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It is currently difficult to successfully choose the correct type of antidepressant for individual patients. To discover patterns in patient characteristics, treatment choices and outcomes, we performed retrospective Bayesian network analysis combined with natural language processing (NLP). This study was conducted at two mental healthcare facilities in the Netherlands. Adult patients admitted and treated with antidepressants between 2014 and 2020 were included. Outcome measures were antidepressant continuation, prescription duration and four treatment outcome topics: core complaints, social functioning, general well-being and patient experience, extracted through NLP of clinical notes. Combined with patient and treatment characteristics, Bayesian networks were constructed at both facilities and compared. Antidepressant choices were continued in 66% and 89% of antidepressant trajectories. Score-based network analysis revealed 28 dependencies between treatment choices, patient characteristics and outcomes. Treatment outcomes and prescription duration were tightly intertwined and interacted with antipsychotics and benzodiazepine co-medication. Tricyclic antidepressant prescription and depressive disorder were important predictors for antidepressant continuation. We show a feasible way of pattern discovery in psychiatry data, through combining network analysis with NLP. Further research should explore the found patterns in patient characteristics, treatment choices and outcomes prospectively, and the possibility of translating these into a tool for clinical decision support., (© 2023. The Author(s).)

Hommel's and Hochberg's procedures for familywise error control are both derived as shortcuts in a closed testing procedure with the Simes local test. Hommel's shortcut is exact but takes quadratic time in the number of hypotheses. Hochberg's shortcut takes only linear time after the P-values are sorted, but is conservative. In this paper, we present an exact shortcut in linear time on sorted P-values, combining the strengths of both procedures. The novel shortcut also applies to a robust variant of Hommel's procedure that does not require the assumption of the Simes inequality., (© 2018 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

The use of multiple testing procedures in the context of gene-set testing is an important but relatively underexposed topic. If a multiple testing method is used, this is usually a standard familywise error rate (FWER) or false discovery rate (FDR) controlling procedure in which the logical relationships that exist between the different (self-contained) hypotheses are not taken into account. Taking those relationships into account, however, can lead to more powerful variants of existing multiple testing procedures and can make summarizing and interpreting the final results easier. We will show that, from the perspective of interpretation as well as from the perspective of power improvement, FWER controlling methods are more suitable than FDR controlling methods. As an example of a possible power improvement, we suggest a modified version of the popular method by Holm, which we also implemented in the R package cherry., (© The Author 2015. Published by Oxford University Press. For Permissions, please email: journals.permissions@oup.com.)

We present a multiple testing method for hypotheses that are ordered in space or time. Given such hypotheses, the elementary hypotheses as well as regions of consecutive hypotheses are of interest. These region hypotheses not only have intrinsic meaning but testing them also has the advantage that (potentially small) signals across a region are combined in one test. Because the expected number and length of potentially interesting regions are usually not available beforehand, we propose a method that tests all possible region hypotheses as well as all individual hypotheses in a single multiple testing procedure that controls the familywise error rate. We start at testing the global null-hypothesis and when this hypothesis can be rejected we continue with further specifying the exact location/locations of the effect present. The method is implemented in the R package cherry and is illustrated on a DNA copy number data set.

We present a novel multiple testing method for testing null hypotheses that are structured in a directed acyclic graph (DAG). The method is a top-down method that strongly controls the familywise error rate and can be seen as a generalization of Meinshausen's procedure for tree-structured hypotheses. Just as Meinshausen's procedure, our proposed method can be used to test for variable importance, only the corresponding variable clusters can be chosen more freely, because the method allows for multiple parent nodes and partially overlapping hypotheses. An important application of our method is in gene set analysis, in which one often wants to test multiple gene sets as well as individual genes for their association with a clinical outcome. By considering the genes and gene sets as nodes in a DAG, our method enables us to test both for significant gene sets as well as for significant individual genes within the same multiple testing procedure. The method will be illustrated by testing Gene Ontology terms for evidence of differential expression in a survival setting and is implemented in the R package cherry., (© 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Detection of early warning signals for the imminent failure of large and complex engineered structures is a daunting challenge with many open research questions. In this paper we report on novel ways to perform Structural Health Monitoring (SHM) of flood protection systems (levees, earthen dikes and concrete dams) using sensor data. We present a robust data-driven anomaly detection method that combines time-frequency feature extraction, using wavelet analysis and phase shift, with one-sided classification techniques to identify the onset of failure anomalies in real-time sensor measurements. The methodology has been successfully tested at three operational levees. We detected a dam leakage in the retaining dam (Germany) and "strange" behaviour of sensors installed in a Boston levee (UK) and a Rhine levee (Germany).

