AB0357 LANDSCAPE REVIEW OF PATIENT-REPORTED OUTCOME MEASURES IN GIANT CELL ARTERITIS

Background:

Giant cell arteritis (GCA) is a systemic large vessel vasculitis that results in symptoms (e.g., headaches, jaw claudication, fatigue, pain, etc.) that can have multiple negative impacts on an individual’s health-related quality of life.

Objectives:

To identify important symptoms and impacts experienced by individuals with GCA, develop a conceptual model, and evaluate available patient reported outcome (PRO) measures for appropriateness for inclusion in GCA clinical studies.

Methods:

Published literature on disease experience from databases, conference abstracts, and Guidance/OMERACT documents were reviewed. A GCA conceptual model was developed based on the symptoms and impacts identified from this literature and supplemented with clinical input. A detailed review of selected PROs was then conducted to assess concept coverage and gaps to evaluate appropriateness for a GCA population.

Results:

Of 245 identified citations, 24 abstracts and 18 articles were reviewed. Key symptoms affecting GCA patients (e.g., ischemic and constitutional symptoms) and impacts to the lives of GCA patients (e.g., reduced physical, social and emotional functioning) formed the basis for a GCA conceptual model (see Figure 1).

No GCA-specific PROs were identified. Therefore, the PROs that were used most frequently in GCA clinical studies were reviewed and evaluated. These included the SF-36, FACIT-Fatigue, Patient Global Assessment (PtGA), Multidimensional Fatigue Inventory (MFI), EQ-5D, Health Assessment Questionnaire (HAQ), Brief Illness Perception Questionnaire (BIPQ), and Visual Functioning Questionnaire-25 (VFQ-25). These PROs included some key impacts but did not assess most GCA-specific symptoms (e.g., headaches, fever, etc.). No measures were developed with input from GCA patients and there has been limited evaluation of the measurement properties of these PROs in GCA patients.

The FACIT-Fatigue, SF-36, and the PtGA, which were frequently administered in published GCA studies, measure key GCA concepts such as fatigue, functioning, impact on daily activities and disease status. The measurement properties (reliability, validity, sensitivity to change) have been documented in several other rheumatologic diseases (Table 1).

Conclusion:

In the absence of a GCA-specific PRO, the SF-36, FACIT- Fatigue, and PtGA are recommended for use in GCA clinical studies for the assessment of key concepts identified in the literature. Qualitative and quantitative research should be conducted with GCA patients to assess the content validity and measurement properties of these PROs in a GCA population.

Table 1.

Summary of Recommended Measures

DescriptionSF-36FACIT-FatiguePtGATypeGeneric, health status measureFatigue and impact on function/daily activitiesMeasure of disease activityMethod of AdministrationSelf/InterviewerSelf/InterviewerSelf# of Items36131Recall periodPast 4 weeks/past weekPast 7 daysVariesScoring8 domain scores; 2 component summary scoresTotal scoreTotal scoreMeasurement propertiesMeasurement properties demonstrated in other rheumatologic diseases (SLE, RA, SpA, and chronic knee pain); construct validity demonstrated in a single study with GCA patientsMeasurement properties demonstrated in rheumatologic populations including SLE, PsA, and RASelect measurement properties have been demonstrated in GCA and other populations (RA, TAK, RP)Concept coverageGCA impacts (emotional, physical, and social functioning, and daily activities), bodily pain, fatigueFatigueOverall assessment of disease activityAdministered in recent GCA studiesYESYESYES

SLE= systemic lupus erythematosus, SpA = spondyloarthritis, PsA=psoriatic arthritis, RA=rheumatoid arthritis, GCA= giant cell arteritis, TAK=Takayasu’s arteritis, RP=relapsing polychondritis

Disclosure of Interests:

Hilary H Colwell Consultant of: Janssen Pharmaceutical Companies of Johnson & Johnson, Susan Mathias Consultant of: Janssen Pharmaceutical Companies of Johnson & Johnson, Kelly Kato Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, Catherine E Najem Shareholder of: Johnson & Johnson, Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson, Amy M Archer Employee of: Janssen Pharmaceutical Companies of Johnson & Johnson

Vancouver's inner-city youth: New approaches for a changing demographic

Introduction

Inner-city youth suffer a high burden of mental illness and seek health care on an episodic basis (McCreary, 2001).

These youth tend to receive limited support services due to a lack of continuity of care as they move from child to adult services. Other barriers include homelessness and substance use.

The Vancouver Inner City Youth Mental Health Program (ICYMHP) is a psychiatry led initiative to provide psychiatric services and further collaboration between inner-city youth agencies providing care to at risk youth.

Aims

To introduce and review a collaborative model of care between psychiatric services and community based organizations.

To review the demographics, presentations and outcomes of youth assessed through the ICYMHP.

Methods

A chart review of all clients assessed through the program from its inception (November 2007) to May 2009 (18 months).

Results

Results from clients seen between November 2007 and June 2008 indicate an incidence of psychosis of 40% in men and 21% in women. Mood disorders were the primary diagnosis in 18% of men and 29% of women. Active substance misuse is high (71% of men, cannabis as drug of choice; 54% of women, methamphetamine as drug of choice). Length of stay at Covenant House nearly tripled for those under the care of the ICYMH versus the general shelter population, a positive outcome (21 days versus 9).

