Physical activity assessment methodology in the Five-City Project

Previous measures of physical activity for epidemiologic studies were considered inadequate to meet the needs of a community-based health education trial. Therefore, new methods of quantifying the physical activity habits of communities were developed which are practical for large health surveys, provide information on the distribution of activity habits in the population, can detect changes in activity over time, and can be compared with other epidemiologic studies of physical activity. Independent self-reports of vigorous activity (at least 6 metabolic equivalents (METs) ), moderate activity (3-5 METs), and total energy expenditure (kilocalories per day) are described, and the physical activity practices of samples of California cities are presented. Relationships between physical activity measures and age, education, occupation, ethnicity, marital status, and body mass index are analyzed, and the reliabilities of the three activity indices are reported. The new assessment procedure is contrasted with nine other measures of physical activity used in community surveys.

A genomic screen of autism: evidence for a multilocus etiology

We have conducted a genome screen of autism, by linkage analysis in an initial set of 90 multiplex sibships, with parents, containing 97 independent affected sib pairs (ASPs), with follow-up in 49 additional multiplex sibships, containing 50 ASPs. In total, 519 markers were genotyped, including 362 for the initial screen, and an additional 157 were genotyped in the follow-up. As a control, we also included in the analysis unaffected sibs, which provided 51 discordant sib pairs (DSPs) for the initial screen and 29 for the follow-up. In the initial phase of the work, we observed increased identity by descent (IBD) in the ASPs (sharing of 51.6%) compared with the DSPs (sharing of 50.8%). The excess sharing in the ASPs could not be attributed to the effect of a small number of loci but, rather, was due to the modest increase in the entire distribution of IBD. These results are most compatible with a model specifying a large number of loci (perhaps >/=15) and are less compatible with models specifying </=10 loci. The largest LOD score obtained in the initial scan was for a marker on chromosome 1p; this region also showed positive sharing in the replication family set, giving a maximum multipoint LOD score of 2.15 for both sets combined. Thus, there may exist a gene of moderate effect in this region. We had only modestly positive or negative linkage evidence in candidate regions identified in other studies. Our results suggest that positional cloning of susceptibility loci by linkage analysis may be a formidable task and that other approaches may be necessary.

Opioids, opioid receptors, and the immune response

It is now clear that opioid receptors participate in the function of the cells of the immune system, and evidence suggests that opioids modulate both innate and acquired immune responses. We review literature here which establishes that mu-, kappa-, and delta-opioid compounds alter resistance to a variety of infectious agents, including the Human Immunodeficiency Virus (HIV). The nature of the immunomodulatory activity of the opioids has been the subject of a great deal of research over the last ten years. There is increasing evidence that effects of opioids on the immune response are mediated at several levels. Modulation of the inflammatory response appears to be a target of these compounds, including effects on phagocytic activity, as well as the response of cells to various chemoattractant molecules. Moreover, findings from several laboratories have demonstrated the impact of opioid treatment on antibody responses, and the molecular basis for this effect is likely due, at least in part, to the modulation of both cytokine and cytokine receptor expression. Future research should provide a clearer understanding of the cellular and molecular targets of opioid action within the immune system.

Extension of a pilot study: impact from the cytochrome P450 2D6 polymorphism on outcome and costs associated with severe mental illness

The influence of cytochrome P450 2D6 (CYP2D6) genetic variability was examined in psychiatric inpatients by evaluating adverse drug events (ADEs), hospital stays, and total costs over a 1-year period in an extension of a previously published brief report. One hundred consecutive psychiatric patients from Eastern State Hospital in Lexington, Kentucky, were genotyped for CYP2D6 expression. ADEs were evaluated by a neurologic rating scale, modified Udvalg for Kliniske Undersogelser Side Effect Rating Scale, or chart review. Information on total hospitalization days and total costs were gathered for a 1-year period. Forty-five percent of the patients received medications that were primarily dependent on the CYP2D6 enzyme for their elimination. When the analysis was restricted to just those patients in each group receiving medication heavily dependent on the CYP2D6 enzyme, the following were observed: (1) a trend toward greater numbers of ADEs from medications as one moved from the group with ultrarapid CYP2D6 activity (UM) to the group with absent CYP2D6 activity (PM); (2) the cost of treating patients with extremes in CYP2D6 activity (UM and PM) was on average $4,000 to $6,000 per year greater than the cost of treating patients in the efficient metabolizer (EM) and intermediate metabolizer (IM) groups; and (3) total duration of hospital stay was more pronounced for those in CYP2D6 PM group. Variance of hospital stays and costs calculated from these preliminary data suggests that 1,500 to 2,000 patients must be evaluated over at least a 1-year period to determine whether the CYP2D6 genetic variation significantly alters the duration of hospital stay and costs.

