The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) trial.

BACKGROUND: Transcranial Doppler ultrasound (TCD) and magnetic resonance angiography (MRA) can identify intracranial atherosclerosis but have not been rigorously validated against the gold standard, catheter angiography. The WASID trial (Warfarin Aspirin Symptomatic Intracranial Disease) required performance of angiography to verify the presence of intracranial stenosis, allowing for prospective evaluation of TCD and MRA. The aims of Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis (SONIA) trial were to define abnormalities on TCD/MRA to see how well they identify 50 to 99% intracranial stenosis of large proximal arteries on catheter angiography. STUDY DESIGN: SONIA standardized the performance and interpretation of TCD, MRA, and angiography. Study-wide cutpoints defining positive TCD/MRA were used. Hard copy TCD/MRA were centrally read, blind to the results of angiography. RESULTS: SONIA enrolled 407 patients at 46 sites in the United States. For prospectively tested noninvasive test cutpoints, positive predictive values (PPVs) and negative predictive values (NPVs) were TCD, PPV 36% (95% CI: 27 to 46); NPV, 86% (95% CI: 81 to 89); MRA, PPV 59% (95% CI: 54 to 65); NPV, 91% (95% CI: 89 to 93). For cutpoints modified to maximize PPV, they were TCD, PPV 50% (95% CI: 36 to 64), NPV 85% (95% CI: 81 to 88); MRA PPV 66% (95% CI: 58 to 73), NPV 87% (95% CI: 85 to 89). For each test, a characteristic performance curve showing how the predictive values vary with a changing test cutpoint was obtained. CONCLUSIONS: Both transcranial Doppler ultrasound and magnetic resonance angiography noninvasively identify 50 to 99% intracranial large vessel stenoses with substantial negative predictive value. The Stroke Outcomes and Neuroimaging of Intracranial Atherosclerosis trial methods allow transcranial Doppler ultrasound and magnetic resonance angiography to reliably exclude the presence of intracranial stenosis. Abnormal findings on transcranial Doppler ultrasound or magnetic resonance angiography require a confirmatory test such as angiography to reliably identify stenosis.

Association of plasma triglyceride concentration and LDL particle diameter, density, and chemical composition with premature coronary artery disease in men and women.

Low density lipoprotein (LDL) physical-chemical characteristics were studied as nontraditional risk factors of coronary artery disease (CAD) in a well-characterized population of 98 men aged < or = 50 and 100 women aged < or = 60 who underwent elective diagnostic coronary arteriography. The average LDL diameter was determined by gradient gel electrophoresis, chemical composition (%w/w) was measured, and the density of the major LDL peak was determined by equilibrium density gradient ultracentrifugation. Logistic regression was used to examine the association of various LDL characteristics with CAD before and after adjustment for other covariates. Smaller, cholesterol-poor LDL particles were associated with CAD independently of traditional risk factors (age, sex, smoking, diabetes, LDL and HDL cholesterol concentrations), other than the plasma triglyceride concentration. These characteristics were generally more strongly associated with CAD when measured on the major LDL subfraction (defined as the density gradient ultracentrifugation fraction with the highest LDL concentration) than the average characteristics of the more heterogeneous parent LDL (d 1.019-1.063 g/ml). The associations with CAD among men and women were generally similar. These data show that a broad range of LDL characteristics are associated with CAD before, but not after, adjustment for the plasma triglyceride concentration. These data further indicate the importance of hypertriglyceridemia and LDL heterogeneity in premature CAD.

Comparison of the plasma levels of apolipoproteins B and A-1, and other risk factors in men and women with premature coronary artery disease.