Conclusions

Inner-city homeless youth suffer from a high burden of mental illness. A collaborative model of care exists to improve health care quality and delivery to this population.

Ultrafast optically induced spin transfer in ferromagnetic alloys

The vision of using light to manipulate electronic and spin excitations in materials on their fundamental time and length scales requires new approaches in experiment and theory to observe and understand these excitations. The ultimate speed limit for all-optical manipulation requires control schemes for which the electronic or magnetic subsystems of the materials are coherently manipulated on the time scale of the laser excitation pulse. In our work, we provide experimental evidence of such a direct, ultrafast, and coherent spin transfer between two magnetic subsystems of an alloy of Fe and Ni. Our experimental findings are fully supported by time-dependent density functional theory simulations and, hence, suggest the possibility of coherently controlling spin dynamics on subfemtosecond time scales, i.e., the birth of the research area of attomagnetism.

Energy enhancement of the target surface electron by using a 200 TW sub-picosecond laser

One order of magnitude energy enhancement of the target surface electron beams with central energy at 11.5 MeV is achieved by using a 200 TW, 500 fs laser at an incident angle of 72° with a prepulse intensity ratio of 5×10^-6. The experimental results demonstrate the scalability of the acceleration process to high electron energy with a longer (sub-picosecond) laser pulse duration and a higher laser energy (120 J). The total charge of the beam is 400±20  pC(E>2.7  MeV). Such a high orientation and mono-energetic electron jet would be a good method to solve the problem of the large beam divergence in fast ignition schemes and to increase the laser energy deposition on the target core.

Revealing the subfemtosecond dynamics of orbital angular momentum in nanoplasmonic vortices

The ability of light to carry and deliver orbital angular momentum (OAM) in the form of optical vortices has attracted much interest. The physical properties of light with a helical wavefront can be confined onto two-dimensional surfaces with subwavelength dimensions in the form of plasmonic vortices, opening avenues for thus far unknown light-matter interactions. Because of their extreme rotational velocity, the ultrafast dynamics of such vortices remained unexplored. Here we show the detailed spatiotemporal evolution of nanovortices using time-resolved two-photon photoemission electron microscopy. We observe both long- and short-range plasmonic vortices confined to deep subwavelength dimensions on the scale of 100 nanometers with nanometer spatial resolution and subfemtosecond time-step resolution. Finally, by measuring the angular velocity of the vortex, we directly extract the OAM magnitude of light.

Self-amplified photo-induced gap quenching in a correlated electron material

Capturing the dynamic electronic band structure of a correlated material presents a powerful capability for uncovering the complex couplings between the electronic and structural degrees of freedom. When combined with ultrafast laser excitation, new phases of matter can result, since far-from-equilibrium excited states are instantaneously populated. Here, we elucidate a general relation between ultrafast non-equilibrium electron dynamics and the size of the characteristic energy gap in a correlated electron material. We show that carrier multiplication via impact ionization can be one of the most important processes in a gapped material, and that the speed of carrier multiplication critically depends on the size of the energy gap. In the case of the charge-density wave material 1T-TiSe₂, our data indicate that carrier multiplication and gap dynamics mutually amplify each other, which explains-on a microscopic level-the extremely fast response of this material to ultrafast optical excitation.

Spin-resolved photoelectron spectroscopy using femtosecond extreme ultraviolet light pulses from high-order harmonic generation

The fundamental mechanism responsible for optically induced magnetization dynamics in ferromagnetic thin films has been under intense debate since almost two decades. Currently, numerous competing theoretical models are in strong need for a decisive experimental confirmation such as monitoring the triggered changes in the spin-dependent band structure on ultrashort time scales. Our approach explores the possibility of observing femtosecond band structure dynamics by giving access to extended parts of the Brillouin zone in a simultaneously time-, energy- and spin-resolved photoemission experiment. For this purpose, our setup uses a state-of-the-art, highly efficient spin detector and ultrashort, extreme ultraviolet light pulses created by laser-based high-order harmonic generation. In this paper, we present the setup and first spin-resolved spectra obtained with our experiment within an acquisition time short enough to allow pump-probe studies. Further, we characterize the influence of the excitation with femtosecond extreme ultraviolet pulses by comparing the results with data acquired using a continuous wave light source with similar photon energy. In addition, changes in the spectra induced by vacuum space-charge effects due to both the extreme ultraviolet probe- and near-infrared pump-pulses are studied by analyzing the resulting spectral distortions. The combination of energy resolution and electron count rate achieved in our setup confirms its suitability for spin-resolved studies of the band structure on ultrashort time scales.

