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The neurobiological underpinnings of mood and anxiety disorders have been linked to the nucleus accumbens (NAc), a region important in processing the rewarding and emotional salience of stimuli. Using chronic social defeat stress, an animal model of mood and anxiety disorders, we investigated whether alterations in synaptic plasticity are responsible for the long-lasting behavioral symptoms induced by this form of stress. We hypothesized that chronic social defeat stress alters synaptic strength or connectivity of medium spiny neurons (MSNs) in the NAc to induce social avoidance. To test this, we analyzed the synaptic profile of MSNs via confocal imaging of Lucifer-yellow-filled cells, ultrastructural analysis of the postsynaptic density, and electrophysiological recordings of miniature EPSCs (mEPSCs) in mice after social defeat. We found that NAc MSNs have more stubby spine structures with smaller postsynaptic densities and an increase in the frequency of mEPSCs after social defeat. In parallel to these structural changes, we observed significant increases in IκB kinase (IKK) in the NAc after social defeat, a molecular pathway that has been shown to regulate neuronal morphology. Indeed, we find using viral-mediated gene transfer of dominant-negative and constitutively active IKK mutants that activation of IKK signaling pathways during social defeat is both necessary and sufficient to induce synaptic alterations and behavioral effects of the stress. These studies establish a causal role for IKK in regulating stress-induced adaptive plasticity and may present a novel target for drug development in the treatment of mood and anxiety disorders in humans.

The adaptor protein APPL1 mediates the stimulatory effect of adiponectin on p38 mitogen-activated protein kinase (MAPK) signaling, yet the underlying mechanism remains unclear. Here we show that, in C(2)C(12) cells, overexpression or suppression of APPL1 enhanced or suppressed, respectively, adiponectin-stimulated p38 MAPK upstream kinase cascade, consisting of transforming growth factor-β-activated kinase 1 (TAK1) and mitogen-activated protein kinase kinase 3 (MKK3). In vitro affinity binding and coimmunoprecipitation experiments revealed that TAK1 and MKK3 bind to different regions of APPL1, suggesting that APPL1 functions as a scaffolding protein to facilitate adiponectin-stimulated p38 MAPK activation. Interestingly, suppressing APPL1 had no effect on TNFα-stimulated p38 MAPK phosphorylation in C(2)C(12) myotubes, indicating that the stimulatory effect of APPL1 on p38 MAPK activation is selective. Taken together, our study demonstrated that the TAK1-MKK3 cascade mediates adiponectin signaling and uncovers a scaffolding role of APPL1 in regulating the TAK1-MKK3-p38 MAPK pathway, specifically in response to adiponectin stimulation.

Ferulated arabinoxylans were alkali-extracted from wheat bran at different incubation times (0.0, 0.5, 1.0, 1.5 and 2.0 h). Wheat bran ferulated arabinoxylans (WBAX) arabinose-to-xylose ratio, ferulic acid content, intrinsic viscosity and viscosimetric molecular weight values decreased as the incubation time of extraction increased. WBAX enzymatic cross-linking capability was affected by incubation time while an increase in WBAX concentration from 5 to 6% (w/v) favored gelation. The WBAX gels formed presented a macroporous structure with mesh size ranging from 40 to 119 nm and hardness values varying from 1.7 to 5 N.

Background: Nonimmune long-term travelers to sub-Saharan Africa are at a high risk of contracting malaria. Most previous studies described risk factors and spatial distribution only in short-term travelers. This study describes the epidemiology and spatial distribution of malaria cases among expatriate healthcare workers in Equatorial Guinea., Methods: We conducted a cohort study evaluating the risk factors for malaria among healthcare personnel working in a hospital in Bata, Equatorial Guinea. Demographic data were recorded for all workers, and the spatial distribution of malaria cases within the hospital perimeters was determined., Results: During 2008 noncomplicated falciparum malaria was diagnosed in 13/102 workers (12.75%). On univariate analysis, the factors negatively associated with the risk of contracting malaria were living above the first floor and being older than 30 years. This association remained significant in multivariate analysis [hazard ratio (HR) = 0.24, 95% confidence interval [CI] = 0.06-0.91 for subjects living above the first floor and HR = 0.14, 95% CI = 0.04-0.52 for subjects above 30 years old]. Males and smokers had increased risk of contracting malaria on univariate analysis. However, this association was not significant in multivariate analysis (HR = 3.37, 95% CI = 0.87-13.1 and HR = 3.12, 95% CI = 0.83-11.75, for univariate and multivariate analysis, respectively). Low compliance with malaria prevention guidelines was observed in the study cohort., Conclusions: Living on the ground floor of apartment buildings in sub-Saharan Africa, as opposed to living on the top floors, confers an increased risk of acquiring malaria in long-term travelers with low compliance to prophylaxis. These findings should be discussed in advance with people intending to stay in sub-Saharan Africa for an extended period of time. The association between belonging to a younger age group and an increased risk of acquiring malaria, and the marginally significant increased risk of malaria in males and smokers, can probably be explained by increased exposure to malaria vectors. The compliance of healthcare workers with malaria prophylaxis is extremely low, as was previously described for other long-term residents., (© 2010 International Society of Travel Medicine.)

