Parathyroid hormone changes in infants investigated for inflicted injury; an observational retrospective single centre cohort study

BACKGROUND

Biochemical and haematological testing is recommended in the United Kingdom when inflicted injury is suspected. We examined the associations of test results with radiologically-confirmed fracture(s), and between test results, in a large retrospective observational cohort.

METHODS

Infants up to age two years presenting with suspected inflicted injury, without clinically or radiologically apparent bone disease, and where a skeletal survey was undertaken during the period 1st August 2013 to 31st December 2020, were included. Biochemical parameters: corrected calcium (cCa); phosphate (P); alkaline phosphatase (ALP); parathyroid hormone (PTH); 25-hydroxyvitamin D (25D); and haematological parameters: haemoglobin (Hb); mean corpuscular haemoglobin (MCH); mean corpuscular haemoglobin content (MCHC); mean corpuscular volume (MCV); platelet count were collated together with the results of the radiological assessments.

FINDINGS

Of 332 eligible infants (190 male), 142 (84 male) had fracture(s) and/or intracranial injury. Mean PTH in the non-fracture group (n measured 50/190) was 27.3 ng/l; in those with intracranial injury alone (n measured 9/23) was 39.4 ng/l; in those with fracture alone (n measured 62/84) was 45.0 ng/l; and in those with fracture and intracranial injury (n measured 20/35) 51.8 ng/l. F-test of multiple means = 0.0369. There was no difference in 25D between the groups.

INTERPRETATION

PTH was raised in infants who had fracture(s), intracranial injury or both. A single raised PTH may not necessarily be an indicator of prior disturbed skeletal health in these circumstances. The relevance of vitamin D status and interpretation of data from biochemical testing should be informed by the overall presentation in suspected inflicted injury cases. A single raised PTH may be a consequence of the child's injuries rather than prior disturbed bone health.

Is urethral microscopy useful in symptomatic male patients without urethral discharge?

National guidelines recommend that male patients presenting with symptoms of urethritis or epididymo-orchitis undergo a urethral swab for microscopy. However, this is resource intensive. The aim of this audit was to determine the proportion of symptomatic patients without urethral discharge who have positive findings on urethral swab microscopy and explore associations between presenting symptoms and microscopy findings. We conducted a retrospective audit of symptomatic male patients who underwent microscopy. There was a significant difference between the percentage of symptomatic patients with positive findings on microscopy in those with and without urethral discharge (67% vs 33%, p < 0.001). In a patient presenting with symptoms other than urethral discharge, the likelihood that positive findings on microscopy would occur in a patient with dysuria was 4.73 times more likely than if they did not have dysuria, when controlling for age, testicular pain or discomfort, and urethral discomfort or penile irritation (p < 0.01). In situations where there are limited resources, patients without urethral discharge presenting with dysuria could be prioritised. However, further research is required to identify and stratify which patients require microscopy.

A User and Their Family's Perspective of The Use of a Low-Tech Vs A High-Tech AAC System

This qualitative case study describes a 9-year-old child, diagnosed with homonymous hemianopia, left side weakness and seizures that has been followed by Access to Communication and Technology Unit in Malta for 5 years. The child previously used a communication book and now uses an iPad as a speech generating device. A semi-structured interview was utilised with the parent to explore preference for each AAC system and the reasons for it. The impact of each AAC system on the family and on the child's communication skills, and perceived barriers in the implementation of the AACs were also explored. The child's own experience using the AAC systems was also investigated using a structured interview format. Talking Mats was used to support the child's understanding of the questions and to explore her perspectives on the two AAC systems using Yes-No responses. The parent interview was analysed thematically and represented visually using a thematic network. This was compared with child responses. Four organising themes emerged including barriers, benefits, facilitators, and expectations. Specific barriers included self-funding in order to provide the child with the best fit high-tech AAC. Perceived benefits for both AAC systems were that it increased her communicative intent. The child's mother perceived access to increased vocabulary and capacity for sentence building, operational autonomy as well as voice output as a benefit of the SGD. The child's results indicated a preference for the high-tech AAC because she found it easier to navigate than the low-tech AAC.

Costs and quality of life in multiple sclerosis patients with spasticity

BACKGROUND

The resource use and health-related quality of life (HRQoL) of patients with multiple sclerosis (MS) spasticity are not well known. The purpose of this study was to obtain estimates of resource utilization, costs, and HRQoL, for patients with different levels of MS spasticity in southern Sweden.

MATERIAL AND METHODS

Cross-sectional data on spasticity severity (using a Numerical Rating Scale, NRS), resource use and HRQoL (using EQ-5D) were collected using a patient questionnaire and chart review. Patients were recruited through a clinic in southern Sweden. The study reviews direct medical, direct non-medical and indirect costs.

RESULTS

Total costs were estimated to €114,293 per patient and year. Direct medical costs (€7898) accounted for 7% of total costs. Direct non-medical costs (€68,509) accounted for 60% of total costs. Total costs increased with severity of spasticity: for patients with severe spasticity, the total cost was 2.4 times greater than those for patients with mild spasticity. HRQoL decreased as spasticity increases.

CONCLUSION

The results of this study show that MS spasticity is associated with a substantial burden on society in terms of costs and HRQoL.

Budget Impact Analysis of Surgical Treatment for Obesity in Sweden

Background:

The recent substantial increase in the number of obese surgeries performed in Sweden has raised concerns about the budget impact.

Objective:

Our aim in this paper is to present an assessment of the budgetary impact of different policies for surgical intervention for obese and overweight subjects from a healthcare perspective in Sweden.

Methods:

The model simulates the annual expected treatment costs of obesity related diseases and surgery in patients of different sex, age and Body Mass Index (BMIMI). Costs evaluated are costs of surgery plus the excess treatment costs that an obese patient has over and above the treatment costs of a normal-weight patient. The diagnoses that are included for costs assessment are diabetes and cardiovascular disease since these diagnoses are the principal diagnoses associated with obesity. Four different scenarios over the number of surgical operations performed each year are simulated and compared: (1) no surgical operation, (2) 3 000 surgical operations in persons with BMI > 40, (3) 4000 (BMI > 40), and (4) 5000 (expanded to BMI > 38).