A profile of osteopathic care in private practices in the United Kingdom: a national pilot using standardised data collection

Increasing interest is being shown in osteopathy on a national and international basis. Since little prospective data had been available concerning the day-to-day practice of the profession, a standardised data collection tool was developed to try and address this issue. The tool development process has been described in an earlier paper. The standardised data collection (SDC) tool underwent national piloting between April and July 2009 in United Kingdom private practices. Osteopaths volunteered to participate and collected data on consecutive new patients or patients presenting with a new symptom episode for a period of one month; follow-up data were collected for a further two months. A total of 1630 completed datasets from the SDC pilot were analysed by the project team. Data generated from the national pilot showed that lumbar symptoms were the most commonly presented in patients (36%), followed by cervical spine (15%), sacroiliac/pelvic/groin (7.9%), head/facial area (7%), shoulder (6.8%), and thoracic spine (6%). A total of 48.8% of patients reported comorbidities, the most common being hypertension (11.7%), followed by asthma (6.6%), and arthritis (5.7%). Outcome data were collected looking at the patients' response to treatment, and any form of treatment reactions. The profiling information collected using the SDC tool provides a contemporary picture of osteopathic practice in the United Kingdom.

Quantum-well-induced giant spin-orbit splitting

We report on the observation of a giant spin-orbit splitting of quantum-well states in the unoccupied electronic structure of a Bi monolayer on Cu(111). Up to now, Rashba-type splittings of this size have been reported exclusively for surface states in a partial band gap. With these quantum-well states we have experimentally identified a second class of states that show a huge spin-orbit splitting. First-principles electronic structure calculations show that the origin of the spin-orbit splitting is due to the perpendicular potential at the surface and interface of the ultrathin Bi film. This finding allows for the direct possibility to tailor spin-orbit splitting by means of thin-film nanofabrication.

Quantum oscillations in coupled two-dimensional electron systems

Quantum oscillations of the electron-phonon coupling of a Shockley surface state induced by the coupling to a metallic quantum well are observed experimentally as the thickness of the quantum well is increased. Microscopic calculations allow us to assign these oscillations to changes in the Eliashberg function, caused by a modulation in the electronic density overlap between the 2D surface state band and the 2D electron system of the quantum well and by the gradient of the one-electron potential in combination with the localized character of the Shockley-type surface state wave function. The findings are important in the context of the control of surface processes such as film growth and surface chemical reactions.

Direct measurement of core-level relaxation dynamics on a surface-adsorbate system

The coupling between electronic states in a surface-adsorbate system is fundamental to the understanding of many surface interactions. In this Letter, we present the first direct time-resolved observations of the lifetime of core-excited states of an atom adsorbed onto a surface. By comparing laser-assisted photoemission from a substrate with a delayed Auger decay process from an adsorbate, we measure the lifetime of the 4d(-1) core level of xenon on Pt(111) to be 7.1+/-1.1 fs. This result opens up time-domain measurements of surface dynamics where energy-resolved measurements may provide incomplete information.

Angle-resolved photoemission spectroscopy with a femtosecond high harmonic light source using a two-dimensional imaging electron analyzer

An experimental setup for time- and angle-resolved photoemission spectroscopy using a femtosecond 1 kHz high harmonic light source and a two-dimensional electron analyzer for parallel energy and momentum detection is presented. A selection of the 27th harmonic (41.85 eV) from the harmonic spectrum of the light source is achieved with a multilayer MoSi double mirror monochromator. The extinction efficiency of the monochromator in selecting this harmonic is shown to be better than 7:1, while the transmitted bandwidth of the selected harmonic is capable of supporting temporal pulse widths as short as 3 fs. The recorded E(k) photoelectron spectrum from a Cu(111) surface demonstrates an angular resolution of better than 0.6 degrees (=0.03 A(-1) at E(kin,e)=36 eV). Used in a pump-probe configuration, the described experimental setup represents a powerful experimental tool for studying the femtosecond dynamics of ultrafast surface processes in real time.

Quantum-well wave-function localization and the electron-phonon interaction in thin Ag nanofilms

The electron-phonon interaction in thin Ag nanofilms epitaxially grown on Cu(111) is investigated by temperature-dependent and angle-resolved photoemission from silver quantum-well states. Clear oscillations in the electron-phonon coupling parameter as a function of the silver film thickness are observed. Different from other thin film systems where quantum oscillations are related to the Fermi-level crossing of quantum-well states, we can identify a new mechanism behind these oscillations, based on the wave-function localization of the quantum-well states in the film.

Nocturnal ghrelin, ACTH, GH and cortisol secretion after sleep deprivation in humans

Ghrelin is an endogenous ligand of the growth hormone (GH) secretagogue (GHS) receptor. It is hypothesised to play a key role in energy balance stimulating food intake and body weight. Besides GH-releasing hormone (GHRH) and somatostatin, it is thought to be a regulating factor of GH release. Ghrelin also appears to be involved in sleep regulation. We showed recently that ghrelin promotes slow-wave sleep and the nocturnal release of GH, cortisol and prolactin in humans. Similarly, promotion of non-rapid-eye-movement (NREM) sleep was reported in mice after systemic ghrelin. If ghrelin is a factor that induces and/or maintains sleep, it should be enhanced after a period of sleep deprivation (SD). To clarify this issue, nocturnal ghrelin, GH, ACTH and cortisol plasma concentrations were determined and simultaneously sleep electroencephalogram (EEG) was recorded (2300-0700 h) during sleep before and after 1 night of total SD in 8 healthy subjects. Compared to baseline, ghrelin levels increased earlier by a non-significant trend, already before the beginning of recovery sleep. Further a non-significant trend occurred, suggesting higher ghrelin secretion in the first half of the night. The ghrelin maximum was found significantly earlier after SD than at baseline. GH secretion during the first half of the night and total night after SD were elevated. ACTH and cortisol were also elevated, which was most pronounced during the second half of the night. No effects of SD on the time of the maximum were found for GH, ACTH and cortisol. The increase in ACTH after SD is a novel finding. Whereas the effects of SD on ghrelin levels were relatively weak, our findings are in line with the hypothesis that ghrelin is a sleep-promoting factor in humans. Ghrelin may be involved in sleep promotion after SD.

