Coronary artery disease severity and aortic stenosis: clinical outcomes according to SYNTAX score in patients undergoing transcatheter aortic valve implantation.

AIM The aim of this study was to evaluate whether coronary artery disease (CAD) severity exerts a gradient of risk in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS A total of 445 patients with severe AS undergoing TAVI were included into a prospective registry between 2007 and 2012. The preoperative SYNTAX score (SS) was determined from baseline coronary angiograms. In case of revascularization prior to TAVI, residual SS (rSS) was also determined. Clinical outcomes were compared between patients without CAD (n = 158), patients with low SS (0-22, n = 207), and patients with high SS (SS >22, n = 80). The pre-specified primary endpoint was the composite of cardiovascular death, stroke, or myocardial infarction (MI). At 1 year, CAD severity was associated with higher rates of the primary endpoint (no CAD: 12.5%, low SS: 16.1%, high SS: 29.6%; P = 0.016). This was driven by differences in cardiovascular mortality (no CAD: 8.6%, low SS: 13.6%, high SS: 20.4%; P = 0.029), whereas the risk of stroke (no CAD: 5.1%, low SS: 3.3%, high SS: 6.7%; P = 0.79) and MI (no CAD: 1.5%, low SS: 1.1%, high SS: 4.0%; P = 0.54) was similar across the three groups. Patients with high SS received less complete revascularization as indicated by a higher rSS (21.2 ± 12.0 vs. 4.0 ± 4.4, P < 0.001) compared with patients with low SS. High rSS tertile (>14) was associated with higher rates of the primary endpoint at 1 year (no CAD: 12.5%, low rSS: 16.5%, high rSS: 26.3%, P = 0.043). CONCLUSIONS Severity of CAD appears to be associated with impaired clinical outcomes at 1 year after TAVI. Patients with SS >22 receive less complete revascularization and have a higher risk of cardiovascular death, stroke, or MI than patients without CAD or low SS.

Optimal target localization for subthalamic stimulation in patients with Parkinson disease

OBJECTIVE To further determine the causes of variable outcome from deep brain stimulation of the subthalamic nucleus (DBS-STN) in patients with Parkinson disease (PD). METHODS Data were obtained from our cohort of 309 patients with PD who underwent DBS-STN between 1996 and 2009. We examined the relationship between the 1-year motor, cognitive, and psychiatric outcomes and (1) preoperative PD clinical features, (2) MRI measures, (3) surgical procedure, and (4) locations of therapeutic contacts. RESULTS Pre- and postoperative results were obtained in 262 patients with PD. The best motor outcome was obtained when stimulating contacts were located within the STN as compared with the zona incerta (64% vs 49% improvement). Eighteen percent of the patients presented a postoperative cognitive decline, which was found to be principally related to the surgical procedure. Other factors predictive of poor cognitive outcome were perioperative confusion and psychosis. Nineteen patients showed a stimulation-induced hypomania, which was related to both the form of the disease (younger age, shorter disease duration, higher levodopa responsiveness) and the ventral contact location. Postoperative depression was more frequent in patients already showing preoperative depressive and/or residual axial motor symptoms. CONCLUSION In this homogeneous cohort of patients with PD, we showed that (1) the STN is the best target to improve motor symptoms, (2) postoperative cognitive deficit is mainly related to the surgery itself, and (3) stimulation-induced hypomania is related to a combination of both the disease characteristics and a more ventral STN location.

Swiss national guideline for reimbursement of enzyme replacement therapy in late-onset Pompe disease.