Results:

Comparing Scenario 2 with Scenario 1 results in a net budget impact of on average SEK 121 million per annum or SEK 40 000 per patient. This implies that 55 percent of the cost of surgery, set equal to SEK 90 000 for each patient, has been offset by a reduction in the excess treatment costs of obesity related diseases. Expanding annual surgery from 3000 to 4000 the cost-offset increased to 58%. By expanding annual surgery further from 4000 to 5000 and at the same time expanding the indication for surgery from BMI > 40 to BMI > 38, no cost-offset is obtained.

Conclusion:

A cost-minimization strategy for bariatric surgery in Sweden should not expand indication, but rather increase the number of surgeries within the currently accepted indication.

Drug and treatment costs in Parkinson's disease patients in Sweden

BACKGROUND

Parkinson's disease (PD) is a chronic neurodegenerative disease expected to cause great costs. The aim of this study was to calculate drug and treatment costs in patients with PD in Sweden.

METHOD

All healthcare contacts of patients with PD in Stockholm County, Sweden, were extracted from registers together with information on reimbursements from the authorities to the caregivers. PD-related costs were calculated together with non-PD-related costs. Cost per patient was calculated and extrapolated to the whole Swedish population, taking population demographics into consideration. In addition, nationwide PD drug sales statistics were included.

RESULTS

The PD prevalence of Stockholm County was estimated to 196 per 100,000 inhabitants, resulting in an estimated total of about 22,000 patients with PD in Sweden. The cost per patient was estimated to SEK 76,000 of which drug costs accounted for SEK 15,880. The annual direct costs in patients with PD in Sweden were SEK 1.7 billion in 2009.

CONCLUSION

Our study estimates high direct costs in patients with PD in Sweden, SEK 1.7 billion, 52% for inpatient care, 27% for outpatient care and 21% for drugs. With an ageing population and the medical progress, the financial burden on society will most probably increase in the future. This study might initiate and provide information for discussions about future cost allocations and healthcare priorities.

Reduction of aggression during benzodiazepine withdrawal: effects of flumazenil

Benzodiazepine withdrawal has been associated with hostile and aggressive behavior. The benzodiazepine antagonist flumazenil has reduced, increased or not affected hostility and aggression in animal and human studies. In the present study we analyzed data collected in a placebo-controlled study of the effects of the benzodiazepine antagonist flumazenil in patients previously treated for benzodiazepine dependency, and healthy controls. The aim was to analyze the effects of flumazenil on hostility and aggression. Ten patients and 10 controls received, on two separate occasions, cumulative doses of flumazenil (0.05, 0.1, 0.25, 0.5 and 1mg at 15min intervals) or placebo. Withdrawal symptoms were rated after each injection. Patients had been free from benzodiazepines for 47 (4-266) weeks on the first occasion. A three-way interaction (groupxtreatmentxdose) was found, and was explained by: 1) patients rating aggression and hostility higher than controls at all times during placebo, while 2) during the flumazenil provocation i) the initial significant difference between patients and controls was no longer significant above the 0.5mg dose, and ii) patients rated aggression and hostility significantly lower above the 0.5mg dose compared to base-line. The results suggest that self-rated aggression and hostility in patients treated for benzodiazepine dependency was reduced by the partial benzodiazepine agonist flumazenil.

Effect of peroral thiamine treatment on thiamine contents and transketolase activity of red blood cells in alcoholic patients

The thiamine contents, transketolase activity and "thiamine diphosphate effect" (TDP effect) of the transketolase activity were measured in the blood of alcoholic patients during withdrawal, before and after thiamine administration (50 mg) for 10 days. The results were compared with those of healthy volunteers. The alcoholic patients showed significantly lower thiamine contents, lower transketolase activity and higher TDP effect in the blood than the healthy volunteers. These biochemical parameters were not significantly changed after 10 days without any exogenous thiamine supplement except the hospital diet. When thiamine was administered in a dose of 50 mg for 10 days, the TDP effect normalized. The transketolase activity and thiamine contents, however, were only slightly increased, probably due to the fact that the apo-enzyme content and the thiamine-binding capacity were lower in the blood of the alcoholics. Thus the TDP effect seems to reflect the relative biochemical deficiency while transketolase activity and thiamine contents seem to be dependent on the amount of apo-enzyme and on the thiamine-binding capacity as well as the degree of thiamine deficiency.

Abnormal microheterogeneity of transferrin in serum and cerebrospinal fluid in alcoholism

The serum and CSF proteins were analyzed by isoelectric focusing in 16 male alcoholics after alcohol intoxication and after 10--14 days of alcohol abstinence. An abnormally marked protein band with pI 5.7 was found in serum in 15 patients and in CSF in 12 at the first examination. On crossed immunoelectrofocusing it appeared as an increased, cathodal, microheterogeneous molecular form of transferrin. The abnormality was reversible and decreased or normalized in serum in all cases after abstinence. In 6 patients with clinical signs of cerebellar degeneration, an abnormal microheterogeneous pattern of CSF transferrin of partly different appearance to that in serum remained after abstinence. Disturbed liver synthesis of transferrin is a probable origin of the serum finding, which may be specifically related to alcohol abuse. Substitution or loss of acidic amino acids and/or decreased iron binding ability are possible structural explanations.

Clinical significance of abnormal heterogeneity of transferrin in relation to alcohol consumption

An abnormal microheterogeneous component of serum transferrin, with a higher isoelectric point than the normal main component, was studied by means of isoelectric focusing and direct immunofixation in 98 alcoholic patients, 22 patients with liver diseases and 100 controls. Its relation to acute and prolonged ethanol intake was studied in healthy volunteers. The abnormal transferrin component was found to be a sensitive indicator of prolonged, high alcohol ingestion, and was observed in 81% of patients with an admitted consumption of more than 60 g ethanol/day, and normalized after at least 10 days of abstinence. It occurred in 1% of the controls and in none of the cases with liver diseases without current alcohol abuse. There is evidence of a reduced sialic acid content in the abnormal transferrin. No similar change has been found in a number of other glycoproteins. This test may be a useful and sensitive tool for the detection of chronic alcohol consumption.

