pressure monitoring in mild hypertension]

BACKGROUND

To contrast the costs of conventional and ambulatory blood pressure monitoring (ABPM) methods in the diagnosis, treatment and follow-up of mild hypertensive patients.

METHODS

Among patients with conventional diagnosis of mild hypertension, the ABPM would discriminate patients with sustained hypertension, who would receive drug treatment, from patients with white coat hypertension (WCH), who would be only followed up. The diagnosis, treatment and control costs were obtained from 446 mild hypertensive patients from the Primary Health Care Center Aranbizkarra II (Vitoria, Spain) during 1996. For each gender, the overall costs per patient were estimated in both conventional and ABPM methods in terms of mean diagnosis age and WCH percentage.

RESULTS

For 45 years old patients and 30% of WCH, the overall costs per patient among men were 414,999 and 371, 101 pesetas with conventional and ABPM methods, respectively. From 30 to 60 years old patients, the ABPM method turned up to be less expensive as long as the WCH percentage was higher than 6%. Similar results were obtained among women with mild hypertension.

CONCLUSIONS

ABPM can be accepted as an useful clinical tool for the screening of patients with conventional diagnosis of mild hypertension. On the one hand, ABPM allows to select patients with low cardiovascular risk (WCH). On the other hand, the savings resulting from treatment reduction and fewer physician visits are higher than the additional costs of ABPM recordings.

[Non-compliance of the treatment with antibiotics in non-severe acute infections]

BACKGROUND

To determine the nonfulfillment of antiinfectious therapy in clinical practice.

MATERIAL AND METHODS

Fulfillment was quantified by tablet counting (TC) in the homes of 366 patients undergoing antibiotic treatment and the motives and predictive factors were identified.

RESULTS

Nonfulfillment was of 61% (95% confidence interval [CI] 55.4-66.6%). Patient improvement was the main reason for discontinuation (54.5%). The predictive factors were greater length of treatment (p = 0.000004), dose (p = 0.0019) and number of tablets (p = 0.0000).

CONCLUSIONS

Nonfulfillment of antiinfectious treatment in clinical practice is high, mainly due to clinical improvement and to the greater complexity and length of treatment.

[Relationship between medical treatment compliance and the degree of control in patients with high blood pressure, non-insulin dependent diabetes mellitus and dyslipidemia]

BACKGROUND

To study the relationship between therapeutic compliance and the control of arterial hypertension, non insulin dependent diabetes mellitus and hyperlipidemia.

PATIENTS AND METHODS

Prospective study performed on 174 hypertensive patients, 107 with diabetes and 107 with hyperlipidemia evaluating compliance by counting of tablets in two home visits.

RESULTS

34% hypertensive patients, 20% diabetics and 37% hyperlipidemics that took medication as instructed or more than they should were badly controlled.

CONCLUSIONS

The control grade of high blood pressure, non insulin dependent diabetes mellitus and hyperlipidemia not only depends on improving compliance but also in adapting pharmacologic prescriptions.

Use of two-segmented logistic regression to estimate change-points in epidemiologic studies

In many epidemiologic data, the dose-response relation between a continuous exposure and the risk of disease abruptly changes when the exposure variable reaches an unknown threshold level, the so-called change-point. Although several methods are available for dose-response assessment with dichotomous outcomes, none of them provide inferential procedures to estimate change-points. In this paper, we describe a two-segmented logistic regression model, in which the linear term associated with a continuous exposure in standard logistic regression is replaced by a two-segmented polynomial function with unknown change-point, which is also estimated. A modified, iteratively reweighted least squares algorithm is presented to obtain parameter estimates and confidence intervals, and the performance of this model is explored through simulation. Finally, a two-segmented logistic regression model is applied to a case-control study of the association of alcohol intake with the risk of myocardial infarction and compared with alternative analyses. The ability of two-segmented logistic regression to estimate and provide inferences for the location of change-points and for the magnitude of other parameters of effect will make this model a useful complement to other methods of dose-response analysis in epidemiologic studies.

