Applicability of a high-throughput shotgun plasma protein screening approach in understanding maternal biological pathways relevant to infant birth weight outcome.

There are reports linking maternal nutritional status, smoking and environmental chemical exposures to adverse pregnancy outcomes. However, biological bases for association between some of these factors and birth outcomes are yet to be established. The objective of this preliminary work is to test the capability of a new high-throughput shotgun plasma proteomic screening in identifying maternal changes relevant to pregnancy outcome. A subset of third trimester plasma samples (N=12) associated with normal and low-birth weight infants were fractionated, tryptic-digested and analyzed for global proteomic changes using a MALDI-TOF-TOF-MS methodology. Mass spectral data were mined for candidate biomarkers using bioinformatic and statistical tools. Maternal plasma profiles of cytokines (e.g. IL8, TNF-α), chemokines (e.g. MCP-1) and cardiovascular endpoints (e.g. ET-1, MMP-9) were analyzed by a targeted approach using multiplex protein array and HPLC-Fluorescence methods. Target and global plasma proteomic markers were used to identify protein interaction networks and maternal biological pathways relevant to low infant birth weight. Our results exhibited the potential to discriminate specific maternal physiologies relevant to risk of adverse birth outcomes. This proteomic approach can be valuable in understanding the impacts of maternal factors such as environmental contaminant exposures and nutrition on birth outcomes in future work. BIOLOGICAL SIGNIFICANCE: We demonstrate here the fitness of mass spectrometry-based shot-gun proteomics for surveillance of biological changes in mothers, and for adverse pathway analysis in combination with target biomarker information. This approach has potential for enabling early detection of mothers at risk for low infant birth weight and preterm birth, and thus early intervention for mitigation and prevention of adverse pregnancy outcomes. This article is part of a Special Issue entitled: Can Proteomics Fill the Gap Between Genomics and Phenotypes?

A force-based protein biochip.

A parallel assay for the quantification of single-molecule binding forces was developed based on differential unbinding force measurements where ligand-receptor interactions are compared with the unzipping forces of DNA hybrids. Using the DNA zippers as molecular force sensors, the efficient discrimination between specific and nonspecific interactions was demonstrated for small molecules binding to specific receptors, as well as for protein-protein interactions on protein arrays. Finally, an antibody sandwich assay with different capture antibodies on one chip surface and with the detection antibodies linked to a congruent surface via the DNA zippers was used to capture and quantify a recombinant hepatitis C antigen from solution. In this case, the DNA zippers enable not only discrimination between specific and nonspecific binding, but also allow for the local application of detection antibodies, thereby eliminating false-positive results caused by cross-reactive antibodies and nonspecific binding.

Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients.

The objective of this study was to examine the interest of non-terminally ill hospitalized elderly patients in euthanasia and physician assisted suicide (PAS) and to determine the stability of these interests over time. Patients age 60 or older (n=158), including both a depressed sample and non-depressed control sample, underwent a structured interview evaluating their interest in euthanasia and PAS in the event of a series of hypothetical outcome scenarios. Substantial proportions of subjects (varying from 13.3%-42% depending on the scenario) expressed hypothetical acceptance of euthanasia and PAS. After six months a subset of patients changed their minds about euthanasia and PAS (8% - 26% depending on the scenario), most often in the direction of initial acceptance to later rejection. Patients depressed in the hospital and interested in PAS for the outcome of their current (non-terminal) condition were significantly more likely express unstable opinions, with most rejecting it six months later. Other correlations of instability, in specific scenarios, included being male, experiencing higher baseline suffering, poorer subjective health and lower instrumental support. Because euthanasia and PAS actions are irreversible, findings of instability have important implications both clinically and for design of PAS legislation.

[Community health documentation as an instrument for further developing recommendations in community health]. / Kommunale Gesundheitsberichterstattung als Instrument zur Weiterentwicklung von Handlungsempfehlungen auf kommunaler Ebene.