Glycogen storage disease type II is a rare multi-systemic disorder characterised by an intracellular accumulation of glycogen due a mutation in the acid alpha glucosidase (GAA) gene. The level of residual enzyme activity, the genotype and other yet unknown factors account for the broad variation of the clinical phenotype. The classical infantile form is characterised by severe muscle hypotonia and cardiomyopathy leading to early death. The late-onset form presents as a limb girdle myopathy with or without pulmonary dysfunction. Enzyme replacement therapy (ERT) with recombinant human GAA (rhGAA) in infants is life saving. In contrast, therapeutic efficacy of rhGAA in the late-onset form is modest. High expenses of rhGAA, on-going infusions and poor pharmacokinetic efficacy raised a discussion of the cost effectiveness of ERT in late-onset Pompe disease in Switzerland. This discussion was triggered by a Swiss federal court ruling which confirmed the reluctance of a health care insurer not to reimburse treatment costs in a 67-year-old female suffering from Pompe disease. As a consequence of this judgement ERT was stopped by all insurance companies in late-onset Pompe patients in Switzerland regardless of their clinical condition. Subsequent negotiations lead to the release of a national guideline of the management of late-onset Pompe disease. Initiation and limitation of ERT is outlined in a national Pompe registry. Reimbursement criteria are defined and individual efficacy of ERT with rhGAA is continuously monitored.

The association between in-stent neoatherosclerosis and native coronary artery disease progression: a long-term angiographic and optical coherence tomography cohort study.

AIMS The purpose of the present study was to investigate the relationship between in-stent neoatherosclerosis (NA) and native atherosclerosis progression of untreated coronary segments. METHODS AND RESULTS In-stent NA was assessed by optical coherence tomography (OCT) among patients included in the SIRTAX-LATE OCT study 5 years after drug-eluting stent (DES) (sirolimus-eluting and paclitaxel-eluting stents) implantation. Neoatherosclerosis was defined as the presence of fibroatheroma or fibrocalcific plaque within the neointima of stented segments with a longitudinal extension >1.0 mm. Atherosclerosis progression in untreated native coronary segments was evaluated by serial quantitative coronary angiography (QCA). The change in minimal lumen diameter (MLD) was serially assessed within matched segments at baseline and 5-year angiographic follow-up. The key clinical endpoint was non-target lesion (non-TL) revascularization throughout 5 years. A total of 88 patients with 88 lesions were available for OCT analysis 5 years after DES implantation. In-stent NA was observed in 16% of lesions with the majority of plaques being fibroatheromas (11.4%) followed by fibrocalcific plaques (5.7%). A total of 704 non-TL segments were serially evaluated by QCA. Between baseline and 5-year follow-up, the reduction in MLD was significantly more pronounced in patients with NA (-0.25 mm, 95% CI -0.36 to -0.17 mm) when compared with patients without NA (-0.13 mm, 95% CI -0.17 to -0.10 mm, P = 0.002). Similarly, non-TL revascularization was more frequent in patients with NA (78.6%) when compared with patients without NA (44.6%, P = 0.028) throughout 5 years. CONCLUSIONS In-stent NA is more common among patients with angiographic and clinical evidence of native atherosclerosis progression suggesting similar pathophysiological mechanisms.SIRTAX trial is registered at http://www.clinicaltrials.gov/ct2/show/NCT00617084.

Optimización de la aplicación de lodos de depuración de aguas residuales al abonado o mejora de suelos