Placentation in the African elephant, Loxodonta africana. IV. Growth and function of the fetal gonads

The gonads, both ovaries and testes, of 44 elephant fetuses weighing 0.09–112 kg (6.1–21.3 months gestation) were examined grossly and histologically. As in equids, elephant fetal gonads undergo a phase of marked growth and enlargement during the second half of gestation, which is more pronounced in ovaries than testes due to growth and antrum formation of numerous follicles in the former. Stromal cells undergo hypertrophy and transformation to form zones of interstitial cells that are associated with the enlarged follicles in the ovaries and in which the primitive seminiferous tubules are embedded in the testes. The interstitial cells have the capacity to synthesize 5α-dihydroprogesterone and other 5α-reduced progestagens from cholesterol and pregnenelone and the hypothesis is raised that these fetal gonadal progestagens may supplement significantly the progestagens secreted by the multiple large corpora lutea of pregnancy in the elephant.

Placentation in the African Elephant, Loxodonta africanus: III. Ultrastructural and Functional Features of the Placenta

Successful transfer of nutrients to the elephant fetus during pregnancy relies on a variety of placental modifications. Our light and electron microscopical investigations show that the structure is endotheliochorial from implantation to term, with unicellular, never syncytial trophoblast. Light and electron microscope immunocytochemistry shows the restriction of the glucose transporter 1 isoform to the basolateral surfaces of the trophoblast, with the glucose transporter 3 restricted to the apical plasmalemma of the trophoblast. Glucose transport to the fetus therefore requires a sequential use of both isoforms. Light and electron microscope cytochemistry indicate the presence of iron deposits only in the haemophagous zones confirming their iron transport function. No trophoblast areas with high concentrations of Calcium binding protein, specialised for Calcium transport were found. In situ hybridisation demonstrated the presence of IGF-II mRNA in the trophoblast from the earliest stage, with TGFbeta1 and HGF-SF mRNA expressed subsequently but only IGF-II and HGF mRNA present in the second half of pregnancy. The results are briefly discussed in terms of placental growth and function and indicate that the elephant placenta is another example of a unique solution to the variety of problems posed by a resident fetus.

Placentation in the African elephant (Loxodonta africana): II morphological changes in the uterus and placenta throughout gestation

The gross and microscopic development of the zonary endotheliochorial placenta in the African elephant was studied in 22 gravid uteri that ranged in gestational stage from 0.5 to 20.6 months. The conceptus only ever occupies one horn of the uterus and is associated with 2-5 large corpora lutea that persist in the ipsilateral ovary throughout gestation. Initially, the trophoblast in the equatorial region of the conceptus completely replaces the lumenal epithelium of the endometrium to which it is apposed. Blunt upgrowths of endometrial stroma then develop, each closely invested by trophoblast, and containing the capillaries that will vascularize this maternal component of the resulting placental band. With advancing gestation the lamellate stromal upgrowths increase markedly in length and become much thinner, thereby bringing the trophoblast into intimate contact with the endothelium of the maternal capillaries. They also become folded or pleated to increase the total area of intimate feto-maternal contact. At the lateral edges of the placental band the lamellae bend over towards the endometrium to form a blind cleft. Leakage of blood into this area creates haemophagous zones in which phenotypically specialized trophoblast cells phagocytose the blood components. The presence of large resorbing blood clots and circumferential scars in the uteri of three post parturient animals initiated the hypothesis that, when the standing elephant gives birth at term, the passage of the 120 kg fetus through the vagina may wrench the placenta off the endometrium by severing its very narrow maternal placental hilus. The resulting intrauterine haemorrhage may then play a role in preventing further conception for around 2 years.

Ghrelin promotes slow-wave sleep in humans

Ghrelin, an endogenous ligand of the growth hormone (GH) secretagogue (GHS) receptor, stimulates GH release, appetite, and weight gain in humans and rodents. Synthetic GHSs modulate sleep electroencephalogram (EEG) and nocturnal hormone secretion. We studied the effect of 4 x 50 microg of ghrelin administered hourly as intravenous boluses between 2200 and 0100 on sleep EEG and the secretion of plasma GH, ACTH, cortisol, prolactin, and leptin in humans (n = 7). After ghrelin administration, slow-wave sleep was increased during the total night and accumulated delta-wave activity was enhanced during the second half of the night. Rapid-eye-movement (REM) sleep was reduced during the second third of the night, whereas all other sleep EEG variables remained unchanged. Furthermore, GH and prolactin plasma levels were enhanced throughout the night, and cortisol levels increased during the first part of the night (2200-0300). The response of GH to ghrelin was most distinct after the first injection and lowest after the fourth injection. In contrast, cortisol showed an inverse pattern of response. Leptin levels did not differ between groups. Our data show a distinct action of exogenous ghrelin on sleep EEG and nocturnal hormone secretion. We suggest that ghrelin is an endogenous sleep-promoting factor. This role appears to be complementary to the already described effects of the peptide in the regulation of energy balance. Furthermore, ghrelin appears to be a common stimulus of the somatotropic and hypothalamo-pituitary-adrenocortical systems. It appears that ghrelin is a sleep-promoting factor in humans.