The local health conference in a North Rhine-Westphalian county of Germany has made proposals to improve immunisation rates against measles, mumps and rubella. Another target was to prevent decubitus by elderly patients in hospitals, nursing homes and in the outpatient nursing. Local public health reports were the basis for the development of (local) health targets in the health conference. The data of 12,830 immunisation papers from 11-19-year old students showed immunisation rates against measles, mumps and rubella from 44% to 14% depending on the type of school. Virus hepatitis B immunisation rates are 32% in the county. There were also great differences between local towns of the county. The decubitus data showed rates from 2.3% in nursing homes to 5.1% in the outpatient sector. It is also shown that health reports and health conferences help to improve local conditions in public and individual health.

Life-sustaining treatment and assisted death choices in depressed older patients.

OBJECTIVES: The major purpose of this study was to examine the effect of depressed mood in older, medically ill, hospitalized patients on their preferences regarding life-sustaining treatments, physician-assisted suicide (PAS), and euthanasia and to determine the degree to which financial constraints affected their choices. DESIGN: Cross-sectional study. SETTING: General medical hospital. PARTICIPANTS: One hundred fifty-eight medically hospitalized, nondemented patients age 60 or older, mean age 74.1 (range 60-94). The sample was divided, based on Center for Epidemiologic Studies-Depression (CES-D) scores, into a depressed group (n = 71) and a nondepressed control group. MEASUREMENTS: Subjects underwent a structured interview evaluating their life-sustaining treatment choices and whether they would accept or refuse PAS or euthanasia under a variety of hypothetical conditions. These choices were reevaluated with the introduction of financial impact. In addition, assessment included measures of depression, suicide, cognition, social support, functioning, and religiosity. RESULTS: Depression was found to be highly associated with acceptance of PAS and euthanasia in most hypothetical clinical scenarios in addition to patients' current condition. Compared with nondepressed people, depressed respondents were 13 times as likely to accept PAS when considering their current condition (95% confidence interval [CI] 1.68-110.98), and over twice as likely to accept PAS when facing a hypothetical terminal illness or coma. Depression alone was weakly associated with life-sustaining treatment choices but, when financial impact was introduced, significantly more depressed subjects refused treatment options they had previously desired than did nondepressed subjects. The presence of suicidal ideation, even passive ideation, was strongly predictive of life-sustaining treatment refusals and increased interest in PAS and euthanasia. Depression's effect on acceptance of PAS was confirmed by logistic regression, which also showed that religious coping was significantly correlated with less interest in PAS in two hypothetical scenarios. CONCLUSION. Depressed subjects and even subjects with subtle, passive suicidal ideation were markedly more interested in PAS and euthanasia than nondepressed subjects in hypothetical situations. Depressed subjects were also particularly vulnerable to rejecting treatments if financial consequences might have resulted.

Prolonged E55+ retrovirus expression in aged mice is associated with a decline in the anti-virus immune response.

E55+ murine leukemia retrovirus (E55+ MuLV) infection of young and aged C57BL/6 (B6) mice was used to investigate the relationship between increased incidences of infection and decreased immune responsiveness of elderly individuals. Young mice decreased E55+ MuLV burden to below detectable levels by 8 weeks postinfection (p.i.). In contrast, virus burden in aged mice did not reach undetectable levels until 20 weeks p.i. A significant T cell proliferative response to E55+ MuLV was detected from 2 to 12 weeks p.i. in young mice, but was never observed in aged mice. Both age groups demonstrated significant E55+ MuLV-specific T-cell-mediated cytotoxic responses at 3 and 4 weeks p.i. and virus neutralizing antibody titers at 2, 4, 8, and 12 weeks p.i. In both cases, responses were consistently higher in young mice (P < 0.04 and P < 0.02, respectively). These results demonstrate that the observed delay in E55+ MuLV clearance by aged mice is associated with an age-related decrease in the immune response to the virus.

Rational design of cytotoxic T-cell inhibitors.

