Anger, negative emotions, and cardiovascular reactivity during interpersonal conflict in women

OBJECTIVE

In order to evaluate the relationship between women's subjective emotional discomfort with anger and cardiovascular responses to stress, cardiovascular and affective responses were examined during two anger-provoking conditions: one in which anger would be in self-defense, and one in which anger would be in defense of a significant other.

METHODS

A total of 42 healthy, normotensive women aged 18-35 years recruited a close female friend to participate in the study with them, and were randomly assigned to one of two harassment conditions: (i) Self-Harass, where women were harassed while performing a math task; (ii) Friend-Harass, where women witnessed a close female friend being harassed while their friend performed a math task.

RESULTS

Self-Harass and Friend-Harass women reported feeling equally angry, annoyed, and irritated (all P's<.01) during their respective anger-provocation conditions. However, Self-Harass women reported experiencing significantly greater increases in feelings of depression and guilt during anger provocation (P's<.05) relative to Friend-Harass women. Interestingly, it was also the Self-Harass women who exhibited significantly greater elevations in heart rate (HR), cardiac output (CO), systolic blood pressure (SBP), forearm blood flow (FBF), and significant reductions in forearm vascular resistance (FVR; P's<.001) relative to Friend-Harass women during anger provocation.

CONCLUSIONS

Results suggest that women may experience other negative emotions (e.g., guilt, depression) when anger is in self-defense relative to when it is in defense of others, and that these emotions may play a more important role than anger in moderating cardiovascular reactivity (CVR) during interpersonal conflict.

Hepatocyte growth factor inhibits apoptosis after ischemic renal injury in rats

Several studies have determined that growth factors, including hepatocyte growth factor (HGF), have a crucial role in the regenerative process of renal tubules after ischemic or toxic insult. Recent research has ascertained that as well as necrotic cell death, there is evidence of apoptosis after an acute renal injury. We attempted to determine the effect of HGF on apoptosis after ischemic renal injury in rats. We administered HGF or vehicle to 12 rats after ischemic insult and compared them with 6 sham-operated controls. Rats were killed at 48 hours, and histopathologic assessments were performed on the renal tissue. The microscale autoradiographic method was used for qualitative analysis of DNA fragmentation. This method was chosen over the widely used ethidium bromide-staining method because it increases the sensitivity of detection of apoptotic DNA. Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling histopathologic staining was used to identify apoptosis in situ. Apoptotic changes were clearly shown by electron microscopy in vehicle-treated animals. Despite showing profound evidence of tubular necrosis, apoptotic changes were markedly reduced in HGF-treated animals compared with vehicle-treated animals. DNA-laddering analysis further confirmed the antiapoptotic effect of HGF. To our knowledge, this is the first in vivo illustration of the inhibitory activity of a growth factor on apoptosis in the setting of tubular necrosis. The role of apoptosis in the setting of acute renal failure has not been elucidated; thus, additional research is necessary to determine the significance of these findings.

Verrucous carcinoma of the foot: a review and report of two cases

Verrucous carcinoma is an uncommon form of squamous cell carcinoma. Clinical and histological features of this condition are reviewed. Excision is the treatment of choice due to local aggressiveness and infrequent metastasis. Two cases involving the foot are presented as well as a survey of previously documented cases of this condition.

Differential localization of P2 receptor subtypes in mesenteric arteries and veins of normotensive and hypertensive rats

ATP acts at P2 receptors to contract blood vessels and reactivity to vasoconstrictor agents is often altered in hypertension. This study was designed to identify P2 receptors in mesenteric arteries and veins and to determine whether ATP reactivity is altered in deoxycorticosterone acetate (DOCA)-salt hypertensive rats. Computer-assisted video microscopy was used to measure vessel diameter in vitro. ATP was a more potent constrictor of veins (EC(50) = 2.7 microM) than arteries (EC(50) = 196 microM) from normotensive rats; there was no change in ATP reactivity in vessels from DOCA-salt rats. The P2X1 receptor agonist alpha,beta-methylene ATP (alpha,beta-MeATP, 0.03-3 microM) contracted arteries but not veins. ATP-induced contractions in arteries were blocked by alpha,beta-MeATP (3 microM) desensitization. 2-Methylthio-ATP (0.1-10 microM), an agonist that can act at P2Y1 receptors, did not contract arteries or veins, whereas UTP, an agonist at rat P2Y2/P2Y4 receptors, contracted veins (EC(50) = 15 microM) and arteries (EC(50) = 24 microM). UTP-induced contractions of veins cross-desensitized with ATP, whereas UTP-induced contractions in arteries were unaffected by alpha,beta-MeATP-desensitization. The P2X/P2Y1 receptor antagonist pyridoxal-phosphate-6-azophenyl-2',4-disulfonic acid blocked ATP-induced contractions of arteries (IC(50) = 4.8 microM) but not veins. Suramin, an antagonist that blocks P2Y2 receptors, partly inhibited ATP- and UTP-induced contractions of veins. Immunohistochemical studies revealed P2X1 receptor immunoreactivity in arteries but not veins. These data indicate that mesenteric vascular reactivity to ATP is not altered in DOCA-salt hypertension. ATP acts at P2X1 and P2Y2 receptors to contract mesenteric arteries and veins, respectively, whereas in arteries UTP acts at an unidentified P2 receptor.

Elevated blood pressure in men accompanying patients to the obstetrician's office

Hypertension is common and leads to increased mortality among adults; yet, one-third of hypertensive adults in the United States are unaware of their condition. The purpose of this study was to determine the frequency of unrecognized elevated blood pressure (BP) in men accompanying pregnant women to the obstetrician's office. Blood pressure measurements were offered to men accompanying pregnant women to four obstetrics practices in St. Louis, Missouri. Age, race, history of hypertension, and relationship to the pregnant woman were also recorded. A total of 191 men participated in the study. Participants' ages ranged from 15 to 69 years, with a mean of 27 years. Elevated BP (> 140/90 mm Hg) was detected in 40 men (21%). Only 5% of men with an elevated BP were aware of a prior history of elevated BP. We conclude that the obstetrician's office provides a good opportunity for initial screening for hypertension in men. Follow-up is necessary to determine the accuracy of the diagnosis.

