Suprascapular nerve blockage for painful shoulder pathology - a systematic review and meta-analysis of treatment techniques

BACKGROUND

Suprascapular nerve blockade (SSNB) through injection (SSNBi) and/or pulsed radiofrequency (PRF) provide options for the management of painful shoulder pathology. Multiple techniques for delivery of SSNB are described but no consensus on optimal symptom control is available. This systematic review and meta-analysis aims to assess patient-focussed outcomes in SSNB and explore the impact of variation in the technical application of this treatment modality.

METHODS

MEDLINE, Embase and CINAHL were searched for case series, cohort studies and randomised control trials published from database inception until 28 January 2021. Articles reporting use of SSNBi or PRF for treatment of shoulder pain with a minimum 3 months follow-up were included. Patient-reported outcome measures (PROMs) were extracted and the pooled standardised mean difference (SMD), weighted by study size, was reported. Quality of methodology was assessed using Wylde's nonsummative four-point system.

FINDINGS

Of 758 references, 18 studies were included, totalling 704 SSNB. Average pain improvement at 3 months was 52.3%, with meta-analysis demonstrating a SMD of 2.37. Whereas SSNBi combined with PRF shows the greatest SMD of 2.75, this did not differ significantly from SSNBi or PRF when used as monotherapy. Location of treatment and the guidance technique used did not influence outcome.

CONCLUSION

SSNBi and PRF provide safe and effective treatment for shoulder pain, as judged by PROMs. This may be of particular value in aging or comorbid patients and with surgical restrictions during the COVID-19 pandemic. Regardless of technique, patients experience a marked improvement in pain that is maintained beyond 3 months.

POS0739 THE RENAL ACTIVITY INDEX FOR LUPUS (RAIL) DIFFERENTIATES ACTIVE AND INACTIVE NEPHRITIS IN ADULT PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Background

Lupus nephritis (LN) confers a poor prognosis, with lack of effective laboratory tests to diagnose and evaluate therapies. We have demonstrated that the RAIL score, based on a set of six urinary biomarkers (NGAL, KIM-1, MCP-1, adiponectin, hemopexin, ceruloplasmin) is sensitive and specific in adult patients with active LN, using renal biopsy as reference.1,2 RAIL has been shown in the pediatric population to be effective in distinguishing inactive vs active LN with no effect from mycophenolate mofetil (MMF) treatment. A comparable study has not been conducted in an adult population.

Objectives

To assess the ability of RAIL to discriminate patients with active LN vs active non-renal SLE and to evaluate if RAIL performance varies by MMF treatment using urine samples from adult LN patients.

Methods

Urine samples were obtained at baseline in two clinical trials: a phase 2 study in adult patients with biopsy-proven active Class III and IV LN (NCT02547922) and a subset of patients from the phase 3 trial in adults with active non-renal SLE (NCT02446912) who had baseline renal BILAG scores C, D, or E. RAIL biomarkers were assayed using single-plex assays. Patient demographics and clinical characteristics were compared between studies. Wilcoxon rank sum test was performed comparing the urinary biomarkers between the two studies and RAIL score was then calculated. Receiver operating characteristic (ROC) analyses were conducted assessing the ability for RAIL scores to distinguish patients with renal activity and involvement.

Results

Comparison of the patient demographic, clinical characteristics, and biomarkers is in the Table 1. Wilcoxon rank sum test showed the six urinary biomarkers were significantly different between two groups of patients as demonstrated (Table 1). Each of the RAIL biomarker concentrations and the creatinine-adjusted median score were higher in the active LN group than the SLE group (P<0.001). ROC analyses including RAIL score showed an area under the ROC curve of 0.8 (Figure 1), with odds ratio of log-transformed RAIL 2.027 (95% CI [1.587, 2.589]). There were no significant interactions between RAIL and MMF. RAIL remained significant after adjusting for estimated glomerular filtration rate (eGFR), which was not statistically significant.

Table 1.

Study Demographics and Biomarkers

VariablesLN study (N=131)SLE study (N=59)Observed NObserved Median (IQR) or %Observed NObserved Median (IQR) or %DemographicsAge13134 (25, 42)5936 (28, 44)Sex, Female10983.21%5593.22%Race, White5642.75%4576.27%Ethnicity, Hispanic or Latino6146.56%915.25%OCS use, yes12797.69%5796.61%MMF use, yes9572.52%2135.59%Spot UPCR (mg/mg)1282.13 (1.22, 4.04)591.11 (0.55, 2.61)eGFR13091.8 (63.1, 125)5998.06 (81.91, 116.54)Non-renal SLEDAI-2K score1304 (4, 6)5912 (9, 13)Renal SLEDAI-2K score1304 (4, 8)590 (0, 0)BiomarkersNGAL (ng/mL)12833.33 (17.55, 56.7)5819.47 (11.37, 42.05)MCP-1 (pg/mL)128658.24 (271.58, 1049.95)58275.62 (106.09, 481.99)Ceruloplasmin (ng/mL)12893.55 (44.5, 311.25)5847.2 (13.05, 231.25)Adiponectin (ng/mL)12842.45 (16.71, 139.64)589.33 (3.35, 25.51)Hemopexin (ng/mL)1281876.8 (745.07, 4743.4)58513.4 (236.36, 1388.74)KIM-1 (pg/mL)1281673.5 (772.5, 2767)58864 (394, 1480)Creatinine (mg/mL)1280.7 (0.46, 1.3)580.99 (0.46, 1.74)Adult RAIL score (creatinine adjusted)1285.59 (4.31, 6.47)583.57 (2.78, 4.47)

eGFR, estimated glomerular filtration rate; IQR, interquartile range; KIM, kidney injury molecule; LN, lupus nephritis; MCP, monocyte chemotactic protein; MMF, mycophenolate mofetil; NGAL, neutrophil gelatinase-associated lipocalin; OCS, oral corticosteroid; SLEDAI-2K, SLE Disease Activity Index 2000; UPCR, urine protein/creatinine ratio.

Conclusion

The analyses performed suggest that creatinine-corrected RAIL discriminates between active LN and non-renal adult SLE, with RAIL scores not influenced by MMF use.

References

[1]Brunner HI. Arthritis Care Res (Hoboken). 2016;68:1003–11.

[2]Gulati G. Lupus. 2017;26:927–36.

Acknowledgements

Writing assistance by Kelly M. Hunter, PhD (Fishawack). This study was sponsored by AstraZeneca.