This study describes the use of the CD8/major histocompatibility complex (MHC) class I crystal structure as a template for the de novo design of low-molecular-weight surface mimetics. The analogs were designed from a local surface region on the CD8 alpha-chain directly adjacent to the bound MHC class I, to block the protein associations in the T-cell activation cluster that occur upon stimulation of the cytotoxic T lymphocytes (CTLs). One small conformationally restrained peptide showed dose-dependent inhibition of a primary allogeneic CTL assay while having no effect on the CD4-dependent mixed lymphocyte reaction (MLR). The analog's activity could be modulated through subtle changes in its side chain composition. Administration of the analog prevented CD8-dependent clearance of a murine retrovirus in BALB/c mice. In C57BL/6 mice challenged with the same retrovirus, the analog selectively inhibited the antiviral CTL responses without affecting the ability of the CTLs to generate robust allogeneic responses.

Physician-assisted suicide in Connecticut: physicians' attitudes and experiences.

OBJECTIVE: This study examined aspects of physician attitudes toward physician-assisted suicide (PAS) not fully examined to date: evaluation of risks related to PAS, particularly the presence of depression, and the influence of religious and professionally-based values. DESIGN: Anonymous, self-administered mailed questionnaire using Dillman methodology. PARTICIPANTS: Targeted sample of physicians licensed by the Connecticut Department of Public Health in 1997 (n = 2,805 completed surveys; 40% response rate). DATA INCLUDE: Physician and patient characteristics, attitudes toward physician assisted suicide, and confidence in treating depression. RESULTS: Religious affiliation, religiosity, ethnicity and medical specialty were strongly associated with views on PAS. Seven percent of respondents had been asked to write a lethal prescription during the past year, 15% of whom (n = 24) had complied with at least one request. CONCLUSIONS: Most respondents expressed concern regarding certain risks associated with PAS, including movement toward involuntary euthanasia and the influence of undetected depression. Findings raise practical issues to be addressed through statutory or professional safeguards if PAS were to be legalized.

Schizophrenia and older adults. An overview: directions for research and policy.

The Group for the Advancement of Psychiatry, Committee on Aging, believes that a crisis has emerged with respect to the understanding of the nature and treatment of schizophrenia in older persons. Moreover, critical gaps exist in clinical services for this population. In this article, we examine the epidemiology of aging and schizophrenia; life-course changes in psychopathology, cognitive function, social functioning, and physical health; and various concerns regarding treatment, services, and financing. Finally, we propose six research and policy recommendations and suggest methods for addressing the research questions that we have posed.

Physicians' voices on physician-assisted suicide: looking beyond the numbers.

Most empirical research examining physician views on physician-assisted suicide (PAS) has used quantitative methods to characterize positions and identify predictors of individual attitudes. This approach has generated limited information about the nature and depth of sentiments among physicians most impassioned about PAS. This study reports qualitative data provided by 909 physicians as part of a larger survey (N = 2,805) regarding attitudes toward and experiences with PAS and palliative care. Emergent themes illustrate important clinical, social, and ethical considerations in this area. The data illustrate the diverse and ardent responses that PAS evokes among certain physicians. The role of physicians' personal values is central to discussions about legalization of PAS. Polarized views such as those expressed by physicians in this study are not likely to be reconciled, thereby constraining the development of public policy regarding PAS.

Neoadjuvant androgen deprivation prior to transperineal prostate brachytherapy: smaller volumes, less morbidity.