El objetivo de este trabajo de investigación fue evaluar el efecto de la aplicación de lodos residuales procedentes de una planta de tratamiento de aguas residuales acondicionados como biosólido para el abonado de tres cultivos agrícolas. Esto se realizó a través del estudio de las variables de producción (desarrollo vegetal de cada cultivo) y de la comparación de las características de los suelos utilizados antes y después de los ensayos experimentales. A través de la investigación se confirmó la mejora en la calidad del suelo y mejor rendimiento de cultivo debido a los biosólidos procedentes de tratamiento de aguas residuales. Este trabajo de investigación de tipo descriptivo y experimental, utilizó lodos optimizados que fueron aplicados a tres cultivos agrícolas de ciclo corto. Fueron evaluados dos cultivos (sandía y tomate) bajo riego y un cultivo (arroz) en secano. En la primera fase del trabajo se realizó la caracterización de los lodos, para ellos se realizaron pruebas físico químicas y microbiológicas. Fue utilizado el método de determinación de metales por espectrometría de emisión atómica de plasma acoplado inductivamente, (ICP-AES) para conocer las concentraciones de metales. La caracterización microbiológica para coliformes totales y fecales se realizó utilizando la técnica del Número más probable (NMP), y para la identificación de organismos patógenos se utilizó el método microbiológico propuesto por Kornacki & Johnson (2001), que se fundamenta en dos procesos: pruebas presuntivas y prueba confirmativa. Tanto los resultados para la determinación de metales y elementos potencialmente tóxicos; como las pruebas para la determinación de microorganismos potencialmente peligrosos, estuvieron por debajo de los límites considerados peligrosos establecidos por la normativa vigente en Panama (Reglamento Técnico COPANIT 47-2000). Una vez establecido la caracterización de los lodos, se evalúo el potencial de nutrientes (macro y micro) presentes en los biosólidos para su potencial de uso como abono en cultivos agrícolas. El secado de lodos fue realizado a través de una era de secado, donde los lodos fueron deshidratados hasta alcanzar una textura pastosa. “La pasta de lodo” fue transportada al área de los ensayos de campo para continuar el proceso de secado y molida. Tres ensayos experimentales fueron diseñados al azar con cinco tratamientos y cuatro repeticiones para cada uno de los tres cultivos: sandía, tomate, arroz, en parcelas de 10m2 (sandía y tomate) y 20 m2 (arroz) para cada tratamiento. Tres diferentes dosis de biosólidos fueron evaluadas y comparadas con un tratamiento de fertilizante comercial y un tratamiento control. La dosis de fertilizante comercial utilizada en cada cultivo fue la recomendada por el Instituto de Investigación Agropecuaria de Panamá. Los ensayos consideraron la caracterización inicial del suelo, la preparación del suelo, semilla, y arreglo topográfico de los cultivos siguiendo las recomendaciones agronómicas de manejo de cultivo establecida por el Instituto de Investigación Agropecuaria. Para los ensayos de sandía y tomate se instaló el sistema de riego por goteo. Se determinaron los ácidos húmicos presentes en los cultivos, y se estudiaron las variables de desarrollo de cada cultivo (fructificación, cosecha, peso de la cosecha, dimensiones de tamaño y color de las frutas, rendimiento, y la relación costo – rendimiento). También se estudiaron las variaciones de los macro y micro nutrientes y las variaciones de pH, textura de suelo y MO disponible al inicio y al final de cada uno de los ensayos de campo. Todas las variables y covariables fueron analizadas utilizando el programa estadístico INFOSAT (software para análisis estadístico de aplicación general) mediante el análisis de varianza, el método de comparaciones múltiples propuesto por Fisher (LSD Fisher) para comparar las medias de los cultivares y el coeficiente de correlación de Pearson que nos permite analizar si existe una asociación lineal entre dos variables. En la evaluación de los aportes del biosólido a los cultivos se observó que los macronutrientes N y P se encontraban de los límites requeridos en cada uno de los cultivos, pero que los niveles de K estuvieron por debajo de los requerimientos de los cultivos. A nivel de la fertilización tradicional con fertilizante químico se observó que la dosis recomendada para cada uno de los cultivos del estudio estaba sobreestimada en los tres principales macronutrientes: Nitrógeno, Fosforo y Potasio. Contenían concentraciones superiores de N, P y K a las requeridas teóricamente por el cultivo. El nutriente que se aporta en exceso es el Fósforo. Encontramos que para el cultivo de sandía era 18 veces mayor a lo requerido por el cultivo, en tomate fue 12 veces mayor y en el cultivo de arroz, 34 veces mayor. El fertilizante comercial tuvo una influencia en el peso final y rendimiento final en cada uno de los cultivos del estudio. A diferencia, los biosólidos tuvieron una influencia directa en el desarrollo de los cultivos (germinación, coloración, tamaño, longitud, diámetro, floración y resistencia a enfermedades). Para el caso de la sandía la dosis de biosólido más cercana al óptimo para el cultivo es la mayor dosis aplicada en este ensayo (97.2 gramos de biosólido por planta). En el caso de tomate, el fertilizante comercial obtuvo los mejores valores, pero las diferencias son mínimas con relación al tratamiento T1, de menor dosis de biosólido (16.2 gramos de biosólido por planta). Los resultados generales del ensayo de tomate estuvieron por debajo del rendimiento esperado para el cultivo. Los tratamientos de aplicación de biosólidos aportaron al desarrollo del cultivo en las variables tamaño, color y resistencia a las enfermedades dentro del cultivo de tomate. Al igual que el tomate, en el caso del arroz, el tratamiento comercial obtuvo los mejores resultados. Los resultados finales de peso y rendimiento del cultivo indican que el tratamiento (T2), menor dosis de biosólido (32.4 gramos por parcela), no tuvo diferencias significativas con los resultados obtenidos en las parcelas con aplicación de fertilizante comercial (T1). El tratamiento T4 (mayor dosis de biosólido) obtuvo los mejores valores para las variables germinación, ahijamiento y espigamiento del cultivo, pero al momento de la maduración obtuvo los menores resultados. Los biosólidos aportan nutrientes a los cultivos y al final del ensayo se observó que permanecen disponibles en el suelo, aportando a la mejora del suelo final. En los tres ensayos, se pudo comprobar que los aportes de los biosólidos en el desarrollo vegetativo de los cultivos. También se encontró