Chemotherapy-induced peripheral neuropathy (CIPN) is a common neurological side-effect of cancer treatment and may lead to declines in patients' daily functioning and quality of life. To date, there are no modern clinimetrically well-evaluated outcome measures available to assess disability in CIPN patients. The objective of the study was to develop an interval-weighted scale to capture activity limitations and participation restrictions in CIPN patients using the Rasch methodology and to determine its validity and reliability properties. A preliminary Rasch-built Overall Disability Scale (pre-R-ODS) comprising 146 items was assessed twice (interval: 2-3 weeks; test-retest reliability) in 281 CIPN patients with a stable clinical condition. The obtained data were subjected to Rasch analyses to determine whether model expectations would be met, and if necessarily, adaptations were made to obtain proper model fit (internal validity). External validity was obtained by correlating the CIPN-R-ODS with the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) neuropathy scales and the Pain-Intensity Numeric-Rating-Scale (PI-NRS). The preliminary R-ODS did not meet Rasch model's expectations. Items displaying misfit statistics, disordered thresholds, item bias or local dependency were systematically removed. The final CIPN-R-ODS consisting of 28 items fulfilled all the model's expectations with proper validity and reliability, and was unidimensional. The final CIPN-R-ODS is a Rasch-built disease-specific, interval measure suitable to detect disability in CIPN patients and bypasses the shortcomings of classical test theory ordinal-based measures. Its use is recommended in future clinical trials in CIPN., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objectives: Topical hemostatic agents are used in all surgical disciplines. Most of these hemostats are based on animal-derived products like collagen and gelatin. They carry the potential risk of pathogen transmission. A newly developed biodegradable, fully synthetic hemostatic agent based on polyurethane foam (PU) with 55 % polyethylene glycol (PEG) would prevent these potential risks., Materials and Methods: The hemostatic efficacy of this new agent was compared to gelatin and collagen in humans who underwent extraction of an upper and lower molar (split-mouth model). After extraction of a molar in the maxilla and mandible, a PU foam and collagen or gelatin were inserted in the extraction socket for 2 min. Hereafter, the agents were removed and stored in ethylenediaminetetraacetic acid to stop coagulation. Then, the concentration of coagulation parameters thrombin-antithrombin III (TAT) complexes, fibrinogen, and thromboxane B2 (TxB2) in blood extracts from the agents was measured. The concentrations were also determined in baseline blood samples which were collected from the extraction socket., Results: The concentrations of TAT and TxB2 were significantly increased, and fibrinogen concentration was significantly reduced compared to baseline wound blood concentrations indicating enhanced hemostasis. No significant differences were seen in the concentrations of these coagulation parameters in the three different hemostatic agents., Conclusions: These results show that PU combined with 55 % PEG is a promising alternative for the animal-derived hemostatic agents., Clinical Relevance: The synthetic hemostatic agent could replace the animal-derived products like collagen and gelatin and therewith prevent the potential risk of pathogen transmission.