The reaction of hydrogen atoms with propyne (CH[triple bond]CCH(3)) was investigated in a heated single pulse-shock tube at temperatures of 874-1196 K and pressures of 1.6-7.6 bar. Stable products from various reaction channels (terminal and nonterminal H addition, and by inference H abstraction) were identified and quantified by gas chromatography and mass spectrometry. The rate constant for the channel involving the displacement of methyl radical from propyne (nonterminal H addition) was determined relative to the methyl displacement from 1,3,5-trimethylbenzene (135-TMB), with k (H + 135-TMB --> m-xylene + CH(3)) = 6.70 x 10(13) exp(-3255/T[K]) cm(3)/mol x s, k(H+propyne-->CH[triple bond]CH+CH3))=6.26 x 10(13) exp(-2267/T[K]) cm3/mole x s. Our results show that the acetylene to allene yield is approximately 2 at 900 K, and decreases with increasing temperature. The rate expression is: k(H+propyne-->CH2=C=CH2+H))=2.07 x 10(14) exp(-3759/T[K]) cm3/mole x s. This is a lower limit for terminal addition. Kinetic information for abstraction of the propargylic hydrogen by H was determined via mass balance. The rate expression is approximately k(H+CH3C[triple bond]CH-->CH[triple bond]C-CH2+H2))=1.20 x 10(14) exp(-4940/T[K])cm3 /mole x s and is only 10% of the rate constant for acetylene formation. All channels from H atom attack on propyne at combustion temperatures have now been determined. Comparisons are made with results of recent ab initio calculations and conclusions are drawn on the quantitative accuracy of such estimates.

For decades, the US public and private sectors have committed substantial resources towards cancer research, but the societal payoff has not been well-understood. We quantify the value of recent gains in cancer survival, and analyze the distribution of value among various stakeholders. Between 1988 and 2000, life expectancy for cancer patients increased by roughly four years, and the average willingness-to-pay for these survival gains was roughly $322,000. Improvements in cancer survival during this period created 23 million additional life-years and roughly $1.9 trillion of additional social value, implying that the average life-year was worth approximately $82,000 to its recipient. Health care providers and pharmaceutical companies appropriated 5-19% of this total, with the rest accruing to patients. The share of value flowing to patients has been rising over time. In terms of economic rates of return, R&D investments against cancer have been a success, particularly from the patient's point of view.

Background: Homer proteins are constituents of scaffolding complexes that regulate the trafficking and function of central Group1 metabotropic glutamate receptors (mGluRs) and N-methyl-d-aspartate (NMDA) receptors. Research supports the involvement of these proteins in ethanol-induced neuroplasticity in mouse. In this study, we examined the effects of short versus long-term withdrawal from chronic ethanol consumption on Homer and glutamate receptor protein expression within striatal and amygdala subregions of selectively bred, alcohol-preferring P rats., Methods: For 6 months, male P rats had concurrent access to 15% and 30% ethanol solutions under intermittent (IA: 4 d/wk) or continuous (CA: 7 d/wk) access conditions in their home cage. Rats were killed 24 hours (short withdrawal: SW) or 4 weeks (long withdrawal: LW) after termination of ethanol access, subregions of interest were micropunched and tissue processed for detection of Group1 mGluRs, NR2 subunits of the NMDA receptor and Homer protein expression., Results: Within the nucleus accumbens (NAC), limited changes in NR2a and NR2b expression were detected in the shell (NACsh), whereas substantial changes were observed for Homer2a/b, mGluRs as well as NR2a and NR2b subunits in the core (NACc). Within the amygdala, no changes were detected in the basolateral subregion, whereas substantial changes, many paralleling those observed in the NACc, were detected in the central nucleus (CeA) subregion. In addition, most of the changes observed in the CeA, but not NACc, were present in both SW and LW rats., Conclusions: Overall, these subregion specific, ethanol-induced increases in mGluR/Homer2/NR2 expression within the NAC and amygdala suggest changes in glutamatergic plasticity had taken place. This may be a result of learning and subsequent memory formation of ethanol's rewarding effects in these brain structures, which may, in part, mediate the chronic relapsing nature of alcohol abuse.

Background: Administrative claims are readily available, but their usefulness for identifying persons with non-small cell lung cancer (NSCLC) is relatively unknown, particularly for younger persons and those enrolled in Medicaid., Objectives: To determine the sensitivity of ICD-9-CM codes for identifying persons with NSCLC., Methods: This was a retrospective analysis of insurance claims records linked to the Surveillance, Epidemiology, and End Results (SEER) cancer registry for the time period January 1, 2002, through December 31, 2005. Persons included in the sample were identified with NSCLC using SEER morphology and histology codes and were enrolled in a commercial health plan, Medicaid, or Medicare fee-for-service health plans in Washington State. The outcome measure was sensitivity, defined as the percentage of SEER-identified patients who were accurately identified as NSCLC cases using ICD-9-CM diagnoses (162.2, 162.3, 162.4, 162.5, 162.8, 162.9, or 231.2) recorded in any claim field in administrative claims data. We examined the influence of varying the number and timing of administrative codes in relation to the SEER cancer diagnosis date. In multivariate models, we examined the influence of age, sex, and comorbidity on sensitivity., Results: The sensitivity of 1 medical claim including at least 1 ICD-9-CM code for identifying NSCLC within 60 days of diagnosis as documented in the SEER registry was 51.1% for Medicaid, 87.7% for Medicare, and 99.4% for commercial plan members. Sensitivity can improve at the expense of identifying a portion of patients who are 3 or more months from their true diagnosis date. In multivariate models, age, race, and noncancer comorbidity but not gender significantly influenced sensitivity., Conclusions: Administrative claims are sensitive for identifying patients with new NSCLC in the commercial and Medicare plans. For Medicaid patients, linkage with cancer registry records is needed to conduct studies using administrative claims.