Epidemiology, diagnosis and treatment of systemic Candida infection in surgical patients under intensive care

The incidence of systemic Candida infections in patients requiring intensive care has increased substantially in recent years as a result of a combination of factors. More patients with severe underlying disease or immunosuppression from anti-neoplastic or anti-rejection chemotherapy and at risk from fungal infection are now admitted to the ICU. Improvements in supportive medical and surgical care have led to many patients who would previously have died as a result of trauma or disease surviving to receive intensive care. Moreover, some therapeutic interventions used in the ICU, most notably broad-spectrum antibiotics and intravascular catheters, are also associated with increased risks of candidiasis. Systemic Candida infections are associated with a high morbidity and mortality, but remain difficult to diagnose and ICU staff need to be acutely aware of this often insidious pathogen. A number of studies have identified risk factors for systemic Candida infection which may be used to identify those at highest risk. Such patients may be potential candidates for early, presumptive therapy. Here we review the epidemiology, pathogenesis, morbidity and mortality of systemic Candida infections in the ICU setting, and examine predisposing risk factors. Antifungal treatment, including the use of amphotericin B, flucytosine and fluconazole, and the roles of early presumptive therapy and prophylaxis, is also reviewed.

Immunomodulatory activity of mu- and kappa-selective opioid agonists

Opioids and opioid peptides have been shown by numerous laboratories to modulate various parameters of the immune response, but little attention has been given to the type of opioid receptor that might be involved. This study focuses on the in vitro influences of morphine and DAMGE (Tyr-D-Ala-Gly-N-Me-Phe-Gly-ol), mu-selective agonists, and U50,488H and U69,593, kappa-selective agonists, on the generation of antibody to sheep erythrocytes in vitro. It was found that the mu and kappa opioid agonists were able to inhibit the capacity of murine lymphoid cells to generate antibody at concentrations as low as 10(-10) M. The effects were almost completely blocked by pretreatment with naloxone or naltrexone, opioid-specific antagonists. Only the kappa-agonist activity was abrogated by pretreatment with norbinaltorphimine, a kappa-specific antagonist. The stereospecificity of the kappa effect was demonstrated using isomers of U50,488H, with the (-) form possessing significantly greater immunomodulatory activity. Additional studies, using a mu receptor-deficient mouse strain, demonstrated that only the kappa agonists were capable of suppressing antibody responses, whereas mu- and kappa-selective agonists suppressed the parent mu-responsive strain. Our results clearly indicate that mu and kappa opioid receptors are involved in regulation of lymphoid cell production of antibodies.

Morphine induces sepsis in mice

Gram-negative sepsis and subsequent endotoxic shock remain major health problems in the United States. The present study examined the role of morphine in inducing sepsis. Mice administered morphine by the subcutaneous implantation of a slow-release pellet developed colonization of the liver, spleen, and peritoneal cavity with gram-negative and other enteric bacteria. In addition, the mice became hypersusceptible to sublethal endotoxin challenge. The effects were blocked by the simultaneous implantation of a pellet containing the opioid antagonist naltrexone. These findings show that morphine pellet implantation in mice results in the escape of gram-negative organisms from the gastrointestinal tract, leading to the hypothesis that morphine used postoperatively or chronically for analgesia may serve as a cofactor in the precipitation of sepsis and shock. In addition, morphine-induced sepsis may provide a physiologically relevant model of gram-negative sepsis and endotoxic shock.