Cost-effectiveness analysis of budesonide/formoterol compared with fluticasone in moderate-persistent asthma

In this economic evaluation, conducted alongside a randomized, double-blind clinical trial, economic data were collected from 339 patients with moderate-persistent asthma randomized to receive twice-daily, double-blind treatment with budesonide/formoterol 160/4.5 microg in a single inhaler (n=166) or fluticasone propionate 250 microg (n=173) for 12 weeks. The mean number of episode-free days (EFD) per patient was significantly greater in the budesonide/formoterol group than the fluticasone group (48.71 compared with 42.34, P=0.0185). Data on medication use, visits to healthcare professionals, and hospitalization were pooled across all six countries and combined with German and Dutch unit cost data to calculate total healthcare costs. Using German unit costs, budesonide/formoterol was associated with significantly lower total healthcare costs per patient over the 12-week period compared with fluticasone (euro 131 compared with euro 210, P=0.0043). Using Dutch unit costs, total healthcare costs were slightly numerically lower in the budesonide/formoterol group than the fluticasone group (euro 102 compared with euro 104), but the difference did not reach statistical significance. Budesonide/formoterol in a single inhaler is more effective than a higher microgram dose of fluticasone alone. It is cost-neutral and may provide cost-savings in some countries.

Budesonide/formoterol in a single inhaler (Symbicort) reduces healthcare costs compared with separate inhalers in the treatment of asthma over 12 months

This open, multinational, randomised, parallel-group, six-month extension conducted in the Swedish centres of a previous six-month study compared the costs of a total of 12 months of treatment with budesonide/formoterol in a single inhaler with budesonide plus formoterol separate inhalers in 320 adults with asthma. Patients received budesonide/formoterol (Symbicort Turbuhaler) 160/4.5 mg delivered doses, two inhalations b.i.d., or corresponding doses of budesonide (Pulmicort Turbuhaler) plus formoterol (Oxis Turbuhaler). Direct costs and indirect costs were estimated. Budesonide/formoterol treatment was associated with reduced healthcare service utilisation and statistically significant reductions in direct (SEK1595, p=0.0004) and total costs (SEK1884, p=0.043) per person per year compared with budesonide plus formoterol. Budesonide/formoterol reduced the average annual emergency room admission cost per person by SEK489.7 (31% of direct cost reduction) and physician costs by SEK235.4 (15%).The direct cost of study, relief and other medication was reduced by SEK893.8 (47% of total reduction). There were no statistically significant differences in efficacy and safety parameters following treatment with budesonide/formoterol from single or separate inhalers, other than a significantly lower proportion of withdrawals with the single inhaler (9.2% vs 19.4%, p=0.008). In summary, budesonide/formoterol treatment from a single inhaler reduced 12-month treatment costs compared with separate inhalers, while maintaining at least as good control of asthma.

A 6-month controlled naltrexone study: combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence

BACKGROUND

In several studies, patients with alcohol dependence treated with the opioid antagonist naltrexone have shown fewer relapses to heavy drinking than those receiving placebo. An interaction between the naltrexone effect and the type of psychological therapy has been observed.

METHODS

A 6-month, double-blind, placebo-controlled, parallel-group study was performed at 10 different investigation sites. After a placebo run-in period of 1 week, 118 patients were randomized into 4 treatment groups-50 mg of naltrexone daily or placebo in combination with either cognitive behavioral therapy (CBT) or supportive therapy. The CBT was performed over nine sessions according to the manual of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). The supportive therapy was defined as "the treatment as usual." Alcohol consumption, craving, carbohydrate-deficient transferrin, medication compliance by tablet count, and adverse clinical events were assessed at all visits. Other liver enzymes and psychiatric symptoms were also determined.

RESULTS

Ninety-one (77%) patients completed the study, and 92 (78%) were 80% compliant with the medication regimen. A lower percentage of heavy-drinking days was shown in the naltrexone group (p = 0.045) compared with the placebo group, as was a lower craving score (p = 0.029). These results are supported by the lower levels of liver enzyme activities (p < 0.010 for aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase), but not by the carbohydrate-deficient transferrin levels, in the naltrexone group. The mean time period before the first day of heavy drinking was longer for the group treated with CBT (p = 0.010), especially in combination with naltrexone (p = 0.007). Naltrexone was well tolerated, and no patients discontinued the study due to side effects.

CONCLUSIONS

This study supports the effect of naltrexone in outpatient treatment of alcohol dependence and suggests that a beneficial interaction effect with CBT can be expected.

The costs of exacerbations in chronic obstructive pulmonary disease (COPD)

Exacerbations are the key drivers in the costs of chronic obstructive pulmonary disease (COPD). The objective was to examine the costs of COPD exacerbations in relation to differing degrees of severity of exacerbations and of COPD. We identified 202 subjects with COPD, defined according to the BTS and ERS criteria. Exacerbations were divided into mild (self-managed), mild/moderate (telephone contact with a health-care centre and/or the use of antibiotics/systemic corticosteroids), moderate (health-care centre visits) and severe (emergency care visit or hospital admission). Exacerbations were identified by sending the subjects a letter inquiring whether they had any additional respiratory problems or influenza the previous winter. At least one exacerbation was reported by 61 subjects, who were then interviewed about resource use for these events. The average health-care costs per exacerbation were SEK 120 (95% C=39-246), SEK 354 (252-475), SEK 2111 (1673-2612) and SEK 21852 (14436-29825) for mild, mild/moderate, moderate and severe exacerbations, respectively. Subjects with impaired lung function experienced more severe exacerbations, which was also reflected in the cost of exacerbations per severity of the disease during the 4 1/2 month study period (ranging from SEK 224 for mild to SEK 13708 for severe cases, median SEK 940). Exacerbations account for 35-45% of the total per capita health-care costs for COPD. In conclusion, costs varied considerably with the severity of the exacerbation as well as with the severity of COPD. The prevention of moderate-to-severe exacerbations could be very cost-effective and improve the quality of life.