The laccase induced gelation of maize bran arabinoxylans at 2.5% (w/v) in the presence of insulin or beta-lactoglobulin at 0.1% (w/v) was investigated. Insulin and beta-lacto-globulin did not modify either the gel elasticity (9 Pa) or the cross-links content (0.03 and 0.015 microg di- and triferulic acids/mg arabinoxylan, respectively). The protein release capability of the gel was also investigated. The rate of protein release from gels was dependent on the protein molecular weight. The apparent diffusion coefficient was 0.99 x 10(-7) and 0.79 x 10(-7) cm(2)/s for insulin (5 kDa) and beta-lactoglobulin (18 kDa), respectively. The results suggest that maize bran arabinoxylan gels can be potential candidates for the controlled release of proteins.

While social factors broadly determine health outcomes, strategic health workforce innovations such as community case management (CCM) can redress social inequalities in access to health care. Community case management enables trained health workers to assess children, diagnose common childhood infections, administer medicines, and monitor life-saving treatment in the poor, remote communities where they reside. This article reports on research that combined focus group discussions and key informant interviews to examine the perceptions of multiple stakeholders, with monitoring data, in order to assess programmatic results, limitations, and lessons learned in implementing CCM in Nicaragua. We found that CCM increases the use of curative services by poor children with pneumonia, diarrhea, or dysentery by five to six-fold over facility-based services. Apart from dramatically increasing geographic access to treatment for underserved groups, our qualitative research suggests that Nicaragua's CCM model also addresses the managerial challenges and social relations that underpin good quality of care, care-giver knowledge and awareness, and community mobilization, all health system-strengthening factors that are central to equitably and effectively improving child health. While our findings are promising, we suggest areas for further operational research to strengthen CCM program learning and functioning.

Bromopropane has been considered as a replacement for chlorofluorocarbons used as the active component of industrial cleaning solvents, more specifically for HCFC-141b. The proposed mechanism for the atmospheric oxidation of bromopropane is studied via ab initio methodology. Ab initio molecular orbital methods at the CCSD(T)/6-311++G(2df,2p)//MP2/6-31G(d) level of theory have been used to determine the structure and energetics of the 58 species and transition states involved in the atmospheric oxidation of bromopropane. The calculations show that the major oxidation species is bromoacetone. Other brominated species that result from the oxidation are BrCH 2CH 2C(O)H, BrC(O)CH 2CH 3, and BrC(O)H, potential new bromine reservoir species that result from bromopropane in the atmosphere.

Objectives: To identify commonly prescribed first-, second-, and third-line chemotherapy regimens for persons with lung cancer and to evaluate the utilization patterns and costs of care associated with receiving these regimens., Study Design: Retrospective data analysis., Methods: Using health insurance claims from January 1, 2002, through December 31, 2006, patients with lung cancer were identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. An algorithm was developed to identify first-, second-, and third-line chemotherapy. Patients were stratified by the number of discrete regimens received or by their specific chemotherapy agent or combination of agents. Data were analyzed for up to 2 years from the date of the initial first-line regimen and for 1 year from the second and third lines. Patient costs were based on total reimbursements for each group during the observation period., Results: Of patients receiving first-line chemotherapy, 25% and 10% received second-line and third-line chemotherapy, respectively. Docetaxel, gefitinib, and erlotinib hydrochloride were the most commonly prescribed second-line regimens; gefitinib and docetaxel were the most commonly prescribed third-line regimens. The most commonly prescribed second- and third-line agents changed substantially over time. Total costs and costs per patient per month increased as the number of lines of chemotherapy prescribed increased., Conclusions: Second- and third-line chemotherapy is prescribed infrequently, and patterns of prescribing are changing over time. Direct medical care costs increase substantially with additional lines of therapy.

A mechanism for the atmospheric oxidation of bromoethane is proposed from an ab initio study. Using CCSD(T)/6-311++G(2df,2p)//MP2/6-31G(d) level of theory, the structure and energetics of the 35 species and transition states involved in the atmospheric oxidation of bromoethane are examined. From these calculations, reaction enthalpies and activation energies to characterize the potential energy surface of the proposed mechanism for the complete atmospheric degradation of bromoethane are determined. The studies revealed that the hydrogen abstraction from the alpha carbon has the lowest activation energy barrier of all the possible abstractions, making this pathway the most energetically favored pathway for the atmospheric oxidation process. The brominated species that result from the oxidation at the alpha carbon are BrC(O)CH(3) and BrC(O)H. Other species resulting from oxidation initiated at the beta carbon are also identified.