Pregnancy outcomes after kidney donation

The outcome of pregnancy in kidney donors has generally been viewed to be favorable. We determined fetal and maternal outcomes in a large cohort of kidney donors. A total of 2102 women have donated a kidney at our institution; 1589 donors responded to our pregnancy surveys; 1085 reported 3213 pregnancies and 504 reported none. Fetal and maternal outcomes in postdonation pregnancies were comparable to published rates in the general population. Postdonation (vs. predonation) pregnancies were associated with a lower likelihood of full-term deliveries (73.7% vs. 84.6%, p = 0.0004) and a higher likelihood of fetal loss (19.2% vs. 11.3%, p < 0.0001). Postdonation pregnancies were also associated with a higher risk of gestational diabetes (2.7% vs. 0.7%, p = 0.0001), gestational hypertension (5.7% vs. 0.6%, p < 0.0001), proteinuria (4.3% vs. 1.1%, p < 0.0001) and preeclampsia (5.5% vs. 0.8%, p < 0.0001). Women who had both pre- and post-donation pregnancies were also more likely to have these adverse maternal outcomes in their postdonation pregnancies. In this large survey of previous living donors in a single center, fetal and maternal outcomes and pregnancy outcomes after kidney donation were similar to those reported in the general population, but inferior to predonation pregnancy outcomes.

Morphine treatment in vitro or in vivo decreases phagocytic functions of murine macrophages

Studies were performed to compare in vitro and in vivo effects of morphine on the phagocytic function of murine peritoneal macrophages. Macrophage monolayers were incubated with Candida albicans for 30 min in the absence of autologous serum. Morphine added in vitro was found to decrease both the phagocytic activity (percent of phagocytic cells) and the phagocytic index (average number of ingested yeasts per cell) in a concentration-dependent manner, with maximal effects of 26% and 41%, respectively, at 10(-6) M. When morphine was administered in vivo via an implanted 75-mg pellet, there was a 22% decrease in phagocytic activity and a 40% decrease in the phagocytic index. Naltrexone completely blocked the effects of morphine both in vitro and in vivo. The results suggest that morphine is capable of interacting directly with opioid receptors on macrophages, resulting in a decrease in phagocytic function.

Opioid and nociceptin receptors regulate cytokine and cytokine receptor expression

Opioids were originally discovered because of their ability to induce analgesia, but further investigation has shown that the opioids regulate the function of cells involved in the immune response. We suggest that the regulation of cytokine, chemokine, and cytokine receptor expression is a critical component of the immunomodulatory activity of the opioids. In this paper we review the literature dealing with the regulation of cytokine and cytokine receptor expression by agonists for the three major opioid receptor types (mu, kappa, and delta), and nociceptin, the natural agonist for the orphanin FQ/nociceptin receptor. Although the opioid receptors share a high degree of sequence homology, opposing roles between the kappa opioid receptor (KOR) and the mu opioid receptor (MOR) have become apparent. We suggest that activation of the KOR induces an anti-inflammatory response through the down-regulation of cytokine, chemokine and chemokine receptor expression, while activation of the MOR favors a pro-inflammatory response. Investigation into the opioid receptor-like (ORL1)/nociceptin system also suggests a role for this receptor as a down-regulator of immune function. These effects suggest a broad role for opioids in the modulation of the function of the immune system, and suggest possible targets for the development of new therapeutics for inflammatory and infectious diseases.

The relevance of opioids and opioid receptors on immunocompetence and immune homeostasis

Since the previous review on the role of opioids in the immune system, numerous investigative teams have contributed to the growing pool of information illustrating the tangible relationship between opioids and immune function, particularly as this association pertains to bacterial and viral pathogens. In addition, the recent cloning of both neural- and immune-derived opioid receptors will ultimately facilitate the identification of molecular events that are responsible for the immunomodulatory effects that are mediated by receptor ligation. Specifically, the administration of opioids in vivo can potentially affect the immune system either through direct interaction with receptors on the effector cells or indirectly, through the ligation of receptors found within the central nervous system. This indirect routing is hypothesized to involve secondary pathways including the hypothalamic pituitary adrenal (HPA) axis and the sympathetic nervous system ultimately resulting in immunomodulation. Consequently, a portion of this review addresses the recent data on leukocyte-derived opioid receptors and the potential immunoregulatory role relative to opiold receptors found within the central nervous system. In addition, recent observations on the effects of opioids and immunocompetence is reviewed from both a molecular and cellular perspective. Finally, the consequence of opioid exposure on the competence of the host immune system to microbial pathogens is summarized.