en todos los ensayos que no hubo diferencias significativas (p > 0.05) entre los tratamientos de biosólidos y fertilizante comercial. Para obtener mejores resultados en estos tres ensayos se requeriría que a la composición de biosólidos (utilizada en este ensayo) se le adicione Potasio, Calcio y Magnesio en las cantidades requeridas por cada uno de los cultivos. ABSTRACT The objective of this investigation was to evaluate the effect of residual sewage sludge obtained from the residual water of a treatment plant conditioned as Biosolid used on three reliable agricultural crops. The effect of the added sewage sludge was evaluated through the measurement of production variables such as crop plant development and the comparison of the soil characteristics used before and after the experimental tests. This investigation confirmed that biosolids from wastewater treatment can contribute to the growth of these crops. In this experimental approach, optimized sludge was applied to three short-cycle crops including two low-risk crops (watermelon and tomato) and one high-risk crop (rice) all grown on dry land. In the first phase of work, the characteristics of the sludge were assessed using chemical, physical and microbiological tests. The concentrations of metals were determined by atomic emission spectrometry inductively coupled plasma, (ICP-AES). Microbiological characterization was performed measuring total coliform and fecal count using the most probable number technique (NMP) and microbiological pathogens were identified using Kornacki & Johnson (2001) method based on two processes: presumptive and confirmatory tests. Both the results for the determination of metals and potentially toxic elements, as testing for the determination of potentially dangerous microorganisms were below the limits established by the applicable standard in Panama (Technical Regulate COPANIT 47-2000). After the metal and bacterial characterization of the sludge, the presence of macro or micronutrients in biosolids was measured to evaluate its potential for use as fertilizer in the growth of agricultural crops. The sludge was dehydrated via a drying process into a muddy slurry. The pulp slurry was transported to the field trial area to continue the process of drying and grinding. Three randomized experimental trials were designed to test with five treatment regimens and four replications for each of the crops: watermelon, tomato, rice. The five treatment regimens evaluated were three different doses of bio solid with commercial fertilizer treatment control and no fertilizer treatment control. Treatment areas for the watermelon and tomato were 10m2 plots land and for rice was 20m2. The amount of commercial fertilizer used to treat each crop was based on the amount recommended by Agricultural Research Institute of Panama. The experimental trials considered initial characterization of soil, soil preparation, seed, and crop topographical arrangement following agronomic crop management recommendations. For the tests evaluating the growth of watermelons and tomatoes and drip irrigation system was installed. The amount of humic acids present in the culture were determined and developmental variable of each crop were studied (fruiting crop harvest weight, size dimensions and color of the fruit, performance and cost effectiveness). Changes in macro and micronutrients and changes in pH, soil texture and OM available were measured at the beginning and end of each field trial. All variables and covariates were analyzed using INFOSAT statistical program (software for statistical analysis of general application) by analysis of variance, multiple comparisons method as proposed by Fisher (LSD Fisher) to compare the means of cultivars and the Pearson ratio that allows us to analyze if there is a linear association between two variables. In evaluating the contribution of biosolids to agricultural crops, the study determined that the macronutrients N & P were within the requirements of crops, but K levels were below the requirements of crops. In terms of traditional chemical fertilizer fertilization, we observed that the recommended dose for each study crop was overestimated for the three major nutrients: nitrogen, phosphorus and potassium. Higher concentrations containing N, P and K to the theoretically required by the crop. The recommended dose of commercial fertilizer for crops study contained greater amounts of phosphorus, crops that need. The level of phosphorous was found to be18 times greater than was required for the cultivation of watermelon; 12 times higher than required for tomato, and 34 times higher than required for rice cultivation. Phosphorus inputs of commercial fertilizer were a primary influence on the weight and performance of each crop. Unlike biosolids had a direct influence on crop development (germination, color, size, length, diameter, flowering and disease resistance). In the case of growth of watermelons, the Biosolid dose closest to the optimum for cultivation was applied the highest dose in this assay (97.2 grams of bio solids per plant). In the case of tomatoes, commercial fertilizer had the best values but the differences were minimal when compared to treatment T1, the lower dose of sewage sludge (Biosolid 16.2 grams per plant). The overall results for the tomato crop yield of the trial were lower than expected. Additionally, the application of biosolids treatment contributed to the development of fruit of variable size, color and disease resistance in the tomato crops. Similar to the tomato crop, commercial fertilizer treatment provided the best results for the rice crop. The final results of weight and crop yield for rice indicated that treatment with T2 amount of biosolids (34.2 grams per plot) was not significantly different from the result obtained in the application plot given commercial fertilizer (T1). The T4 (higher dose of bio solid) treatment had the best values for the germination, tillering and bolting variables of the rice crop but for fruit ripening yielded lower results. In all three trials, biosolids demonstrated the ability to contribute in the vegetative growth of crops. It was also found in all test no significant differences (p>0.05) between treatment of bio solid and commercial fertilizer. Biosolids provided nutrients to the crops and even at the end of the trial remained available in the ground soil, contributing to the improvement of the final ground. The best results from these three trials is that the use of bio solids such as those used in this assay would require the addition of potassium, calcium and magnesium in quantities required for each crop.