PURPOSE: Prostate brachytherapy is becoming increasingly utilized in the definitive treatment of men with early-stage prostate cancer. Others have reported a close relation between total dose to the gland and genitourinary and gastrointestinal toxicity. We tested the hypothesis that 3 months of hormone deprivation would decrease gland size and decrease radioactivity implanted, which would result in less morbidity. Here, we report the toxicity associated with this novel treatment strategy. METHODS: One hundred fifty-five prostate cancer patients underwent ultrasound-guided transperineal implantation of palladium-103 at the Hospital of the University of Pennsylvania between January 1994 and July 1998. All men received at least 3 months of neoadjuvant luteinizing hormone-releasing hormone (LHRH) agonist therapy and were registered in the study. This group of men were compared with 55 men treated at the Hospital of the University of Pennsylvania with brachytherapy alone between December 1991 and December 1993. RESULTS: Compared with men treated with implant alone, men who received LHRH agonist therapy had significantly smaller glands at the time of implant (27.7 cm3 vs 36.3 cm3), required fewer seeds (47.9 vs 83.2), and had significantly less radioactivity implanted (76.3 mCi vs 117 mCi). The genitourinary and gastrointestinal morbidity in the men receiving hormone deprivation was minimal, with long-term side effects occurring in only three patients. In addition, potency was preserved in 83% of men. DISCUSSION: Three months or more of neoadjuvant LHRH agonist therapy before transperineal brachytherapy is safe, significantly reduces the amount of radioactivity implanted, and is associated with very low rates of genitourinary and gastrointestinal toxicity. In addition, potency preservation after combined-modality therapy is excellent and is similar to that of implantation alone. Further studies of this treatment approach are warranted.

Genetic regulation of long-term nonprogression in E-55+ murine leukemia virus infection in mice.

Certain inbred mouse strains display progression to lymphoma development after infection with E-55+ murine leukemia virus (E-55+ MuLV), while others demonstrate long-term nonprogression. This difference in disease progression occurs despite the fact that E-55+ MuLV causes persistent infection in both immunocompetent BALB/c-H-2(k) (BALB.K) progressor (P) and C57BL/10-H-2(k) (B10.BR) long-term nonprogressor (LTNP) mice. In contrast to immunocompetent mice, immunosuppressed mice from both P and LTNP strains develop lymphomas about 2 months after infection, indicating that the LTNP phenotype is determined by the immune response of the infected mouse. In this study, we used bone marrow chimeras to demonstrate that the LTNP phenotype is associated with the genotype of donor bone marrow and not the recipient microenvironment. In addition, we have mapped a genetic locus that may be responsible for the LTNP trait. Microsatellite-based linkage analysis demonstrated that a non-major histocompatibility complex gene on chromosome 15 regulates long-term survival and is located in the same region as the Rfv3 gene. Rfv3 is involved in recovery from Friend virus-induced leukemia and has been demonstrated to regulate neutralizing virus antibody titers. In our studies, however, both P and LTNP strains produce similar titers of neutralizing and cytotoxic anti-E-55+ MuLV. Therefore, while it is possible that Rfv3 influences the course of E-55+ MuLV infection, it is more likely that the LTNP phenotype in E-55+ MuLV-infected mice is regulated by a different, closely linked gene.

Strain-dependent migration of lymphocytes to the vaginal mucosa after peripheral immunization.

We have previously demonstrated a genetic predisposition among mice regarding their ability to be protected against vaginal candidiasis after peripheral immunization. Both BALB/c and (BALB/cx C57BL/6) F1 mice are protected against vaginal candidiasis after subcutaneous immunization with Candida albicans extract and C57BL/6 mice are not protected by this immunization. In the present study, the ability of F1-derived immune cells to transfer protection to naive parental strains was observed in BALB/c recipient mice, but not apparent in B6 recipient mice. This result is highly suggestive that the microenvironment of the B6 mouse is responsible for the susceptible phenotype. Genetic studies using (BALB/cx C57BL/6)F1x C57BL/6 backcross mice demonstrated that two genes appeared to regulate the protective effect of peripheral immunization to vaginal challenge. Microsatellite mapping indicated that candidate loci involved in controlling the immune response to vaginal candidiasis after peripheral immunization included the intercellular adhesion molecule-1 (ICAM-1), the Icam-1 related sequence 1, and the Fc epsilon RII (P<0.01). Thus, the ability of cells to bind to vaginal endothelial cells may play an important role in protection against vaginal candidiasis mediated by peripheral immunization.

The physician-assisted suicide policy dilemma: a pilot study of the views and experiences of Connecticut physicians.