Ambulatory blood pressure monitoring and diagnostic errors in hypertension: a Bayesian approach

Random variability of blood pressure complicates the diagnosis and subsequent treatment of hypertension. To evaluate the importance of the number of blood pressure measurements in the correct diagnosis and control of hypertension, the authors used a Bayesian model to estimate the true average blood pressure of a group of newly diagnosed hypertensives, then calculated the diagnostic error that would result from monitoring methods using 24 daytime measurements or from using only three random monitoring measurements. The study population consisted of 129 individuals with newly diagnosed mild hypertension according to standard criteria, who were also evaluated with an ambulatory blood pressure monitor. In true normotensives (daytime diastolic blood pressure <90 mm Hg), the negative predictive value with three measurements was 0.92, and it rose to 0.96 with monitoring methods. In mild hypertensives (90-104 mm Hg), the positive predictive value was 0.64 with three measurements and 0.84 with monitoring methods, thus reducing the rate of false mild hypertensives from 35% to 15%. Finally, in patients with moderate or severe hypertension (>104 mm Hg), the positive predictive value improved from 0.26 with three readings to 0.61 with monitoring methods. Similar results were observed with daytime systolic pressure measurements. As the number of measurements increased, the diagnostic error due to the random variability of blood pressure became progressively smaller. In cases of hypertension, the large improvement in predictive values may justify using monitoring methods to confirm standard diagnosis.

Microalbuminuria in normotensive patients with autosomal-dominant polycystic kidney disease

Microalbuminuria (MA) is present in hypertensive autosomal-dominant polycystic kidney disease (ADPKD) patients, but has not been reported in normotensive ADPKD patients. We examined the prevalence of MA and the effect of different determinants on urinary albumin excretion in a group of 42 normotensive ADPKD patients. Metabolic parameters, plasma renin activity and aldosterone and serum angiotensin-converting enzyme (ACE) activity were determined. A 24-h urine sample two or three times over a 6-month period was collected to evaluate MA. Each patient underwent an echocardiography to measure left ventricular mass. Eight patients (19%) showed MA (61.6 mg/day, range 37-164), whereas 34 patients (81%) were normoalbuminuric (8.8 mg/day, range 2-29). The groups were matched for all possible confounding variables, but microalbuminuric patients showed a tendency towards greater systolic blood pressure, plasma renin activity and left ventricular mass. There was no correlation between MA and age, sex, body mass index, systolic or diastolic blood pressure, plasma renin activity, serum ACE levels or left ventricular index. The present study demonstrates a high prevalence of MA in normotensive ADPKD patients. MA may be a predictor of early renal and vascular damage in these patients.

GLUT1 gene polymorphism in non-insulin-dependent diabetes mellitus: genetic susceptibility relationship with cardiovascular risk factors and microangiopathic complications in a Mediterranean population

OBJECTIVE

It has been suggested that the polymorphic variation of GLUT1 glucose transporter may contribute to genetic susceptibility to type 2 diabetes in some populations. We have evaluated the GLUT1-XbaI polymorphism in an association study of a Caucasian Mediterranean population and its role in the susceptibility to displaying either microangiopathic complications or any of the risk factors associated with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 193 type 2 diabetic patients (104 women and 89 men, 31-82 years of age, diabetes duration 13.2 +/- 6.2 years) and 90 healthy subjects (48 women and 42 men, 20-72 years of age) were recruited for the association study. For the evaluation of nephropathy and retinopathy, type 2 diabetic patients were matched with those not having microangiopathic complications.

RESULTS

Genotypic or allelic frequencies did not differ significantly between controls and type 2 diabetic patients. Regarding the distribution of clinical or metabolic parameters according to GLUT1 genotype, patients with X1X1 genotype tended to have higher diastolic blood pressure levels compared with the remaining genotypes (P = 0.008). There were no differences in genotypic or allelic distribution among patients for either the presence or absence of retinopathy or nephropathy.

