Physical abuse among depressed women

BACKGROUND: The evidence-based approach to medical care involves the explicit use of evidence on the magnitude of the effects of interventions to inform diagnostic and treatment decisions. This article critiques current mainstream guidelines on the management of hypertension in the elderly (aged 60 years and over) and presents an alternative evidence-based approach. METHODS: Three major national and international guidelines for the management of hypertension from the United Kingdom (UK), the United States (US) and from a joint World Health Organisation/International Society of Hypertension (WHO/ISH) Working Party were appraised and the evidence on which they were based was reviewed. The relevant evidence was also assessed to determine the likely magnitude of risks and benefits of anti-hypertensive treatment in older people and an alternative approach to making treatment decisions, based on the New Zealand guidelines for the management of hypertension, is described. RESULTS: Hypertension management guidelines from the UK, US and WHO/ISH made similar recommendations about which elderly patients should be treated, although there were some ambiguities in their advice. Treatment recommendations were based primarily on blood pressure levels which were set at about 160 mm Hg systolic and/or 90 mm Hg diastolic. The threshold levels were based mainly on the cut-off blood pressure levels used in randomised trials of anti-hypertensive drug treatment, rather than the estimated magnitude of treatment benefit. Each of the guidelines acknowledged the important effect of associated cardiovascular disease (CVD) risk factors on the likely benefits of treatment, but did not expand on the magnitude of this effect. No patient-specific estimates of the likely absolute benefits of treatment were provided in any of the guidelines. In contrast the New Zealand guidelines for the management of hypertension recommend the use of explicit estimates of absolute CVD risks and benefits to inform treatment decisions. They were designed to provide practitioners with estimates of the likely absolute risk of CVD in patients with different risk factor profiles and with estimates of the absolute benefits of treatment. The New Zealand guidelines recommend that drug treatment be considered in patients with a 5-year risk of CVD of about 10-15% or more; approximately 25 patients with a 10-15% risk would require treatment for 5 years to prevent one CVD event. As elderly patients are generally at higher absolute CVD risk than younger people, the New Zealand recommendation give priority to the treatment of older patients. In order to take account of differences in life expectancy and the medical costs of caring for elderly people, absolute risk-based guidelines can be improved by incorporating potential years of life gained from treatment and the cost-effectiveness of treatment expressed as $/quality adjusted life years gained. Preliminary analyses indicate that the cost-effectiveness of treatment is generally greatest in patients in their 60s and early 70s. Treatment in younger people is not usually very cost-effective because of their low absolute risk of CVD and the cost-effectiveness of treatment in people over about 75 years declines because of the increasing cost of non-CVD morbidity. CONCLUSIONS: The explicit assessment of absolute CVD risks and likely treatment benefits in patients with hypertension can usefully inform treatment decisions and provide a more rational basis for initiating therapy than blood pressure levels alone. This approach highlights the generally greater CVD risk and potential treatment benefits in older compared with younger hypertensive patients. The absolute risk-based approach can be further enhanced by providing decision makers with patient-specific data on the potential life years gained from treatment and its cost-effectiveness. (ABSTRACT TRUNCATED)     

D-subgenome bias of Xcm resistance genes in tetraploid Gossypium (cotton) suggests that polyploid formation has created novel avenues for evolution

A detailed RFLP map was used to determine the chromosomal locations and subgenomic distributions of cotton (Gossypium) genes/QTLs that confer resistance to the bacterial blight pathogen, Xanthomonas campestris pv. malvacearum (Xcm). Genetic mapping generally corroborated classic predictions regarding the number and dosage effects of genes conferring Xcm resistance. One recessive allele (b6) was a noteworthy exception to the genetic dominance of most plant resistance alleles. This recessive allele appeared to uncover additional QTLs from both resistant and ostensibly susceptible genotypes, some of which corresponded in location to resistance (R)-genes effective against other Xcm races. One putatively "defeated" resistance allele (B3) reduced severity of Xcm damage by "virulent" races. Among the six resistance genes derived from tetraploid cottons, five (83%) mapped to D-subgenome chromosomes-if each subgenome were equally likely to evolve new R-gene alleles, this level of bias would occur in only about 1.6% of cases. Possible explanations of this bias include biogeographic factors, differences in evolutionary rates between subgenomes, gene conversion or other intergenomic exchanges that escaped detection by genetic mapping, or other factors. A significant D-subgenome bias of Xcm resistance genes may suggest that polyploid formation has offered novel avenues for phenotypic response to selection.     