Development of fully informed public policy regarding physician-assisted suicide (PAS) requires a thorough understanding of the experiences, attitudes, and beliefs of physicians with respect to this issue. This study gathered data on physician characteristics, attitudes toward PAS, factors influencing attitudes toward PAS, and sensitivity to the role of depression in a sample of 397 psychiatrists, internists, and family practitioners in Connecticut. Central considerations included: the influence of religious values, professional discipline and practice patterns, and ability to diagnose depression in a single evaluation. Psychiatrists were significantly more likely to be supportive of PAS than were internists or family practitioners. Most respondents expressed concern regarding the influence of depression on PAS requests. A subset of physicians endorse PAS yet do not share such concern about risks, suggesting substantial challenges for policy-makers.

The utility of serial complete blood count monitoring in patients receiving radiation therapy for localized prostate cancer.

PURPOSE: It is standard practice in our department to monitor weekly complete blood counts (CBCs) in patients receiving definitive radiation therapy for prostate cancer. The clinical utility and cost effectiveness of this practice has not been analyzed. METHODS AND MATERIALS: The charts of all prostate cancer patients treated with radiation therapy between January 1994 and July 1996 at the Veterans Administration Hospital, Philadelphia, PA were reviewed. CBC values were available for 89 patients. Patients received a median dose of 68 Gy using a four-field box technique and megavoltage photons. Whole-pelvic radiotherapy followed by a conedown to the prostate was administered to 29 patients. Fifty-nine patients received radiation to the prostate alone or prostate and seminal vesicles. Fifty-seven patients received concurrent hormonal therapy which included luteinizing hormone-releasing hormone (LHRH) agonist, antiandrogens, or both. RESULTS: No patient experienced a drop in their hemoglobin, white blood cells (WBCs), or platelets below critical nadirs (defined as WBC < 2 counts x 1000/mm(3), hemoglobin < 8 g/dl, platelet < 50 counts x 1000/mm(3) 2 in WBCs. In the urban area surrounding the Philadelphia Veterans Administration Medical Center, the cost of obtaining a CBC is approximately $30. However, if staff time is considered, the cost of obtaining a weekly CBC during prostate cancer radiotherapy approached $400 per patient. CONCLUSION: These results suggest that weekly monitoring of CBCs in prostate cancer patients undergoing definitive radiotherapy may not be necessary. We recommend a baseline CBC be performed, and if normal, no other monitoring unless clinically indicated. This strategy would result in a cost savings approaching $30,000 per 100 treated patients. Further research on the cost effectiveness and utility of serial blood tests in patients receiving partial body radiation therapy is needed.

Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer.

CONTEXT: Interstitial radiation (implant) therapy is used to treat clinically localized adenocarcinoma of the prostate, but how it compares with other treatments is not known. OBJECTIVE: To estimate control of prostate-specific antigen (PSA) after radical prostatectomy (RP), external beam radiation (RT), or implant with or without neoadjuvant androgen deprivation therapy in patients with clinically localized prostate cancer. DESIGN: Retrospective cohort study of outcome data compared using Cox regression multivariable analyses. SETTING AND PATIENTS: A total of 1872 men treated between January 1989 and October 1997 with an RP (n = 888) or implant with or without neoadjuvant androgen deprivation therapy (n = 218) at the Hospital of the University of Pennsylvania, Philadelphia, or RT (n = 766) at the Joint Center for Radiation Therapy, Boston, Mass, were enrolled. MAIN OUTCOME MEASURE: Actuarial freedom from PSA failure (defined as PSA outcome). RESULTS: The relative risk (RR) of PSA failure in low-risk patients (stage T1c, T2a and PSA level < or =10 ng/mL and Gleason score < or =6) treated using RT, implant plus androgen deprivation therapy, or implant therapy was 1.1 (95% confidence interval [CI], 0.5-2.7), 0.5 (95% CI, 0.1-1.9), and 1.1 (95% CI, 0.3-3.6), respectively, compared with those patients treated with RP. The RRs of PSA failure in the intermediate-risk patients (stage T2b or Gleason score of 7 or PSA level >10 and < or =20 ng/mL) and high-risk patients (stage T2c or PSA level >20 ng/mL or Gleason score > or =8) treated with implant compared with RP were 3.1 (95% CI, 1.5-6.1) and 3.0 (95% CI, 1.8-5.0), respectively. The addition of androgen deprivation to implant therapy did not improve PSA outcome in high-risk patients but resulted in a PSA outcome that was not statistically different compared with the results obtained using RP or RT in intermediate-risk patients. These results were unchanged when patients were stratified using the traditional rankings of biopsy Gleason scores of 2 through 4 vs 5 through 6 vs 7 vs 8 through 10. CONCLUSIONS: Low-risk patients had estimates of 5-year PSA outcome after treatment with RP, RT, or implant with or without neoadjuvant androgen deprivation that were not statistically different, whereas intermediate- and high-risk patients treated with RP or RT did better then those treated by implant. Prospective randomized trials are needed to verify these findings.