Disease sequence from mutant rhodopsin allele to rod and cone photoreceptor degeneration in man

Mutations in the gene encoding rhodopsin, the visual pigment in rod photoreceptors, lead to retinal degeneration in species from Drosophila to man. The pathogenic sequence from rod cell-specific mutation to degeneration of rods and cones remains unclear. To understand the disease process in man, we studied heterozygotes with 18 different rhodopsin gene mutations by using noninvasive tests of rod and cone function and retinal histopathology. Two classes of disease expression were found, and there was allele-specificity. Class A mutants lead to severely abnormal rod function across the retina early in life; topography of residual cone function parallels cone cell density. Class B mutants are compatible with normal rods in adult life in some retinal regions or throughout the retina, and there is a slow stereotypical disease sequence. Disease manifests as a loss of rod photoreceptor outer segments, not singly but in microscopic patches that coalesce into larger irregular areas of degeneration. Cone outer segment function remains normal until >75% of rod outer segments are lost. The topography of cone loss coincides with that of rod loss. Most class B mutants show an inferior-nasal to superior-temporal retinal gradient of disease vulnerability associated with visual cycle abnormalities. Class A mutant alleles behave as if cytotoxic; class B mutants can be relatively innocuous and epigenetic factors may play a major role in the retinal degeneration.