In model building and model evaluation, cross-validation is a frequently used resampling method. Unfortunately, this method can be quite time consuming. In this article, we discuss an approximation method that is much faster and can be used in generalized linear models and Cox' proportional hazards model with a ridge penalty term. Our approximation method is based on a Taylor expansion around the estimate of the full model. In this way, all cross-validated estimates are approximated without refitting the model. The tuning parameter can now be chosen based on these approximations and can be optimized in less time. The method is most accurate when approximating leave-one-out cross-validation results for large data sets which is originally the most computationally demanding situation. In order to demonstrate the method's performance, it will be applied to several microarray data sets. An R package penalized, which implements the method, is available on CRAN., (© 2013 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and dose-limiting complication of cancer treatment. Thus far, the impact of CIPN has not been studied in a systematic clinimetric manner. The objective of the study was to select outcome measures for CIPN evaluation and to establish their validity and reproducibility in a cross-sectional multicenter study., Patients and Methods: After literature review and a consensus meeting among experts, face/content validity were obtained for the following selected scales: the National Cancer Institute-Common Toxicity Criteria (NCI-CTC), the Total Neuropathy Score clinical version (TNSc), the modified Inflammatory Neuropathy Cause and Treatment (INCAT) group sensory sumscore (mISS), the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, and CIPN20 quality-of-life measures. A total of 281 patients with stable CIPN were examined. Validity (correlation) and reliability studies were carried out., Results: Good inter-/intra-observer scores were obtained for the TNSc, mISS, and NCI-CTC sensory/motor subscales. Test-retest values were also good for the EORTC QLQ-C30 and CIPN20. Acceptable validity scores were obtained through the correlation among the measures., Conclusion: Good validity and reliability scores were demonstrated for the set of selected impairment and quality-of-life outcome measures in CIPN. Future studies are planned to investigate the responsiveness aspects of these measures.

The Medical Research Council grading system has served through decades for the evaluation of muscle strength and has been recognized as a cardinal feature of daily neurological, rehabilitation and general medicine examination of patients, despite being respectfully criticized due to the unequal width of its response options. No study has systematically examined, through modern psychometric approach, whether physicians are able to properly use the Medical Research Council grades. The objectives of this study were: (i) to investigate physicians' ability to discriminate among the Medical Research Council categories in patients with different neuromuscular disorders and with various degrees of weakness through thresholds examination using Rasch analysis as a modern psychometric method; (ii) to examine possible factors influencing physicians' ability to apply the Medical Research Council categories through differential item function analyses; and (iii) to examine whether the widely used Medical Research Council 12 muscles sum score in patients with Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy would meet Rasch model's expectations. A total of 1065 patients were included from nine cohorts with the following diseases: Guillain-Barré syndrome (n = 480); myotonic dystrophy type-1 (n = 169); chronic inflammatory demyelinating polyradiculoneuropathy (n = 139); limb-girdle muscular dystrophy (n = 105); multifocal motor neuropathy (n = 102); Pompe's disease (n = 62) and monoclonal gammopathy of undetermined related polyneuropathy (n = 8). Medical Research Council data of 72 muscles were collected. Rasch analyses were performed on Medical Research Council data for each cohort separately and after pooling data at the muscle level to increase category frequencies, and on the Medical Research Council sum score in patients with Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. Disordered thresholds were demonstrated in 74-79% of the muscles examined, indicating physicians' inability to discriminate between most Medical Research Council categories. Factors such as physicians' experience or illness type did not influence these findings. Thresholds were restored after rescoring the Medical Research Council grades from six to four options (0, paralysis; 1, severe weakness; 2, slight weakness; 3, normal strength). The Medical Research Council sum score acceptably fulfilled Rasch model expectations after rescoring the response options and creating subsets to resolve local dependency and item bias on diagnosis. In conclusion, a modified, Rasch-built four response category Medical Research Council grading system is proposed, resolving clinicians' inability to differentiate among its original response categories and improving clinical applicability. A modified Medical Research Council sum score at the interval level is presented and is recommended for future studies in Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy.

Objectives: To revise the static and dynamic normative values for the two-point discrimination test and to examine its applicability and validity in patients with a polyneuropathy., Methods: Two-point discrimination threshold values were assessed in 427 healthy controls and 99 patients mildly affected by a polyneuropathy. The controls were divided into seven age groups ranging from 20-29, 30-39,..., up to 80 years and older; each group consisted of at least 30 men and 30 women. Two-point discrimination examination took place under standardised conditions on the index finger. Correlation studies were performed between the scores obtained and the values derived from the Weinstein Enhanced Sensory Test (WEST) and the arm grade of the Overall Disability SumScore (ODSS) in the patients' group (validity studies). Finally, the sensitivity to detect patients mildly affected by a polyneuropathy was evaluated for static and dynamic assessments., Results: There was a significant age-dependent increase in the two-point discrimination values. No significant gender difference was found. The dynamic threshold values were lower than the static scores. The two-point discrimination values obtained correlated significantly with the arm grade of the ODSS (static values: r = 0.33, p = 0.04; dynamic values: r = 0.37, p = 0.02) and the scores of the WEST in patients (static values: r = 0.58, p = 0.0001; dynamic values: r = 0.55, p = 0.0002). The sensitivity for the static and dynamic threshold values was 28% and 33%, respectively., Conclusion: This study provides age-related normative two-point discrimination threshold values using a two-point discriminator (an aesthesiometer). This easily applicable instrument could be used as part of a more extensive neurological sensory evaluation.