Chemopreventive effects of tea extracts and various components on human pancreatic and prostate tumor cells in vitro

Pancreatic and prostate cancers pose serious problems to human health. To determine the potential for chemopreventive intervention against pancreatic and prostate cancers, black and green tea extracts and components of these extracts were examined in vitro for their effect on tumor cell growth. Components included a mixture of polyphenols from green tea (GTP), mixtures of polyphenols (BTP) and of theaflavins (MF) from black tea, and the purified components epicatechin-3-gallate (ECG) and epigallocatechin-3-gallate (EGCG). Two human cell lines, pancreatic adenocarcinoma (HPAC) and prostate tumor (LNCaP), were exposed to these agents for 24 hours. Results showed inhibition (approx 90%) of cell growth in pancreatic tumor cells by black and green tea extracts (0.02%). GTP (10 micrograms/ml) and MF (100 micrograms/ml) significantly inhibited growth (approx 90%); ECG and EGCG inhibited growth as well (approx 95%). Black and green tea extracts, GTP, and EGCG decreased the expression of the K-ras gene, as determined by reverse transcription-polymerase chain reaction. Green and black tea extracts decreased the multidrug-resistant gene (mdr-1), although GTP and EGCG increased expression. Similar data were obtained in the prostate cell line LNCaP. All agents significantly inhibited growth. These agents increased expression of the mdr-1 gene. This study suggests that components from black and green tea extracts can modulate the expression of genes known to play a role in the carcinogenesis process and, therefore, may be potential agents for chemoprevention against pancreatic cancer.

Differential effects of morphine and naltrexone on the antibody response in various mouse strains

Morphine treatment has been shown to suppress several immunologic parameters. In this study, we examined the effects of morphine pellet implantation in vivo on the primary antibody response measured in vitro in various mouse strains. Effects of mouse strain and sex on morphine-induced suppression of the plaque-forming cell response, as well as spleen weight and mortality were determined. Morphine suppressed the primary antibody response in C3HeB/FeJ, C3H/HeJ and C57Bl/6 mice, while Balb/cByJ and the mu-receptor-deficient strain CxBk/ByJ mice were not affected. There was no difference in the response to morphine between male and female C3HeB/FeJ mice. Naltrexone reversed the morphine-induced suppression in the C3H strains, but not in C57Bl/6 mice. In addition, naltrexone caused significant mortality in Balb/cByJ mice. Spleen weight was decreased by morphine treatment in all the strains, but only the C3H strains were sensitive to the lethal effects of morphine. Thus, immune suppression did not correlate with splenic atrophy or mortality. The strain differences in response to chronic morphine and naltrexone treatment suggest that morphine may be acting through both opioid and non-classical opioid (e.g., not blocked by naltrexone) mechanisms.

Inhibition of primary murine macrophage cytokine production in vitro following treatment with the kappa-opioid agonist U50,488H

Previous work in our laboratory has shown that both mu- and kappa-opioid agonists exhibit immunosuppressive activity for antibody responses in vitro. Our earlier work has suggested that both accessory cells and T cells may be altered following treatment with the kappa-opioid agonist U50,488H. We intend to further determine the identity of the immune cell population(s) which are affected by opioid treatment, and to determine the nature of the opioid receptor type expressed on these cells. In this study, non- elicited peritoneal macrophages were treated simultaneously with the kappa-agonist U50,488H and lipopolysaccharide (LPS), and the levels of the cytokines interleukin (IL)-1, IL-6 and tumor necrosis factor (TNF)-alpha were determined. The results show that U50,488H had a suppressive effect on the production of TNF-alpha and IL-1 at concentrations as low as 1 nM, while IL-6 was suppressed at concentrations as low as 10 nM. Additional experiments utilizing the opiate antagonist naloxone and the kappa-selective antagonist norbinaltorphimine (norBNI) were performed in order to further characterize the opioid receptor involved in the cytokine suppression produced by treatment with U50,488H. Results showed that naloxone was able to partially block U50,488H suppression while norBNI was able to completely reverse the suppression of IL-6 production. These results suggest that macrophage/monocyte function is significantly modulated following activation of the kappa-opioid receptor.