One of the most abundant carboxylic acids measured in the atmosphere is acetic acid (CH(3)C(O)OH), present in rural, urban, and remote marine environments in the low-ppb range. Acetic acid concentrations are not well reproduced in global 3-D atmospheric models because of the poor inventory of sources and sinks to model its global distribution. To understand the complete oxidation of acetic acid in the atmosphere initiated by OH radicals, ab initio calculations are performed to describe in detail the energetics of the reaction potential energy surface (PES). The proposed reaction mechanism suggests that the CH(3)C(O)OH + OH reaction takes place via three pathways: the addition of OH to the central carbon, the abstraction of a methyl hydrogen, and the abstraction of an acidic hydrogen. The PES is characterized by prereactive H-complexes, transition states, and more interestingly unique radical-mediated isomerization reactions. From the analysis of the energetics, acetic acid atmospheric oxidation will proceed mainly via the abstraction of the acidic hydrogen, consistent with previous experimental and theoretical studies. The major byproducts from each pathway are identified. Glyoxylic acid is suggested to be a major byproduct of the atmospheric oxidation of acetic acid. The atmospheric fate of glyoxylic acid is discussed.

Dimethyl ether (DME) has been proposed for use as an alternative fuel or additive in diesel engines and as a potential fuel in solid oxide fuel cells. The oxidation chemistry of DME is a key element in understanding its role in these applications. The reaction between methoxymethyl radicals and O(2) has been examined over the temperature range 295-600 K and at pressures of 20-200 Torr. This reaction has two product pathways. The first produces methoxymethyl peroxy radicals, while the second produces OH radicals and formaldehyde molecules. Real-time kinetic measurements are made by transient infrared spectroscopy to monitor the yield of three main products-formaldehyde, methyl formate, and formic acid-to determine the branching ratio for the CH(3)OCH(2) + O(2) reaction pathways. The temperature and pressure dependence of this reaction is described by a Lindemann and Arrhenius mechanism. The branching ratio is described by f = 1/(1 + A(T)[M]), where A(T) = (1.6(+2.4)(-1.0) x 10(-20)) exp((1800 +/- 400)/T) cm(3) molecule(-1). The temperature dependent rate constant of the methoxymethyl peroxy radical self-reaction is calculated from the kinetics of the formaldehyde and methyl formate product yields, k(4) = (3.0 +/- 2.1) x 10(-13) exp((700 +/- 250)/T) cm(3) molecule(-1) s(-1). The experimental and kinetics modeling results support a strong preference for the thermal decomposition of alkoxy radicals versus their reaction with O(2) under our laboratory conditions. These characteristics of DME oxidation with respect to temperature and pressure might provide insight into optimizing solid oxide fuel cell operating conditions with DME in the presence of O(2) to maximize power outputs.

Context: Although considerable data exist on the use of long-acting somatostatin analogs to treat acromegaly, their reported efficacy differs substantially among trials., Objective: We conducted a meta-analysis to derive definitive estimates of their efficacy for biochemical control and tumor shrinkage., Data Sources: A search of literature was conducted through 2003, primarily via PubMed., Study Selection: Inclusion criteria, met in 44 trials, included at least 3 months of secondary octreotide long-acting release (LAR) or lanreotide slow release (SR) therapy or of primary octreotide LAR, lanreotide SR, or sc octreotide therapy and clearly reported data on biochemical efficacy and/or tumor shrinkage. Fifty other trials screened did not meet analysis inclusion criteria., Data Extraction: Data were extracted by three independent observers., Data Synthesis: Among subjects not selected for somatostatin analog responsiveness before study entry, both GH efficacy criteria and IGF-I normalization were met in a greater proportion of those treated with octreotide LAR vs. lanreotide SR (GH: B = 0.2310, P = 0.016; IGF-I: B = 0.2325, P = 0.007). Prestudy selection for somatostatin analog responsiveness was not a significant predictor of meeting GH efficacy criteria (B = 0.0992; P = 0.12). Preselection was a positive predictor of IGF-I normalization rate (B = 0.1213; P = 0.04), which was greater among preselected than unselected subjects (B = 0.1472; P = 0.0475). IGF-I normalization occurred in a greater proportion of secondary octreotide LAR- vs. primary octreotide-treated subjects (B = 0.2056; P = 0.009). The odds of tumor shrinkage more than 10% were lower in the unselected vs. preselected subjects. However, the effect of drug type was an important predictor of shrinkage; such that regardless of preselection or not, the odds of shrinkage with lanreotide SR were lower than with octreotide LAR (P = 0.003). Shrinkage greater than 10% occurred in a higher percentage of primary octreotide LAR-treated vs. primary octreotide sc-treated subjects (odds ratio = 9.4; P < 0.0001). The overall rate of tumor increase was 1.4%., Conclusions: In this meta-analysis, we have shown that the efficacy of octreotide LAR is greater than lanreotide SR among subjects unselected for prior somatostatin analog responsiveness. Preselection is a significant positive predictor of IGF-I normalization and is associated with increased odds of tumor shrinkage, which is also greatest with octreotide LAR. Biochemical efficacy is similar, but tumor shrinkage is greater when these drugs are given as primary vs. secondary therapy.