The GABA(A) agonist gaboxadol improves the quality of post-nap sleep

RATIONALE

Previous studies demonstrated that gaboxadol, a selective GABA(A) agonist, increases both non-REM sleep and EEG delta activity within non-REM sleep in rats and slow wave sleep (SWS) as well as low-frequency activity in the EEG within non-REM sleep in healthy humans under normal conditions.

OBJECTIVE

Because the hypnotic actions of drugs may be more readily demonstrated under conditions of poor sleep quality, we investigated the influence of gaboxadol on postnap sleep.

METHODS

In a randomized, placebo-controlled cross-over study using a late afternoon nap model, we assessed the effects of a single oral dose of 20 mg gaboxadol on disturbed nighttime sleep in young, healthy subjects.

RESULTS

Comparisons of visually scored sleep parameters between baseline and placebo postnap nights showed that the nap prolonged sleep latency, decreased total sleep time and SWS and attenuated delta, theta and alpha activity in the EEG within non-REM sleep. Compared with the placebo postnap night, gaboxadol tended to shorten sleep latency, significantly decreased intermittent wakefulness, increased total sleep time and SWS and enhanced delta and theta activity in the non-REM EEG. Furthermore, gaboxadol increased subjective sleep quality.

CONCLUSIONS

These data show that gaboxadol counteracts the disrupting effects of a nap on subsequent sleep and suggest that, in addition to promoting deep sleep and sleep maintenance, gaboxadol is able to facilitate sleep initiation and thus, exhibits significant hypnotic actions under conditions in which sleep quality is experimentally reduced.

Acute effects of melatonin on spontaneous and picrotoxin-evoked sleep-wake behaviour in the rat

Various studies indicate that exogenous melatonin has hypnotic properties in humans, which may be mediated by its influence on the circadian timing system or direct sleep-promoting actions, e.g. through a modulation of GABAergic transmission. The aim of the present placebo-controlled study was to examine the effects of melatonin on sleep in rats and the contribution of gamma-aminobutyric acid (GABA)A receptors. Sleep-wake behaviour was assessed in nine rats after intraperitoneal (i.p.) administration of pharmacological doses of melatonin (5 and 10 mg kg(-1)) and after combined administration of the GABAA receptor antagonist picrotoxin (1.5 mg kg(-1)) and melatonin (10 mg kg(-1)). To prevent chronobiotic effects, melatonin was delivered in the middle of the light period. Neither doses of melatonin exerted significant effects on brain temperature, sleep architecture or sleep electroencephalogram (EEG). Moreover, melatonin failed to attenuate the picrotoxin-induced promotion of wakefulness. These observations indicate that melatonin hardly influences sleep-wake behaviour in rats.

Effect of the GABAA agonist gaboxadol on nocturnal sleep and hormone secretion in healthy elderly subjects

Aging is associated with a dramatic decrease in sleep intensity and continuity. The selective GABA(A) receptor agonist gaboxadol has been shown to increase non-REM sleep and the duration of the non-REM episodes in rats and sleep efficiency in young subjects and to enhance low-frequency activity in the electroencephalogram (EEG) within non-REM sleep in both rats and humans. In this double-blind, placebo-controlled study, we investigated the influence of an oral dose of 15 mg of gaboxadol on nocturnal sleep and hormone secretion (ACTH, cortisol, prolactin, growth hormone) in 10 healthy elderly subjects (6 women). Compared with placebo, gaboxadol did not affect endocrine activity but significantly reduced perceived sleep latency, elevated self-estimated total sleep time, and increased sleep efficiency by decreasing intermittent wakefulness and powerfully augmented low-frequency activity in the EEG within non-REM sleep. These findings indicate that gaboxadol is able to increase sleep consolidation and non-REM sleep intensity, without disrupting REM sleep, in elderly individuals and that these effects are not mediated by a modulation of hormone secretion.

The GABA uptake inhibitor tiagabine promotes slow wave sleep in normal elderly subjects

Aging is associated with a dramatic decrease in slow wave sleep (SWS) and sleep consolidation. Previous studies revealed that various GABA(A) agonists and the GABA uptake inhibitor tiagabine augment slow frequency components in the EEG within non-REM sleep, and thus promote deep sleep in young individuals and/or rats. In the present double-blind, placebo-controlled study, we assessed the effect of a single oral dose of 5 mg tiagabine on nocturnal sleep in ten healthy elderly volunteers (6 females). During the placebo night the subjects displayed a low sleep efficiency, due to high amounts of intermittent wakefulness, and little SWS. Tiagabine significantly increased sleep efficiency, tendentially decreased wakefulness and prominently increased both SWS and low-frequency activity in the EEG within non-REM sleep. The present findings demonstrate that tiagabine increases sleep quality in aged subjects. Moreover, the effects of tiagabine closely match those evoked by the GABA(A) agonist gaboxadol in young subjects and indicate that such compounds may have prospects in the treatment of sleep disturbances, particularly of those commonly occurring in the elderly.