The effects of cognitive behavioral intervention on the attitude and behavior of stockpersons and the behavior and productivity of commercial dairy cows

Two experiments, one involving 29 commercial farms and the other involving 94 commercial farms, were conducted to examine the effects of a training program targeting a number of attitudinal and behavioral variables in stockpeople. These stockperson variables had been previously shown to be related to fear of humans and productivity of commercial cows. In both experiments, two treatments were imposed: an Intervention treatment, consisting of a cognitive-behavioral intervention procedure designed to improve the attitude and behavior of stockpeople toward cows, and a Control treatment, in which no intervention was attempted. In Exp. 1, an analysis of covariance, using previous lactation variables as the covariate, revealed effects of the Intervention treatment on the attitude and behavior of the stockpeople and the behavior of cows. Stockpeople at Intervention farms showed more (P < 0.01) positive beliefs about handling cows and used a lower (P < 0.05) number and percentage of negative tactile interactions in handling cows than stockpeople at the Control farms. Cows at the Intervention farms showed a shorter (P < 0.05) flight distance to humans, indicating a lower level of fear of humans by these cows. However, 36% of the Intervention farms failed to show a reduction in average flight distance over the two lactations. Although there was no significant treatment effect on milk yield, the Intervention farms in which fear levels declined following the intervention had a higher (P < 0.05) milk yield than the other farms. In Exp. 2, a significant (P < 0.05) increase was found in the milk yield of cows following the Intervention treatment. Similar treatment effects were observed on both milk protein and milk fat. These results indicate that cognitive-behavioral interventions that successfully target the key attitudes and behavior of stockpeople that regulate the cow's fear of humans offer the industry good opportunities to improve the productivity of cows.

Crucial influence of solvent and chirality-the formation of helices and three-dimensional nets by hydrogen-bonded biimidazolate complexes

Deprotonation and recrystallisation of racemic [Co(2,2'-biimidazole)3][NO3]3 by ammonia in water/dimethylformamide solutions gave crystals of [Co(Hbiim)3] x 0.8H2O x 0.5DMF (2: Hbiim = monoanion of 2,2'-biimidazole, DMF = dimethylformamide), a porous material that contains fourfold interpenetrating (10.3) three-dimensional nets formed by neutral, hydrogen-bonded [Co(Hbiim)3] units, with DMF molecules in the narrow channels. Recrystallisation of [delta-Co(2,2'-biimidazolate)3] gave helices instead of the expected (10,3)-a net. These results are discussed in the light of additional density functional theory and molecular mechanics calculations and the X-ray structure of [Co(H2biim)3][NO3]3.

Toward an integrative approach in the analysis of dependency problems

This article takes some preliminary steps towards an integrated analysis of dependency problems e.g., long-term tranquillizer use, alcohol dependence, problematic use of narcotics. It argues for the need to outline important theoretical, epistemological, and methodological prerequisites in the analysis of the complex dynamic developmental processes involved in dependency problems. The dynamic process leading to dependence can be studied by the aid of an artificial science neural network approach in combination with a mixed method strategy including a clarification of a combination of different epistemological positions. It is intended that the empirical output of this complex strategy will provide a starting point for a new theoretical analysis which, in turn, will lead to new and more relevant input variables in the neural network approach that will help us to extend our knowledge of the dynamic processes leading to dependency.

Epilogue: drawing together the threads and perspectives on the long-term use of psychotropics

The aims of the epilogue are to draw together the threads in this issue by reviewing some themes presented in the previous chapters and to consider the relationship between the perspectives mentioned. The implications of a multidimensional perspective for future research, treatment and prevention are discussed. It is emphasized that the social sciences have an important part to play in helping us understand long-term use of psychotropics. The social sciences provide insights of importance for research, treatment and prevention of dependency on psychotropics, and also, may help us deal better with these kind of problems in the future.

[CDT a valuable marker of overconsumption of alcohol. Guidelines for its use in connection with automobile driver examination]

According to the medical regulations for obtaining a driver's license in Sweden, alcohol abuse/dependency constitutes sufficient grounds for denial. In the case of a conviction for gross drunk driving, it is incumbent upon the offender to present a medical certificate verifying a "sober lifestyle". Biological markers are important tools for proving alcohol abuse in each of these contexts. In this connection, CDT analyses play a key role through their high marked specificity for increased alcohol consumption. The authors have agreed upon the guidelines as presented in this paper for determining sobriety as it pertains to possession of a driver's license. Special emphasis is placed on how CDT tests should be used and interpreted in such contexts, as well as their value as evidence in the case of increased CDT levels.

Gender-related differences in response to placebo in benzodiazepine withdrawal: a single-blind pilot study

RATIONALE

Benzodiazepines have dependency-producing properties, and the majority of patients who are prescribed benzodiazepines and are treated for benzodiazepine dependency are women. Inability to cope with withdrawal symptoms may lead to continued consumption of benzodiazepines, often with the development of tolerance and dose escalation as a consequence.

OBJECTIVE

In the present study we analyzed gender-related differences in reactions to placebo injections in a placebo-controlled study of the effects of the benzodiazepine antagonist flumazenil among patients previously treated for benzodiazepine dependency and healthy controls.

METHODS

Ten patients and ten controls (five males and five females in each group) received two placebo injections (separated by 15 min) on two separate occasions (1-13 weeks apart). The patients had been benzodiazepine free for 47 (4-266) weeks on the first occasion. Subjective ratings of symptoms, thought to be important during/after withdrawal of benzodiazepines, were made before and after each injection, as well as registrations of blood pressure and heart rate.

RESULTS

An overall difference existed between previously benzodiazepine-dependent subjects and healthy controls, with patients scoring higher on negative and somatic aggregates and lower on a positive aggregate. A four-way interaction (group x gender x occasion x time) was found for negative and somatic aggregates, which could mainly be explained by the reactions of female patients. Thus, females had the highest base-line ratings and were the only group that showed a significant reduction in symptom ratings after placebo injections on the first occasion. Gender differences were also found for systolic and diastolic blood pressure. There was no significant response to placebo among male patients or for controls (males or females) for ratings of any variable.

