Time-dependent lipid profile inversely associates with mortality in hemodialysis patients - independent of inflammation/malnutrition.

BACKGROUND: Patients with end-stage kidney disease have an extremely high cardiovascular mortality rate, but there is a paradoxical relationship between lipid profile and survival in haemodialysis patients. To investigate whether inflammation/malnutrition confounds the associations between lipids and mortality, we studied a full lipid profile comprising of five clinically well-established lipid parameters and its associations with mortality in a large, multinational European cohort with a median follow-up >3 years. METHODS: The association between quartiles of total, high-density lipoprotein (HDL), non-HDL, low-density lipoprotein (LDL) cholesterol, as well as triglyceride, levels and the end-points of all-cause, cardiovascular and non-cardiovascular mortality was assessed in a cohort of 5,382 incident, adult haemodialysis patients from >250 Fresenius Medical Care dialysis centres out of 14 participating countries using baseline and time-dependent Cox models. Analyses were fully adjusted and stratified for inflammation/malnutrition status and other patient-level variables. RESULTS: Time-dependent quartiles of total, HDL, non-HDL and LDL cholesterol were inversely associated with the hazard for all-cause, cardiovascular and non-cardiovascular mortality. Compared with the lowest quartile of the respective lipid parameter, hazard ratios of other quartiles were <0.86. Similar, albeit weaker, associations were found with baseline lipid profile and mortality. Neither time-dependent nor baseline associations between lipid profile and mortality were affected by inflammation/malnutrition, statin use or geography. CONCLUSIONS: Baseline and time-dependent lipid profile are inversely associated with mortality in a large, multicentre cohort of incident haemodialysis patients. Inflammation/malnutrition is not a confounder nor effect modificator of the associations between lipid profile and mortality in European haemodialysis patients.

Epstein-Barr virus latent membrane protein-2A-induced DeltaNp63alpha expression is associated with impaired epithelial-cell differentiation.

Epstein-Barr virus (EBV) is an oncogenic gamma-herpes virus associated with malignancies that develop in both lymphoid and epithelial cells including nasopharyngeal carcinoma (NPC). The EBV protein, latent membrane protein 2A (LMP2A), is expressed in NPC and can modulate epithelial proliferation, transformation and differentiation, and as such may promote malignancy. A key regulator of epithelial-cell differentiation is the transcription factor p63, a member of the p53 family. This study examines the potential contribution of p63 to LMP2A-mediated inhibition of epithelial-cell differentiation. Stable expression of LMP2A increased the protein level and stability of the DeltaNp63alpha isoform and in two epithelial cell lines, LMP2A interacted with DeltaNp63alpha under stable- and transient-expression systems. LMP2A and DeltaNp63alpha were localized to the cytoplasm and nuclear membrane and co-immunoprecipitated in the same fractions. Following induction of epithelial-cell differentiation by calcium, expression of differentiation markers was impaired in both DeltaNp63alpha- and LMP2A-expressing cells. Induction of p63alpha, association of p63alpha with LMP2A and impairment of differentiation required the PY and immunoreceptor tyrosine-based activation motif (ITAM) signaling motif of LMP2A. By associating with and being regulated by LMP2A, DeltaNp63alpha may function as a unique regulator of LMP2A effects on epithelial differentiation and contribute to EBV-associated epithelial cancers.

Information required to provide informed consent for endoscopy: an observational study of patients' expectations.

BACKGROUND AND STUDY AIMS: The aim of this study was to determine how much information patients require about the risk of complications in order to provide informed consent to undergo endoscopy. PATIENTS AND METHODS: Endoscopic complications and their consequences were discussed with consecutive patients who had undergone endoscopy. The patients were asked how common each complication would have to be for them to require information about the complication before providing adequately informed consent. RESULTS: Data were obtained from 150 gastroscopy patients (51% male, median age 55.5 years) and 150 colonoscopy patients (60% male, median age 54.4 years). Patients in both groups were more likely to want to know about major rather than minor complications at a lower level of risk (P < 0.001 at a risk greater than one in 1000). Similar proportions of gastroscopy patients (n = 29, 19%) and colonoscopy patients (n = 21, 14 %) wanted to know about all possible complications, no matter how inconsequential or rare. Colonoscopy patients were less likely to want no information about any complications than gastroscopy patients (n = 1, 0.7% and n = 15, 10%, respectively; P < 0.001). CONCLUSIONS: The information patients require in order to provide informed consent is very variable. Many appear to make a judgement about the need for information depending on the perceived severity of the complication, but some want information about all complications, irrespective of risk and severity. The level of risk at which they require this information is likely to be higher than the level used by doctors who are obtaining consent from patients. The process may be improved by providing procedure-specific information leaflets that offer information regarding common and serious complications.