A breadboard 4.5 K helium sorption cooler for use in vibration-sensitive space missions was developed and successfully tested. This type of cooler has no moving parts and is, therefore, essentially vibration-free. The absence of moving parts also simplifies scaling down of the cooler to small sizes, and it contributes to achieving a very long lifetime. In addition, the cooler operates with limited dc's so that hardly any electromagnetic interference is generated. This cooler is a favorite option for future missions such as ESA's Darwin mission, a space interferometer in which the sensitive optics and detectors can hardly accept any vibration. The system design consists of a hydrogen stage cooling from 80 to 14.5 K and a helium stage establishing 5 mW at 4.5 K. Both stages use microporous activated carbon as the adsorption material. The two cooler stages need about 3.5 W of total input power and are heat sunk at two passive radiators at temperatures of about 50 and 80 K-radiators which are constructed at the cold side of the spacecraft. We developed, built, and tested a demonstrator of the helium cooler. This demonstrator has four sorption compressor cells in two compressor stages. Test experiments on this cooler showed that it performs within all specifications imposed by ESA. The cooler delivered 4.5 mW at 4.5 K with a long-term temperature stability of 1 mK and an input power of 1.96 W. So far, the cooler has operated continuously for a period of 2.5 months and has not shown any sign of performance degradation.

Objective: To identify the modifiable determinants of delayed hospital admission of stroke patients., Design: Multicentre observational study., Method: In the period from 1 October 1998 to 31 May 1999, before thrombolysis was an accepted treatment for ischaemic stroke in the Netherlands, we interviewed 252 consecutively admitted patients with stroke upon admission. The patients were asked to describe their symptoms and personal reaction to the stroke event in everyday language. The study was carried out in 14 regional hospitals and one university hospital in the Netherlands. The determinants of delay were calculated by means of multiple linear regression analysis., Results: A total of 252 patients took part in the study: 136 men and 116 women, of whom 130 (52%) were 75 years of age or older. The median time from onset of symptoms to calling in any professional assistance was 60 minutes. The median time from onset of symptoms to arrival at the hospital was 5 hours and 10 minutes. One-third (n = 87; 34%) of the patients reached the hospital within 2.5 hours. Nearly half of the patients (46%) recognised their symptoms as a stroke. Patients who had not recognised their symptoms as a stroke (54%) and patients who had waited until their symptoms had worsened (20%) waited longer before calling in professional assistance than those who did not. Hospital admission was delayed in patients who had waited until their symptoms had worsened, and in those who had first called a family physician (87%). On the other hand, a more rapid admission was achieved in case of referral by the family physician by telephone and also after transportation by ambulance (77%)., Conclusion: The modifiable determinants of delayed calling for professional help by stroke patients were the fact that they did not recognise the symptoms as a stroke, and the circumstance that they waited until the symptoms would disappear or become worse. This latter circumstance, referral by the family physician by telephone and transportation by ambulance, were modifiable determinants of delayed hospital admission.