Cardiopulmonary baroreflex stimulation and blood pressure-related hypoalgesia

Results from both experimental animals and humans suggest that baroreflex stimulation may be involved in blood pressure-related hypoalgesia. However, most of this research, especially in the area of human experimentation, has focused on sinoaortic baroreceptors. Cardiopulmonary baroreflex stimulation may also be an important moderator of pain. Sixty-six healthy male undergraduates varying in risk for hypertension participated in an experimental protocol in which painful mechanical finger pressure was presented three times in a counterbalanced fashion. One pain stimulus was preceded by 6 min of supine rest, another by a period of rest interspersed with periodic Valsalva manoeuvres, and another by a period in which cardiopulmonary baroreceptors were stimulated by passive leg elevation. Significantly lower pain was reported by men with relatively elevated systolic blood pressure following leg elevation but not the other conditions. Cardiopulmonary baroreflex stimulation was documented by increased forearm blood flow and other data obtained via impedance cardiography. These results suggest that blood pressure related hypoalgesia may be at least partially related to cardiopulmonary baroreflex stimulation.

Clinical use of growth factors in chronic renal failure

Erythropoietin has been demonstrated to improve the quality of life in patients with chronic renal failure, and growth hormone has been approved for use in children with chronic renal failure and short stature as a growth promoting agent. Growth factors also have great therapeutic potential to improve glomerular function in the setting of chronic renal failure. Further studies are required to delineate the role of insulin-like growth factor I in the setting of end-stage chronic renal failure.

Insulin-like growth factor 1 enhances renal function in a patient with chronic renal failure on peritoneal dialysis

Insulin-like growth factor 1 (IGF1) has been shown to improve renal function in healthy subjects, as well as those with chronic renal failure. To our knowledge, IGF1 has not been shown to be efficacious in patients who were already undergoing dialysis. We present the case of a 70-year-old woman with end-stage renal disease (ESRD) and overt uremic symptoms treated with IGF1 after peritoneal dialysis was discontinued because of complications. There was a significant improvement in her inulin clearance during the course of treatment. The patient remained well and did not require dialytic support for 19 weeks. Although further data are necessary, we believe this case shows that IGF1 may be a short-term alternative to dialysis in patients with ESRD.

Effects of potassium on blood pressure in salt-sensitive and salt-resistant black adolescents

This study examined the effects of increasing dietary potassium on ambulatory blood pressure nondipping status (<10% decrease in blood pressure from awake to asleep) and cardiovascular reactivity in salt-sensitive and salt-resistant black adolescents. A sample of 58 normotensive (blood pressure, 101/57+/-9/4 mm Hg) black adolescents (aged 13 to 16 years) participated in a 5-day low sodium diet (50 mmol/24 h) followed by a 10-day high sodium diet (150 mmol/24 h NaCl supplement) to determine salt-sensitivity status. Participants showed a significant increase in urinary sodium excretion (24+/-19 to 224+/-65 mmol/24 h) and were identified as salt-sensitive if their mean blood pressure increase was >/=5 mm Hg from the low to high sodium diet. Sixteen salt-sensitive and 42 salt-resistant subjects were then randomly assigned to either a 3-week high potassium diet (80 mmol/24 h) or usual diet control group. Urinary potassium excretion significantly increased in the treatment group (35+/-7 to 57+/-21 mmol/24 h). At baseline, a significantly greater percentage of salt-sensitive (44%) compared with salt-resistant (7%) subjects were nondippers on the basis of diastolic blood pressure classifications (P<0.04). After the dietary intervention, all of the salt-sensitive subjects in the high potassium group achieved dipper status as a result of a drop in nocturnal diastolic blood pressure (daytime, 69 versus 67 mm Hg; nighttime, 69 versus 57 mm Hg). No significant group differences in cardiovascular reactivity were observed. These results suggest that a positive relationship between dietary potassium intake and blood pressure modulation can still exist even when daytime blood pressure is unchanged by a high potassium diet.

Acute renal failure in the cardiac care unit: etiologies, outcomes, and prognostic factors

BACKGROUND

Heart disease is a leading cause of hospitalizations, and its prevalence is expected to grow rapidly over the next few decades. The purpose of this study was to examine the incidence, etiologies, outcomes, and risk factors for mortality of acute renal failure (ARF) in cardiac care unit (CCU) patients.

METHODS

A retrospective, cohort study examining all patients who developed ARF while in the CCU at Barnes-Jewish Hospital over a 17-month time period was performed. Charts were reviewed to determine etiologies, hospital mortality rates, and risk factors for mortality.

RESULTS

Four percent of admissions to the CCU met criteria for ARF while in the unit. The etiologies of ARF were congestive heart failure (CHF; 35%), multifactorial (usually involving CHF; 26%), arrest/arrhythmia (13%), contrast (11%), volume depletion (6%), sepsis (6%) and obstruction (3%). The mortality rate was 50%. Oliguria, mechanical ventilation, and decreased cardiac function were statistically significant risk factors for mortality by univariate but not multivariate analysis. Thirty percent of patients with a cardiac index of less than 2.0 liter/min/m2 survived to discharge.

CONCLUSIONS

ARF occurs commonly in CCU patients and is associated with a high mortality rate. However, there are a significant number of survivors even among patients with severely depressed cardiac function.

Insulin-like growth factor I improves renal function in patients with end-stage chronic renal failure

There is no pharmacological treatment to increase the glomerular filtration rate in end-stage renal disease (ESRD). The administration of 100 microgram/kg of insulin-like growth factor (IGF) I twice a day to patients with ESRD increases inulin clearance. However, its effect is short-lived and IGF-I has major side effects when given this way. To assess whether the use of a lower intermittent dose of IGF-I would effect sustained improved function with tolerable side effects we performed 1) a prospective open-labeled 24-day trial in which we enrolled five patients and 2) a 31-day randomized, double-blinded, placebo-controlled trial in which we enrolled 10 patients. Patients with ESRD [creatinine clearance of <15 ml. min-1. (1.73 m2)-1] and scheduled to initiate renal replacement therapy received subcutaneous IGF-I, 50 microgram. kg-1. day-1, or vehicle. Treatment with IGF I resulted in significantly increased glomerular filtration rates (inulin clearances) during the 3rd and 4th wk of therapy in both prospective and double-blinded studies. Vehicle had no effect. No patient required discontinuation of drug secondary to side effects. We conclude that IGF-I effects sustained improvement of renal function (clearances comparable to those generally achieved by dialysis) in patients with ESRD and is well tolerated.