Incidence and prevalence of different uveitis entities in Finland

A prospective, open, multicentre study was performed to investigate the efficacy and safety of long-term treatment with cyclosporin in adults with severe atopic dermatitis. Subjects were treated for a maximum of 48 weeks. For the first 8 weeks, cyclosporin was administered at 2.5 mg/kg per day. The dose was then adjusted according to response. Disease activity was monitored using the six-area, six-sign score and the proportion of skin involved. Pruritus and sleep disturbance were assessed using four-point scales. Response was further evaluated on a five-point scale. Adverse events, blood pressure and serum biochemistry were monitored. Tolerability was assessed on a five-point scale. One hundred subjects were enrolled and 65 completed 48 weeks of treatment. Withdrawals occurred due to remission (three), inadequate response (seven), protocol violations (11) and adverse events (14, of which seven were probably treatment related). Cyclosporin produced rapid and highly significant improvements in all indices of disease activity. Sixty-five subjects considered that they had shown a considerable improvement or complete clearance of disease. Most patients relapsed after cessation of treatment, but neither signs nor symptoms had returned to baseline severity 8 weeks later. Blood pressure and serum creatinine levels increased slightly, and in one subject renal impairment was a major factor contributing to withdrawal of the drug. Overall, 85 subjects rated the tolerability of cyclosporin as good or very good. The results indicate that cyclosporin has a place in the long-term treatment of severe atopic dermatitis provided that appropriate patients are selected and careful monitoring is performed.     

HLA gene and haplotype frequencies in the North American population: the National Marrow Donor Program Donor Registry

BACKGROUND: As of May 1, 1995, the National Marrow Donor Program had a donor registry consisting of over 1.35 million HLA-typed volunteers recruited from most major cities and states in the United States. This registry represents the largest single HLA-typed pool of normal individuals in the world. METHODS: We analyzed the HLA-A, -B, -DR locus phenotypes of the National Marrow Donor Program donors in order to estimate gene and haplotype frequencies for major racial groups of the United States: Caucasian American, Asian American, African American, Latin American, and Native American. The large size of the database allowed us to calculate the frequencies of relatively rare antigens and haplotypes with more accuracy than previous studies. RESULTS: We observed 89,522 distinguishable HLA-A, -B phenotypes in 1,351,260 HLA-A, -B-typed donors and 302,867 distinguishable HLA-A, -B, -DR phenotypes in 406,503 HLA-A, -B, -DR-typed donors. Gene and haplotype frequencies differed remarkably among the five racial groups, with African Americans and Asian Americans having a large number of haplotypes that were specific to their racial groups, whereas Caucasian Americans, Latin Americans, and Native Americans shared a number of common haplotypes. CONCLUSIONS: These data represent an important resource for investigators in the fields of transplantation and population genetics. The gene and haplotype frequencies can be used to aid clinicians in advising patients about the probability of finding a match within a specific ethnic group, or to determine donor recruitment goals and strategies. The information is also a valuable resource for individuals who are interested in population genetics, selection and evolution of polymorphic human genes, and HLA-disease association.     

Assessing obesity: classification and epidemiology

Obesity is generally defined as a body mass index (BMI) of 30 kg/m2 and higher. Overweight is defined as a BMI between 25 and 30 kg/m2. The prevalence varies considerably between countries, and between regions within countries. It is estimated that more than half of adults aged 35-65 living in Europe are either overweight or obese. Overweight is more common among men than among women but obesity is more common among women. The prevalence of obesity in Europe is probably in the order of 10-20% in men and 15-25% in adult women. In most European countries who have reliable data on time-trends the prevalence of obesity seems to be increasing. In most European countries, obesity is usually inversely associated with socio-economic status, particularly among women. New classifications of overweight may be based on cut-off points for simple anthropometric measures which reflects both total adiposity as well as abdominal fatness.     