Abnormal transport along the lysosomal pathway in Mucolipidosis, type IV disease

Mucolipidosis, type IV (ML-IV) is an autosomal recessive storage disease that is characterized by lysosomal accumulation of sphingolipids, phospholipids, and acid mucopolysaccharides. Unlike most other storage diseases, the lysosomal hydrolases participating in the catabolism of the stored molecules appear to be normal. In the present study, we examined the hypothesis that the ML-IV phenotype might arise from abnormal transport along the lysosomal pathway. By using various markers for endocytosis, we found that plasma membrane internalization and recycling were nearly identical in ML-IV and normal fibroblasts. A fluorescent analog of lactosylceramide (LacCer) was used to study plasma membrane lipid internalization and subsequent transport. Lipid internalization at 19°C was similar in both cell types; however, 40–60 min after raising the temperature to 37°C, the fluorescent lipid accumulated in the lysosomes of ML-IV cells but was mainly concentrated at the Golgi complex of normal fibroblasts. Biochemical studies demonstrated that at these time points, hydrolysis of the lipid analog was minimal (∼7%) in both cell types. A fluorescence ratio imaging assay was developed to monitor accumulation of fluorescent LacCer in the lysosomes and showed that the apparent concentration of the lipid increased more rapidly and to a greater extent in ML-IV cells than in normal fibroblasts. By 60 min, LacCer apparently decreased in the lysosomes of normal fibroblasts but not in ML-IV cells, suggesting that lipid efflux from the lysosomes was also impaired. These results demonstrate that there is a defect in ML-IV fibroblasts that affects membrane sorting and/or late steps of endocytosis.

Apolipoprotein E4 allele as a predictor of cholinergic deficits and treatment outcome in Alzheimer disease.

Apolipoprotein E (apoE) is critical in the modulation of cholesterol and phospholipid transport between cells of different types. Human apoE is a polymorphic protein with three common alleles, APO epsilon 2, APO epsilon 3, and APO epsilon 4. ApoE4 is associated with sporadic and late-onset familial Alzheimer disease (AD). Gene dose was shown to have an effect on risk of developing AD, age of onset, accumulation of senile plaques in the brain, and reduction of choline acetyltransferase (ChAT) activity in the hippocampus of AD subjects. To characterize the possible impact of the apoE4 allele on cholinergic markers in AD, we examined the effect of apoE4 allele copy number on pre- and postsynaptic markers of cholinergic activity. ApoE4 allele copy number showed an inverse relationship with residual brain ChAT activity and nicotinic receptor binding sites in both the hippocampal formation and the temporal cortex of AD subjects. AD cases lacking the apoE4 allele showed ChAT activities close or within age-matched normal control values. The effect of the apoE4 allele on cholinomimetic drug responsiveness was assessed next in a group (n = 40) of AD patients who completed a double-blind, 30-week clinical trial of the cholinesterase inhibitor tacrine. Results showed that > 80% of apoE4-negative AD patients showed marked improvement after 30 weeks as measured by the AD assessment scale (ADAS), whereas 60% of apoE4 carriers had ADAS scores that were worse compared to baseline. These results strongly support the concept that apoE4 plays a crucial role in the cholinergic dysfunction associated with AD and may be a prognostic indicator of poor response to therapy with acetylcholinesterase inhibitors in AD patients.

Viral particles are required for infection in neurodegenerative Creutzfeldt-Jakob disease.