CONCLUSIONS

The results suggest that there might be gender-specific differences in reactions to placebo injections, with female patients being more affected. Arguments for and against explanatory factors such as expectation, provider factors, habituation, regression toward the mean, and reduction of anxiety are presented.

Relationships between human-animal interactions and productivity of commercial dairy cows

This study examined the relationships between a number of stockperson and cow variables at 66 commercial dairy farms. Variables such as the attitudes and behavior of stockpeople toward their cows and the behavioral response to humans and productivity of cows were studied over one lactation. There were consistent and significant correlations between some of these stockperson and cow variables. For example, a positive attitude by stockpeople toward the behavior of dairy cows was negatively correlated with the number of forceful, negative, tactile interactions used by stockpeople in handling cows (r = -0.27, df = 127, P < 0.01). Furthermore, based on farm averages, the number of forceful, negative, tactile interactions used by stockpeople was negatively correlated with the percentage of cows approaching within 1 m of an experimenter in a standard test (r = -0.27, df= 64, P< 0.05). Although not confirming a fear-productivity relationship, a moderate but nonsignificant correlation was found between flight distance of cows to an experimenter in a standard test and milk yield (r = -0.27, df = 33, P > 0.05). Support for the existence of a negative fear-productivity relationship was the finding that the use of negative interactions by stockpeople was significantly and negatively correlated with milk yield, protein, and fat at the farm (r = -0.36, -0.35 and -0.33, respectively, df = 64, P < 0.01) and was significantly and positively correlated with milk cortisol concentrations at the farm (r = 0.34, df= 64, P < 0.01). Furthermore, the percentage of cows approaching within 3 m of an experimenter in a standard test was positively correlated with conception rate to the first insemination (r = 0.38, df = 46, P < 0.01). The significant correlations found in the present study between stockperson attitudes and behavior and cow behavior and productivity, although not evidence of causal relationships, indicate the possibility of targeting these human characteristics to reduce fear responses of dairy cows to humans and improve the cows' productivity.

Acute tolerance during intravenous infusion of alcohol: comparison of performance during ascending and steady state concentrations--a pilot study

Although acute tolerance (AT) to alcohol has been demonstrated in many single-dose studies, the existence of AT at steady state concentrations of alcohol has been questioned. In the present study, six subjects were examined as (1) 7.5% alcohol or (2) placebo was administered intravenously (IV). The order of the infusions was randomized. The alcohol infusions were designed to result in similar blood alcohol concentrations at 20, 60, and 140 min (approximately 0. 7 per thousand). At 20 min, the concentrations were rising; the steady state (+/-0.10 per thousand) was reached after 60 min and continued until 140 min. Three reaction time (RT) tests from the automated psychological test system were used (simple RT, two-choice RT, and two-choice RT with auditory inhibition). When the performance of the subjects was compared at rising and steady-state concentrations of alcohol, AT was shown for the most complex task requiring parallel processing, i.e., RT with failed inhibition, test. However, at steady state (i.e., 60 vs. 140 min), AT was not found for any of the tests. Further, the analysis showed that the test results of different individuals were related to their estimated normal alcohol consumption and that these differences presumably influenced the test results in accordance with our earlier findings.

Salmonella typhimurium mutants that downregulate phagocyte nitric oxide production

To examine the potential and strategies of the facultative intracellular pathogen Salmonella typhimurium to increase its fitness in host cells, we applied a selection that enriches for mutants with increased bacterial growth yields in murine J774-A.1 macrophage-like cells. The selection, which was based on intracellular growth competition, rapidly yielded isolates that out-competed the wild-type strain during intracellular growth. J774-A.1 cells responded to challenge with S. typhimurium by mounting an inducible nitric oxide synthase (iNOS) mRNA and protein expression and a concomitant nitric oxide (NO) production. Inhibition of NO production with the use of the competitive inhibitor N-monomethyl-L-arginine (NMMA) resulted in a 20-fold increase in bacterial growth yield, suggesting that the NO response prevented bacterial intracellular growth. In accordance with this observation, five out of the nine growth advantage mutants isolated inhibited production of NO from J774-A.1 cells, despite an induction of iNOS mRNA and iNOS protein. Accompanying bacterial phenotypes included alterations in lipopolysaccharide structure and in the profiles of proteins secreted by invasion-competent bacteria. The results indicate that S. typhimurium has the ability to mutate in several different ways to increase its host fitness and that inhibition of iNOS activity may be a major adaptation.

The Salmonella YopJ-homologue AvrA does not possess YopJ-like activity

The YopJ protein of Yersinia pseudotuberculosis inhibits several eukaryotic signalling pathways that are normally activated in cells following their contact with bacteria. Salmonella encodes a protein, AvrA, that is secreted by the typeIII inv/spa secretion system which is clearly homologous to YopJ (56% identical, 87% similarity). Since AvrA and YopJs similarity also encompassed a region of YopJ that had previously been shown to be critical for its biological activity, we were interested whether AvrA and YopJ provoked similar responses in eukaryotic cells. Two different approaches were used to determine whether AvrA possesses YopJ-like activity in modulating cytokine expression or killing macrophages. An avrA strain of Salmonella dublin was constructed and its activity was compared to an isogenic wildtype counterpart in cellular response assays. In a complementary approach, AvrA was expressed in and delivered into eukaryotic cells by a yopJ strain of Yersinia pseudotuberculosis. We show here that AvrA affects neither cytokine expression or plays a role in macrophage killing when expressed by either Salmonella or Yersinia. Additionally, AvrA does not possess SopB/D-like activity in promoting fluid secretion into infected calf ileal loops. These data indicate that Salmonella and Yersinia trigger and/or modulate eukaryotic cell responses by different typeIII-secreted proteins and suggests that despite their close evolutionary relatedness, AvrA and YopJ perform different functions for Salmonella and Yersinia, respectively.