Disclosure of Interests

Ellen Cody: None declared, Hermine Brunner Speakers bureau: Novartis, Pfizer, GSK, Consultant of: AbbVie, Astra Zeneca-Medimmune, Biogen, Boehringer, Bristol Myers Squibb, Celgene, Lilly,EMD Serono, Idorsia, Cerocor, Janssen, GSK, F. Hoffmann-La Roche, Merck, Novartis, R-Pharm, Sanofi, Grant/research support from: Pfizer, Bin Huang: None declared, Tingting Qiu: None declared, Prasad Devarajan Speakers bureau: Reata, Alnylam, Dicerna, Consultant of: BioPorto Inc, Madhu Ramaswamy Shareholder of: AstraZeneca, Employee of: AstraZeneca, Dominic Sinibaldi Shareholder of: AstraZeneca, Employee of: AstraZeneca, Philip Z Brohawn Shareholder of: AstraZeneca, Employee of: AstraZeneca, Jacob Knagenhjelm Shareholder of: AstraZeneca, Employee of: AstraZeneca, Frederick Jones Shareholder of: AstraZeneca, Employee of: AstraZeneca, Raj Tummala Shareholder of: AstraZeneca, Employee of: AstraZeneca, Catharina Lindholm Employee of: AstraZeneca, Wendy White Shareholder of: AstraZeneca, Employee of: AstraZeneca

POS0688 CHARACTERIZATION OF PK/PD OF ANIFROLUMAB IN PATIENTS WITH MODERATE TO SEVERE SLE

Background:

In the TULIP-1 and TULIP-2 trials, anifrolumab, a type I interferon (IFN) receptor antibody, at a dosage of 300 mg once every 4 weeks (Q4W), demonstrated consistent median pharmacokinetic (PK) concentrations1 and sustained neutralization of the pharmacodynamic (PD) 21-gene type I IFN gene signature (IFNGS)2–4 in patients with moderate to severe systemic lupus erythematosus (SLE) despite standard therapy.

Objectives:

To characterize the PK/PD relationship of anifrolumab and to confirm anifrolumab 300 mg provides adequate PD neutralization in IFNGS test–high patients.

Methods:

This study included IFNGS test–high patients from the phase 3 randomized, placebo-controlled, 52-week TULIP-12 (NCT02446912) and TULIP-23 (NCT02446899) trials of intravenous anifrolumab 150 mg or 300 mg Q4W plus standard therapy. IFNGS test status (high or low) at screening was classified with an analytically validated 4-gene qPCR based test on whole blood.2 PD neutralization was measured with 21-gene type I IFNGS and expressed as a percentage change from baseline.3 For the graphic PK/PD analysis, patients with ≥1 quantifiable serum PK sample and ≥1 PD measurement before discontinuation were categorized depending on Cave (individual predicted average anifrolumab concentration over treatment duration) median and tertiles (T) for anifrolumab 150 mg and 300 mg, respectively. Median PD IFNGS neutralization and medium absolute deviations were compared across Cave subgroups. PK/PD modeling was assessed in patients with ≥1 quantifiable serum PK sample and a baseline and ≥1 postbaseline PD measurement before discontinuation, using a nonlinear mixed-effects model (NONMEM; version 7.3; ICON) to estimate parameters and characterize the PK/PD data. The PD/efficacy analysis included patients with ≥1 postbaseline PD measurement before discontinuation. BILAG-based Combined Lupus Assessment (BICLA) response rates at Week (W)52 were compared across median PD neutralization quartiles (Q) for pooled anifrolumab 300 mg and 150 mg groups.

Results:

The PK/PD graphic analysis included 654 IFNGS test–high patients (placebo [n=293]; anifrolumab 150 mg [n=72] or 300 mg [n=289]). Cave was generally higher with anifrolumab 300 mg (µg/mL, TULIP-1: T1 <32, T2 32–<44.3, T3 ≥44.3; TULIP-2: T1 <32.4, T2 32.4–<47.9, T3 ≥47.9) than with anifrolumab 150 mg (median 11.5 µg/mL); overlap between anifrolumab 300 mg and 150 mg Cave subgroups was small owing to nonlinearity. Anifrolumab 300 mg elicited rapid (by W44) and sustained median PD neutralization >80%, vs a lower and delayed PD neutralization (median >50% at W52) with anifrolumab 150 mg, and minimal PD neutralization with placebo. The median PD neutralization increased with higher Cave subgroups, plateauing at ~90% at W12–W52. All anifrolumab 300 mg Cave tertiles had a median PD neutralization ~80%; however, the variability was greater in the lowest Cave tertiles vs higher Cave tertiles across trials (Figure 1). The PK/PD modeling, which included 646 IFNGS test–high patients (placebo [n=289], anifrolumab 150 mg [n=70] or 300 mg [n=287]), gave an IC80 estimate of 3.88 μg/mL. The median W24 (study midpoint) Ctrough was higher with anifrolumab 300 mg vs 150 mg (15.6 vs 0.2 μg/mL); thus, the W24 Ctrough exceeded the IC80 in a higher proportion of patients treated with anifrolumab 300 mg vs 150 mg (~83% vs ~27%). The PD/efficacy analysis included 341 patients who received anifrolumab. Higher median percentage PD neutralization quartiles (Q1 <51.7%, Q2 51.7%–85.3%, Q3 85.3%–92.6%, Q4 >92.6%) were associated with higher W52 BICLA response rates (Q1 37.6%, Q2 49.4%, Q3 51.8%, Q4 58.1%).

Conclusion:

In TULIP-1 and TULIP-2, anifrolumab 300 mg yielded higher anifrolumab Cave vs 150 mg. High Cave was associated with rapid (W44–W12), substantial, and sustained PD neutralization of the 21-gene IFNGS in IFNGS test–high patients, which in turn was associated with higher efficacy.

References:

[1]Kuruvilla D. Poster 360, AAPS 2020.

[2]Furie RA. Lancet Rheumatol. 2019;1:e208–19.

[3]Morand EF. N Engl J Med. 2020;382:211–21.

[4]Furie R. Arthritis Rheumatol. 2017;69:379–86.

Acknowledgements:

Writing assistance by Matilda Shackley, MPhil, of JK Associates Inc., part of Fishawack Health. This study was sponsored by AstraZeneca.

Disclosure of Interests:

Yen Lin Chia Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Tu Mai Employee of: Genentech, Tomas Rouse Employee of: AstraZeneca, Wendy White Employee of: AstraZeneca, Eric F. Morand Speakers bureau: AstraZeneca, Consultant of: AstraZeneca, Grant/research support from: AstraZeneca, Richard Furie Consultant of: AstraZeneca, Grant/research support from: AstraZeneca

Impact of timing of randomization after an acute coronary syndrome and subsequent events in patients with type 2 diabetes mellitus: an analysis of the EXAMINE trial

Background

The timing of enrolment following an acute coronary syndrome (ACS) may influence cardiovascular (CV) outcomes and potentially treatment effect in clinical trials. Using a large contemporary trial in patients with type 2 diabetes mellitus (T2DM) post-ACS, we examined the impact of timing of enrolment on subsequent CV outcomes.