CONCLUSIONS

We conclude that GLUT1 loci did not contribute significantly to type 2 diabetes in this cohort and is not a determinant for cardiovascular risk factors or chronic microangiopathic complications associated with type 2 diabetes. The weak association with diastolic hypertension must be confirmed in other populations.

[Factors involved in the non-compliance of the pharmacologic treatment of dyslipidemia]

OBJECTIVES

To find how much non-compliance with lipid-lowering drug treatment there is, its causes and to describe the profile of non-compliant patients.

DESIGN

Prospective study.

SETTING

Primary Care Centres in the province of Alicante.

PATIENTS

107 patients under drugs treatment for lipaemic disorders and belonging to live General Medical practices.

MEASUREMENTS AND MAIN RESULTS

To evaluate compliance, the method of a surprise count of pills in the patient's home was used. Compliant patients were defined as those with between 80 and 110% compliance. 46.7% were non-compliant (C.I. 37.3-56.2), with 42% under-compliant and 4.7% over. Forgetfulness and unawareness accounted for 68% of the reasons for non-compliance. Associated factors were: moderate to high cardiovascular risk (p = 0.03), stating that the drug treatment was followed badly (p = 0.01), less than a year in regular treatment (p = 0.006), monitoring lipaemia poorly (p = 0.003).

CONCLUSIONS

Non-compliance with pharmacological treatment in patients with lipaemia is high. Its causes are known, as are several factors associated to non-compliance which could be used to identify the non-complier.

[Factors involved in noncompliance with pharmacological treatment in arterial hypertension]

OBJECTIVES

To find the amount of non-compliance with medical treatment for Hypertension and its causes, and to describe the profile of non-compliant patients.

DESIGN

A crossover study performed on two home visits.

SETTING

A rural Health Centre at Calpe, Alicante.

PATIENTS

The sample was obtained from the census of medically treated hypertense patients. 174 of the 200 patients chosen completed the study.

MEASUREMENTS AND MAIN RESULTS

Compliance was evaluated by a surprise count of pills in the patient's home. Patients complying between 80 and 110% were considered compliant. There was 47.7% non-compliance (C.I. 95%: 40.3-55.1), with 31% under-compliers and 16.7% over-compliers. Lack of information (39.8%) and forgetfulness (28.9%) were the most common causes of non-compliance.

CONCLUSIONS

A high amount of non-compliance was shown, including an important number of over-compliers. Its causes were defined along with other reasons predicting non-compliance.

Angiotensin I-converting enzyme and angiotensinogen gene polymorphisms in non-insulin-dependent diabetes mellitus. Lack of relationship with diabetic nephropathy and retinopathy in a Caucasian Mediterranean population

Genotypic abnormalities of the renin-angiotensin system have been suggested as a risk factor for the development of microangiopathic complications in diabetic patients. We studied the relationship of either an insertion-deletion polymorphism in the angiotensin-converting enzyme (ACE) gene and the M235T and T174M variant polymorphisms of the angiotensinogen (AGT) gene in non-insulin-dependent diabetes mellitus (NIDDM) patients and its relationship with cardiovascular complications. A total of 193 NIDDM patients (89 men and 104 women aged 59.2 +/- 10.0 years; diabetes duration, 13.2 +/- 6.2 years) and 90 control subjects (42 men and 48 women aged 45.4 +/- 12.6 years) were recruited for the association study. Distribution of the genotype or allelic frequencies for all the studied polymorphisms did not differ significantly between controls and NIDDM patients. ACE and AGT genes did not display any difference in clinical or metabolic parameters according to each gene's genotype for either the control or the NIDDM group. For evaluation of nephropathy and retinopathy, NIDDM patients were matched with subjects not having microangiopathic complications. Thus, a total of 60 patients had diabetic nephropathy and were compared with 100 patients with normoalbuminuria. Sixty-eight NIDDM patients had diabetic retinopathy, and 92 patients presented no signs of retinopathy. There were no differences in genotypic or allelic distribution between NIDDM patients for either the presence or absence of retinopathy or nephropathy. We conclude that the ACE and AGT polymorphisms do not contribute to the genetic susceptibility to diabetic nephropathy and retinopathy in a caucasian Mediterranean population.