Ambulatory blood pressure nondipping status in salt-sensitive and salt-resistant black adolescents

This study examined the relationship between salt sensitivity and ambulatory blood pressure in 53 healthy black adolescents. Salt sensitivity was defined as an increase in mean blood pressure greater than or exceeding 5 mm Hg from a 5-day low-salt diet (50 mmol/24 h) to a 10-day high-salt diet (150 mmol/24 h NaCl supplement). Sixteen subjects were salt sensitive and 37 subjects were salt resistant (showed < 5 mm Hg increase in mean blood pressure). Subjects were classified as dippers (> or =10% decrease in blood pressure from awake to asleep) based on their 24-h ambulatory blood pressure values. Nondippers showed higher systolic, diastolic, and mean asleep blood pressures than dippers (P < .05 for all). Salt-sensitive subjects showed greater daytime diastolic and mean blood pressures than salt-resistant subjects (P < .05 for both). A significantly greater percentage of nondippers were salt sensitive, compared with salt resistant for diastolic blood pressure (P < .001) and mean blood pressure (P < .05). For both of these blood pressure measures, 50% of the salt-sensitive subjects had a nondipping status, compared with only 5.4% of the salt-resistant subjects for diastolic blood pressure, and 18.9% of the salt-resistant subjects for mean blood pressure. These results are the first to indicate that salt sensitivity is associated with nondipper blood pressure status in a black normotensive adolescent population.

Risk factors for abnormal anal cytology in young heterosexual women

Although anal cancers are up to four times more common in women than men, little is known about the natural history of anal human papillomavirus (HPV) infections and HPV-related anal lesions in women. This study reports on the prevalence of and risks for anal cytological abnormalities over a 1-year period in a cohort of young women participating in a study of the natural history of cervical HPV infection. In addition to their regularly scheduled sexual behavior interviews and cervical testing, consenting women received anal HPV DNA and cytological testing. Anal cytology smears were obtained from 410 women whose mean age was 22.5 +/- 2.5 years at the onset of the study. Sixteen women (3.9%) were found to have abnormal anal cytology: 4 women had low-grade squamous intraepithelial lesions (SILs) or condyloma; and 12 women had atypical cells of undetermined significance. Factors found to be significantly associated with abnormal anal cytology were a history of anal sex [odds ratio (OR), 6.90; 95% confidence interval (CI), 1.7-47.2], a history of cervical SILs (OR, 4.13; 95% CI, 1.3-14.9), and a current anal HPV infection (OR, 12.28; 95% CI, 3.9-43.5). The strong association between anal intercourse and the development of HPV-induced SILs supports the role of sexual transmission of HPV in anal SILs. Young women who had engaged in anal intercourse or had a history of cervical SILs were found to be at highest risk.

Recombinant human insulin-like growth factor-I (IGF-I) therapy decreases plasma leptin concentration in patients with chronic renal insufficiency

OBJECTIVE

To determine the relationship between plasma leptin and insulin-like growth factor-I (IGF-I) levels in healthy subjects and patients with chronic renal insufficiency at baseline, and during administration of recombinant human IGF-I in the renal impaired patients.

SUBJECTS

20 healthy subjects (six men, 14 women, age: 42.7 +/- 3.2 y) and nine subjects with chronic renal insufficiency (five men, four women, age: 53.6 +/- 3.7 y).

INTERVENTION

Daily s.c. injection of recombinant human IGF-I (50 micrograms/kg) for 24 d.

MEASUREMENTS

Fasting plasma levels of leptin, IGF-I, growth hormone, C-peptide, glucagon and IGF binding proteins by specific radioimmunoassays at baseline in all subjects and serially during IGF-I therapy in the renal impaired subjects.

RESULTS

Baseline leptin levels were correlated with body mass index (BMI, R = 0.72, P = 0.0001) but not IGF-I levels (R = 0.02). During IGF-I therapy, plasma IGF-I levels increased from 128 +/- 17.4 ng/ml at baseline to 250 +/- 36.8 ng/ml on day 3 (P = 0.003) and 323 +/- 61.6 ng/ml on day 24 (P = 0.01), whereas leptin levels declined: 24.4 +/- 10.3 ng/ml (baseline), 19.5 +/- 6.2 ng/ml (day 3, P = 0.028), and 17.2 +/- 4.9 ng/ml (day 24, P = 0.05).

CONCLUSION

Basal plasma leptin and IGF-I levels are not correlated; however, chronic administration of recombinant IGF-I is associated with an early and sustained decrease in plasma leptin levels. IGF-I may have an inhibitory effect on leptin secretion in humans.

Plasma leptin concentrations are only transiently increased in nephrectomized rats

Leptin is an adipocyte-secreted hormone that has effects on appetite and energy expenditure. Several studies have shown that end-stage renal disease results in elevated plasma leptin concentrations and that the kidney is responsible for most of leptin elimination in rodents. Leptin metabolism was investigated in rats that underwent unilateral nephrectomy to experimentally limit renal elimination function. Within 4 h of nephrectomy, plasma leptin concentrations increased from 2.9 +/- 0.8 to 5.8 +/- 1.0 & microg/l but thereafter rapidly (<24 h) decreased to prenephrectomy concentrations, despite continued elevated plasma creatinine levels. Sham-operated rats maintained presurgical concentrations of leptin and creatinine throughout the experiment. Kinetic studies of 125I-labeled leptin elimination showed that fractional catabolic rates and half-lives of leptin in circulation were similar at 48 h in nephrectomized and sham-operated rats, suggesting that production of leptin was unchanged after nephrectomy. Excretion of 125I derived from leptin in urine of nephrectomized rats was similar to that of sham-operated rats, and residual radioactivity was increased in the remaining kidneys excised from nephrectomized rats. These results demonstrate that 1) leptin concentrations are quickly restored to presurgical levels in nephrectomized rats, and 2) it is leptin elimination, not leptin production, that compensates to maintain leptin concentrations. Rapid metabolic adaptation of remaining renal tissue may explain the restoration of normal leptin elimination in nephrectomized rats.

Acute renal failure: prevention and nondialytic therapy

Acute renal failure (ARF) is a common illness with significant associated mortality and morbidity. Despite the advent of renal replacement therapy and the advancement in dialytic technology, the mortality of ARF has not significantly changed in the last 30 years. The cost of treating acute renal failure with the available therapies inflicts a tremendous financial burden on the health care system. The majority of patients with acute renal failure have multiple etiologies which are frequently iatrogenic. Physicians frequently underestimate the level of renal dysfunction in patients and therefore interventions to curb or treat renal failure are delayed. It is clear that ARF can be averted with more vigilance and early interventions. No pharmacological agent has yet been approved for the treatment of acute renal failure. Several substances are in the various stages of animal and human trials. Until one becomes available for use in the treatment of renal failure, it is clear that prevention is the principal element in the management of ARF. The purpose of this review is to discuss the various risk factors for acute renal failure, methods of prevention, and pharmacological interventions that may be beneficial in the treatment of ARF.