Methods

EXAMINE was a randomized trial of alogliptin versus placebo in 5380 patients with T2DM and a recent ACS. The primary outcome was a composite of CV death, non-fatal myocardial infarction [MI], or non-fatal stroke. The median follow-up was 18 months. In this post hoc analysis, we examined the occurrence of subsequent CV events by timing of enrollment divided by tertiles of time from ACS to randomization: 8–34, 35–56, and 57–141 days.

Results

Patients randomized early (compared to the latest times) had less comorbidities at baseline including a history of heart failure (HF; 24.7% vs. 33.0%), prior coronary artery bypass graft (9.6% vs. 15.9%), or atrial fibrillation (5.9% vs. 9.4%). Despite the reduced comorbidity burden, the risk of the primary outcome was highest in patients randomized early compared to the latest time (adjusted hazard ratio [aHR] 1.47; 95% CI 1.21–1.74) (Figure 1). Similarly, patients randomized early had an increased risk of recurrent MI (aHR 1.51; 95% CI 1.17–1.96) and HF hospitalization (1.49; 95% CI 1.05–2.10).

Conclusion

In a contemporary cohort of T2DM with a recent ACS, early randomization following the ACS increases the risk of CV events including recurrent MI and HF hospitalization. This should be taken into account when designing future clinical trials.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Takeda Pharmaceutical

A Method for Automatic Coding of Medical Information in Patient Records

An automated method for coding hospital patient records is described, which uses a combination of simple computer programs and a structured dictionary. The system accepts unrestricted medical language in French as input, and generates code combinations which represent the semantic values of the original statements. The coding structure is the trial version of the Systematized Nomenclature of Medicine (SNOMED) [9], A prototype system has been developed from a 20,000 word corpus of obstetrical and gynecological data, recorded from patient records written by French-speaking Quebec physicians. Preliminary test results on a small sample show that the system generates accurate codes and code combinations for 97.9% of the data tested. The programs were written in Fortran IV and implemented on a DEC PDP-9 computer. The dictionary keys are word segments and the entries contain operators, word segments and SNOMED codes. The dictionary structure permits a single entry to generate multiple SNOMED codes and to handle the types of linguistic paraphrase found in hospital records. The SNOMED codes and code combinations constitute a metalanguage which provides the means for data compression and uniform representation of natural language medical data.

Variability in multiple paternity rates for grey reef sharks (Carcharhinus amblyrhynchos) and scalloped hammerheads (Sphyrna lewini)

This study assessed the presence and prevalence of multiple paternity (MP) in litters of grey reef sharks (Carcharhinus amblyrhynchos) and scalloped hammerheads (Sphyrna lewini) opportunistically caught in Papua New Guinea (PNG). Litter size between species were significantly different with an average of 3.3 pups for grey reef sharks and 17.2 pups for scalloped hammerhead. Using 14 and 10 microsatellite loci respectively, we identified MP in 66% of grey reef sharks (4 out of 6 litters) and 100% MP in scalloped hammerheads (5 litters). We found high paternal skew (the uneven contribution of sires per litter) and a positive correlation between female adult size and litter size in scalloped hammerheads but not in grey reef sharks. Differences in the frequency of MP between species and the identification of paternal skew may be linked with mating strategies and post-copulatory mechanisms. Multiple paternity is thought to benefit populations by enhancing genetic diversity therefore increasing the population’s genetic resilience to extrinsic pressures. The identification of MP in two shark species reported here, further elucidates the complex breeding strategies elasmobranchs undertake.

Primary total knee arthroplasty using the P.F.C Sigma®-rotating platform cruciate retaining endoprosthesis--a 6 year follow up

BACKGROUND

Mobile-bearing Total Knee Replacement allows unconstrained axial rotation. Increased articular conformity minimizes polyethylene contact stresses, thereby reducing linear wear and fatigue failure.

METHODS

We prospectively reviewed a consecutive series of 161 patients with mobile bearing total knee replacements using the PFC Sigma Cruciate Retaining Rotating Platform System. (DePuy, Leeds, United Kingdom) with midterm follow up (minimum 6 and maximum 9 years, mean 7.2 years). One hundred forty-seven patients from February 2001 to March 2004 were followed up till date. Primary osteoarthritis 96%; was the main indication followed by rheumatoid arthritis 3% and one case of psoriatic arthritis. Fifty-seven percent were females with mean age of 69.5 years (Range 51-90 years). Oxford and American Knee Society scores were measured.

RESULTS

Mean Oxford score improved from 43 (Range 29-55) pre operatively to 21(Range 13-44) at last follow up and mean Knee Society score from 53 (Range 43-70) to 80 (Range 58-90). Range of movement improved from 91° (Range 70-110) to 113° (Range 75-130) at last follow up. One patient had dislocation of bearing needing manipulation. One patient had superficial infection treated with antibiotics. No patients had deep infection. There was one case reported of deep vein thrombosis and one of non-fatal pulmonary embolism.

CONCLUSION

The midterm results in our series with PFC Sigma mobile bearing knee replacement are excellent with good outcome scores. Cohort will be followed for long term results. Level of Evidence IV.

Auger electron angular distribution of double core-hole states in the molecular reference frame

The Linac Coherent Light Source free electron laser is a source of high brightness x rays, 2×10(11) photons in a ∼5 fs pulse, that can be focused to produce double core vacancies through rapid sequential ionization. This enables double core vacancy Auger electron spectroscopy, an entirely new way to study femtosecond chemical dynamics with Auger electrons that probe the local valence structure of molecules near a specific atomic core. Using 1.1 keV photons for sequential x-ray ionization of impulsively aligned molecular nitrogen, we observed a rich single-site double core vacancy Auger electron spectrum near 413 eV, in good agreement with ab initio calculations, and we measured the corresponding Auger electron angle dependence in the molecular frame.