Background: Body temperature is a strong predictor of outcome in acute stroke. In a previous randomized trial we observed that treatment with high-dose acetaminophen (paracetamol) led to a reduction of body temperature in patients with acute ischemic stroke, even when they had no fever. The purpose of the present trial was to study whether this effect of acetaminophen could be reproduced, and whether ibuprofen would have a similar, or even stronger effect., Methods: Seventy-five patients with acute ischemic stroke confined to the anterior circulation were randomized to treatment with either 1000 mg acetaminophen, 400 mg ibuprofen, or placebo, given 6 times daily during 5 days. Treatment was started within 24 hours from the onset of symptoms. Body temperatures were measured at 2-hour intervals during the first 24 hours, and at 6-hour intervals thereafter., Results: No difference in body temperature at 24 hours was observed between the three treatment groups. However, treatment with high-dose acetaminophen resulted in a 0.3 degrees C larger reduction in body temperature from baseline than placebo treatment (95% CI: 0.0 to 0.6 degrees C). Acetaminophen had no significant effect on body temperature during the subsequent four days compared to placebo, and ibuprofen had no statistically significant effect on body temperature during the entire study period., Conclusions: Treatment with a daily dose of 6000 mg acetaminophen results in a small, but potentially worthwhile decrease in body temperature after acute ischemic stroke, even in normothermic and subfebrile patients. Further large randomized clinical trials are needed to study whether early reduction of body temperature leads to improved outcome.

Background: There is a large variability in clinical response to corticosteroid treatment in patients with asthma. Several markers of inflammation like eosinophils and eosinophil cationic protein (ECP), as well as exhaled nitric oxide (NO), are good candidates to predict clinical response., Aim: We wanted to determine whether we could actually predict a favourable response to inhaled corticosteroids in individual patients., Methods: One hundred and twenty patients with unstable asthma were treated with either prednisolone 30 mg/day, fluticasone propionate 1000 microg/day b.i.d. or fluticasone propionate 250 microg/day b.i.d., both via Diskhaler. They were treated during 2 weeks, in a double-blind, parallel group, double dummy design. We measured eosinophils and ECP in blood and sputum, and exhaled nitric oxide as inflammatory parameters before and after 2 weeks in order to predict the changes in forced expiratory volume in 1 s (FEV1), provocative concentration of methacholine causing a 20% fall in FEV1 (PC20 Mch), and asthma quality of life (QOL). Secondly, to test whether these results were applicable in clinical practice we determined the individual prediction of corticosteroid response., Results: We found that changes in FEV1, PC20 Mch and QOL with corticosteroids were predominantly predicted by their respective baseline value and to a smaller extent by eosinophils in blood or sputum. ECP, measured in blood or sputum, was certainly not better than eosinophils in predicting clinical response to corticosteroids. Smoking status was an additional predictor for change in FEV1, but not for change in PC20 Mch or QOL. Prediction of a good clinical response was poor. For instance, high sputum eosinophils (> or = 3%) correctly predicted an improvement in PC20 Mch in only 65% of the patients., Conclusion: Our findings show that baseline values of the clinical parameters used as outcome parameters are the major predictors of clinical response to corticosteroids. Eosinophil percentage in blood or sputum adds to this, whereas ECP provides no additional information. Correct prediction of clinical response in an individual patient, however, remains poor with our currently used clinical and inflammatory parameters.

It has been suggested in cross-sectional studies that provocation with adenosine 5'-monophosphate (AMP) more closely reflects the inflammatory process in asthma than does provocation with methacholine or histamine. We investigated whether the steroid-induced improvement in the provocative concentration of AMP producing a 20% decline in FEV1 (PC20 AMP) is more closely associated with the concomitant reduction in airway inflammation than is the improvement in PC20 methacholine. In 120 asthmatic patients, we measured PC20 methacholine and PC20 AMP as well as sputum induction and nitric oxide (NO) in exhaled air before and after 2 weeks of treatment with corticosteroids. Improvement in PC20 AMP was solely related to reduction in airway inflammation (i.e., change in the number of sputum eosinophils, lymphocytes, epithelial cells, and concentration of NO in exhaled air). In contrast, improvement in PC20 methacholine was related to both reduction in airway inflammation (i.e., change in the number of sputum eosinophils and lymphocytes) and increase in FEV1 %predicted. The total explained variance of the improvement in bronchial hyperresponsiveness was greater for AMP than for methacholine (36% versus 22%, respectively). We conclude that PC20 AMP is more sensitive to changes in acute airway inflammation than is PC20 methacholine, further reinforcing the notion that PC20 AMP can be a useful tool for monitoring the effects of antiinflammatory therapy.