Adenosine receptors control HIV-1 Tat-induced inflammatory responses through protein phosphatase.

Recently, adenosine has been proposed to be a "metabolic" switch that may sense and direct immune and inflammatory responses. Inflammation and pro-inflammatory cytokine production are important in development of HIV-1 associated dementia, a devastating consequence of HIV-1 infection of the CNS. The HIV-1 protein Tat induces cell death in the CNS and activates local inflammatory responses partially by inducing calcium release from the endoplasmic reticulum. Because activation of adenosine receptors decreases production of the pro-inflammatory cytokine TNF-alpha in several experimental paradigms both in vitro and in vivo, we hypothesized that adenosine receptor activation would control both increased intracellular calcium and TNF-alpha production induced by Tat. Treatment of primary monocytes with Tat significantly increased the levels of intracellular calcium released from IP3 stores. Activation of adenosine receptors with CGS 21680 inhibited Tat-induced increases of intracellular calcium by 90 +/- 8% and was dependent on protein phosphatase activity because okadaic acid blocked the actions of CGS 21680. Tat-induced TNF-alpha production was inhibited 90 +/- 6% by CGS 21680 and concurrent treatment with okadaic acid blocked the inhibitory actions of CGS 21680. Using a model monocytic cell line, CGS 21680 treatment increased cytosolic serine/threonine phosphatase. Together, these data indicate that A2A receptor activation increases protein phosphatase activity, which blocks IP3 receptor-regulated calcium release and reduction of intracellular calcium inhibits TNF-alpha production in monocytes.

Adenosine A2A receptor activation reduces proinflammatory events and decreases cell death following intracerebral hemorrhage.

The ubiquitous neuromodulator adenosine inhibits the production of several proinflammatory cytokines through activation of specific cell-surface adenosine receptors. We demonstrated recently that antisense oligonucleotides to tumor necrosis factor-alpha (TNF-alpha) are neuroprotective in a rat model of intracerebral hemorrhage. Therefore, we hypothesized that activation of adenosine receptors would provide protection against intracerebral hemorrhage-induced TNF-alpha production and inflammatory events. In vitro experiments showed that adenosine A1, A2A, and A3 receptor subtypes were present on U937 cells, and activation of these subtypes inhibited TNF-alpha production with a rank order of A2A > > A1 > A3. Prolonged treatment of U937 cells with the A2A receptor agonist 2-p-(carboxyethyl)phenethylamino-5'-N-ethylcarboxamidoadenosine hydrochloride (CGS 21680) desensitized adenosine A2A, A1, and A3 receptors. CGS 21680 administration directly into the striatum immediately prior to the induction of intracerebral hemorrhage inhibited TNF-alpha mRNA and, 24 hours following induction, reduced parenchymal neutrophil infiltration (p < 0.001) and TUNEL-positive cells (p < 0.002) within and bordering the hematoma. These results suggest that pharmacological strategies targeting A2A receptors may provide effective inhibition of acute neurotoxic proinflammatory events that occur following intracerebral hemorrhage.

Lysophosphatidylethanolamine acyltransferase activity is elevated during cardiac cell differentiation.