Time-resolved pump-probe experiments at the LCLS

The first time-resolved x-ray/optical pump-probe experiments at the SLAC Linac Coherent Light Source (LCLS) used a combination of feedback methods and post-analysis binning techniques to synchronize an ultrafast optical laser to the linac-based x-ray laser. Transient molecular nitrogen alignment revival features were resolved in time-dependent x-ray-induced fragmentation spectra. These alignment features were used to find the temporal overlap of the pump and probe pulses. The strong-field dissociation of x-ray generated quasi-bound molecular dications was used to establish the residual timing jitter. This analysis shows that the relative arrival time of the Ti:Sapphire laser and the x-ray pulses had a distribution with a standard deviation of approximately 120 fs. The largest contribution to the jitter noise spectrum was the locking of the laser oscillator to the reference RF of the accelerator, which suggests that simple technical improvements could reduce the jitter to better than 50 fs.

Anti-Emetic Effect of Midazolam Added to Morphine Patient-Controlled Analgesia After Total Abdominal Hysterectomy

Nausea and vomiting are frequent adverse effects of patient-controlled analgesia with opioids. This study was designed to compare the effect of midazolam to that of ondansetron for prevention of nausea and vomiting during morphine patient-controlled analgesia. In a randomised, double-blind, prospective trial, 90 patients were allocated to one of three groups of 30 each, to receive one of three patient-controlled analgesia regimens to manage postoperative pain: a combination of midazolam and morphine (group M), a mixture of ondansetron and morphine (group O) or morphine alone (group C). Patients were assessed for the incidence of nausea and vomiting, the degree of sedation (awake, mild, moderate, deep) and other side-effects during the first 24 hours after the operation. The frequency of nausea and vomiting was significantly lower in groups M (27%) and O (37%) compared with group C (70%) (P <0.05). The incidence of mild sedation in group M was significantly higher than that in groups O or C (P <0.05). We conclude that midazolam is as effective as ondansetron in preventing opioid-induced nausea and vomiting following total abdominal hysterectomy and has acceptable side-effects.

Measurements and simulations of ultralow emittance and ultrashort electron beams in the linac coherent light source

The Linac Coherent Light Source (LCLS) is an x-ray free-electron laser project presently in a commissioning phase at the SLAC National Accelerator Laboratory. We report here on very low-emittance measurements made at low bunch charge, and a few femtosecond bunch length produced by the LCLS bunch compressors. Start-to-end simulations associated with these beam parameters show the possibilities of generating hundreds of GW at 1.5 A x-ray wavelength and nearly a single longitudinally coherent spike at 1.5 nm with 2-fs duration.

Rapid wavelength-swept spectrally encoded confocal microscopy

Spectrally encoded confocal microscopy (SECM) is a technique that allows confocal microscopy to be performed through the confines of a narrow diameter optical fiber probe. We present a novel scheme for performing SECM in which a rapid wavelength swept source is used. The system allows large field of view images to be acquired at rates up to 30 frames/second. Images of resolution targets and tissue specimens acquired ex vivo demonstrate high lateral (1.4 mum) and axial (6 mum) resolution. Imaging of human skin was performed in vivo at depths of up to 350 mum, allowing cellular and sub-cellular details to be visualized in real time.

Reanalysis of the Harvard Six Cities Study, part I: validation and replication

Because the results of the Harvard Six Cities Study played a critical role in the establishment of the current U.S. ambient air quality objective for fine particles (PM(2.5)), the U.S. Environmental Protection Agency, industry, and nongovernmental organizations called for an independent reanalysis of this study to validate the original findings reported by Dockery and colleagues in the New England Journal of Medicine (vol. 329, pp. 1753-1759) in 1993. Validation of the original findings was accomplished by a detailed statistical audit and replication of original results. With the exception of occupational exposure to dust (14 discrepancies of 249 questionnaires located for evaluation) and fumes (15/249), date of death (2/250), and cause of death (2/250), the audit identified no discrepancies between the original questionnaires and death certificates in the audit sample and the analytic file used by the original investigators. The data quality audit identified a computer programming problem that had resulted in early censorship in 5 of the 6 cities, which resulted in the loss of approximately 1% of the reported person-years of follow-up; the reanalysis team updated the Six Cities cohort to include the missing person-years of observation, resulting in the addition of 928 person-years of observation and 14 deaths. The reanalysis team was able to reproduce virtually all of the original numerical results, including the 26% increase in all-cause mortality in the most polluted city (Stubenville, OH) as compared to the least polluted city (Portage, WI). The audit and validation of the Harvard Six Cities Study conducted by the reanalysis team generally confirmed the quality of the data and the numerical results reported by the original investigators. The discrepancies noted during the audit were not of epidemiologic importance, and did not substantively alter the original risk estimates associated with particulate air pollution, nor the main conclusions reached by the original investigators.

Reanalysis of the Harvard Six Cities Study, part II: sensitivity analysis

Following the validation and replication of the Harvard Six Cities Study (Krewski et al., this issue), we conducted a wide range of sensitivity analyses to explore the observed associations between long-term exposure to fine particle or sulfate air pollution and mortality. We examined the impact of alternative risk models on estimates of risk, taking into account covariates not included in the original analyses. These risk models provided a basis for identifying covariates that may confound or modify the association between fine particle or sulfate air pollution and mortality, and for identifying sensitive population subgroups. The possibility of confounding due to occupational exposures was also investigated. Residence histories were coded for the study subjects and were used to examine temporal patterns of exposure and risk. Our sensitivity analyses showed the mortality risk estimates for fine particle and sulfate air pollution to be highly robust against alternative risk models of the Cox proportional hazards family, including models with additional covariates from the original questionnaires not included in the original published analyses. There was limited evidence of departures from the proportional hazards assumption. Flexible exposure-response models provided some evidence of departures from linearity at both low and high sulfate concentrations. Incorporating information on changes over time in cigarette smoking and body mass index had little effect on the association between fine particles and mortality. There was limited evidence of variation in risk with attained age, gender, smoking status, occupational exposure to dust and fumes, marital status, heart or lung diseases, or lung function. However, air pollution risk did appear to decreasing with increasing educational attainment. Extensive adjustment for occupation using aggregate indices of occupational "dirtiness" and occupational exposure to known lung carcinogens had little impact on the mortality risks associated with particulate air pollution. Our evaluation of population mobility indicated that relatively few subjects moved from their original city of residence. Attempts to identify critical exposure time windows were limited by the lack of marked interindividual variation in temporal exposure patterns throughout the study period. Overall, this extensive sensitivity analysis both supported the conclusions reached by the original investigators and demonstrated the robustness of these conclusions to alternative analytic approaches.