IGF-I levels normalize in the majority of patients with acromegaly treated with the GH receptor antagonist pegvisomant. To date, the efficacy of pegvisomant has been demonstrated with daily administration of doses ranging from 10 to 40 mg. However, given the known long half-life of the drug in circulation, we hypothesized that dosing less frequently than daily would still maintain the drug's efficacy. We studied 10 patients with active acromegaly treated with pegvisomant. This therapy was begun at 10 mg daily but then titrated up in dose or down to alternate-day dosing to try to maintain serum IGF-I levels in the upper half of the patients' age-adjusted normal range. We found that in five of 10 patients, serum IGF-I levels remained normal on less frequent than daily pegvisomant. Signs and symptoms of the disease and a disease-related morbidity, insulin resistance, remained improved in these patients. We demonstrate for the first time the continued efficacy of alternate-day administration of pegvisomant.

This review compares the cost-effectiveness of four biologics - adalimumab (Humira, Abbott Laboratories), anakinra (Kineret, Amgen Inc.), etanercept (Enbrel, Wyeth) and infliximab (Remicade, Schering-Plough) - used in the treatment of rheumatoid arthritis. A decision analytic model was constructed to estimate the costs and effectiveness of these biologics used alone or in combination with methotrexate during 1 year, from the perspective of a managed care organization. The direct costs consisted of drugs and healthcare resources. Effectiveness was measured by quality-adjusted life years based on preference weights and health states in which patients achieved one out of four levels of response according to the American College of Rheumatology (ACR) response criteria (No ACR, ACR20, ACR50 and ACR70), and experienced one of the four levels of adverse events (e.g., no, mild, moderate and severe) due to their treatments. Results were sensitive to changes in treatment costs and probabilities of health states in directions as predicted. For monotherapy and combination therapy regimens, anakinra was the least expensive option while etanercept dominated other treatments.

Our initial study in postoperative patients with acromegaly identified a group of patients in remission, as defined by normal IGF-I levels, but who had a subtle abnormality of GH suppression after oral glucose. To investigate the significance of this abnormality, we have undertaken further detailed testing of GH secretion and a longitudinal follow-up of some of these patients. Of the 110 postoperative patients with acromegaly evaluated by oral glucose tolerance test, 76 were in remission (i.e. normal IGF-I level), and of these subjects with acromegaly in remission, 50 had normal nadir GH (<0.14 microg/ml) (group I), and 26 had abnormal nadir GH (>0.14 microg/ml) (group II). Fourteen subjects in remission, seven from remission group I and seven from remission group II, underwent additional testing consisting of both hourly GH sampling over 8 h and, on a separate day, arginine stimulation testing. The mean of hourly GH was higher in group II (0.47 +/- 0.04 microg/liter) than in group I (0.19 +/- 0.07 microg/liter; P = 0.002). GH response to arginine was greater in group II than in group I (P < 0.01). Of those patients in remission from the initial cohort studied, 49 (30 subjects from group I and 19 from group II) underwent serial longitudinal oral glucose tolerance testing every 1-2 yr over a 1- to 6.5-yr period (mean follow-up, 3.2 yr). The initial pattern of GH suppression persisted in most patients. IGF-I levels remained normal in all patients in group II, but five subjects from group II developed an elevated IGF-I level and, thus, a biochemical recurrence. The rate of disease recurrence was greater in group II than in group I (P = 0.003). We have found that some postoperative subjects with acromegaly in remission with normal IGF-I levels have persistently abnormal nadir GH levels after oral glucose that may be accompanied by other evidence of greater GH secretion than postoperative patients with normal GH suppression. This abnormal pattern of GH suppression may be associated with increased risk of disease recurrence in some patients.

Dopamine agonists have been used as adjunctive therapy for acromegaly for many years, but relatively few studies have assessed the efficacy of a newer agonist, cabergoline. Some data suggest that cabergoline may be more effective than bromocriptine, in particular for those patients whose tumors secrete both growth hormone and prolactin. In order to assess this possibility further, we have evaluated the biochemical response to cabergoline therapy in patients with acromegaly at our center. We describe first an unusual patient who presented with a pituitary macroadenoma secreting both GH and prolactin. At presentation he had elevated levels of growth hormone 6.0 microg/L, IGF-I, 722 ng/ml, and prolactin, 6000 ng/ml. Cabergoline therapy alone was highly effective in this patient and normalized his levels of all three hormones and his gonadal function as well as produced significant shrinkage of his pituitary tumor. Fourteen other patients with more typical, active postoperative acromegaly were administered cabergoline in a 6-month, open label, dose-escalation study. Mean baseline GH was 1.3 +/- .23 ng/ml and fell to a nadir of 0.85 +/- .18 ng/ml on cabergoline therapy (p = 0.03). Mean baseline IGF-I was 520 +/- 45.2 ng/ml and fell to a mean nadir during cabergoline therapy of 368 +/- 29.8 ng/ml (p = 0.0013). At the completion of the cabergoline therapy study period, however, mean IGF-I was 453 +/- 46 ng/ml, not significantly lower than the baseline value (p = 0.11). No changes in tumor sizes occurred on cabergoline therapy. Eight of 14 patients achieved a normal IGF-I at some point during the 24 weeks study period, but the efficacy of cabergoline waned with time as only 3 of 14 (21%) of patients had a persistently normal IGF-I with up to 18 months of cabergoline therapy. Six patients had modest hyperprolactinemia at diagnosis (26-142 ng/ml) and 5 patients had positive immunohistochemical staining of their tumor for prolactin, but in neither of these small groups was cabergoline therapy more effective at normalizing IGF-I than in those patients with apparently pure GH secreting tumors. Three of 14 patients (21%) had side effects that limited therapy. A trial of cabergoline as adjunctive therapy may be considered in select patients with mild disease and small tumor residuals, but the expectation for biochemical control in these patients needs to be kept low, even for tumors that co-secrete GH and prolactin.