Diurnal variations in lipopolysaccharide-induced sleep, sickness behavior and changes in corticosterone levels in the rat

Inoculation of rats with microorganisms or microbial constituents that activate host defense promotes non-rapid eye movement sleep (non-REMS) and suppresses REMS. In this study, we evaluated circadian influences on the effects of lipopolysaccharide (LPS) on sleep, sickness behavior and plasma corticosterone levels in the rat. Three sets of experiments were performed. In each, the animals were intraperitoneally injected with vehicle for LPS (30 microg/kg) during 2 consecutive days, at the beginning of either the circadian rest or the activity phase. In experiment 1, sleep-wake behavior and brain temperature were recorded, and in experiment 2, core body temperature, locomotor activity as well as food and water intake. In experiment 3, corticosterone blood levels were measured. The results show that LPS-evoked changes in temperature, sleep and other behavioral parameters depend markedly on the time of day LPS is administered. However, a direct comparison of the LPS data demonstrates that, except for sleep parameters, the absolute time course of the assessed parameters was rather similar between the rest and activity phases. These findings suggest that LPS evokes a state characterized by high temperature and low vigilance, which is reached independently of the circadian phase.

Immunization with stallion lymphocytes for treatment of recurrent spontaneous abortion in thoroughbred mares

The incidence of recurrent spontaneous abortion within the human population in the Western world is low (2-5%) but significant, and a proportion of these pregnancy losses are thought to have an underlying immunological cause. Immunization of women who have a history of recurrent spontaneous abortion with lymphocytes isolated from their husband or a third party donor is one of several forms of immunotherapy used to treat the problem. Early pregnancy loss in Thoroughbred mares is also significant and, as in women, a small number of mares undergo repeated pregnancy losses. Two trials have been performed in which Thoroughbred mares suffering from recurrent spontaneous abortion before day 150 of gestation were immunized with lymphocytes isolated from the mating stallion or from an unrelated stallion. The first trial, which was conducted without control mares, resulted in a very high live birth rate (97%) for the mares (n=24) treated. Therefore, a second controlled double-blinded trial was established in which randomly selected mares (n=17) were treated with stallion (heterologous) lymphocytes and control mares (n=13) were injected with their own (autologous) lymphocytes. The live birth rates after these treatments were 88 and 77%, respectively. Thus, immunization with stallion lymphocytes had no effect on the incidence of abortion in mares suffering from recurrent spontaneous abortion.

Signal transduction of stress via ceramide

The sphingomyelin (SM) pathway is a ubiquitous, evolutionarily conserved signalling system analogous to conventional systems such as the cAMP and phosphoinositide pathways. Ceramide, which serves as second messenger in this pathway, is generated from SM by the action of a neutral or acidic SMase, or by de novo synthesis co-ordinated through the enzyme ceramide synthase. A number of direct targets for ceramide action have now been identified, including ceramide-activated protein kinase, ceramide-activated protein phosphatase and protein kinase Czeta, which couple the SM pathway to well defined intracellular signalling cascades. The SM pathway induces differentiation, proliferation or growth arrest, depending on the cell type. Very often, however, the outcome of signalling through this pathway is apoptosis. Mammalian systems respond to diverse stresses with ceramide generation, and recent studies show that yeast manifest a form of this response. Thus ceramide signalling is an older stress response system than the caspase/apoptotic death pathway, and hence these two pathways must have become linked later in evolution. Signalling of the stress response through ceramide appears to play a role in the development of human diseases, including ischaemia/reperfusion injury, insulin resistance and diabetes, atherogenesis, septic shock and ovarian failure. Further, ceramide signalling mediates the therapeutic effects of chemotherapy and radiation in some cells. An understanding of the mechanisms by which ceramide regulates physiological and pathological events in specific cells may provide new targets for pharmacological intervention.

Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries

STUDY OBJECTIVE

Two separate clinical decision rules, one developed in Ottawa and the other in Pittsburgh, for the use of radiography in acute knee injuries have been previously validated and published. In this study, the rules were prospectively validated and compared in a new set of patients.

METHODS

A prospective, blinded, multicenter trial was conducted in the emergency departments of three urban teaching hospitals. A convenience sample of 934 patients with knee pain requiring radiographs was enrolled. A standardized data form was completed for each patient, comprising the 10 clinical variables included in the two rules. Standard knee radiographs were then taken in each patient. The rules were interpreted by the primary investigator on the basis of the data sheet and the final radiologist radiograph reading.

RESULTS

In the 745 patients in whom the Pittsburgh rules could be applied there were 91 fractures (12.2%). The use of the Pittsburgh rule missed one fracture, yielding a sensitivity of 99% (95% confidence interval [CI], 94% to 100%); the specificity was 60% (95% CI, 56% to 64%). The Ottawa inclusion criteria were met by 750 patients, with 87 fractures (11.6%). The Ottawa rule missed three fractures, for a sensitivity of 97% (95% CI, 90% to 99%); specificity was 27% (95% CI, 23% to 30%).