Early experience with transmission of data from moving ambulances to improve the care of patients with myocardial infarction

We conducted a feasibility study of a mobile unit capable of recording a 12-lead electrocardiogram (ECG) and transmitting it to a receiving hospital workstation. Two ambulances were equipped with the mobile unit and the ECGs recorded were compared with standard ECGs recorded on the hospital ward after admission. In six months, 62 patients participated in the study. The ambulance crew transmitted messages to the coronary care unit for 56 patients. Thirty-five patients were directed to the coronary care unit, four were directed to the emergency department as no beds were available and then transferred to the coronary care unit later, and the remaining 23 were directed to the emergency department. Comparative hospital and mobile ECGs were available for 31 patients. Although the mobile unit recorded smaller R- and S-wave deflections than on the standard hospital ECGs, the medical and nursing staff were able to differentiate between normal and abnormal tracings. The mobile unit may be useful to triage patients with chest pain before they reach hospital.

Interscalene brachial plexus block with continuous intraarticular infusion of ropivacaine

Providing intraarticular analgesia with a continuous infusion of local anesthetic via a disposable infusion pump has gained popularity. Despite the prevalence of this technique, data comparing this method of analgesia to conventional regional anesthesia are not available. We present a prospective study that compared a single-dose interscalene block with a single-dose interscalene block plus continuous intraarticular infusion of local anesthetic. Forty patients scheduled for shoulder arthroscopy were entered in this prospective, double-blinded study. All patients received an interscalene brachial plexus block as their primary anesthetic. Patients were randomly assigned to 1 of 2 groups: 1. interscalene block with 1.5% mepivacaine (40 mL) followed by a postoperative intraarticular infusion of 0.5% ropivacaine at 2 mL/h, or 2. interscalene block with 0.5% ropivacaine (40 mL) followed by a postoperative intraarticular infusion of 0.9% saline (placebo) at 2 mL/h. Postoperative infusions were maintained for 48 h. Visual analog scale pain scores and postoperative oxycodone consumption were measured for 48 h. Visual analog scale scores at rest and with ambulation in the Mepivacaine/Intraarticular Ropivacaine group were reduced when compared with the Ropivacaine/Saline group (rest: P = 0.003, ambulation: P = 0.006). Oxycodone consumption was also decreased (28 +/- 21 mg vs 44 +/- 28 mg, P = 0.046), respectively. We conclude that a brachial plexus block with 1.5% mepivacaine and a continuous intraarticular infusion of 0.5% ropivacaine at 2 mL/h provides improved analgesia for minor surgery at 24 and 48 h versus a single-injection interscalene block with 0.5% ropivacaine.

The role of gender in MPH graduates' salaries

Several studies have demonstrated that workforce roles and salaries differ substantially between men and women in administrative positions within the health care industry. Recent studies of graduates with masters of business administration (MBA) and masters of health administration (MHA) degrees have indicated that women tend to experience lower salaries, given like responsibilities. However, the impact of gender on salary has been less studied among masters of public health (MPH) graduates in the health care field. Our objective was to assess the impact of gender on salary among MPH degree graduates. Using a cross-sectional survey of all graduates from the MPH program at Yale University between 1991-1997 (n = 201, response rate = 51%), we ascertained graduates' reported salary in the first job post-graduation and reported salary in their current position. Bivariate and multivariate analyses were used to assess the unadjusted and adjusted associations between gender and salary. Salaries in both the first job post-graduation and in the current job differed significantly by gender, with women earning less than men (p-values < .05). Moreover, these differences persisted after controlling for a set of human capital measures including pre-MPH work experience, age at graduation, years since graduation, area of specialization within the MPH degree, and type of work site (governmental or nonprofit versus for-profit). Unlike studies of MBA and MHA graduates, however, this study did not find evidence that the gender-related salary gap widened as the years since graduation increased, although the sample size did not allow comprehensive testing of this trend.

The discriminative stimulus and reinforcing effects of nicotine in humans following nicotine pretreatment

Smokers often report that the first cigarette of the day is the most rewarding, and subsequent smoking is less rewarding. Reduction in smoking enjoyment later in the day may be related to acute tolerance to the discriminative stimulus effects of nicotine. We examined changes in nicotine discrimination behaviour in humans as a function of acute nicotine pretreatment. Male and female dependent smokers (n = 15) were initially trained to discriminate 20 microg/kg nicotine by nasal spray from placebo (0 microg/kg) without nicotine pretreatment. They then were tested on generalization of discrimination across a range of spray doses from 0-20 microg/kg following pretreatment with placebo, moderate dose (14-21 mg) or high dose (28-42 mg) transdermal nicotine. Generalization testing involved both two- and three-response ('novel' option) quantitative procedures. Subjects also engaged in a self-administration phase at the end of each session, involving choices between nicotine (20 microg/kg) and placebo spray. Nicotine pretreatment significantly attenuated nicotine-appropriate responding at higher nicotine spray doses, suggesting acute tolerance, but only in women. Similar results were seen for subjective 'head rush', suggesting this effect may be related to discrimination behaviour in women. However, nicotine pretreatment also increased novel-appropriate responding, especially in men, following intermediate generalization doses, suggesting qualitatively different stimulus effects. Although differences were not significant, nicotine self-administration tended to be inversely associated with nicotine pretreatment dose in men but not in women. These results only modestly support the notion of acute tolerance to the discriminative stimulus effects of nicotine, and even then only in women and not in men.

Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump

Continuous interscalene brachial plexus blockade traditionally requires a hospital stay for local anesthetic infusion, and achieving consistent catheter insertion may be difficult. Incorporating long-acting pain relief from a continuous peripheral nerve block, with a reliable method of catheter insertion, and a self-contained infusion system would be a valuable asset for short-stay care. We compared the efficacy of single injection interscalene brachial plexus blockade to a continuous peripheral nerve block, with an insulated Tuohy system and a disposable infusion pump. Forty adult patients scheduled for open rotator cuff repair were entered in this randomized, double-blinded, placebo-controlled study. Patients received an interscalene brachial plexus blockade and a continuous peripheral nerve catheter as their primary anesthetic and then, were assigned to receive one of two different postoperative infusions: either 0.2% ropivacaine at 10 mL/h via a disposable infusion pump or normal saline at 10 mL/h via a disposable infusion pump (n = 18-20 per group). Visual analog pain scores and postoperative morphine consumption were measured for 24 h. The ropivacaine group showed less pain than the placebo group (P: = 0.0001) between 12 and 24 h after the initial injection of local anesthetic. In addition, initial interscalene blockade was successful in all patients and all redosed catheters were functional after 24 h with the continuous catheter insertion system. We conclude that it is possible to achieve a high rate of successful catheter placement and analgesia by using the continuous catheter insertion system and a disposable infusion pump in the ambulatory setting. This method of analgesia may offer improved pain relief after outpatient rotator cuff repair.