Parental history of hypertension and hostility moderate cardiovascular responses to interpersonal conflict

A parental history of hypertension has been implicated in the development of hypertension, perhaps by virtue of an elevated cardiovascular response to stress. Similarly, hostility has been hypothesized to be linked to cardiovascular disease through cardiovascular hyperreactivity. The interaction of parental history and hostility in moderating cardiovascular response has been infrequently examined, though research suggests the two may be linked through familial factors. The present study examined the cardiovascular response of 98 healthy young adult males categorized as offspring of hypertensive subjects (PH+) or offspring of normotensive subjects (PH-) and as high or low hostile, based on Cook-Medley Hostility scores (HiHo vs. LoHo). Subjects were exposed to either an harassment or non-harassment stressor. Results indicated elevated cardiac output and forearm blood flow responses in PH+/HiHo subjects who were harassed as compared to any other harassed subject and all non-harassed individuals. This hemodynamic response pattern of elevated blood flow suggests a mechanism of hypertensive disease development.

The natural history of human papillomavirus infection as measured by repeated DNA testing in adolescent and young women

OBJECTIVES

The objectives of this study were to describe the early natural history of human papillomavirus (HPV) infection by examining a cohort of young women positive for an HPV test and to define within this cohort (1) the probability of HPV regression, (2) the risk of having a squamous intraepithelial lesion, and (3) factors that were associated with HPV regression.

STUDY DESIGN

The study was a cohort analytic design. An inception cohort of 618 women positive for HPV participated. HPV testing, cytologic evaluation, and colposcopic evaluation were performed at 4-month intervals. HPV testing was characterized for two groups: low risk (five types rarely associated with cancers) and high risk (nine types most commonly associated with cancers).

RESULTS

Estimates provided by Kaplan-Meier curves showed that approximately 70% of women were found to have HPV regression by 24 months. Women with low-risk HPV type infections were more likely to show HPV regression than were women with high-risk HPV type infections (log rank test p = 0.002). The relative risk for the development of high-grade squamous intraepithelial lesion (HSIL) was 14.1 (95% confidence interval: 2.3, 84.5) for women with at least three positive tests for high-risk HPV preceding the development of the HSIL compared with that for women with negative tests for high-risk HPV. However, 88% of women with persistent positive HPV tests have not had HSIL to date. No factors associated with high-risk HPV type regression were identified except for a negative association with an incident history of vulvar condyloma (relative risk = 0.5 [95% confidence interval: 0.3 to 0.8]).

CONCLUSION

Most young women with a positive HPV test will become negative within a 24-month period. Persistent positive tests with oncogenic HPV types represented a significant risk for the development of HSIL. However, we found that most young women with persistent positive HPV tests did not have cytologically perceptible HSIL over a 2-year period. Factors thought to be associated with the development of HSIL were found not to be important in HPV regression.

A one-hour active coping stressor reduces small bowel transit time in healthy young adults

OBJECTIVE

To examine the effect of a prolonged active coping stressor on the transit of a substance from the mouth through small intestine in normal human volunteers.

METHOD

Twelve healthy undergraduate males were administered 10 g of the nonabsorbable carbohydrate lactulose in two experimental sessions. In normal individuals, lactulose produces hydrogen gas upon exposure to bacteria residing in the colon. Repeated measurements of breath hydrogen were obtained for 2 hours. In one session, subjects rested quietly for the 2-hour period. In the other counterbalanced session, subjects avoided mild electric shocks by playing videogames for the first hour.

RESULTS

Stress produced a statistically and clinically significant reduction in mean transit time, from 79 to 55 minutes. The magnitude of stress-induced reduction in small bowel transit time was significantly correlated with change in an index of cardiac sympathetic activity, pulse transit time.

CONCLUSIONS

A prolonged active coping stressor with minimal motor requirements produced a decrease in small bowel transit time comparable with that observed in several studies of the effects of physical exercise and in comparisons between normal controls and patients with diarrhea-predominant irritable bowel syndrome.

Hostility, sodium consumption, and cardiovascular response to interpersonal stress

OBJECTIVE

Previous studies have reported poorer health behaviors in high vs. low hostile subjects. The role of stress in these observed differences has not been explored although interpersonal stress does increase cardiovascular response in high hostiles. Given evidence that stress may induce increased salt-intake, this study examined the role of hostility and interpersonal stress in increasing sodium consumption in addition to cardiovascular reactivity.

METHOD

Sixty-nine male undergraduates were categorized into high (HiHo) and low hostile (LoHo) groups based on Buss-Durkee Hostility Inventory scores. Subjects engaged in either a math task with harassment, math task without harassment, or a control/rest condition. Sodium intake was assessed posttask by having subjects ingest a sodium-free soup that was presented with a saltshaker without any comments. Cardiovascular measures were also recorded.

RESULTS

HiHo subjects consumed more salt than LoHo subjects irrespective of experimental condition. HiHo subjects who were harassed also exhibited greater cardiac output, systolic blood pressure, and forearm blood flow than did HiHo nonharassed, HiHo control, or LoHo subjects.

CONCLUSION

HiHo subjects exhibited increased salt-intake, although evidence for stress-induced salt-intake was not obtained. Nonetheless, the combination of salt and stress may contribute to the cardiovascular hyperreactivity and risk for cardiovascular disease in hostile individuals.

Whole body leptin kinetics and renal metabolism in vivo

Leptin metabolism was investigated in male Sprague-Dawley rats by use of 125I-labeled leptin plasma kinetic and arteriovenous balance studies. When conscious rats received bolus venous injections of 125I-leptin, intact (precipitable) leptin quickly disappeared from circulation in a biexponential manner during the 2-h experimental period. After substantial delay, most of the injected radioactivity appeared in the urine. The data were described by a two-compartment model, which postulated that plasma leptin exchanged with a nonplasma pool and that all of the tracer cleared from plasma appeared in urine or in a degraded form in plasma. The half-life of leptin was 9.4 +/- 3.0 min, and the leptin production rate was 3.6 +/- 1.2 ng 100 g fat-1.min-1. The left kidney extracted 21 +/- 1.5% of intact arterial 125I-leptin 5 min after femoral venous injection. Endogenous arterial leptin was reduced 21 +/- 8 and 18 +/- 12%, respectively, in simultaneously sampled left and right renal veins. Renal elimination appears to be the major elimination mechanism for leptin in normal rats, and the kinetic studies suggest that uptake of leptin by renal tissue rather than glomerular filtration is the predominant elimination mechanism.