Design, synthesis, and evaluation of Phe-Gly mimetics: heterocyclic building blocks for pseudopeptides

Enantiopure heterocyclic Boc-protected Phe-Gly dipeptidomimetics containing 1,3,4-oxadiazole, 1,2,4-oxadiazole, and 1,2,4-triazole ring systems have been synthesized as building blocks in the synthesis of pseudopeptides. Three derivatives (1-3) have the carboxylic acid function directly bound to the heterocyclic ring, and three derivatives (4-6) have an extra methylene group between the heterocyclic ring and the acid function to allow for an increased conformational flexibility. The mimetics were used as Phe-Gly replacements in the biologically active peptides dermorphin (Tyr-D-Ala-Phe-Gly-Tyr-Pro-Ser-NH(2)) and substance P (Arg-Pro-Lys-Pro-Gln-Gln-Phe-Phe-Gly-Leu-MetNH(2), SP). The pseudopeptide synthesis was performed using solid-phase methodology on a MBHA-resin using Boc-chemistry. The biological evaluation was performed by testing the micro- and delta-opioid receptor affinities of the dermorphin pseudopeptides and the NK(1) receptor affinities of the SP pseudopeptides. The results showed that all mimetics except 3 were excellent replacements of Phe-Gly in dermorphin since they displayed affinities for the micro-receptor (IC(50) = 12-31 nM) in the same range as dermorphin itself (IC(50) = 6.2 nM). The agonist activity of three pseudopeptides at human micro-receptors was also evaluated. It was shown that the tested compounds retained their agonist activity. The SP pseudopeptides showed considerably lower affinities (IC(50) > 1 microM) for the NK(1) receptor than SP itself (IC(50) = 1.5 nM) indicating that the Phe-Gly replacements prevent the pseudopeptides from adopting bioactive conformations.

Comparison of urinary 5-hydroxytryptophol, breath ethanol, and self-report for detection of recent alcohol use during outpatient treatment: a study on methadone patients

This study compared urinary 5-hydroxytryptophol (5HTOL) with breath-ethanol testing as objective ways to disclose recent drinking by outpatients attending a methadone maintenance treatment clinic. Information about quantity and frequency of alcohol use was obtained by confidential self-reports. Random screening was performed on Mondays-Fridays in connection with routine clinic visits for methadone dosing. An observed urine sample for monitoring of illicit drug use and determination of 5HTOL, expressed as a ratio to 5-hydroxyindole-3-acetic acid (5HIAA), was obtained from 202 patients (59 women and 143 men), 16 of whom refused to complete the self-report and/or do a breath-ethanol test. Patients taking disulfiram or calcium carbimide for alcohol detoxification were excluded. Among the 177 subjects remaining, 47 (26.6%) reported intake of any alcohol on the previous day (range, 10-230 g ethanol; median, 40). Only four of those could be identified by a positive breath-test, while 17 showed a urinary 5HTOL/5HIAA ratio above the cutoff limit. Their alcohol consumption (median, 60 g) was significantly higher compared with those showing ratios within the reference interval (median, 35 g). The sensitivity of 5HTOL/5HIAA testing for detecting self-reported drinking in excess of 50 g ethanol was 77%. An additional nine patients who claimed abstinence still showed abnormal 5HTOL/5HIAA ratios, and so did three of the patients who refused to do a breath-ethanol test and/or complete the self-report. Altogether, 59 of 190 methadone-maintained patients (31.1%) had been drinking any alcohol on the previous day (i.e. Sunday-Thursday) according to self-report and/or urinalysis data, 29 (49.2%) of whom were identified by the urinary 5HTOL/5HIAA ratio and only four (6.8%) by utilizing breathalyzer.

Plant cell growth and differentiation may involve GAP regulation of Rac activity

Two Rac GTPase cDNAs, LjRac1 and LjRac2, were identified in the legume Lotus japonicus. Two-hybrid screening with dominant-constitutive mutations in the two Rac GTPases target three plant cDNAs, LjRacGAP1, LjRacGAP2 and LjRacGAP3, that encode putative GTPase activating proteins of Rho-GTPase subfamily members. Employing Rac antiserum, purified recombinant LjRac GTPases and recombinant LjRacGAP1, for ligand overlay assays, in vitro GAP affinity assays and GTPase activation, we confirmed that eukaryote Rac/RacGAP interplay is conserved in plants. In this investigation we have developed some tools that can be used to characterize the role of enhanced LjRac2 expression in developing root nodules.

Novel Salmonella typhimurium properties in host--parasite interactions

Inflammatory bowel disease (IBD) comprises different diseases in the gastrointestinal tract in human, of which Crohn's disease (CD) and ulcerative colitis (UC) are the most prominent. A key factor in the etiology of IBD is the chronic inflammatory process, and a large body of evidence suggests that the transcription factor nuclear factor-kappa B (NF-kappaB) is the key regulator of responses determining the clinical inflammatory condition. Recent findings using antisense oligonucleotides provide direct evidence that the p65 subunit of NF-kappaB plays a central role in chronic intestinal inflammation. It has previously been shown that the Gram negative bacteria Yersinia pseudotubercolosis targets the eukaryotic signal transduction pathway(s) that lead to NF-kappaB activation (and thus avoid an anti-bacterial inflammatory response). In this paper, growth-based selected Salmonella typhimurium clones have been used to generate a clearer picture of the molecular mechanisms involved in host-parasite interactions. From the results presented here, S. typhimurium and Y. pseudotubercolosis may use the same mechanism to block NF-kappaB activation, following host cell infection. A new adaptational feature could also be shown, where a growth-based selected bacteria avoided the normally induced translocation of NF-kappaB in host cells.