Effects of administering cocaine at the same versus varying times of day on circadian activity patterns and sensitization in rats

The effects of different schedules of cocaine administration on circadian activity patterns and locomotor sensitization were studied. Rats received intraperitoneal injections of either saline or 20 mg/kg cocaine at either 24- or 33-hr intervals for 8 cycles (development). After a 2-day withdrawal, they were given a cocaine challenge in a novel environment. Rats given cocaine at 24-hr intervals were hypoactive 4 to 9 hr postinjection during development and, during cocaine challenge, showed sensitization of locomotor activity. Rats given cocaine at 33-hr intervals did not show these effects. On the 33-hr-period schedule, activity was enhanced beginning 24 hr after drug receipt. Different intermittent schedules of cocaine receipt may alter the vulnerability to cocaine, and altered vulnerability may be more likely when a subsequent cocaine injection interacts with a distal state of sensitivity produced by a prior injection.

The effects of ibotenic acid lesions of the medial and lateral prefrontal cortex on latent inhibition, prepulse inhibition and amphetamine-induced hyperlocomotion

Hypofunction of prefrontal cortical regions, such as dorsolateral and orbital regions, has been suggested to contribute to the symptomatology of schizophrenia. In the rat, the medial and the lateral prefrontal cortices are considered as homologs of the primate dorsolateral and orbital prefrontal cortices, respectively. The present study investigated in rats the effects of lesions of the medial and lateral prefrontal cortices on latent inhibition, prepulse inhibition and amphetamine-induced activity. These paradigms are known to be modulated by the mesolimbic dopaminergic system, a system that has been suggested to be involved in the symptomatology of schizophrenia. Latent inhibition and prepulse inhibition are disrupted in schizophrenic patients as well as in rats treated with amphetamine. Amphetamine-induced activity was tested under dim light (low stress) and bright light (high stress) because stressful situations selectively increase mesocortical dopamine activity. Lateral prefrontal cortex lesioned animals did not differ in their behavior from control animals in any of the paradigms used in this study. Medial prefrontal cortex lesions did not affect latent inhibition but increased prepulse inhibition. In the amphetamine-induced activity experiment, prior to drug administration, open field locomotion was reduced under bright illumination for all lesion groups. After amphetamine administration, medial prefrontal cortex lesions attenuated the hyperlocomotor effect of the drug under the dim light condition and potentiated it under the bright light condition. The results indicate that medial and lateral prefrontal cortex can be functionally differentiated by their involvement in the modulation of behavior requiring mesocorticolimbic dopamine activation. The results in amphetamine induced activity suggest that the behavioral outcomes associated with medial prefrontal cortex depend on the background (stress) against which the evaluation is made. The results also support the notion that prepulse inhibition may be a better model than latent inhibition of the symptoms of schizophrenia associated with dysfunctional prefrontal activity.

Guidance for the performance evaluation of three-dimensional air quality modeling systems for particulate matter and visibility

Guidance for the performance evaluation of three-dimensional air quality modeling systems for particulate matter and visibility is presented. Four levels are considered: operational, diagnostic, mechanistic, and probabilistic evaluations. First, a comprehensive model evaluation should be conducted in at least two distinct geographical locations and for several meteorological episodes. Next, streamlined evaluations can be conducted for other similar applications if the comprehensive evaluation is deemed satisfactory. In all cases, the operational evaluation alone is insufficient, and some diagnostic evaluation must always be carried out. Recommendations are provided for designing field measurement programs that can provide the data needed for such model performance evaluations.

Task force IV: Clinical use of ambulatory blood pressure monitoring. Participants of the 1999 Consensus Conference on Ambulatory Blood Pressure Monitoring

OBJECTIVE

To reach a consensus on the clinical use of ambulatory blood pressure monitoring (ABPM).

METHODS

A task force on the clinical use of ABPM wrote this overview in preparation for the Seventh International Consensus Conference (23-25 September 1999, Leuven, Belgium). This article was amended to account for opinions aired at the conference and to reflect the common ground reached in the discussions.

POINTS OF CONSENSUS

The Riva Rocci/Korotkoff technique, although it is prone to error, is easy and cheap to perform and remains worldwide the standard procedure for measuring blood pressure. ABPM should be performed only with properly validated devices as an accessory to conventional measurement of blood pressure. Ambulatory recording of blood pressure requires considerable investment in equipment and training and its use for screening purposes cannot be recommended. ABPM is most useful for identifying patients with white-coat hypertension (WCH), also known as isolated clinic hypertension, which is arbitrarily defined as a clinic blood pressure of more than 140 mmHg systolic or 90 mmHg diastolic in a patient with daytime ambulatory blood pressure below 135 mmHg systolic and 85 mmHg diastolic. Some experts consider a daytime blood pressure below 130 mmHg systolic and 80 mmHg diastolic optimal. Whether WCH predisposes subjects to sustained hypertension remains debated. However, outcome is better correlated to the ambulatory blood pressure than it is to the conventional blood pressure. Antihypertensive drugs lower the clinic blood pressure in patients with WCH but not the ambulatory blood pressure, and also do not improve prognosis. Nevertheless, WCH should not be left unattended. If no previous cardiovascular complications are present, treatment could be limited to follow-up and hygienic measures, which should also account for risk factors other than hypertension. ABPM is superior to conventional measurement of blood pressure not only for selecting patients for antihypertensive drug treatment but also for assessing the effects both of non-pharmacological and of pharmacological therapy. The ambulatory blood pressure should be reduced by treatment to below the thresholds applied for diagnosing sustained hypertension. ABPM makes the diagnosis and treatment of nocturnal hypertension possible and is especially indicated for patients with borderline hypertension, the elderly, pregnant women, patients with treatment-resistant hypertension and patients with symptoms suggestive of hypotension. In centres with sufficient financial resources, ABPM could become part of the routine assessment of patients with clinic hypertension. For patients with WCH, it should be repeated at annual or 6-monthly intervals. Variation of blood pressure throughout the day can be monitored only by ABPM, but several advantages of the latter technique can also be obtained by self-measurement of blood pressure, a less expensive method that is probably better suited to primary practice and use in developing countries.

CONCLUSIONS

ABPM or equivalent methods for tracing the white-coat effect should become part of the routine diagnostic and therapeutic procedures applied to treated and untreated patients with elevated clinic blood pressures. Results of long-term outcome trials should better establish the advantage of further integrating ABPM as an accessory to conventional sphygmomanometry into the routine care of hypertensive patients and should provide more definite information on the long-term cost-effectiveness. Because such trials are not likely to be funded by the pharmaceutical industry, governments and health insurance companies should take responsibility in this regard.