Several models have been proposed for the infectious agents that cause human Creutzfeldt-Jakob disease (CJD) and sheep scrapie. Purified proteins and extracted nucleic acids are not infectious. To further identify the critical molecular components of the CJD agent, 120S infectious material with reduced prion protein (PrP) was treated with guanidine hydrochloride or SDS. Particulate and soluble components were then separated by centrifugation and molecularly characterized. Conditions that optimally solubilized residual PrP and/or nucleic acid-protein complexes were used to produce subfractions that were assayed for infectivity. All controls retained > 90% of the 120S titer (approximately 15% of that in total brain) but lost > 99.5% of their infectivity after heat-SDS treatment (unlike scrapie fractions enriched for PrP). Exposure to 1% SDS at 22 degrees C produced particulate nucleic acid-protein complexes that were almost devoid of host PrP. These sedimenting complexes were as infectious as the controls. In contrast, when such complexes were solubilized with 2.5 M guanidine hydrochloride, the infectious titer was reduced by > 99.5%. Sedimenting PrP aggregates with little nucleic acid and no detectable nucleic acid-binding proteins had negligible infectivity, as did soluble but multimeric forms of PrP. These data strongly implicate a classical viral structure, possibly with no intrinsic PrP, as the CJD infectious agent. CJD-specific protective nucleic acid-binding protein(s) have already been identified in 120S preparations, and preliminary subtraction studies have revealed several CJD-specific nucleic acids. Such viral candidates deserve more attention, as they may be of use in preventing iatrogenic CJD and in solving a fundamental mystery.

Minimal mutation of the cytoplasmic tail inhibits the ability of E-cadherin to activate Rac but not phosphatidylinositol 3-kinase - Direct evidence of a role for cadherin-activated Rac signaling in adhesion and contact formation

Classic cadherins are adhesion-activated cell signaling receptors. In particular, homophilic cadherin ligation can directly activate Rho family GTPases and phosphatidylinositol 3-kinase (PI3-kinase), signaling molecules with the capacity to support the morphogenetic effects of these adhesion molecules during development and disease. However, the molecular basis for cadherin signaling has not been elucidated, nor is its precise contribution to cadherin function yet understood. One attractive hypothesis is that cadherin-activated signaling participates in stabilizing adhesive contacts ( Yap, A. S., and Kovacs, E. M. ( 2003) J. Cell Biol. 160, 11-16). We now report that minimal mutation of the cadherin cytoplasmic tail to uncouple binding of p120-ctn ablated the ability of E-cadherin to activate Rac. This was accompanied by profound defects in the capacity of cells to establish stable adhesive contacts, defects that were rescued by sustained Rac signaling. These data provide direct evidence for a role of cadherin-activated Rac signaling in contact formation and adhesive stabilization. In contrast, cadherin-activated PI3-kinase signaling was not affected by loss of p120-ctn binding. The molecular requirements for E-cadherin to activate Rac signaling thus appear distinct from those that stimulate PI3-kinase, and we postulate that p120-ctn may play a central role in the E-cadherin-Rac signaling pathway.

Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement

Background: In clinical trials, at the group level, results are usually reported as mean and standard deviation of the change in score, which is not meaningful for most readers. Objective: To determine the minimal clinically important improvement (MCII) of pain, patient's global assessment of disease activity, and functional impairment in patients with knee and hip osteoarthritis (OA). Methods: A prospective multicentre 4 week cohort study involving 1362 outpatients with knee or hip OA was carried out. Data on assessment of pain and patient's global assessment, measured on visual analogue scales, and functional impairment, measured on the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) function subscale, were collected at baseline and final visits. Patients assessed their response to treatment on a five point Likert scale at the final visit. An anchoring method based on the patient's opinion was used. The MCII was estimated in a subgroup of 814 patients ( 603 with knee OA, 211 with hip OA). Results: For knee and hip OA, MCII for absolute ( and relative) changes were, respectively, ( a) -19.9 mm (-40.8%) and -15.3 mm (-32.0%) for pain; ( b) -18.3 mm ( - 39.0%) and -15.2 mm ( -32.6%) for patient's global assessment; ( c) -9.1 ( -26.0%) and -7.9 ( -21.1%) for WOMAC function subscale score. The MCII is affected by the initial degree of severity of the symptoms but not by age, disease duration, or sex. Conclusion: Using criteria such as MCII in clinical trials would provide meaningful information which would help in interpreting the results by expressing them as a proportion of improved patients.