[The validity of 6 indirect methods for assessing drug treatment compliance in arterial hypertension]

OBJECTIVE

To validate six indirect methods, which were simple and easy to apply in clinical practice, of identifying patients who did not comply with drugs treatment for hypertension.

DESIGN

A prospective study based on two visits to patient's home.

SETTING

rural health centre at Calpe, Alicante.

PATIENTS

174 patients (58 men and 116 women) were included. They were chosen at random from the centre's records of hypertense patients.

MEASUREMENTS AND MAIN RESULTS

Compliance was assessed by the method of a surprise counting of pills in the patient's home. Patients who had between 80 and 110% compliance were defined as compliant. The six indirect methods validated were: communication of self-compliance (CS), attendance at appointments (AA), doctor's judgment (DJ), information about the illness (II), hypertension control (HC) and the Morisky-Green test (MG). II was the most sensitive (81.9%). CS reached the highest specificity (93.4%), the best positive predictive value (81.8%) and the best concordance index (kappa, 0.26).

CONCLUSIONS

II and CS are the indirect methods with the best validity indicators and could be used together to assess compliance with drugs treatment for hypertension.

[Apolipoprotein AI-CIII, B, and CII gene polymorphisms in patients with non-insulin dependent diabetes mellitus. Association with hyperlipemia]

BACKGROUND

Dislipidaemia is an usual feature in patients affected by non insulin dependent diabetes mellitus. Several studies show that this disease could be genetically determined. The aim of this study was to ascertain whether any of the genetic polymorphism remaining in three apolipoprotein loci (apolipoprotein AI-CIII, B100 and CII) is related with the presence of dislipidaemia in non insulin dependent diabetes mellitus patients.

PATIENTS AND METHODS

53 non insulin dependent diabetes mellitus patients with less than 5 years evolution and treated only with diet, were included. 86 healthy persons were included as the control group. The lipidic parameters analyzed were: cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apolipoprotein AI, B and lipoprotein (a). The following polymorphic variants were analyzed: RFLP-Sacl of the apolipoprotein AI-CIII-AIV cluster, RFLP-Xbal of the apolipoprotein B100 region and the RFLP-Taql of the apolipoprotein E-CI-CII cluster.

RESULTS

There were no genetic nor allelic differences in the distribution of the genes, between controls and diabetic patients. Regarding the apolipoprotein CII gen, the diabetic patients with the T2T2 genotype had higher triglyceride levels (p < 0.01) compared with the remaining genotypes and compared with the control group having the same genotype (p < 0.01) matched for sex, age and body mass index. There was no difference in the metabolic parameters' distribution related to the genotypic distribution of the apolipoproteins AI-CIII and B100 genes.

CONCLUSIONS

The apolipoprotein CII can be related with the presence of hypertriglyceridaemia in non insulin dependent diabetes mellitus patients.

A tumor necrosis factor-beta polymorphism associated with hypertriglyceridemia in non-insulin-dependent diabetes mellitus

Non-insulin-dependent (type II) diabetes mellitus is associated with significant abnormalities of lipoprotein metabolism. Control of glycemia rarely completely corrects the alterations in lipid metabolism, suggesting a participation of environmental and genetic factors. The observation that tumor necrosis factor (TNF) can modulate triglyceride metabolism offers a new genetic candidate to be analyzed. Samples of DNA from 91 control subjects and 61 diet-treated type II diabetic patients were analyzed to determine the lipid profile and a possible association with TNF genetic polymorphisms. For TNF restriction fragment length polymorphisms, we used the Nco I restriction enzyme and a TNF-alpha probe obtaining two allelic bands at 10.5 and 5.5 kb. We found a significant association (P < .01) of the 10.5-kb homozygous genotype in type II diabetic subjects with high triglyceride levels. Furthermore, these patients showed significant differences in triglycerides as compared with matched control subjects with the same genotype (P < .001). This study provides support for considering the TNF locus as a susceptibility genetic region in the hypertriglyceridemia of type II diabetes.