CONCLUSION

Prospective validation and comparison found the Pittsburgh rule for knee radiographs to be more specific without loss of sensitivity compared with the Ottawa rule.

Soluble tumor necrosis factor receptor (p75) does not attenuate the sleep changes induced by lipopolysaccharide in the rat during the dark period

Sleep is generally enhanced during the early phase of infection. The cytokine tumor necrosis factor (TNF) has been postulated to play an important role in the acute phase sleep response. After demonstrating the ability of a soluble p75 TNF receptor (TNFR) to inhibit TNF activity in vitro, we assessed the influence of TNFR on the sleep changes evoked by lipopolysaccharide (LPS). In this vehicle-controlled experiment, 24 rats received either an intracerebroventricular injection of 10 micrograms TNFR, an intraperitoneal injection of 30 micrograms/kg LPS, or both, at the beginning of the dark period. EEG, EMG and brain temperature (Tbr) were recorded during the first 12 h post injection. Compared with vehicle, LPS had minimal effects on Tbr, but promoted non-rapid eye movement sleep (non-REMS), suppressed REMS, shortened the sleep episodes and decreased high-frequency (> or = 8 Hz) EEG activity during non-REMS. TNFR alone had no significant effects and did not attenuate any of the LPS-induced sleep changes. These results may either indicate that TNF is not critically involved in the sleep response to a low level LPS challenge during the activity phase or that the soluble p75 TNFR does not effectively antagonize the sleep changes evoked by TNF.

Resurgence of tuberculosis: implications for emergency nurses

An emergency nurse is often the first person with contact with patients with suspected or known TB when they come to the emergency department. With rapid recognition of signs and symptoms of active TB and prompt implementation of precautions, emergency nurses can reduce the transmission of the "greatest killer of mankind" to other patients, visitors, health care workers, and ourselves.

Maternal response to paternal trophoblast antigens

PROBLEM

What is the function of the immunoglobulin (Ig) G antibody bound to trophoblast in normal pregnancy, and what is the antigen?

METHOD

IgG was acid eluted from term human placental microvesicles and reacted with the antigen, R80K, left on the vesicles. The eluted antibody was used to detect the antigen on monocytes, lymphocytes, and lymphoblastoid cell lines. The eluted antibody is highly polymorphic, but monoclonal antibodies (mAbs) were made against conserved regions of the molecule. These also reacted with the murine equivalent of the human R80K and were used in inhibition studies of natural killer (NK) cell killing and the mouse abortion models, CBA x DBA2 F1 resorption in CBA females, the endotoxin-induced resorption model, and a sonic stress-induced murine resorption model.

RESULTS

All 600 syncytiotrophoblast microvesicle preparations of human term placenta had IgG antibody bound, elutable at pH 3.0. The eluted antibody reacted with about 15% of unrelated human placentae. In horses mares make detectable antibody early in pregnancy, at about the time of implantation. The IgG antibody was bound to an 80-kDa protein (R80K) also detected on B lymphocytes and monocytes. In HLA homozygous lymphoblastoid B cell lines, which reacted with one or more eluted antibodies, had a pattern of cytotoxicity independent of HLA Class I; and as a single 80-kDa peptide chain, R80K did not resemble HLA molecules. Genetic studies in horses show that of the two paternal allotypes of R80K detectable by placental alloantibodies, only one, usually the grandpaternal one, is present in all the placentae of a sibship. Two of 26 eluted human antibodies had affinity for K562 and inhibited killing by human peripheral blood NK cells. One mAb, BA11, against a conserved site on R80K inhibited killing of K562, and also reacted with the murine R80K homologue. BA11 inhibited murine NK cell killing and virtually completely inhibited three NK cell-dependent mouse resorption models.

CONCLUSION

R80K protein is a target molecule for NK cell activity expressed on all placentae. It has a polymorphic alloantigenic determinant completely covered with maternal antibody in all successful term pregnancies. In murine NK cell-dependent models of abortion, a mAb against a monomorphic determinant present in human and murine R80K prevents abortion very effectively. It seems that the R80K molecule must be covered with antibody to prevent NK attacks on trophoblast.

Muscimol and midazolam do not potentiate each other's effects on sleep EEG in the rat

The interaction of a gamma-aminobutyric acid-A (GABAA) receptor agonist and a benzodiazepine-type modulator of GABAA receptors on sleep was investigated. Low doses of muscimol (0.3 mg/kg) and the benzodiazepine midazolam (1.5 mg/kg) were administered alone and in combination, in random order, to eight rats. All injections were given intraperitoneally at light onset. Electroencephalogram (EEG) and electromyogram were recorded during the first 6 h post injection. Compared with vehicle, muscimol hardly affected the time spent in non-rapid eye movement sleep (non-REMS) and REMS, but significantly enhanced EEG activity in the frequency range between 2 and 6 Hz during non-REMS. Midazolam significantly increased the time spent in non-REMS, reduced EEG activity at frequencies < 12 Hz, and elevated EEG activity in most higher frequencies during this state. The combined administration of muscimol and midazolam affected non-REMS-specific EEG activity in an unexpected fashion: the effects were intermediate between those of muscimol and midazolam. These results indicate that muscimol and midazolam have dissimilar effects on EEG within non-REMS and demonstrate that midazolam does not augment but attenuates the muscimol-induced changes in sleep EEG. Our data are at variance with established mechanisms, according to which agonistic modulators would have similar effects and should potentiate the effects of GABAA agonists. The present data suggest that application of agonists and agonistic modulators of GABAA receptors causes differential net effects on sleep parameters.