We examined if elevation in lysophosphatidylethanolamine acyltransferase activity was associated with elevation in phosphatidylethanolamine content during differentiation of P19 teratocarcinoma cells into cardiac myocytes. P19 cells were induced to undergo differentiation into cardiac myocytes by the addition of 1% dimethylsulfoxide to the medium. Immunofluorescence microscopy revealed the presence of striated myosin at 8 days post-dimethylsulfoxide addition confirming differentiation into cardiac cells. The content of phosphatidylethanolamine was increased 2.1-fold (P<0.05) in differentiated cells compared to undifferentiated cells, whereas the content of phosphatidylcholine was reduced 29% (P<0.05). There were no alterations in the pool sizes of other phospholipids, including cardiolipin. The relative abundance of fatty acids in phospholipids of P19 cells was 18:1 > 18:0 > 16:1 = 18:2 > 16:0 = 14:0 > 20:4 and differentiation did not affect the relative amounts of these fatty acids within individual phospholipids. When cells were incubated with [1,3-(3)H]glycerol, radioactivity incorporated into phosphatidylethanolamine was elevated 5.8-fold, whereas radioactivity incorporated into phosphatidylcholine was unaltered. Ethanolaminephosphotransferase, cholinephosphotransferase and membrane CTP:phosphocholine cytidylyltransferase activities were elevated in differentiated cells compared to undifferentiated cells, whereas membrane and cytosolic phospholipase A2 activities were unaltered. Lysophosphatidylethanolamine acyltransferase activities were elevated 2.4-fold (P<0.05). Lysophosphatidylcholine acyltransferase, monolysocardiolipin acyltransferase, acyl-Coenzyme A synthetase and acyl-Coenzyme A hydrolase activities were unaltered in differentiated cells compared to undifferentiated cells. We postulate that during cardiac cell differentiation, the observed elevation in lysophosphatidylethanolamine acyltransferase activity accompanies the elevation in phosphatidylethanolamine mass, possibly to maintain the fatty acyl composition of this phospholipid within the membrane.

Living arrangement requirements for individuals with developmental disability and behavioural problems.

OBJECTIVE: To review the need for a wide range of living arrangements and community support services for individuals with developmental disability (DD) and behavioural problems and for their caregivers. METHODS: An analysis of a 1-year caseload of a consulting psychiatrist to 2 community support agencies for individuals with DD. RESULTS AND CONCLUSIONS: Of the individuals seen with DD and behavioural problems, one-half needed a different living arrangement, immediately in many cases. Living arrangements and support services are extensively deficient. Correcting these deficiencies requires the concerted involvement of local, provincial, and federal governments as well as of community groups and agencies.

Case report of a person with Down's syndrome and multiple personality disorder.

A case is presented of an individual with Down's syndrome and multiple personality disorder. No such cases were found in a review of the literature. Three other individuals with Down's syndrome are also discussed whose symptoms range from experiencing imaginary friends to experiencing borderline multiple personality disorder. In all these cases the imaginary friends became more evident and resistive of diversion as the levels of stress increased. We speculate that experiencing imaginary friends progresses to experiencing multiple personality disorder in some individuals as personal stress increases. These cases also indicate that limited cognitive development does not preclude individuals from presenting with imaginary friends or multiple personality disorder.

Survey of community adjustment of previously institutionalized developmentally disabled persons.

A survey was conducted of the community adjustment of 108 developmentally disabled (mentally retarded) persons who had spent at least three years in an institution in southeastern Ontario. On average, they had resided 3.5 years in the community, were 40 years of age, with a mental age of five years and a median IQ of 41, and most had one or more moderate to severe physical disabilities. During their most recent year living in the community it was found that their daily living skills remained unchanged compared with their skill level in the year prior to community placement. As well, the community staff rated them as average in level of performance and amount of supervision required compared with others of similar ability. About one third were found to have a moderate to severe behavioural/psychiatric problem with aggressive disruptive behaviour being most frequent. Of the two-thirds capable of being interviewed, over three-quarters expressed satisfaction with their present living, work, education and recreation environment and had no desire to return to the institution. Most had few if any meaningful relationships with non developmentally disabled persons other than caregivers. Support agency staff and psychiatric consultants identified additional service needs for those with behavioural/psychiatric problems who may be placed in the community.

Autism: its primary psychological and neurological deficit.

Autism is a perplexing condition because of its unique presenting signs and high degree of variability. Evidence is presented that the basic underlying information processing disorder is a dysfunction of the appreciation of the emotional significance of incoming stimuli and attaching motivational value to the stimuli. It is proposed that this dysfunction occurs when the amygdaloid nucleus and/or its connections are disrupted, resulting in the variability of the presentation of this syndrome among individuals. Herpes simplex encephalitis sometimes results in signs of autism. The virus has a predilection to attack specific areas of the brain, which provides information on the probable underlying neurological dysfunction in autism.

Counselling the families of children with learning disorders.

Learning disorders in children tend to disrupt the whole family. The physician can help parents to recognize realistic and unrealistic expectations, so that their attitude towards the child can be as positive as possible. Use of community services and appropriate medication are discussed.

Preventing mental retardation.

INFLUENCES PRODUCING MENTAL RETARDATION CAN BE DIVIDED INTO THREE CATEGORIES: inherited factors, health problems and social-emotional influences. This article outlines steps which can be taken to reduce the first two categories, both pre and postnatally.