Effects of training dose and two- versus three-choice testing procedure on nicotine discrimination responding in humans

RATIONALE

Discrimination of a drug's interoceptive stimulus effects often depends substantially on training and testing conditions.

OBJECTIVES

We examined changes in nicotine discrimination behavior in humans as a function of lowering the training dose and of varying the discrimination testing procedure.

METHODS

Smokers and never-smokers (n=10 each) were initially trained to discriminate 20 microg/kg nicotine by nasal spray from placebo (0) and tested on generalization of discrimination responding across a range of doses from 0 to 20 microg/kg. Each subsequently learned to reliably discriminate progressively smaller doses of nicotine from placebo until his or her threshold dose for discrimination was identified (mean=2.7 microg/kg). A repeat testing of generalization responding across 0-20 microg/kg was then conducted, using placebo and the subject's threshold dose as training doses. Generalization testing involved both two-choice and three-choice (novel response option) quantitative procedures.

RESULTS

A significant shift to the left was seen in nicotine-appropriate responding in the two-choice procedure when the nicotine training dose was lowered (i.e. from the first to the second test of generalization). In the three-choice procedure, however, there was no such leftward shift. Instead, in never-smokers, a flattening of nicotine-appropriate responding occurred with a lowering of the training dose, while novel-appropriate responding significantly increased. The subjective effects of "head rush" and, in never-smokers only, "jittery" also showed a shift to the left in their relationship with nicotine generalization dose when the training dose was lowered.

CONCLUSIONS

These results confirm the importance of training and testing conditions on discrimination behavior and subjective drug responses within subjects and demonstrate the utility of the novel-response, three-choice procedure for assessing qualitatively different stimulus effects of novel drug doses.

Meal-synchronized CEA in rats: effects of meal size, intragastric feeding, and subdiaphragmatic vagotomy

Within a feeding schedule of intermittent food access, large meals have the ability to induce activity at the same time the next day [circadian ensuing activity (CEA)]. In these experiments, we evaluated the minimum meal size necessary to induce CEA and whether oral-pharyngeal factors and afferent vagal activity played necessary roles in the induction of the underlying process. In experiment 1, every 33 h rats were given two meals separated by a 2-h interval. The size of the first meal was varied, while total intake every feeding cycle was held constant. When the initial meal was <10 g (34 kcal) CEA occurred later, indicating that such a meal size was subthreshold for inducing CEA. In experiment 2, rats were given intragastric (IG) meals every 33 h, before and after complete subdiaphragmatic vagotomy. IG nutrient meals induced CEA, indicating that extensive oral-pharyngeal experience was not necessary for CEA induction. CEA occurred in vagotomized rats but, compared with intact rats, appeared to occur later relative to nutrient infusion, indicating that afferent vagal activity may be sufficient but not necessary to induce CEA.

Effects of central and peripheral nicotinic blockade on human nicotine discrimination

Nicotine produces interoceptive stimulus effects in humans, which may be critical in understanding tobacco use. It has not yet clearly been demonstrated that discrimination of nicotine, or any drug, in humans is due to its central effects. We compared effects of mecamylamine (10 mg p.o.), a central and peripheral nicotine antagonist, on nicotine discrimination with those of trimethaphan (10-40 microg/kg per min i.v.), a peripheral nicotine antagonist only, and placebo. Smokers (n = 6) were first trained to reliably discriminate 0 versus 20 microg/kg nicotine by nasal spray and then tested on generalization of this discrimination across a range of nicotine doses (0, 3, 6, 12, 20 microg/kg) following antagonist/placebo pretreatment. Nicotine self-administration was also assessed after generalization testing by having participants intermittently choose between nicotine versus placebo spray. Compared with responding following placebo pre-treatment, discrimination of the highest dose of nicotine was significantly attenuated following mecamylamine but not trimethaphan. Similar results were observed for some subjective responses to nicotine. Mecamylamine also tended to increase nicotine self-administration. Consistent with previous animal studies, these results suggest that discriminative stimulus effects of nicotine in humans are mediated at least in part by its central effects.

Meal-engendered circadian-ensuing activity in rats

Large meals scheduled at greater-than-circadian periods (such as T = 31 h) tend to elicit enhanced activity approximately 24 h subsequent to receipt. These studies characterized the process responsible for this meal-engendered "circadian ensuing activity" (meal CEA). Female Sprague-Dawley rats were housed in stations containing a running wheel, pellet dispenser, and lights. Young, middle-aged, or suprachiasmatic-nucleus (SCN)-lesioned rats were given two 1-h meals every 31 or 34 h. Meals were separated by alternating short and long fasts. Most young intact rats engaged in enhanced activity approximately 24 h subsequent to the start of the two-meal series. This circadian ensuing activity underwent large, abrupt daily displacements in response to daily meal delays, was manifested to some degree at all times of day, had an amplitude that was modulated by circadian time of day, was attenuated in middle-aged rats, was evident in SCN-lesioned rats, and oscillated following termination of the feeding schedule. A single experience with food at a novel time of day can "reset" an SCN-independent oscillating process responsible for a circadian activity pattern. CEA has features not readily accommodated by present models of "food-anticipatory activity." The readiness with which the process can be reset implies a keen sensitivity to shifts in the time of food availability but could also produce aberrant behavioral patterns. A T >> 24-h feeding schedule appears to be an ideal procedure with which to study the specific food-related factors responsible for resetting circadian processes and producing a subsequent reallocation of daily activity.

The histopathology of pathergy: a chronologic study of skin hyperreactivity in Behçet's disease

BACKGROUND

Many patients with Behçet's disease (BD) demonstrate hyperreactivity (pathergy), and the induced skin lesions may serve as a model for the disease.

OBJECTIVE

This study examined the sequence of histopathologic changes after needle prick trauma.

METHODS

Eight patients fulfilling the International Study Group Criteria for Behçet's Disease, two patients with recurrent aphthous stomatitis, and two healthy controls each underwent intradermal injections with subsequent biopsies at 0, 4, 24, and 48 h. Hematoxylin and eosin sections were evaluated in a blinded fashion according to 11 histopathologic criteria.

RESULTS

At time zero, normal skin was seen. By 4 h, neutrophils were present usually admixed with lymphocytes (8 out of 10). The inflammatory cell density peaked by 24 h in 8 out of 10 patients and at 48 h in 2 out of 10 patients. Sparse leukocytoclasis was identifiable from 4 to 48 h, but was not associated with fibrin. True vasculitis (as evidenced by fibrin within vessel walls and/or intraluminal thrombi) was not seen. Intraepidermal pustules (IEPs) and polymorphonuclear (PMN) aggregates within the needle tract were seen as early as 4 h. The control patients and three out of eight of the BD patients failed to develop clinical lesions. Among this group histopathologic IEPs were lacking in all but two BD patients.