The use of growth factors to increase glomerular filtration rate in chronic renal failure patients

Insulin-like growth factor-1 has been safely administered to humans with chronic renal failure in an attempt to increase glomerular filtration rate. The results of short-term studies have been encouraging. Further studies will be required to better define the role of this or other growth factors in increasing glomerular filtration rate in patients with chronic renal failure.

Effects of growth hormone and insulin-like growth factor I on renal growth and function

Polypeptide growth factors regulate kidney development, growth, and function and participate in the repair processes after renal injury. The use of one or more growth factors as therapeutic agents in the settings of acute and chronic renal failure has been proposed. Insulin-like growth factor I (IGF-I) accelerates the restoration of kidney function and the normalization of structure and reduces mortality rates in animal models of acute renal injury. The mechanisms by which IGF-I acts in acute renal failure include stimulation of anabolism, maintenance of glomerular filtration, acceleration of tubular regeneration, and increased expression of ischemia-induced renal genes. It has been safely used in persons at risk of having acute renal failure and in patients with end-stage chronic renal failure, in whom it increases the glomerular filtration rate. Further studies to determine the role of IGF-I as a therapeutic agent for acute renal failure and its utility as a medical therapy for chronic renal insufficiency are required.

Insulin-like growth factor I preserves renal function postoperatively

Deterioration of renal function, which can lead to postoperative renal failure, is a complication of surgery involving the suprarenal aorta and surgery involving the renal arteries. Fifty-four patients who were at risk for developing this complication were enrolled in a double-blind, randomized, placebo-controlled trial of insulin-like growth factor (IGF-I) as a therapeutic agent to prevent the decline in renal function. The primary end point was the incidence of renal dysfunction, defined as a reduction of the glomerular filtration rate (creatinine clearance) at each of three measurements over 72 h. IGF-I (100 microg/kg subcutaneously every 12 h for 6 doses) or placebo was administered on admission to the intensive care unit immediately postoperatively. IGF-I- and placebo-treated groups were well matched for sex, age, type of surgery, renal ischemic time during surgery (ischemic index), baseline creatinine clearance, and baseline serum creatinine. No patient in the study developed acute renal failure postoperatively. IGF-I was well tolerated. A smaller proportion of patients in the IGF-I group had a postoperative decline in renal function (22%) than in the placebo-treated group (33%). There were no significant differences in levels of serum creatinine at time of discharge, length of hospital stay, length of intensive care unit stay, length of intubation, or incidence of dialysis or death. Our findings establish the feasibility and potential utility for the use of IGF-I to reduce the incidence of postoperative renal dysfunction in high-risk patients.

Functional MR imaging of the porcine kidney: physiologic changes of prolonged pneumoperitoneum

BACKGROUND

Increased intraabdominal pressure (IPA) during laparoscopy has been associated with decreased urine output. The purpose of this study was to use a noninvasive MRI technique to measure renal vessel flow velocity and change in differential renal medulla and cortex perfusion during pneumoperitoneum.

STUDY DESIGN

Six female farm pigs underwent general endotracheal anesthesia and dynamic imaging following left ventricular (LV) injection of Gd-DTPA, utilizing a dual echo gradient echo sequence. MRI was repeated after three hours of continuous 15 mm Hg pneumoperitoneum in three study pigs and after three hours of monitored general anesthesia without pneumoperitoneum in three control pigs. Renal artery and renal vein flow velocities were calculated using cine phase-contrast technique. Renal perfusion was independently measured by LV injection of radiolabelled microspheres.

RESULTS

There was a decrease in mean renal vein flow velocity in the pneumoperitoneum group as compared to the control group. During pneumoperitoneum there was a similar percentage reduction in the perfusion of the cortex (-28%) and medulla (-31%); this corresponded with a decreased urine output. In addition, radiolabelled microspheres corroborated the similar decrease in both cortical and medullary perfusion rates during pneumoperitoneum.

CONCLUSIONS

Prolonged IAP is associated with a decrease in renal vein flow velocity and urine output. There is a similar decrease in the renal medulla and cortex perfusion rates during pneumoperitoneum of 15 mm Hg.

Control of cytomegalovirus-associated morbidity in renal transplant patients using intensive monitoring and either preemptive or deferred therapy

The objective of this randomized, prospective study was to compare preemptive to deferred treatment of cytomegalovirus (CMV) infection in high-risk renal transplant recipients. Conducted at a university-affiliated transplant center, the study included 36 renal allograft recipients with donor or recipient CMV-seropositivity who received anti-thymocyte induction therapy. Ganciclovir was administered intravenously for 21 days upon detection of CMV viremia (preemptive, N = 15) or detection of CMV viremia associated with a CMV syndrome (deferred, N = 21). Shell vial culture, conventional culture, and polymerase chain reaction (PCR) were performed upon buffy-coat specimens weekly for 12 to 16 wk. CMV and non-CMV-associated charges were calculated. The comparative sensitivities of PCR, shell vial culture, and conventional culture were 91%, 44%, and 47%, respectively. A delay in specimen processing of > 24 h severely compromised the sensitivity of culture techniques but not that of PCR. Preemptive therapy tended to decrease symptomatic CMV episodes (0.4 versus 0.6 episodes per patient randomized; P = 0.22). One patient in each group had organ involvement, and no patient died. Allograft function and survival were similar. Ganciclovir use was increased in the preemptive group (1.2 versus 0.6 courses per patient randomized; P = 0.02). CMV-associated charges were $10,368 (preemptive) versus $5,752 (deferred); P = 0.13. PCR is superior to conventional monitoring to detect CMV viremia. Culture cannot be considered the "gold standard" for detection of CMV viremia, especially when transport of specimens over distances results in processing delays. Preemptive therapy may reduce symptomatic CMV infections in renal transplant recipients. It was associated with higher CMV-related charges but equivalent overall charges versus deferred treatment with intensive monitoring. Either strategy can achieve control of CMV infection after renal transplantation.