Characterization of the conformations of antigenic peptides of protein lactate dehydrogenase (LDH-C4) by electrospray ionization mass spectrometry

The conformations of several rationally designed antigenic peptides that mimic, to varying degrees, an antibody-binding region of protein lactate dehydrogenase isozyme (LDH-C4) are investigated by deuterium/hydrogen exchange and electrospray ionization mass spectrometry (ESI-MS). The approach involves monitoring the reverse-exchange of deuterium, incorporated at the labile sites in the peptides, with hydrogen as a function of time by ESI-MS. Idealized forms of a segment of the native antigen are shown to be more conformationally restricted than the native peptide based on level of deuterium that remains incorporated at the labile sites over time. From the number of amide groups of the peptide backbone that retain deuterium, estimates of the helical content of each peptide have been measured that are in close agreement with those determined by Fourier transform infrared (FTIR) spectroscopy in separate experiments. A single amino acid substitution in the idealized helical construct results in a conformational change easily detected by the deuterium exchange ESI-MS method. The approach is shown to be a viable method for characterizing the conformations of protein antigens at the local level and for screening the conformations of antigenic peptides designed to elicit optimal immune responses.     

Unrelated donor bone marrow transplantation for chronic myelogenous leukemia: a decision analysis

BACKGROUND: Chronic myelogenous leukemia (CML) is an indolent but ultimately fatal disease. Because the natural history of CML varies and quality of life with CML may be excellent until shortly before death, deciding whether and when to pursue unrelated donor bone marrow transplantation is often difficult. OBJECTIVE: To compare early transplantation, delayed transplantation, and no transplantation for patients with chronic-phase CML on the basis of discounted, quality-adjusted life expectancy. DESIGN: A markov model comparing different strategies was constructed. This model considers patient age, quality of life, risk aversion, and the competing risks for CML progression and transplant toxicity. SETTING: Therapeutic decision at the time of diagnosis of CML. PATIENTS: The base case is a 35-year-old patient with intermediate-prognosis CML. Younger and older patients with better and worse prognoses are also evaluated. INTERVENTION: Early transplantation, delayed transplantation, and no transplantation. MEASUREMENTS: Quality-adjusted, discounted life expectancy. RESULTS: For patients with newly diagnosed CML, transplantation within the first year provides the greatest quality-adjusted expected survival, although this benefit decreases with increasing patient age. For a 35-year-old patient with intermediate-prognosis CML, transplantation within the first year results in 53 more discounted, quality-adjusted years of life expectancy than does no transplantation. This finding is robust even with varying baseline assumptions. CONCLUSIONS: These results support the use of early unrelated donor bone marrow transplantation for most patients with CML.     

The number and biodiversity of the parasites from small mammals in the evacuation area of the Chernobyl Nuclear Power Station

The study of the micromammalian parasite complexes in the Belorussian part of the evacuation zone of the Chernobyl nuclear station revealed 13 species of Coccidia and 30 species of ectoparasitic Arthropoda. Total increase of abundance and biodiversity of both parasites and their hosts was observed. The part of ectoparasites being epidemically hazardous was significantly increased. An analysis of a long-term dynamics of parasite abundance reveals their adaptation to new conditions in the Belorussia.     

Cardiovascular, renal, and neurohumoral responses to single large-volume paracentesis in patients with cirrhosis and diuretic-resistant ascites

OBJECTIVE: Large volume paracentesis is an effective treatment for refractory ascites, but the need for routine infusion of albumin or other volume expanders remains controversial. The aim of this study was to assess the short term effects of a single 5-L paracentesis without albumin replacement on total central blood volume, systemic and renal hemodynamics, sodium homeostasis, and neurohumoral factors. PATIENTS AND METHODS: Twelve patients with biopsy-proven cirrhosis and tense, diuretic-resistant ascites were studied before and 48 h after a single 5-L paracentesis without albumin infusion. Systemic hemodynamics and total central blood volume were assessed using radionuclide angiography. Glomerular filtration rate and effective renal plasma flow were measured by inulin and para-aminohippurate clearances, respectively. Lithium clearance was used as an index of proximal tubular reabsorption of sodium. In addition, plasma concentrations of neurohumoral factors were determined. RESULTS: Total central blood volume was 2.41 +/- 0.33 L/m2 (mean +/- SEM) before and 2.34 +/- 0.18 L/m2 48 h after large volume paracentesis (p = 0.76). Similarly, no differences were detected in the cardiac index, glomerular filtration rate, effective renal plasma flow, urinary sodium excretion, hematocrit, plasma renin activity, or concentrations of plasma aldosterone, norepinephrine, or atrial natriuretic factor. CONCLUSIONS: A single large volume paracentesis without albumin replacement causes no disturbances in systemic and renal hemodynamics 48 h after the procedure. These results suggest that a single 5-L paracentesis without albumin infusion is a safe and satisfactory short term option for the management of patients with cirrhosis and tense, diuretic-resistant ascites.