The orexigenic peptide, ghrelin, is regulated by acute and chronic nutritional state. Although exogenously administered ghrelin stimulates pituitary GH secretion, little is known about the role of ghrelin in endogenous GH secretion or how high GH and IGF-I levels in acromegaly could affect ghrelin secretion and vice versa. Therefore, we evaluated fasting and post oral glucose tolerance test serum ghrelin levels in 19 patients with active acromegaly at baseline and after either surgery in 9 of these or administration of long-acting octreotide (Sandostatin LAR) in the other 10 patients. After surgical cure, fasting ghrelin rose from 312 +/- 56 pg/ml to 548 +/- 97 pg/ml (P = 0.013). Fasting serum ghrelin levels were higher in all patients after surgery and ranged between 112% and 349% of presurgery levels. Ghrelin levels fell significantly during long-acting octreotide therapy from 447 +/- 34 pg/ml to 206 +/- 15 pg/ml (P < 0.0001); ghrelin levels on octreotide ranged between 26% and 70% of baseline levels. Serum ghrelin levels were suppressed significantly during the oral glucose tolerance test in both groups. Pretherapy ghrelin levels correlated negatively with serum insulin levels (r = -0.494; P = 0.03) and insulin resistance as estimated by the homeostasis model assessment score (r = -0.573; P = 0.01). In patients without diabetes mellitus, serum insulin levels in the surgical group were 19.7 +/- 5.4 microU/ml before surgery and fell to 9.7 +/- 0.93 microU/ml after surgery (P = 0.05); levels in the octreotide group were 13.9 +/- 2.8 microU/ml before and fell to 11.2 +/- 2.8 microU/ml on octreotide (P = 0.03). Pretherapy ghrelin levels did not correlate with weight or body mass index, but after therapy in the surgery group ghrelin correlated negatively with weight (r = -0.823, P = 0.012) as has been demonstrated by others in healthy subjects. Ghrelin secretion is dysregulated in active acromegaly; lowered serum levels of ghrelin in active acromegaly rise along with the postsurgery normalization of GH and IGF-I and improved insulin resistance. In contrast to surgical therapy, long-acting octreotide therapy persistently suppressed serum ghrelin levels. It remains to be determined whether altered circulating ghrelin concentrations could impact on body composition changes in acromegaly.

The development of highly sensitive and specific GH assays has necessitated a critical re-evaluation of the biochemical criteria needed for the diagnosis of acromegaly. Use of these assays has revealed that GH levels after oral glucose in healthy subjects and postoperative patients with active acromegaly can be significantly less than previously recognized with older GH assays. In order to assess GH criteria for newly diagnosed acromegaly with a modern assay we have evaluated GH levels in 25 patients referred to our Neuroendocrine Unit for evaluation of untreated acromegaly. All patients underwent measurement of basal GH and IGF-I levels and 15 of these patients also underwent oral glucose tolerance testing for GH suppression (OGTT). Basal GH levels were < 1.0 microg/L at diagnosis in 5 of these 25 patients. Nadir GH levels were less than 1 microg/L also in 5 of 15 patients, and as low as 0.42 microg/L. All patients had elevated IGF-I levels preoperatively and pathological confirmation of a GH secreting pituitary tumor at the time of transsphenoidal surgery. The clinical presentations of these patients was variable. Most patients presented with classical manifestations of acromegaly, but 3 of the 5 patients with low nadir GH values had only very subtle signs of acromegaly. Although most newly diagnosed patients have classically elevated GH levels and obvious clinical features of acromegaly, early recognition of disease may uncover patients with milder biochemical and clinical abnormalities. The diagnosis should not be discounted in patients who have elevated IGF-I levels, but have basal or nadir GH levels less than 1 microg/L. Conventional GH criteria for the diagnosis of acromegaly cannot be applied to the use of modern sensitive and specific GH assays.