Insulin-like growth factor-I attenuates delayed graft function in a canine renal autotransplantation model

BACKGROUND

Insulin-like growth factor-I (IGF-I) has been shown to accelerate recovery in animal models of ischemic or toxic acute renal injury. Ischemic renal injury is frequently encountered after cadaveric transplantation manifested as delayed graft function. This study was performed to determine whether perfusion of kidneys with preservation solution supplemented with IGF-I would improve the course of renal injury in a canine autotransplantation model of delayed graft function.

METHODS

Dogs underwent unilateral nephrectomy with kidneys perfused and stored in Euro-Collins solution supplemented with vehicle (n = 11) or IGF-I (n = 8). After 24 hours of kidney preservation, a contralateral nephrectomy was performed and the stored kidney was autotransplanted. Renal function was examined for 5 days after the transplantation, and an inulin clearance was obtained at the time of death.

RESULTS

Compared with dogs that received kidneys preserved in the vehicle, dogs receiving the IGF-I preserved kidneys had significantly lower daily serum creatinine and blood urea nitrogen levels during the course of 5 days after transplantation. Inulin clearance at death was nearly double in the IGF-I treated animals compared with the vehicle-treated controls (1.37 +/- 0.16 ml/min/kg versus 0.77 +/- 0.13 ml/min/kg; p < 0.05).

CONCLUSIONS

Perfusion and storage of kidneys with preservation solution supplemented with IGF-I can attenuate the course of delayed graft function in a canine renal autotransplantation model. IGF-I may have potential for use in cadaveric human renal transplantation.

Dimensions of hostility and cardiovascular response to interpersonal stress

Emerging research suggests that hostility is a multidimensional construct with different dimensions conferring different cardiovascular disease risk. This study examined two dimensions of hostility, expressive and neurotic, and their hemodynamic response patterns upon exposure to interpersonal stress. Fifty-seven male undergraduates were categorized into high and low expressive hostility (HiEH, LoEH) and high and low neurotic hostility (HiNH, LoNH) groups based on their Buss-Durkee Hostility Inventory scores. Subjects engaged in a mathematical subtraction task, with half of the subjects harassed through anger-provoking statements. Separate analyses were conducted for the expressive and neurotic hostility groupings. For expressive hostility, results indicated that HiEH/harassed subjects exhibited greater systolic blood pressure, heart rate, and cardiac output responses than did HiEH/nonharassed subjects or LoEH subjects irrespective of harassment. Neurotic hostility analyses revealed elevated forearm blood flow in HiNH/harassed subjects as compared to HiNH/nonharassed subjects or LoNH subjects in either harassment condition. The hemodynamic response pattern of expressive hostiles is consistent with their risk for heart disease. The response pattern of neurotic hostiles may indicate risk for hypertension, though this remains to be established.

Estradiol, progesterone and cardiovascular response to stress

The present study examined the relationship between endogenous estradiol and progesterone levels and cardiovascular activity at rest and during stress in healthy young women. Subjects were tested in both the follicular and luteal phases of the menstrual cycle. Results indicated that, during the luteal phase, higher levels of estradiol were associated with lower levels of cardiac output responses to the combined video game and speech tasks, and lower levels of heart rate and systolic blood pressure responses to the cold pressor; estradiol levels were also associated positively with PEP responses to the cold pressor but only under high levels of progesterone. Additionally, during the luteal phase, higher levels of progesterone were associated with higher TPR and lower stroke volume responses to the cold pressor. In contrast, during the follicular phase, higher levels of progesterone were associated with lower vascular resistance responses to the cold pressor. Consistent with data from studies using exogenous estrogens, these results suggest that estradiol may contribute to a lowering of cardiovascular responses to stress.

Altered EGF expression and thyroxine metabolism in kidneys following acute ischemic injury in rat

To define the relationship between renal epidermal growth factor (EGF) expression and thyroid hormones in acute renal failure, we performed an analysis of the renal thyroid hormone-EGF axis following acute ischemic renal injury in rats. Levels of mature EGF extractable from kidney were elevated 24 h postinjury, and levels of membrane-associated EGF precursor were reduced. Administration of triodothyronine (T3) to rats, either prior to or immediately following the induction of injury, did not further increase levels of extractable EGF. Levels of EGF mRNA in kidneys were reduced 24 h following acute ischemic damage and not affected by administration of T3. Enhanced production of mature EGF from EGF precursor occurred in membranes isolated from kidneys of rats 24 h postinjury compared with production in membranes from kidneys of normal rats. In addition, levels of thyroxine 5'-deiodinase activity in renal membranes were increased 24 h following injury. Levels of circulating total thyroxine (T4), free T4, and free T3 were reduced postischemic injury. Total T3 was unchanged. The administration of T3 to normal rats increased renal 5'-deiodinase activity and EGF precursor cleavage. Administration of propylthiouracil to rats inhibited renal 5'-deiodinase activity and prevented the increase in extractable EGF postischemic injury. We conclude that the increase in levels of mature EGF extractable from kidneys of rats postischemic injury results from enhanced activity of the serine protease that cleaves the EGF precursor. This activity may be stimulated by T3 produced in kidney. These alterations in renal T4 metabolism and EGF expression could serve to facilitate recovery of renal function following ischemia.

Parental history of hypertension and cardiovascular response to stress in black and white men

White offspring of hypertensives typically exhibit an elevated cardiovascular response to stress. Studies of Black offspring of hypertensives have been fewer, with inconsistent results. This may be due, in part. to incomplete characterizations of hemodynamic responses. This study examines cardiovascular reactivity in Black and White offspring of hypertensives with a particular focus on vascular resistance responses. A total of 62 healthy normotensive men, 41 with a parental history of hypertension (PH+: 21 Blacks, 20 Whites), and 21 without parental hypertension (PH-: 7 Blacks, 14 Whites) engaged in a series of laboratory tasks. Both Black and White PH+ participants exhibited elevated diastolic blood pressure (DBP) responses, but to different patterns of stressor tasks. Familial differences in total peripheral resistance response were also obtained for Black and White participants in a comparison across all tasks, but were particularly evident in tasks when PH+ participants had elevated DBP responses. These results suggest that a parental history of hypertension is an important moderator of cardiovascular, and in particular peripheral vascular, responses to stress in Black and White individuals.