Placental localization of relaxin in the pregnant mare

In situ hybridization employing a cRNA probe derived from a 428-bp fragment of equine relaxin was used to localize relaxin mRNA, and immunocytochemistry was used to localize relaxin itself, in tissues of the placenta-endometrium interface recovered between 33 and 153 days of gestation from mares carrying intraspecific horse, interspecific mule and extraspecific donkey conceptuses. Immunocytochemical staining was also used to localize trophoblast-specific and class I major histocompatibility complex (MHC) antigens on some specimens. Relaxin mRNA and relaxin were both present in the single-cell non-invasive trophoblast layer of the allantochorion between 45 and 153 days of gestation in all three types of equine pregnancy examined. Both, however, were absent from the invasive trophoblast cells of the progenitor chorionic girdle and the differentiated trophoblast cells of the endometrial cups throughout the latters' 60-80-day period of development and regression. Discrete and irregularly spaced clusters of elongated pseudostratified trophoblast cells on the allantochorion remained negative for relaxin mRNA and ligand, but stained strongly for equine trophoblast-specific antigens. These areolae-like structures of the mature horse placenta overlie the mouths of endometrial glands between adjacent microcotyledons and they are clearly involved with the uptake of uterine milk for fetal sustenance. It is speculated that their loose attachment to the endometrium and weak expression of class 1 MHC antigens may serve to tolerize the mother to the paternally-inherited histocompatibility antigens of the fetus.

Effect of interleukin-1 beta on EEG power density during sleep depends on circadian phase

The cytokine interleukin (IL)-1 is a key mediator of the somnogenic response to immune challenge. In this vehicle-controlled study we evaluated circadian interference with the sleep-promoting effects of IL-1 beta. In two randomized experiments, rats were injected intracerebroventricularly with 5 ng IL-1 beta either at the beginning of the rest phase or at the beginning of the activity phase. Recordings were made during the 24 h preceding the injections (baseline) and during the first 12 postinjection hours. To avoid masking effects of light, the rats were maintained under a skeleton photoperiod during recording. During both the rest and activity phase, IL-1 beta induced fever and initially promoted non-rapid eye movement sleep (REMS). The effect of IL-1 beta on the duration of non-REMS and electroencephalogram (EEG) power densities within non-REMS was related to circadian phase. During the rest phase, IL-1 beta resulted in a minor increase in non-REMS duration but a prominent enhancement in EEG activity in the delta (0.5-4 Hz) and most other frequency bands. During the activity phase, IL-1 beta evoked a larger increase in the duration of non-REMS but hardly affected EEG activity within this state. Thus the effects of IL-1 beta on non-REMS are strongly influenced by diurnal phase. The alterations in EEG power density are in contrast to those elicited by sleep deprivation, which are largely independent of time of day. It is concluded that IL-1 beta activates EEG regulatory mechanisms mediated by processes that depend on circadian phase.

The use of propofol for sedation in the emergency department

OBJECTIVE

To evaluate the effectiveness of propofol and fentanyl when used by emergency physicians (EPs) for systemic sedation and analgesia in the ED.

METHODS

Over an eight-month period, a convenience sample of consenting patients at an urban teaching hospital ED who required sedation for painful procedures were enrolled in a descriptive study of therapeutic propofol sedation. After receiving 2 micrograms/kg of fentanyl i.v. the patients received a continuous infusion of propofol at 0.21 mg/kg/min i.v. to the desired level of sedation. A maintenance infusion of 3-6 mg/kg/hr was administered during the remainder of the procedure. Sedation time, total procedure time, and recovery time were recorded and the presence of side effects was noted. The patients and the physicians rated their satisfaction with the technique on a 100-mm visual analog scale. The patients were contacted at 24 hours for follow-up information.

RESULTS

Twenty patients (aged 19-62 years) received propofol infusion for procedures that included ten abscess incision and drainages, eight orthopedic reductions, one chest tube placement, and one wound exploration. The mean (+/- SD) total dose of propofol was 200 +/- 160 mg. The mean time to onset of sedation was 6.6 +/- 3.2 min, the mean procedure interval was 9.6 +/- 6.3 min, and the mean interval until recovery was 6.1 +/- 4.1 min. The median patient satisfaction score was 97 mm (range 40-100 mm); the median rating by physicians was 88 mm (range 4-100 mm). Side effects were noted in six patients: three had pain on injection, one had pain on injection and brief (< 1 min) hypotension (systolic blood pressure = 80 mm Hg), and two had apnea (< 30 sec). Seven patients had some recall of the procedure immediately afterwards, but only five had any recall at 24 hours. All 20 patients stated they would be willing to receive the same sedation again for a future procedure.

CONCLUSION

Propofol appears to be an effective agent to provide systemic sedation and analgesia when used in conjunction with fentanyl for procedures in the ED. Given its rapidity of onset and elimination, it may become a useful agent to EPs for i.v. sedation in the ED.