The predictors of premature coronary atherosclerosis were examined in 203 patients (99 men aged less than or equal to 50 years, and 104 women aged less than or equal to 60 years) undergoing elective diagnostic coronary arteriography. Age, cigarette smoking, hypertension, obesity, diabetes, positive family history of premature coronary artery disease (CAD), and plasma levels of total cholesterol, triglyceride, lipoproteins (i.e., very low, intermediate-, low-, and high-density [HDL] lipoproteins and their subfractions [HDL2 and HDL3], and lipoprotein [a]) and apolipoproteins (apoA-1, apoA-2 and apoB, respectively) were examined using univariate analyses and multivariate logistic regression. In men, age (p less than 0.05), smoking (p less than 0.05), and plasma triglyceride (p less than 0.02) and apoA-1 (p less than 0.05) levels were independently associated with CAD. In women, smoking (p less than 0.001) and plasma apoB levels (p less than 0.04) were the strongest variables independently associated with CAD. It is concluded that the "nontraditional" risk factors (plasma apoA-1 and apoB levels) are better predictors of premature CAD than are plasma lipoproteins and that smoking is the strongest of the traditional nonlipid risk factors.

Human CYP1A1 gene: cosegregation of the enzyme inducibility phenotype and an RFLP.

The human CYP1A1 (cytochrome P1450) gene encodes an enzyme involved in the activation of procarcinogens, such as benzo[a]pyrene, to the ultimate reactive intermediate. Approximately 10% of the human population exhibit high CYP1A1 inducibility, and Kouri et al. reported that the high-inducibility phenotype might be at greater risk than low-inducibility individuals for cigarette smoke-induced bronchogenic carcinoma. In one 3-generation family of 15 individuals, we show here that the high-CYP1A1-inducibility phenotype segregates concordantly with an infrequent polymorphic site located 450 bases downstream from the CYP1A1 gene. Our findings are consistent with the study of Kawajiri et al., who demonstrated an association between this polymorphism and an increased incidence of squamous-cell lung cancer. Our data suggest that the CYP1A1 structural gene, or a region near this gene, might be correlated with the inducibility phenotype.

Apolipoprotein A1 Baltimore (Arg10----Leu), a new ApoA1 variant.

A new apolipoprotein A1 (APOA1) gene variant has been identified in a family ascertained through a proband undergoing coronary angiography. The variant, ApoA1 Baltimore, was due to a mutation at codon 34 of the third exon of the APOA1 gene (CGA to CTA) that resulted in an arginine-to-leucine substitution at the tenth amino acid of the mature ApoA1 and a change in charge of -1. The mutation abolishes a TaqI restriction site and it is easily detectable after polymerase chain reaction amplification of genomic DNA. The proband was heterozygous for the mutation. Eight other members of the pedigree had the same ApoA1 variant. Cosegregation of the variant with hypoalphalipoproteinemia could not be demonstrated and the association of this mutation with hypoalphalipoproteinemia was confined to three affected members of the nuclear family. No effect of the mutant on any lipoprotein phenotype could be established.

Apolipoprotein B-100 Hopkins (arginine4019----tryptophan). A new apolipoprotein B-100 variant in a family with premature atherosclerosis and hyperapobetalipoproteinemia.

A 43-year-old woman with severe coronary artery disease and hyperapobetalipoproteinemia was heterozygous for an abnormal Msp I apolipoprotein B (APOB) gene fragment because of the absence of the MspI site around codon 4046 in exon 29 of the APOB gene. Using the polymerase chain reaction technique, 134 base pairs containing the mutant Msp I site were amplified, cloned, and sequenced. The mutation was a C to T transition, substituting tryptophan for arginine at amino acid position 4019 of the mature ApoB-100 protein. Seven relatives of the proband had the same mutation, which has been called "ApoB-100 Hopkins." Only three of seven relatives with the mutation had hyperapobetalipoproteinemia; one was borderline while two other relatives without the mutation had hyperapobetalipoproteinemia. Mutant low-density lipoprotein (LDL) was bound and degraded to a greater extent than normal LDL in cultured human fibroblasts. In conclusion, a new mutation, ApoB-100 Hopkins, was not linked to the hyperapobetalipoproteinemia phenotype, which also was segregating in this family. The increased affinity of this mutant LDL for the LDL receptor may be due to a specific effect of ApoB-100 Hopkins or to altered LDL size and composition.