CONCLUSIONS

These data suggest that early pathergy is mediated by PMNs and lymphocytes without vasculitis. Hyperchemotaxis may explain the rapid accumulation of PMNs along the injection site.

Auditory scene analysis by European starlings (Sturnus vulgaris): perceptual segregation of tone sequences

Like humans, animals that use acoustic stimuli to perceive their world ought to be able to parse the auditory scene into functionally significant sounds. The ability to do so ought to have significant adaptive value when, for example, an animal can identify the sounds of a predator among other natural noises. In earlier work it was shown that a species of songbird, the European starling, can identify excerpts of both its own song and songs from other avian species when the songs are mixed concurrently with other natural signals. In this experiment it is demonstrated that starlings can segregate two synthetic pure-tone sequences when the sequences differ in frequency. Taken together, the experiments show that at least one nonhuman species is capable of auditory scene analysis both for natural and for non-natural acoustic stimuli. This suggests in turn that auditory scene analysis may be a general perceptual process that occurs in many species that make use of acoustic information.

Green tobacco sickness

OBJECTIVE

To describe the health impact of harvesting tobacco and to suggest prevention and risk reduction strategies to avoid contracting green tobacco sickness (GTS).

DATA SOURCES

A literature search of Medline, Toxline, and Toxline65 with the terms "green", "tobacco", and "sickness" covering the years 1966-1998.

STUDY SELECTION

All studies, reviews, and commentaries that provided information on the health effects of harvesting green tobacco and disease prevention strategies.

DATA SYNTHESIS

GTS occurs when tobacco workers hand-harvest, cut, or load tobacco plants, usually in the early morning or after a rainfall when tobacco plants are covered with moisture. GTS occurs through skin exposure to dissolved nicotine from tobacco leaves. Symptoms of GTS include weakness, headache, nausea, vomiting, dizziness, abdominal cramps, breathing difficulty, abnormal temperature, pallor, diarrhoea, chills, fluctuations in blood pressure or heart rate, and increased perspiration and salivation. The onset of the illness is three to 17 hours after exposure and the duration of illness is one to three days. Initial treatment includes cessation of work, change of clothing, showering, fluid intake, and rest. In more extreme cases, intravenous rehydration, anti-emetics, and dimenhydrinate are administered. Protective, water-resistant clothing; chemical-resistant gloves, boots, and socks; working in dry conditions; and dimenhydrinate can reduce the likelihood of contracting GTS.

CONCLUSIONS

It is important to provide education to tobacco workers and employers about GTS. An international public awareness campaign about GTS timed to coincide with the tobacco harvest, along with enforced worker safety regulations, should be undertaken to protect the health of individuals working in tobacco production.

Expression of interleukin-10 in human gestational tissues

OBJECTIVE

To determine production of interleukin-10 (IL-10) by interleukin-1 beta (IL-1 beta) in cultured decidual, chorion, and amnion cells and whether IL-10 is produced in gestational tissues under the setting of infection-associated preterm labor.

METHODS

Decidual, chorion, and amnion cells were isolated from term placentas and grown in primary culture. The cells were incubated with various concentrations of IL-1 beta and then culture supernatants were assayed for IL-10 by enzyme-linked immunosorbent assay. In subsequent studies, gestational membranes were isolated from a normal-term pregnancy and a preterm pregnancy complicated by chorioamnionitis. Tissues were evaluated for IL-10 expression by immunohistology and in situ hybridization. Human gestational tissues were collected from 38 women experiencing: 1) term cesarean delivery without labor; 2) normal-term vaginal delivery; 3) preterm cesarean delivery without labor; 4) preterm vaginal delivery without chorioamnionitis; and 5) preterm vaginal delivery with concomitant chorioamnionitis. Amnion, chorion, and decidua were isolated, total RNA from each tissue was extracted, and the presence of IL-10 mRNA was determined by reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Decidual cells in culture produced IL-10 in response to IL-1 beta, but chorion and amnion cells produced no IL-10 protein. In vivo protein expression by immunohistology showed that most protein was detected within decidua while cells within amnion and chorion rarely had detectable IL-10 protein. In vivo RT-PCR samples demonstrated the strongest IL-10 mRNA signal from decidua samples, although IL-10 mRNA was also noted in chorion and amnion of placentas obtained after preterm labor.

CONCLUSION

Maternal decidual cells can potentially produce IL-10, but fetal membranes (amnion and chorion) appear to have limited capabilities to produce IL-10. The relative inability of fetal tissues to produce IL-10 may play an important role in the pathophysiology of infection-associated preterm labor.

Deletions in Xq26.3-q27.3 including FMR1 result in a severe phenotype in a male and variable phenotypes in females depending upon the X inactivation pattern

High resolution cytogenetics, microsatellite marker analyses, and fluorescence in situ hybridization were used to define Xq deletions encompassing the fragile X gene, FMR1, detected in individuals from two unrelated families. In Family 1, a 19-year-old male had facial features consistent with fragile X syndrome; however, his profound mental and growth retardation, small testes, and lover limb skeletal defects and contractures demonstrated a more severe phenotype, suggestive of a contiguous gene syndrome. A cytogenetic deletion including Xq26.3-q27.3 was observed in the proband, his phenotypically normal mother, and his learning-disabled non-dysmorphic sister. Methylation analyses at the FMR1 and androgen receptor loci indicated that the deleted X was inactive in > 95% of his mother's white blood cells and 80-85% of the sister's leukocytes. The proximal breakpoint for the deletion was approximately 10 Mb centromeric to FMR1, and the distal breakpoint mapped 1 Mb distal to FMR1. This deletion, encompassing approximately 13 Mb of DNA, is the largest deletion including FMR1 reported to date. In the second family, a slightly smaller deletion was detected. A female with moderate to severe mental retardation, seizures, and hypothyroidism, had a de novo cytogenetic deletion extending from Xq26.3 to q27.3, which removed approximately 12 Mb of DNA around the FMR1 gene. Cytogenetic, and molecular data revealed that approximately 50% of her white blood cells contained an active deleted X. These findings indicate that males with deletions including Xq26.3-q27.3 may exhibit a more severe phenotype than typical fragile X males, and females with similar deletions may have an abnormal phenotype if the deleted X remains active in a significant proportion of the cells. Thus, important genes for intellectual and neurological development, in addition to FMR1, may reside in Xq26.3-q27.3. One candidate gene in this region, SOX3, is thought to be involved in neuronal development and its loss may partly explain the more severe phenotypes of our patients.