Strengthening individual and community capacity to prevent disease and promote health: in search of relevant theories and principles

The dominant theoretical models used in health education today are based in social psychology. While these theories have increasingly acknowledged the role of larger social and cultural influences in health behavior, they have many limitations. Theories seek to explain the causes of health problems, whereas principles of practice, which are derived from practical experience, assist intervenors to achieve their objectives. By elucidating the relationships between theory and practice principles, it may be possible to develop more coherent and effective interventions. The key research agenda for health education is to link theories at different levels of analysis and to create theory-driven models that can be used to plan more effective interventions in the complex environments in which health educators work.

The evolution of the Fenway Community Health model

Fenway Community Health was founded by community activists in 1971 in the Fenway neighborhood of Boston, Mass, and within a decade had rapidly expanded its medical services for gay men in response to the AIDS epidemic. Increased expertise and cultural competence in lesbian, gay, bisexual, and transgender (LGBT) care led to expansion of medical services to address broader community concerns, ranging from substance use to parenting issues to domestic and homophobic violence, as well as specialized programs for lesbians, bisexuals, and transgendered individuals. Fenway began as a grassroots neighborhood clinic. In 1975, the center recorded 5000 patient care visits; in 2000, Fenway's clinical departments recorded 50,850 visits by 8361 individuals, including more than 1100 individuals receiving HIV-associated care. The center now has more than 170 staff people responsible for clinical programs, community education, research, administration, planning, and development. Over the past few years, Fenway's annual budget has exceeded $10 million. Fenway has established standards for improved cultural competence about LGBT health issues for other health providers and has developed programs to educate the general community about specific LGBT health concerns. This health center may provide a model of comprehensive LGBT health services that have a local impact.

Mu-opioid induction of monocyte chemoattractant protein-1, RANTES, and IFN-gamma-inducible protein-10 expression in human peripheral blood mononuclear cells

Strong evidence for the direct modulation of the immune system by opioids is well documented. Mu-opioids have been shown to alter the release of cytokines important for both host defense and the inflammatory response. Proinflammatory chemokines monocyte chemoattractant protein-1 (MCP-1), RANTES, and IFN-gamma-inducible protein-10 (IP-10) play crucial roles in cell-mediated immune responses, proinflammatory reactions, and viral infections. In this report, we show that [D-Ala(2),N:-Me-Phe(4),Gly-ol(5)]enkephalin (DAMGO), a mu-opioid-selective agonist, augments the expression in human PBMCs of MCP-1, RANTES, and IP-10 at both the mRNA and protein levels. Because of the proposed relationship between opioid abuse and HIV-1 infection, we also examined the impact of DAMGO on chemokine expression in HIV-infected cells. Our results show that DAMGO administration induces a significant increase in RANTES and IP-10 expression, while MCP-1 protein levels remain unaffected in PBMCs infected with the HIV-1 strain. In contrast, we show a dichotomous effect of DAMGO treatment on IP-10 protein levels expressed by T- and M-tropic HIV-infected PBMCs. The differential modulation of chemokine expression in T- and M-tropic HIV-1-infected PBMCs by opioids supports a detrimental role for opioids during HIV-1 infection. Modulation of chemokine expression may enhance trafficking of potential noninfected target cells to the site of active infection, thus directly contributing to HIV-1 replication and disease progression to AIDS.

Indirect measures of cigarette use: expired-air carbon monoxide versus plasma thiocyanate

Indirect, biochemical measures of cigarette use are valuable in confirming smoking status in both cross-sectional and cessation studies. This study compares two such biochemical markers, expired-air carbon monoxide (CO) and plasma thiocyanate (SCN), in a representative population sample of 2,237 adults (ages 18-74) from the baseline survey of the Stanford Five City Project. CO and SCN are both significantly higher in self-reported smokers than in nonsmokers and correlate well with number of cigarettes smoked per day. CO appears to be more sensitive and specific than SCN in comparison to self-report, and CO misclassifies a significantly smaller number of nonsmokers, regular smokers, and light smokers (less than 9 cigarettes per day) than does SCN. Together, CO and SCN better classify smokers and nonsmokers than do either alone. Neither biochemical is a reliable indicator in irregular smokers (no cigarettes in past 48 hr). Despite its much shorter metabolic half-life, CO is a better indicator of cigarette use than is SCN in this cross-sectional study. CO is generally simpler and less expensive to measure than is SCN, and CO may be a preferable indirect measure of smoking status in some studies of smoking cessation.