Developmental induction of glutaminase in primary cultures of cerebellar granule cells.

Glutaminase mRNA levels increased over 3-fold relative to total RNA, poly(A)+ RNA, and beta-actin mRNA in neonatal rat cerebellar granule cells as the cells differentiated between days 3 and 8 in culture. In contrast, mRNA levels of another glutamate cycle enzyme, glutamine synthetase, remained constant. Glutaminase protein levels increased per cell more than 2-fold between days 3 and 8, and at least 3-fold by day 10 in these cells. The total amount of glutamate per cell increased about 40% during this period. Glutaminase induction paralleled the development of Ca2+-dependent glutamate release, and the formation of neurites, synaptic vesicles, and synapses. The induction of glutaminase in developing granule cells is consistent with a special role for glutaminase in the synthesis of neurotransmitter glutamate.

Compliance with anti-tuberculous therapy: a field trial of a pill-box with a concealed electronic recording device.

We have conducted a field trial of a pill-box containing a concealed electronic device for monitoring compliance in 23 consecutive adult out patients taking a rifampicin/isoniazid combination once daily. In 22 cases, the times when the box was opened were successfully recorded for the entire period (mean (SD) 26 (5) days) between successive clinic visits. In the other patient the record terminated after one week, a broken box being returned. Both totality of compliance (as assessed by box openings) and consistency of compliance (the proportion of the total number of intervals between openings which were of 22 to 26 h in length) were significantly greater in those studied in the intensive than in the maintenance phase of therapy. Patients may have taken the reduction in medication at the end of the intensive phase as signalling cure. A computer program has been developed to display the recorded data. This allowed the physician responsible to assimilate at a glance the patient's tablet-taking habits. In routine practice knowledge of the presence of the device may improve compliance and a discussion of the graphical display may prove of value in counselling.

Comparison of human brain and liver glutamate dehydrogenase cDNAS.

In order to investigate suggestions that more than one glutamate dehydrogenase (GDH) gene may be active in humans, seven human brain and seventeen human liver GDH cDNAs were isolated by probing with a 590 base cDNA from the coding region of human brain GDH. No sequence heterogeneity was revealed among any of the cDNAs by an oligonucleotide binding assay, nor did any cDNA appear to encode a hexapeptide contained in a published amino acid sequence of human liver GDH. Homologous regions of three liver and three brain cDNAs had identical sequences over more than 2 kb, including 3' nontranslated regions. This suggests that identical GDH mRNAs are present in human brain and human liver. Although only one gene appears to be expressed, human genomic DNA blots show a pattern of hybridization consistent with the existence of more than one GDH gene.

Analysis of two benzo[a]pyrene-resistant mutants of the mouse hepatoma Hepa-1 P(1)450 gene via cDNA expression in yeast.

Two benzo[a]pyrene-resistant mutant clones (c1 and c37) of the mouse hepatoma Hepa-1 wild-type (wt) cell line were examined for their lack of P(1)450 [aryl hydrocarbon (benzo[a]pyrene) hydroxylase (AHH)] activity. From lambda gt11 cDNA libraries, the nearly full-length P(1)450 cDNAs of wt, c1 and c37 were isolated and sequenced. The c1 cDNA was found to have a single mutation leading to premature termination of the protein after Asn-414; a rapidly migrating band corresponding to this truncated protein was found on Western immunoblots. The c37 cDNA was found to have two point mutations, leading to Leu-118----Arg-118 and Arg-245----Pro-245, but otherwise to encode the normal (524-residue) protein; the mature protein was confirmed by Western blot analysis. P(1)450 cDNA from wt, c1 and c37 and chimeric cDNAs between wt and c37 were inserted into the expression vector pAAH5 and expressed in Saccharomyces cerevisiae strain 50.L4. The Leu-118----Arg-118 mutation alone was found to have negligible effect on AHH activity, while the Arg-245----Pro-245 mutation alone leads to a 2- to 3-fold decrease in enzyme activity. The two mutations together totally abrogate AHH activity. The biologic mutant c37 provides the first evidence for the importance of Arg-245, and the complementary function of Leu-118, in normal P(1)450 enzymic function. This alteration in a single amino acid from arginine to proline might block electron flow directly, or change secondary structure of the protein, such that normal monooxygenation of benzo[a]pyrene cannot occur.