Clinical studies have demonstrated that high dose adjuvant interferon therapy improves disease-free and overall survival among high risk (stage IIb and III) melanoma patients. Sentinel lymph node mapping (SLM) has been shown to accurately detect micrometastasis and may be used to identify higher risk stage II patients, who might benefit most from adjuvant interferon therapy. We modelled the cost-effectiveness of first testing with SLM and then treating with adjuvant interferon (IFN) therapy for stage II melanoma. We used a decision analytical model to compare four strategies for stage II patients after surgical excision of their melanoma: (1) treat all with low dose IFN; (2) test first with SLM and then treat only those with positive micrometastasis with high dose IFN; (3) test first with SLM and treat positives with high dose IFN and negatives with low dose IFN (test and treat appropriately); and (4) surgery only. Treatment, toxicity, follow-up and relapse costs were included over a 5 year time period. The primary outcome was cost per quality-adjusted relapse-free life year saved. Our analysis shows that, compared with the current surgery-only strategy, all three treatment strategies provide incremental benefits. The test and treat appropriately strategy is the most effective, with an incremental improvement of 0.64 quality-adjusted life-years (QALY). The cost-effectiveness of test and treat some with high dose IFN compared with the surgery-only strategy is $18,700/QALY. The test and treat appropriately strategy is also cost-effective compared with test and treat some at $31,100/QALY. In conclusion appropriate dosing of IFN therapy based on the results of SLM is a cost-effective strategy for stage II melanoma patients.

Background: Molecular testing for hereditary nonpolyposis colorectal carcinoma (HNPCC) is becoming standard care and it is cost-effective compared with no genetic testing. However, the best strategy for detection of HNPCC gene carriers is unknown., Methods: We use a decision analytic model to evaluate the effectiveness and incremental cost-effectiveness of four commonly used testing strategies to detect HNPCC gene carriers. The model starts with a population of colorectal carcinoma (CRC) patients and measures costs, the number of gene carriers detected, and incremental costs per gene carrier detected., Results: We found that germline testing on only those CRC probands who meet the Amsterdam criteria detects the fewest gene carriers and has the lowest cost whereas tumor microsatellite instability (MSI) testing of all CRC patients and families has the highest cost and detects the most gene carriers. When cost-effectiveness is considered, the mixed strategy (MSH2 and MLH1 testing on those who meet the Amsterdam criteria and germline testing for the remainder who meet less stringent modified criteria and are MSI-High) seems superior. The mixed strategy detects 59.6 mutation carriers per 1000 CRC cases and costs much less than the test all strategy, which has an incremental cost-effectiveness of $51,151. The mixed strategy often other strategies and when compared to the Amsterdam strategy, has a cost-effectiveness of only $6441 per gene carrier detected., Conclusions: It is not very effective to limit genetic testing to only individuals who meet the Amsterdam criteria, as many gene carriers are missed. However, testing all CRC patients for tumor MSI-H, although effective, may be prohibitively expensive. A mixed strategy is the more cost-effective approach., (Copyright 2002 American Cancer Society.)

Background: Clinical and pharmacokinetic studies have shown that target hemoglobin or hematocrit levels can be maintained using a reduced recombinant human erythropoietin (epoetin) dosage by switching from intravenous (IV) to subcutaneous (SC) administration., Methods: We conducted a meta-analysis of comparative studies of epoetin administered IV versus SC to assess the relative costs of these administration routes. Twenty-seven prospective clinical studies involving 916 patients were included in the analysis. The average difference between IV and SC doses of epoetin and average difference in drug costs between administration routes were determined., Results: The average reduction in dose in patients treated with SC versus IV epoetin was 48 IU/kg/wk (P < 0.001), representing an average annual cost savings with SC administration of US $1,761 +/- $1,080 (SD) per patient. The difference between SC and IV doses was similar in both parallel- and crossover-design studies. A retrospective US survey showed a dose reduction of 26 IU/kg/wk (P < 0.001) with SC administration, translating to an annual savings of $946 per patient., Conclusion: This study indicates that the cost of epoetin is reduced substantially when administered SC in comparison to IV. Recommendations of current US and European guidelines, which encourage the use of SC administration, not only have a sound rationale in terms of efficacy and safety, but also have a sound economic basis., (Copyright 2002 by the National Kidney Foundation, Inc.)

Objectives: In this study we determined the incidence and direct inpatient and outpatient costs of systemic fungal infections (candidiasis, aspergillosis, cryptococcosis, histoplasmosis) in 1998., Methods: Using primarily the National Hospital Discharge Survey (NHDS) for incidence and the Maryland Hospital Discharge Data Set (MDHDDS) for costs, we surveyed four systemic fungal infections in patients who also had HIV/AIDS, neoplasia, transplant, and all other concomitant diagnoses. Using a case-control method, we compared the cases with controls (those without fungal infections with the same underlying comorbidity) to obtain the incremental hospitalization costs. We used the Student's t-test to determine significance of incremental hospital costs. We modeled outpatient costs on the basis of discharge status to calculate the total annual cost for systemic fungal infections in 1998., Results: For 1998, the projected average incidence was 306 per million US population, with candidiasis accounting for 75% of cases. The estimated total direct cost was $2.6 billion and the average per-patient attributable cost was $31,200. The most commonly reported comorbid diagnoses with fungal infections (HIV/AIDS, neoplasms, transplants) accounted for only 45% of all infections., Conclusions: The cost burden is high for systemic fungal infections. Additional attention should be given to the 55% with fungal disease and other comorbid diagnoses.