Unliganded c-erbA/thyroid hormone receptor induces trkB expression in neuroblastoma cells

Neurotrophins are responsible for the differentiation and survival of neurons in the developing and in the adult nervous system. They bind to specific membrane receptors with tyrosine kinase activity whose prototype is the product of the trkA proto-oncogene. TrkB, a member of this family, is the receptor for the neurotrophins brain derived growth factor (BDNF) and neurotrophins-3, -4/5. In this study, we show that stable expression of the c-erbA proto-oncogene, which encodes the alpha 1-isoform of the nuclear receptor for thyroid hormone (Tr alpha 1) induces the expression of trkB mRNA with a concomitant decrease to undetectable levels of trkA and trkC mRNAs in the mouse neuroblastoma N2a cell line. trkB induction by c-erbA is ligand independent, since addition of T3 had no effect. The induced trkB transcript encodes a functional gp145trkB protein, which is phosphorylated on tyrosine in response to BDNF. Furthermore, induction of trkB mRNA is also caused by transient expression of either TR alpha 1 or beta 1 isoforms. Our results are compatible with the idea that there are certain pathways which are under control of unliganded thyroid hormone receptor, and that one of these pathways results in regulation of trk expression.

T3 receptor occupancy and T3 levels in plasma and cytosol during rat brain development

The concentration and occupancy of the thyroid hormone receptor have been measured in rat brain nuclear extracts at the end of the fetal period and during the postnatal period. Receptor occupancy attained maximal values at postnatal day 15 (52% of total receptor binding sites occupied by T3) and correlated with plasma and cytosol total and free T3. The values for these parameters showed greater differences throughout development than did receptor occupancy. From gestational day 21 to postnatal day 15, total T3 increased in plasma from 0.18 to 1 nmol/l and in cytosol from 1 to 7.5 pmol/l. Free T3 increased in plasma from 1.2 to 6 pmol/l and in cytosol from 8 to 59 pmol/l. Nuclear free T3, calculated on the basis of receptor occupancy, and Kd increased in parallel, from 39.8 to 107 pmol/l at the same ages. Values for nuclear free T3 were between 2 and 5 times those in cytosol and between 10 and 40 times those in plasma, suggesting the presence of a small free T3 gradient from plasma to the nucleus. All of the above changes take place during the critical period of oligodendrocyte differentiation and the start of myelin gene expression, suggesting that thyroid hormone influences these important events of brain maturation.

Effects of maternal iodine deficiency on thyroid hormone economy of lactating dams and pups: maintenance of normal cerebral 3,5,3'-triiodo-L-thyronine concentrations in pups during major phases of brain development

Female rats were fed a diet with a low iodine content (LID), or the same LID supplemented with KI, and mated. Fetuses were obtained at 17 and 21 days of gestation, or pups were killed at different ages after birth. The dams on LID were markedly iodine deficient and developed a large goiter. Their thyroidal iodine content was only 4% of that of LID + I dams. The iodine deficiency of the LID mothers was severe enough to result in very low plasma T4 levels and in hepatic and cerebral T3 deficiency, despite normal circulating levels of T3. The fetuses from LID dams had low concentrations of iodine in their placentas and thyroid glands, and were deficient both in T4 and T3 in all tissues studied, including the brain. After birth, however, suckling LID pups were able to increase the plasma T4 to levels which were higher than those found in either LID fetuses or in adult LID progeny, although plasma T4 was always lower than in age-paired LID + I animals. This increase in T4 was probably due to an approximately 5-fold increase in iodine intake while suckling. Milk from LID mothers was found to contain 22% of the amount of iodine found in milk from LID + I dams, in contrast to their iodine intake, which was about 4% that of the LID + I rats. Cerebral T3 levels were the same for LID and for LID + I pups throughout most of the postnatal period of brain development. This finding might explain the difficulties encountered in obtaining an experimental model of neurological cretinism in rats.