Genetic analysis of plasma sitosterol, apoprotein B, and lipoproteins in a large Amish pedigree with sitosterolemia.

We previously reported the finding of phytosterolemia, xanthomatosis, and hyperapobetalipoproteinemia (hyperapoB) in five siblings in a large Amish pedigree ascertained through a 13-year-old boy who died suddenly from advanced coronary atherosclerosis. Here, we present further analyses of the plasma levels of the plant sterol, sitosterol, of low density (beta) lipoprotein (LDL) sterol, and of LDL B protein. Of 254 relatives and spouses of the proband, 90.5% were examined. A series of genetic models were explored using a pedigree analysis where parameters reflecting frequency, transmission, and penetrance of putative genotypes were examined simultaneously using a maximum likelihood approach. Segregation analysis of the sitosterol levels showed that the phenotype of sitosterolemia was controlled by a rare autosomal recessive gene. There was also significant familial correlation in plasma sitosterol levels that was attributed to a polygenic component under a mixed model but could also be due to shared environments such as diets. The recessive model was supported by our finding that the plasma sitosterol levels in the parents and in six children born to three of the five sitosterolemics were less than 1 mg/dl, well within the normal range. The phenotype of hyperapoB is based on an elevated level of LDL B protein in the presence of a normal LDL cholesterol level (low LDL sterol to LDL B ratio). For both LDL sterol and LDL B, a polygenic model showed a slightly greater improvement in ln likelihood than did the Mendelian single locus model when both were compared to a sporadic model. Similar results were obtained for sterol levels of high density (alpha) lipoprotein (HDL) sterol. When segregation analysis was performed using the ratio of LDL sterol to LDL B, the Mendelian single locus model gave a slightly better fit to the data than did the polygenic model. While the analyses presented here provided unequivocal evidence for the recessive phenotype of phytosterolemia, we also identified a possible single gene factor that could account for the major portion of the strong familial aggregation in the ratio of LDL sterol to LDL B, and to a lesser extent LDL B. However, there is clear evidence of familial aggregation for these traits in this pedigree beyond that due to Mendelian components.

Discharge against medical advice (AMA) from an acute care private psychiatric hospital.

Discharge from psychiatric hospitals against medical advice (AMA) is noncompliance with a physician's treatment regimen. Forty-one patients (26 male, 15 female) discharged AMA from a 32-bed proprietary acute care psychiatric hospital were matched by sex to 41 regularly discharged patients. Data that pertained to account status, marital status, race, month of admission, day of week of admission, time of admission, day of week of discharge, time of discharge, length of stay, religion, diagnosis, employment status, presence of prior psychiatric treatment, attending physician, hospital census, and adolescent census at time of admission were analyzed by Student's t-test, Chi-square, and Pearson correlation coefficients. Significant differences were found for length of stay (p less than .01), time of discharge (p less than .002), presence of prior psychiatric treatment (p less than .0005), and attending physician (p less than .02). Age and length of stay for the regularly discharged group were correlated (r = .47; p less than .001). The failure of this study to support much prior research may be related to differences in hospital setting, client population, and therapist variables.

Hyperapobetalipoproteinaemia in two families with xanthomas and phytosterolaemia.