[Vaccination status and implementation of recommendations for vaccination with special reference to measles-mumps-rubella vaccination. 1995 program for school entrance]. / Impfstatus und Umsetzung von Impfempfehlungen unter besonderer Berücksichtigung der Masern-Mumps-Röteln-Impfung. Eine Aktion bei der Einschulung 1995.

Children who took part in the medical examination for elementary school starters and who could present a certificate of vaccination were given a written vaccination recommendation. On the first day of school the recommendation sheets filled out by the family doctor or a paediatrician were collected and analysed anonymously. 2194 of 2965 children received a vaccination recommendation. 1047 sheets could be interpreted. Based on the current recommendation of the STIKO (German official vaccination council) a MMR (measles, mumps, rubella) vaccination was suggested in 1001 cases. Only 53.1% of the proposed vaccinations have been given, despite consultation with the family doctor or paediatrician.

Differences in the immune response during the acute phase of E-55+ murine leukemia virus infection in progressor BALB and long term nonprogressor C57BL mice.

E-55+ murine leukemia virus infection of both progressor (BALB) and long term nonprogressor (C57BL) mouse strains is characterized by an acute and a persistent phase of infection. During the acute phase, progressor strains require CD8+ T cells to decrease virus burden, whereas the long term nonprogressor strains do not. In the present studies the immune response in BALB and C57BL mice during the acute phase of E-55+ murine leukemia virus infection was examined. The results demonstrate that BALB mice produce both IL-4 and IFN-gamma, in contrast to C57BL mice, which produce only IFN-gamma. In BALB mice, IL-4 production results in the absolute requirement for CD8+ T cells to reduce the virus burden during the acute phase of infection. The anti-virus immune response in these mice is IFN-gamma dependent. On the other hand, C57BL mice do not produce IL-4 and, in the absence of both CD8+ T cells and IFN-gamma, still generate an effective anti-virus immune response. Genetic studies suggest that these distinct immune responses are regulated by more than one non-MHC-linked gene. Two candidate regions that may encode this gene(s), located on chromosomes 7 and 19, respectively, were identified by recombinant inbred strain linkage analysis.

Genetic basis for protection against experimental vaginal candidiasis by peripheral immunization.

In these studies, significant protection against experimental vaginal candidiasis after a subcutaneous immunization with Candida albicans extract was achieved in BALB/c mice but not in C57BL/6 (B6) mice. Protection from vaginal candidiasis was transferred to naive BALB/c mice by a population of spleen cells derived from immunized BALB/c mice. Removal of CD3 or CD4 but not CD8 T cells before transfer completely abrogated resistance to vaginal candidiasis. Recombinant inbred (RI) strains of mice derived from BALB/c and B6 strains were used for mapping loci that might be responsible for regulating vaginal protection after subcutaneous immunization. Linkage analysis using microsatellite-based genome mapping in these RI strains revealed four candidate loci on chromosomes 3, 7, 8, and 18 that exhibit statistically significant linkage to the strain distribution pattern. These results may contribute to the understanding of host genetic factors controlling the immune response to vaginal infections.