Prediction of single episodes of drinking during the treatment of alcohol-dependent patients

Drinking episodes during the treatment (relapses or lapses) of alcohol-dependent patients is predicted from clinical ratings of patients and individual background data such as alcohol drinking history and social status. The probability of these relapses (or lapses) is determined up to three days in advance using a logistic regression procedure. The study group consisted of 33 male alcohol-dependent persons, who participated in a treatment program. Clinical ratings were performed three times a week by a trained person during a visit to the clinic. The questionnaire contained 23 different items about irritation, craving for alcohol. sleep disturbances, etc. The relapses were either self-reported or detected by a biochemical marker in a urine sample that was taken daily. The most important factor for a relapse in alcohol drinking was shown to be if the patient already had had one relapse during the treatment. Other important clinical factors were the levels of irritation and autonomic disturbances. None of the variables measuring mood shifts was significant. Family conditions during childhood were the most important background variables. The predictions turned out to have a rather high specificity, but the sensitivity was lower. Half of the relapses were not predicted by an increased probability for relapse. Self-reported relapses were predictable from preceding interviews and were also less frequent compared to those detected objectively by the biochemical markers.

Rated well-being in relation to plasma concentrations of l- and d-methadone in satisfied and dissatisfied patients on methadone maintenance treatment

RATIONALE

One of the major problems in methadone maintenance treatment is to find optimal individual doses for the patients.

OBJECTIVE

The present study investigated whether the use of rating scales together with enantioselective analysis of l-methadone might facilitate dose adjustments in a clinical situation.

METHODS

Rating scales were used to evaluate subjective and objective signs of well-being in relation to plasma methadone concentrations in two groups of patients receiving methadone maintenance treatment. The first group (n = 25) was well-adjusted according to clinical observations and were satisfied with their methadone doses (86.2+/-4.3 mg). The second group (n = 25) was in need of the methadone dose adjustment; they complained of low dosing, despite a dose level of 69.2+/-4.0 mg/day.

RESULTS

Results indicated a significant correlation between dose and methadone concentration among dissatisfied patients only. The trough levels of d,l-methadone and l-methadone, as well as their elimination rates, were similar in the two groups of patients. There was a variable predominance of l- over d-methadone in plasma (ratio approximate to 1.2; range 0.7-3.6). Illicit use of drugs by the patients was related to the methadone dose and to satisfaction with the dose received. Increased illicit drug use among dissatisfied patients was successfully eliminated by raising the methadone dose. Subjective and objective ratings of the satisfied patients were quite stable throughout the evaluation period, whereas the ratings of the dissatisfied patients were unstable. These patients seemed to be more sensitive to low trough levels of methadone than the satisfied patients. Associations between the subjective and objective ratings and plasma methadone, along with background characteristics, were characterized by multiple regression analyses. The plasma concentrations of l-methadone were one of the most important explanatory variables in these analyses. Associations between well-being and methadone concentrations in plasma were stronger for l-methadone than for d,l-methadone.

CONCLUSIONS

Selective measurements of the active isomer and the use of rating scales should be of clinical value when monitoring methadone maintenance treatment patients.

Induction of antibodies to methadone during methadone maintenance treatment of heroin addicts and its possible clinical implications

By means of two different types of enzyme-linked immunosorbent assay (ELISA) techniques, antibodies to methadone were detected in blood plasma of heroin addicts on methadone maintenance treatment. In 11-15% of cases immunoglobulin (Ig) M antibodies were detected, while IgG antibodies were observed in 33-40%. At least two types of antibodies to methadone were induced-antibodies with high affinity to methadone and low-affinity antibodies more specific for morphine than for methadone. The methadone antibody-positive group of patients had a significantly higher plasma methadone concentration--440 ng/ml, than the antibody-negative group--250 ng/ml (P < 0.005) despite almost the same mean therapeutic doses of methadone. Of patients with all types of antibodies to methadone 52% were human immunodeficiency virus (HIV)-positive, whereas in the group without antibodies, HIV-positive reactions were observed in 10.5% only (P < 0.002). Alternatively, 87.5% of HIV-positive patients had antibodies to methadone, a fact which should be taken into consideration during methadone dose adjustment.

The urinary ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid in surgical patients with chronic alcohol misuse

The urinary ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid was reported to be elevated for a period of up to 22 h following acute alcohol ingestion. Therefore, the ratio could detect continuous alcohol consumption, in what was considered to be a high-risk surgical group, on the evening prior to surgery. The aim of this study was to determine the preoperative ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid in patients with continuous preoperative alcohol misuse. Forty-two patients participated in this institutionally approved study, once their written informed consent had been obtained. Chronic alcoholics were defined by meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders criteria and an ethanol consumption > or =60 g/day. The urine samples were taken preoperatively and determined by means of gas chromatography-mass spectrometry and high performance liquid chromatography. The urinary ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid was significantly increased in chronic alcoholics. The ICU stay of these patients was significantly prolonged due to an increased incidence of pneumonia and sepsis. Five chronic alcoholics died, whereas no deaths occurred in the nonalcoholic group (p = 0.05). As the measurement of the urinary ratio of 5-hydroxy-tryptophol to 5-hydroxyindole-3-acetic acid could detect alcohol consumption immediately prior to operation, this marker could assist the carbohydrate-deficient transferrin in screening for patients with high-level dependency; these patients were considered to be at a high risk of developing intercurrent complications.

Intra- and interindividual variability of carbohydrate-deficient transferrin, gamma-glutamyltransferase, and mean corpuscular volume in teetotalers

Blood samples for determination of the biochemical alcohol markers carbohydrate-deficient transferrin (CDT) in serum, gamma-glutamyltransferase (GGT) in serum, and erythrocyte mean corpuscular volume (MCV) were collected once every 1-2 weeks over approximately 5 months from 10 female and 4 male teetotalers. Mean values for serum CDT (using the CDTect assay) ranged from 9.9 to 29.4 units/L (median, 14.2 units/L), and the highest results were obtained in the women. The mean values for serum GGT ranged from 0.15 to 0.49 microkat/L (median, 0.30 microkat/L, or 18 U/L) except for one woman with a very high mean of 3.07 microkat/L. For MCV, the mean values ranged from 79.5 to 91.5 fL. Two women showed several CDT results above the upper reference limit (mean values, 27.6 and 29.4 units/L, respectively); however, their GGT and MCV values fell within the reference intervals. One of these women exhibited an increased total transferrin concentration (mean value, 5.38 g/L), which was possibly related to the use of oral contraceptives and/or a low serum iron concentration. When the CDTect value was expressed relative to total transferrin, a ratio within the reference interval was observed for this woman but not for the other woman with increased CDTect values. The present study demonstrates a considerable variation between individuals in CDT, GGT, and MCV without drinking any alcohol. The results also show that these baseline values are fairly constant over time within the same individual.