Population pharmacokinetics and association between A77 1726 plasma concentrations and disease activity measures following administration of leflunomide to people with rheumatoid arthritis

Aims To investigate the concentration-effect relationship and pharmacokinetics of leflunomide in patients with rheumatoid arthritis (RA). Methods Data were collected from 23 RA patients on leflunomide therapy (as sole disease modifying antirheumatic drug (DMARD)) for at least 3 months. Main measures were A77 1726 (active metabolite of leflunomide) plasma concentrations and disease activity measures including pain, duration/intensity of morning stiffness, and SF-36 survey. A population estimate was sought for apparent clearance (CL/F ) and volume of distribution was fixed (0.155 l kg(-1)). Factors screened for influence on CL/F were weight, age, gender and estimated creatinine clearance. Results Significantly higher A77 1726 concentrations were seen in patients with less swollen joints and with higher SF-36 mental summary scores than in those with measures indicating more active disease (P < 0.05); concentration-effect trends were seen with five other disease activity measures. Statistical analysis of all disease activity measures showed that mean A77 1726 concentrations in groups with greater control of disease activity were significantly higher than those in whom the measures indicated less desirable control (P < 0.05). There was large between subject variability in the dose-concentration relationship. A steady-state infusion model best described the pharmacokinetic data. Inclusion of age as a covariate decreased interindividual variability (P < 0.01), but this would not be clinically important in terms of dosage changes. Final parameter estimate (% CV interindividual variability) for CL/F was 0.0184 l h(-1) (50%) (95% CI 0.0146, 0.0222). Residual (unexplained) variability (% CV) was 8.5%. Conclusions This study of leflunomide in patients using the drug clinically indicated a concentration-effect relationship. From our data, a plasma A77 1726 concentration of 50 mg l(-1) is more likely to indicate someone with less active disease than is a concentration around 30 mg l(-1). The marked variability in pharmacokinetics suggests a place for individualized dosing of leflunomide in RA therapy.

Alveolar haemorrhage in anti-glomerular basement membrane disease without detectable antibodies by conventional assays

Anti-glomerular basement membrane (anti-GBM) disease represents the spectrum of disease attributable to circulating anti-GBM antibodies. While active anti-GBM disease in the absence of circulating anti-GBM antibodies has been described, it is considered rare with the use of current routinely available assays. We report four subjects with features consistent with active anti-GBM antibody disease without detectable antibodies by routinely available enzyme linked immunosorbent assay (ELISA) and immunoblot techniques. All were smokers who presented with diffuse alveolar haemorrhage, minimal renal involvement, and undetectable anti-GBM antibodies. Seronegative anti-GBM disease with predominant pulmonary involvement may be more common than previously appreciated and should be part of the differential diagnosis for otherwise unexplained diffuse alveolar haemorrhage. Renal biopsy with immunofluorescent studies should be considered in the diagnostic evaluation of such subjects, including those with idiopathic pulmonary haemosiderosis.

Dosing of gentamicin in patients with end-stage renal disease receiving hemodialysis

The aim of this study was to evaluate dosing schedules of gentamicin in patients with end-stage renal disease and receiving hemodialysis. Forty-six patients were recruited who received gentamicin while on hemodialysis. Each patient provided approximately 4 blood samples at various times before and after dialysis for analysis of plasma gentamicin concentrations. A population pharmacokinetic model was constructed using NONMEM (version 5). The clearance of gentamicin during dialysis was 4.69 L/h and between dialysis was 0.453 L/h. The clearance between dialysis was best described by residual creatinine clearance (as calculated using the Cockcroft and Gault equation), which probably reflects both lean mass and residual clearance mechanisms. Simulation from the final population model showed that predialysis dosing has a higher probability of achieving target maximum concentration (C-max) concentrations (> 8 mg/L) within acceptable exposure limits (area under the concentration-time curve [AUC] values > 70 and < 120 mg.h/L per 24 hours) than postdialysis dosing.