Parental history of hypertension, sodium loading, and cardiovascular response to stress

Parental history of hypertension, dietary sodium, and psychological stress have all been implicated in the development of essential hypertension and may interact in elevating disease risk. The mechanism by which this might occur is unclear, but it may be related to changes in the peripheral vasculature. The present study examined the effects of parental history and sodium on cardiovascular responses to an extended stressor. Eighteen normotensive offspring of hypertensives and 18 offspring of normotensives were exposed to a 1-hour shock-avoidance video-game procedure after 14 days of sodium loading (10 1-g tablets/day) and again after 14 days of placebo tablets. Order of sessions was counterbalanced between subjects in a double-blind design. In offspring of hypertensives, sodium loading elevated total peripheral resistance and norepinephrine responses to stress relative to placebo conditions and compared with offspring of normotensives. These increases were accompanied by decreases in stroke volume and cardiac output, which may explain the absence of familial differences in blood pressure responses to stress and sodium. Sodium loading had no effect on offspring of normotensives. The elevated resistance in offspring of hypertensives may suggest the initiation of pathological processes. The absence of sodium effects on resting values indicates the importance of research under conditions of stress.

Zaprinast accelerates recovery from established acute renal failure in the rat

Atrial natriuretic factor (ANF) has been demonstrated to be effective in the treatment of acute renal failure (ARF) in both rat and humans. The biological effects of ANF are presumed to be mediated by the generation of intracellular 3',5'-cyclic guanosine monophosphate (cGMP). Therefore, the current investigation examined whether zaprinast (M&B 22948), a guanosine 3',5'-cyclic monophosphate (cGMP)-specific phosphodiesterase inhibitor, would be effective in the treatment of established acute renal failure in the rat. Acute renal failure was induced by 60 minutes of bilateral renal artery clamping. Twenty-four hours after the ischemic insult, rats received either vehicle (5% Dextrose), zaprinast (0.03 or 0.3 mg/kg/min) or ANF24 (0.2 micrograms/kg/min) intravenously for four hours. Renal function, as measured by daily serum creatinine (days 1 to 7) and day 2 inulin clearances, was dramatically improved by zaprinast but not ANF treatment. Forty-eight hours post-renal ischemia, glomerular filtration rate (GFR) was 0.14 +/- 0.04 (ml/min/100 g body wt) in the vehicle and 0.94 +/- 0.29 in the zaprinast treated animals. To evaluate the mechanism by which zaprinast accelerated renal recovery, we measured regional blood flow in the postischemic rat kidneys during drug treatment with a laser doppler flowmeter. Both high and low dose zaprinast significantly increased cortical (17%) and outer medullary blood flow (40% and 60%), an effect not seen with ANF. In summary, zaprinast is effective in the treatment of established ischemic ARF. The mechanism by which zaprinast accelerates renal recovery is due to its unique ability to stimulate regional renal blood flow and increase intracellular cGMP in the setting of tissue ischemia.

Growth factor gene expression in tubular epithelial injury

In animal models of acute renal injury, administration of epidermal, insulin-like or hepatocyte growth factor accelerates restoration of kidney function and normalization of histology, and reduces mortality. Mechanisms for such action include stimulation of anabolism, maintenance of glomerular filtration, and enhancement of tubular regeneration. Further studies are needed to establish the utility of growth factors as therapeutic agents for acute renal failure in humans.

Severe anemia as the presenting manifestation of giant cell arteritis

Giant cell (temporal, cranial) arteritis (GCA) is usually confirmed in patients presenting with classic features. Those who present with atypical features often undergo prolonged evaluations until a diagnosis is established. Severe anemia as an initial manifestation of GCA has rarely been described. We describe herein 2 patients with biopsy-proven GCA who presented with severe anemia and significant weight loss, which corrected after corticosteroid therapy.

Analytical artifacts in hematocrit measurements by whole-blood chemistry analyzers

Compact analyzers suited to near-patient testing estimate hematocrit by measuring the conductivity of undiluted blood. We evaluated the accuracy of hematocrit determination of one such analyzer (Instrumentation Laboratory BGE analyzer) against an automated cell counter (EPC) and packed cell volume (PCV) microhematocrit. When specimens (n = 34) from outpatient and ward patients were analyzed with all three methods, the BGE analyzer correlated well with both EPC and PCV hematocrit determinations (BGE = 1.00 PCV + 0.3%, S(y)/x = 2.0%), suggesting that all three methods are similar in performance for most patients. However, a patient with increased plasma osmolality showed significant decreases in BGE and PCV hematocrits relative to the EPC method. The differences in hematocrit measurements could be reproduced by adding solutes to blood in vitro or by modifying the plasma osmolality of rats in vivo. Samples from patients undergoing cardiac surgery, whose blood had large changes in protein concentration, showed discrepancies between hematocrits by conductivity and other methods; similar effects could be produced by changes in protein concentration or in vitro addition of polyethylene glycol. We conclude that conductivity measurements provide accurate hematocrit results for physiologically normal subjects but not for some intensive-care and surgical patients.

Analytical artifacts in hematocrit measurements by whole-blood chemistry analyzers

Compact analyzers suited to near-patient testing estimate hematocrit by measuring the conductivity of undiluted blood. We evaluated the accuracy of hematocrit determination of one such analyzer (Instrumentation Laboratory BGE analyzer) against an automated cell counter (EPC) and packed cell volume (PCV) microhematocrit. When specimens (n = 34) from outpatient and ward patients were analyzed with all three methods, the BGE analyzer correlated well with both EPC and PCV hematocrit determinations (BGE = 1.00 PCV + 0.3%, S(y)/x = 2.0%), suggesting that all three methods are similar in performance for most patients. However, a patient with increased plasma osmolality showed significant decreases in BGE and PCV hematocrits relative to the EPC method. The differences in hematocrit measurements could be reproduced by adding solutes to blood in vitro or by modifying the plasma osmolality of rats in vivo. Samples from patients undergoing cardiac surgery, whose blood had large changes in protein concentration, showed discrepancies between hematocrits by conductivity and other methods; similar effects could be produced by changes in protein concentration or in vitro addition of polyethylene glycol. We conclude that conductivity measurements provide accurate hematocrit results for physiologically normal subjects but not for some intensive-care and surgical patients.