The online screening technique for urinary benzodiazepines: comparison with EMIT, FPIA, and GC-MS

Three commercial immunoassay systems (EMIT, EPIA, Online) for the screening of benzodiazepines in urine were evaluated using authentic patient samples with gas chromatography-mass spectrometry (GC-MS) as the reference method. The Online system (kinetic interaction of microparticles in solution) gained in performance by applying a 100-ng/mL cutoff limit and by incorporating beta-glucuronidase treatment, which could be automated on the Cobas Mira Plus instrument. When using enzymatic hydrolysis, all three immunoassay systems had high levels of sensitivity, including samples containing only flunitrazepam and nitrazepam metabolites. A high degree of concordance was observed between the Online and FPIA (fluorescence polarization immunoassay) systems when analyzing 138 randomly selected patient samples. The EMIT II and EMIT d.a.u. (enzyme multiplied immuno technique) systems gave a higher number of positive results, but the presence of benzodiazepines could not be verified by GC-MS in a substantial number of these cases. The rate of unconfirmed positive results was increased when enzyme hydrolysis was incorporated in the EMIT II assay. Although differences in the performances of the investigated assay systems were observed, they all seem appropriate for clinical use in detecting benzodiazepine intake in drug abusers when enzymatic hydrolysis is included.

Patient perceptions of psychological and physiological withdrawal symptoms and positive factors associated with gradual withdrawal from methadone maintenance treatment: a prospective study

Psychological and physiological withdrawal symptoms and some positive factors were studied in 10 methadone maintenance treatment patients during methadone dose reduction. The subjective ratings were made during a period of 10 days around each reduction occasion, 3 days before dose reduction and 7 days after (i.e., within the periods). To permit comparisons of the subjects' ratings between earlier and later stages of the dose reduction process, a division has been made between the first half and the second half of the total reduction occasions (i.e., between the periods). Three of the patients completed the dose reduction, while the others interrupted their withdrawal attempts. The results show that the aggregate psychological symptoms were rated low, but that, as expected, they increased significantly from the first to the second half of the dose reduction. A significant increase of the psychological symptoms also occurred from the days before each reduction to the days after. The aggregate physiological symptoms were rated very low. A significant increase in rated withdrawal intensity is found within the reduction occasions. There were no significant changes with regard to the aggregate positive factors, either within or between the reduction occasions.

Effects of flumazenil in the treatment of benzodiazepine withdrawal--a double-blind pilot study

Flumazenil, a partial benzodiazepine agonist with low intrinsic activity, was tested for potential use in patients experiencing withdrawal symptoms after traditional treatment for benzodiazepine dependency. On two occasions, separated by 1-13 weeks, ten patients treated for benzodiazepine dependency and ten controls received cumulative doses of flumazenil (0.05, 0.10, 0.25, 0.50 and 1.00 mg at 15-min intervals) or placebo, with assessments of withdrawal symptoms and physiological variables after each dose. As expected, there was an overall difference between patients and controls, with patients scoring higher on negative and somatic items and lower on positive psychological items. Flumazenil reduced symptoms thought to be important in withdrawal in patients treated for benzodiazepine dependency. In contrast to the patient group, controls reacted in the opposite direction with increases in negative experience when given flumazenil. Further research may develop flumazenil as a therapeutic option in the treatment of benzodiazepine withdrawal.

Abstinence fear in methadone maintenance withdrawal: a possible obstacle for getting off methadone

The present study attempts to shed light on methadone maintenance patients expectations regarding withdrawal symptoms during voluntary methadone detoxification. The study includes two groups of subjects; one group who have tried on their own initiative to terminate their methadone maintenance treatment (Group 1) and one group that contains rehabilitated patients who have not tried to quit using methadone (Group 2). Two main results have emerged. Group 1 has negative expectations beforehand about the intensity of withdrawal which significantly exceed the later, actual experience. Group 2 has negative expectations about the intensity of withdrawal that significantly exceed the negative expectations of Group 1. The clinical implications of these results are discussed.

Identification of new protein species among 33 different small GTP-binding proteins encoded by cDNAs from Lotus japonicus, and expression of corresponding mRNAs in developing root nodules

In this study, 266 cDNA clones were isolated from a cDNA library made from mRNA of three-week-old root nodules of Lotus japonicus, employing a degenerate oligonucleotide probe that corresponds to a conserved region of small GTP-binding (SMG) proteins. The clones were sorted into groups by cross hybridization and 3' sequencing, and 33 contigs were sequenced in an orderly fashion. Twenty-seven complete and six incomplete protein structures were deduced, which represent three subfamilies of the superfamily of signal transducing GTP-binding proteins. The 33 proteins are divided into nine subclasses, of which seven belong to the Ypt/Rab subfamily, one subclass represents the Rho/Rac subfamily, and one subclass represents the Ran subfamily of small GTP-binding proteins. The protein sequences were compared with related proteins from other plants, from mammals and other species, and discussed with respect to structure and function in different cellular processes. It is apparent that the number of genes encoding SMG proteins in plants must be quite large, since the large number of subclasses found in other eukaryotes is not fully represented in our analysis. Transcription patterns through root nodule development were analysed for 27 of the 33 cDNAs. Differential expression patterns may reflect whether the coded gene product is of importance for organ development. Most mRNAs appear to be constitutively expressed; however, a few unique mRNAs representing the subclasses Rab1, Rab2, Rab5, Rab7 and Rac show elevated levels in root nodules, and certain Rab7, Rab8 and Rab11 species are enriched in aerial parts of the plant. This suggests that most small GTPases have household functions, whereas a few may be required for specialized activities that are important for specialized cells.