The death of a 13-year-old boy from coronary atherosclerosis prompted the study of an Amish family. Five of his twelve sibs had tendon and tuberous xanthomas, and increased plasma plant sterols, particularly beta-sitosterol. The plasma level of the major apoprotein of low density lipoprotein (LDL), the B protein, was very high (mean 173 mg/dl) in these five sibs, while the LDL cholesterol level was moderately increased (209 mg/dl). Four other sibs and both parents had an increased LDL B protein level with a normal or mildly raised plasma total and LDL cholesterol level (hyperapobeta-lipoproteinaemia). Evidence for coronary artery disease was found in both parents and three xanthomatous sibs. The original family with beta-sitosterolaemia and xanthomatosis, described in 1974, was re-examined. The proband and her sister had persistent phytosterolaemia and normocholesterolaemia but increased LDL B protein levels. Both parents, two uncles, and three of four grandparents had increased LDL B protein levels and normal total and LDL cholesterol levels. The proband's father had atypical angina pectoris. People with the full syndrome (phytosterolaemia, xanthomas, and hyperapobetalipoproteinaemia) are most probably homozygous for a mutant allele. An increased LDL B protein level permits the identification of heterozygotes in these families, even though in the fasting state they show no phytosterolaemia. The homozygote and probably the heterozygote are at increased risk for cardiovascular atherosclerotic disease.

Chloroplast DNA distribution in parasexual hybrids as shown by polypeptide composition of fraction I protein.

Sixteen different mature interspecific parasexual hybrids, produced by fusing leaf protoplasts of Nicotiana glauca (G) and N. langsdorffii (L), were analyzed for fraction I protein (ribulose-1,5-bisphosphate carboxylase/oxygenase) which consists of large subunit polypeptides coded by chloroplast DNA and small subunit polypeptides coded by nuclear DNA. All the hybrids showed the combined small subunits of both parents, thus confirming the hybridity of each of the fusion products. Fourteen of the hybrids displayed the large subunit electrofocusing pattern characteristic of only one parent (eight L and six G). From one hybrid callus, two plants were regenerated, of which one had exclusively L-type large subunit and the other had exclusively G. A single plant retained a mixture of L ang G chloroplast DNA's; this later yielded six F2 progeny from one branch, all of which were G type, and three asexual progeny from another branch, all of which had the L-type pattern. In all, 46 F2 progeny and 8 different F3s were analyzed and each of these, with few if any exceptions, showed the same single subunit type as the F1 and F2 parent hybrid plants. Reasons for the rapid sorting out of the chloroplast types are discussed.

WAIS functioning of cirrhotic and non-cirrhotic alcoholics.

This study was done to determine whether the cognitive dysfunction often found in chronic alcoholics would be greater for alcoholics with Laennec's cirrhosis than for alcoholics without cirrhosis. It was hypothesized that cirrhotic alcoholics would score lower than non-cirrhotic alcoholics, who in turn would score lower than non-alcoholic, non-cirrhotic controls on (1) WAIS Verbal, Performance, and Full Scale IQ; (2) scaled score configuration; and (3) the Wechsler Deterioration Quotient. The WAIS was administered in a Veterans Administration Center to 60 Caucasian male patients aged 35-64 who had been assigned to one of the three groups (N = 20 per group). No differences were found among groups on age, education, or the Information and Vocabulary subtests (p greater than .05). Significant differences (p less than .05) were found on Verbal, Performance, and Full Scale IQ, the remaining nine subtests, and the Deterioration Quotient. A stepwise discriminate function analysis substantiated these differences. It was concluded that Laennec's cirrhosis is a physical condition that negatively affects intellectual functioning in alcoholics.

Interkingdom fusion between human (HeLa) cells and tobacco hybrid (GGLL) protoplasts.

The fusion of human HeLa cells with tobacco protoplasts has been accomplished with the use of polyethylene glycol. The sequence from heterocellular adherence to heterokaryon formation has been followed with light microscopy and confirmed by autoradiographs of heterokaryons containing unlabeled tobacco nuclei and tritium-labeled HeLa nuclei. The HeLa nucleus retained its integrity in the tobacco cytoplasm up to 6 days after fusion.