We have performed molecular dynamics (MD) simulations, with particle-mesh Ewald, explicit waters, and counterions, and binding specificity analyses using combined molecular mechanics and continuum solvent (MM-PBSA) on the bovine immunodeficiency virus (BIV) Tat peptide-TAR RNA complex. The solution structure for the complex was solved independently by Patel and co-workers and Puglisi and co-workers. We investigated the differences in both structures and trajectories, particularly in the formation of the U-A-U base triple, the dynamic flexibility of the Tat peptide, and the interactions at the binding interface. We observed a decrease in RMSD in comparing the final average RNA structures and initial RNA structures of both trajectories, which suggests the convergence of the RNA structures to a MD equilibrated RNA structure. We also calculated the relative binding of different Tat peptide mutants to TAR RNA and found qualitative agreement with experimental studies.

Computer modeling has been developed and widely applied in studying molecules of biological interest. The force field is the cornerstone of computer simulations, and many force fields have been developed and successfully applied in these simulations. Two interesting areas are (a) studying enzyme catalytic mechanisms using a combination of quantum mechanics and molecular mechanics, and (b) studying macromolecular dynamics and interactions using molecular dynamics (MD) and free energy (FE) calculation methods. Enzyme catalysis involves forming and breaking of covalent bonds and requires the use of quantum mechanics. Noncovalent interactions appear ubiquitously in biology, but here we confine ourselves to review only noncovalent interactions between protein and protein, protein and ligand, and protein and nucleic acids.

The dynamic behavior of HIV-1 TAR and its complex with argininamide is investigated by means of molecular dynamics simulations starting from NMR structures, with explicit inclusion of water and periodic boundary conditions particle mesh Ewald representation of the electrostatic energy. During simulations of free and argininamide-bound TAR, local structural patterns, as determined by NMR experiments, were reproduced. An interdomain motion was observed in the simulations of free TAR, which is absent in the case of bound TAR, leading to the conclusion that the free conformation of TAR is intrinsically more flexible than the bound conformation. In particular, in the bound conformation the TAR-argininamide interface is very well ordered, as a result of the formation of a U.A.U base triple, which imposes structural constraints on the global conformation of the molecule. Free energy analysis, which includes solvation contributions, was used to evaluate the influence of van der Waals and electrostatic terms on formation of the complex and on the conformational rearrangement from free to bound TAR.

An adaptive binding mechanism, requiring large conformational rearrangements, occurs commonly with many RNA-protein associations. To explore this process of reorganization, we have investigated the conformational change upon spliceosomal U1A-RNA binding with molecular dynamics (MD) simulations and free energy analyses. We computed the energetic cost of conformational change in U1A-hairpin and U1A-internal loop binding using a hybrid of molecular mechanics and continuum solvent methods. Encouragingly, in all four free energy comparisons (two slightly different proteins, two different RNAs), the free macromolecule was more stable than the bound form by the physically reasonable value of approximately 10 kcal/mol. We calculated the absolute binding free energies for both complexes to be in the same range as that found experimentally., (Copyright 2000 Academic Press.)

The mammalian spliceosomal protein U1A binds a hairpin RNA with picomolar affinity. To examine the origin of this binding specificity, we carried out computational mutagenesis on protein and RNA residues in the U1A-RNA binding interface. Our computational mutagenesis methods calculate the relative binding affinity between mutant and wild-type as the sum of molecular mechanical energies and solvation free energies estimated with a continuum solvent model. We obtained good agreement with experimental studies and we verified mutations that abolish and improve binding. Therefore, we offer these methods as computationally inexpensive tools for investigating and predicting the effects of site-specific mutagenesis., (Copyright 2000 Academic Press.)

The U1A protein binds to a hairpin RNA and an internal-loop RNA with picomolar affinities. To probe the molecular basis of U1A binding, we performed state-of-the-art nanosecond molecular dynamics simulations on both complexes. The good agreement with experimental structures supports the protocols used in the simulations. We compare the dynamics, hydrogen-bonding occupancies, and interfacial flexibility of both complexes and also describe a rigid-body motion in the U1A-internal loop complex that is not observed in the U1A-hairpin simulation. We relate these observations to experimental mutational studies and highlight their significance in U1A binding affinity and specificity.

Hepatitis B virus markers were studied in 2,842 Philippine rural subjects from four villages in 1979-1982. The prevalence of hepatitis B surface antigen (HBsAg) and all markers for hepatitis B virus averaged 12% and 58%, respectively, in these rural populations. It is estimated that five million Filipinos are HBsAg positive. The rural age-specific HBsAg prevalence shows an "early peak" (in persons 3-4-years-old) in two communities and a "late peak" (in persons 30-40-years-old) in the other two communities. Family studies suggest that the prevalence of HBsAg and hepatitis B e antigen (HBeAg) among parents of the young children in an "early peak" and a "late peak" village cannot fully account for the difference in the patterns of prevalence of all markers, or the HBsAg marker. Horizontal intrafamilial and extrafamilial transmission may also be significant. Further research is needed on risk factors for hepatitis B virus infection.