Effects of maternal iodine deficiency on the L-thyroxine and 3,5,3'-triiodo-L-thyronine contents of rat embryonic tissues before and after onset of fetal thyroid function

Female rats were placed on a low iodine diet (LID) or LID supplemented with KI. They were mated 3-6 months later. Maternal and embryonic tissues were obtained both before the onset of fetal thyroid function, at 11 and 17 days of pregnancy, and at 21 days of gestation. T4 and T3 concentrations were measured by RIA. T4 concentrations were very low in the plasma, liver, and lung of LID dams and in all embryonic samples obtained from such mothers, namely 11-day-old embryotrophoblasts, 17-day-old placentas and embryos, 21-day-old placentas, embryos, plasma, liver, lung, and carcass (whole embryos minus the trachea, thyroid, blood, liver, and brain). T3 was low in 17-day-old placentas and embryos and in all fetal tissues obtained at 21 days of gestation from LID dams. These results show that when iodine deficiency is severe enough to result in very low maternal plasma T4 levels, embryonic tissues are deficient in T4 and T3 both before and after the onset of fetal thyroid function. This finding might be relevant to the etiopathology of human iodine deficiency disorders.

Effects of maternal hypothyroidism on the weight and thyroid hormone content of rat embryonic tissues, before and after onset of fetal thyroid function

Embryonic tissues were obtained from normal (C) and thyroidectomized (T) rats between 9 and 21 days of pregnancy. We determined the number and weight, as well as the T4 and T3 contents (RIA), of 9- to 12-day-old embryotrophoblasts, of 13- to 21-day-old embryos and placentas, and of liver, lung, and brain from 20- and 21-day-old fetuses. T4 and T3 were found in all samples obtained from C dams, both before and after onset of fetal thyroid function. Despite low levels of both iodothyronines in fetal plasma near term, their concentrations in fetal brain and lung had reached half the maternal values. The T3/T4 ratio in fetal organs was the same, or higher, than in adult rats. Maternal thyroidectomy resulted in a marked decrease of the number and individual weights of viable conceptuses, throughout gestation. Fetal organ weights near term were also decreased, and changes were found in brain DNA and protein concentrations. T4 and T3 were undetectable in all embryotrophoblasts, embryos and placentas obtained from T dams before onset of fetal thyroid secretion. They were still markedly reduced in 21-day-old placentas. Total extrathyroidal contents of T3 and T4 in 20- and 21-day-old fetuses from T dams were also low as compared to those from normal mothers, but individual organs were not affected to the same degree. Thus concentrations were decreased in the carcass (whole embryo minus the trachea + thyroid + liver + lung + brain), but normal in the brain. These results show that maternal hypothyroidism is accompanied by thyroid hormone deficiency of the conceptus before the fetal thyroid functions. After this, alterations of T4 and T3 concentrations persist until term. Development is also delayed. Thus, adverse effects of maternal hypothyroidism may be due, at least in part, to the thyroid hormone deficiency of the embryonic tissues, and not only to the hypothyroid condition of the mother.

L-thyroxine and 3,5,3'-triiodo-L-thyronine in rat embryos before onset of fetal thyroid function

T4 and T3 have been measured by RIA in 10-12-day-old rat embryo-trophoblasts, and in 13-20-day-old embryos and placentas, as well as in a few samples of amniotic fluid. Both T4 and T3 were measured after extraction of the samples with ethanol, purification by paper chromatography, anion exchange resin, or both. T4 and T3 could be shown in all samples studied. The amounts of T4 and T3 per conceptus and their concentrations were higher in embryo-trophoblasts and placentas than in 13-18-day-old embryos. The concentrations of T4 and T3 remained fairly constant in the embryos until day 19, when they appeared to increase. The molar ratios of T4 to T3 were 1.4, 8.5 and 103 for embryos, placentas and maternal plasma, respectively. These data show that, for at least one mammalian species, embryonic tissues are provided with T4 and T3 from the earliest date studied, namely 4 days after uterine implantation, and well before onset of thyroid function, which in the rat starts after 17 days gestational age. Such a result suggests that statements denying a possible role of thyroid hormones in early embryogenesis ought to be reconsidered.