The performance of three serum creatinine-based formulas in estimating GFR in former kidney donors

Studies addressing long-term consequences of living with one kidney have used serum creatinine-based formulas that have not been validated in former kidney donors. Therefore, we evaluated the performance of Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Mayo Clinic formulas in predicting iohexol glomerular filtration rate (iGFR) after donation in 112 randomly selected former kidney donors. Mean time from donation was 12.2 +/- 8.5 years. Serum creatinine was 1.1 +/- 0.2 mg/dL and iohexol GFR was 72 +/- 12 mL/min/1.73 m(2). The majority, 83.9%, of donors had a GFR >60 mL/min. CG formula overestimated GFR by 3.35 +/- 13.6 mL/min and was within 10% of iohexol GFR in only 43.7% of cases. MDRD formula underestimated iohexol GFR by 6.45 +/- 9.5 mL/min and was within 10% of actual GFR in half of the cases. In contrast, the Mayo Clinic equation was the most biased at 14.71 +/- 12.3 mL/min and was within 10% of measured GFR in only a fifth of the cases. Only MDRD and CG formulas provide estimates of GFR in former kidney donors that are within a clinically acceptable range of actual GFR. In conclusion, the majority of former kidney donors have excellent kidney function and the MDRD formula should be the recommended GFR estimating model in this population.

Bidirectional heterologous desensitization of opioid and chemokine receptors

Opioids are known to suppress a number of elements of the immune response, including antimicrobial resistance, antibody production, and delayed-type hypersensitivity. Phagocytic cells may be particularly susceptible to opioid administration, since reduced production of the cytokines IL-1, IL-6 and TNF-alpha, monocyte-mediated phagocytosis, and both neutrophil and monocyte chemotaxis have all been well established. Earlier studies have shown that both mu- and delta-opioid agonists induce a chemotactic response in monocytes and neutrophils. In addition, mu- and delta-opioid administration inhibited the chemotactic response of these cell populations to a number of chemokines through a process of heterologous desensitization. We report here that mu-, delta-, and kappa-opioid agonists also induce a chemotactic response in T lymphocytes. Using the human T-cell line Jurkat, we have confirmed previous observations that pre-incubation with met-enkephalin (MetEnk), an endogenous opioid agonist, prevents the subsequent chemotactic response to the chemokine RANTES. On the other hand, treatment with MetEnk does not alter the response to the chemokine SDF-1 alpha. Moreover, we found that pre-treatment with RANTES prevented a subsequent response of monocytes to the mu-opioid agonist DAMGO. These results suggest that activation of members of the opioid and chemokine receptor families leads to downregulation of each other's leukocyte migratory activities.

Economic evaluation of voriconazole compared with conventional amphotericin B for the primary treatment of aspergillosis in immunocompromised patients

OBJECTIVE

The objective of this study was to conduct an economic evaluation of voriconazole compared with conventional amphotericin B deoxycholate (CAB) using data from a recently reported randomized comparative trial in patients with various underlying immunosuppressive conditions. This trial demonstrated the superiority of voriconazole in terms of clinical response, survival and safety when used as primary therapy for invasive aspergillosis.

METHODS

A decision analytic model was designed using an expert panel and populated primarily with efficacy and resource utilization data collected prospectively during the clinical trial. The analysis was carried out from the perspective of the health care system and all costs are reported in 2002 US dollars.

RESULTS

Average total treatment costs per patient were 10% lower in the voriconazole arm ($30 664) than in the CAB arm ($34 144), resulting from reduced consumption of hospital resources and fewer changes in antifungal therapy. In the base case analysis, voriconazole provided an average saving of $3481 per treated patient, resulted in a lower cost per survivor ($43 310 versus $58 971) and a lower cost per successfully treated patient ($58 100 versus $108 124) compared with CAB. Sensitivity analyses demonstrated that the cost savings observed were maintained over a wide range of alternative values for both unit costs and resource utilization, including length of hospital stay, time spent in intensive care units, bed day costs and the cost of lipid formulations of amphotericin B.

CONCLUSION

Incremental cost-effectiveness analysis indicated the dominance of voriconazole because of both lower costs and greater efficacy.