Triiodothyronine stimulates renal epidermal growth factor expression in adult rat

To define the role that thyroid hormones play in regulation of renal epidermal growth factor (EGF) production, we characterized the effect of triiodothyronine (T3) administration on renal EGF expression in adult rats. The action of T3 to regulate EGF production was examined under one condition in which renal EGF expression is known to be diminished, posthypophysectomy, and in pituitary-intact rats. Levels of mature EGF, EGF precursor, and EGF mRNA, reduced in kidneys of hypophysectomized rats compared with pituitary-intact animals, increased significantly following the administration of T3 to hypophysectomized rats. Thus replacement of thyroid hormone alone was sufficient to enhance renal EGF expression. Induction of a hyperthyroid state in normal rats by injection of T3 for 4 days increased levels of extractable immunoreactive mature EGF, EGF precursor present in renal membranes, and EGF mRNA measured in kidneys. Levels of EGF in circulation were undetectable under all experimental conditions. We conclude that T3 enhances the renal synthesis of EGF in both hypopituitary and pituitary-intact rats. Enhancement of renal EGF expression is one mechanism that must be considered to explain the actions of thyroid hormones on kidney.

Effects of growth hormone on rat renal epidermal growth factor expression

The kidney is a site of synthesis for several polypeptide growth factors including epidermal growth factor (EGF) and insulin-like growth factor I (IGF-I). Interactions between growth hormone (GH) and growth factors have been described that regulate renal growth factor expression. For example, GH and EGF each enhances the expression of IGF-I in kidney. To further define interrelationships in this renal GH-growth factor axis, we characterized the effect of GH on renal EGF expression in hypophysectomized, pituitary-intact (normal) rats, and hypersomatotropic rats. Levels of extractable immunoreactive mature EGF, levels of a 142-kDa EGF-precursor present in renal membrane fractions, and levels of EGF mRNA were significantly reduced in kidneys from hypophysectomized rats compared with levels in normal rats. Each was increased significantly after the administration of GH to hypophysectomized rats. In contrast, induction of hypersomatotropism in normal rats by injection of GH for 17 days did not affect levels of extractable mature EGF or EGF mRNA measured in kidneys. We conclude that GH enhances the renal synthesis of EGF in hypopituitary, but not in hypersomatotropic states.

Effects of IGF-I on renal function in end-stage chronic renal failure

To determine whether insulin-like growth factor I (IGF-I) affects kidney function in patients with end-stage chronic renal failure, we administered recombinant human IGF-I (rhIGF-I) (100 micrograms/kg body wt subcutaneously twice daily) to nine individuals with baseline inulin clearances below 21 ml/min/1.73 m2. Four patients were treated for four days (short-term treatment) and five for periods between 13 and 27 days (long-term treatment). Administration of rhIGF-I increased inulin clearance, p-aminohippurate (PAH) clearance and the percent tubular reabsorption of filtered phosphate, and decreased plasma creatinine, blood urea nitrogen (BUN) and plasma phosphate during short-term administration. Kidney volume was unchanged in patients receiving the growth factor. rhIGF-I did not cause weight gain, proteinuria or hypoglycemia. Inulin clearance was not increased significantly above baseline after 13 or 20 days of IGF-I administration. PAH clearance remained elevated after 13 days, but not after 20 days of IGF-I. Levels of total circulating IGF-I were elevated above basal levels during the entire course of long-term IGF-I administration. In contrast, levels of circulating IGF binding protein 3 (IGFBP3) declined over time. Side effects related to IGF-I forced discontinuation of its use in two of five patients undergoing long-term treatment, and side-effects possibly related to IGF-I prompted discontinuation of its use in two others. We conclude that rhIGF-I can enhance glomerular filtration rate and renal plasma flow when administered short-term to humans with end-stage chronic renal renal failure. Further studies will be required to define its efficacy and usefulness long-term.

Therapeutic use of growth factors in renal failure

Polypeptide growth factors regulate kidney development, growth, and function and participate in processes of repair after renal injury. The use of one or more growth factors as therapeutic agents has been proposed in the settings of acute and chronic renal failure. In animal models of acute renal injury, the administration of epidermal growth factor, insulin-like growth factor I (IGF-I), or hepatocyte growth factor accelerates the restoration of kidney function and the normalization of histology post-acute renal injury and reduces mortality. The mechanisms by which the growth factors act in acute renal failure include the stimulation of anabolism, the maintenance of glomerular filtration, and the enhancement of tubular regeneration. IGF-I has been safely administered to humans with chronic renal failure. The growth factor enhances GFR and RPF in these individuals. Further studies will be required to establish a role for IGF-I or other growth factors as therapeutic agents for acute renal failure in humans and to define the utility of IGF-I as a medical therapy for chronic renal insufficiency.

Rat models for clinical use of insulin-like growth factor I in acute renal failure

Insulin-like growth factor I (IGF-I) improves kidney function and histopathology, when given within a short time (0.5 or 5 h) after an ischemic renal insult in rats. To examine the effects of IGF-I at times that would be more applicable if it were to be used as a therapeutic agent for acute renal failure in humans, we administered IGF-I to rats 24 h after ischemic injury or prior to the induction of injury (pretreatment). In rats that received IGF-I 24 h postischemia, serum creatinine and blood urea nitrogen (BUN) values were significantly lower during the subsequent 6 days than in vehicle-treated rats, and incorporation of 5-bromo-2'-deoxyuridine into tubular cells of the regenerating cortex, measured 48 h postischemia, was enhanced. When examined 7 days postinjury, kidneys from rats that received IGF-I 24 h postischemia were improved in histopathological appearance compared with kidneys from vehicle-treated animals. Whereas creatinine and BUN values were elevated above baseline in both vehicle and IGF-I-pretreated groups, recovery of normal renal function was accelerated by pretreatment with IGF-I. In addition, although we could detect no differences in histopathology at 24 h postinjury, IGF-I pretreatment resulted in more normal renal histology at 7 days postischemic injury and reduced weight loss after injury. Our data show that IGF-I hastens recovery and accelerates regeneration or repair of damaged epithelia following acute renal failure in rats when administered either 24 h postinjury or prior to induction of acute renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Optimal management of gout in older patients

Gout in older patients tends to be sub-acute to chronic, often tophaceous, polyarticular, erosive, symmetrical, and causes persistent, recurrent and chronic arthritis. Clinically, it may closely mimic rheumatoid arthritis; thus, a correct diagnosis requires a high index of clinical suspicion and the identification of uric acid crystals. An optimal therapeutic strategy for most older patients with chronic tophaceous gout could involve the following: avoidance of alcohol and diuretic use if possible; avoidance of long term nonsteroidal anti-inflammatory drug (NSAID) therapy; use of short term corticosteroids (systemic or intra-articular) for acute exacerbations; prophylactic colchicine daily or every other day according to the degree of renal dysfunction present; and long term allopurinol therapy in dosages adjusted to the degree of hyperuricaemia and renal dysfunction.