The clinical observation that patients with an alcohol amnestic disorder get grey hair at a higher age was investigated by comparing a group of Korsakov patients and patients with alcohol abuse with a reference sample from the literature. Korsakoff patients appeared to be significantly less grey than age-matched alcoholics and controls. Some putative etiological factors including the mechanism of apoptosis are discussed.

Inhalation of a direct stimulus such as histamine or methacholine is generally used to measure bronchial hyperresponsiveness (BHR). Provocation with adenosine 5'-monophosphate (AMP), an indirect airway challenge, has been suggested to be a better marker of airway inflammation than direct challenges. However, so far little information on this subject is available. The aim of our study was to assess whether the concentration of AMP causing the FEV(1) to drop by 20% (PC(20)) is more closely associated with inflammatory parameters in asthma than PC(20) methacholine. In 120 patients with atopic asthma (median FEV(1) 81% predicted [pred], median age 27 yr), PC(20) methacholine and PC(20) AMP as well as sputum induction, blood sampling, and measurement of nitric oxide in exhaled air were performed. PC(20) methacholine was predominantly predicted by FEV(1) %pred (explained variance [ev] = 18%) with the percentage of peripheral blood monocytes being a weak additional independent predictor (total ev = 23%). By contrast, PC(20) AMP was predominantly predicted by the percentage of eosinophils in sputum (ev = 25%), while FEV(1) %pred was only an additional independent predictor (total ev = 36%). PC(20) AMP reflects more closely the extent of airway inflammation due to asthma than PC(20) methacholine.

Background: Guidelines state that oral and inhaled corticosteroids are the cornerstone of asthma treatment. The effect of both types of treatment can be assessed by measuring lung and systemic parameters. Treatment for two weeks with either oral prednisolone (30 mg/day), high dose fluticasone propionate (2000 microg/day, FP2000), or lower dose FP (500 microg/day, FP500), both given by a dry powder inhaler, were compared., Methods: One hundred and twenty patients with asthma were treated for two weeks in a double blind parallel group design. Lung function, asthma symptoms, airway hyperresponsiveness (PC(20) methacholine and adenosine-5'-monophosphate), sputum eosinophil and eosinophilic cationic protein (ECP) levels were measured as lung parameters. In addition, morning serum blood cortisol, blood eosinophil, and serum ECP levels were measured as systemic parameters., Results: PC(20) methacholine and adenosine-5'-monophosphate showed significantly greater improvement with FP2000 (1.99 and 4.04 doubling concentrations (DC), respectively) than prednisolone (0.90 DC, p = 0.02; 2.15 DC, p = 0. 05) and marginally more than with FP500 (1.69 and 3.54 DC). Changes in sputum eosinophil and ECP concentrations showed similar trends; the decrease in ECP was significantly greater with FP2000 than with FP500. In contrast, the systemic parameters of steroid activity (cortisol, peripheral blood eosinophils, and serum ECP) decreased to a similar extent with FP2000 and prednisolone but significantly less with FP500., Conclusions: Oral prednisolone (30 mg/day) was inferior to FP2000 in improving airway hyperresponsiveness to both methacholine and AMP, with similar trends in forced expiratory volume in one second (FEV(1)), sputum eosinophil and ECP concentrations. Systemic effects were similar with prednisolone and FP2000 and less with FP500.

Nitric oxide (NO) can be measured in exhaled air with the single-breath (SB) and tidal-breathing (TB) methods. To allow comparison between different laboratories, a European Respiratory Society task force recently reported guidelines for standardization of both methods. To facilitate comparison between laboratories further, this study investigated whether there is a difference between NO values measured with SB and TB methods in subjects with asthma or chronic obstructive pulmonary disease (COPD), and in healthy subjects. Moreover, the differences between groups were studied and the influence of smoking in asthma was assessed. Sixteen atopic nonsmoking asthmatics, 16 atopic currently smoking asthmatics, 16 nonatopic nonsmoking healthy controls, 16 nonatopic exsmokers with COPD and 16 nonatopic exsmoking healthy controls were studied. NO concentrations differed substantially between both methods. Mean NO concentrations were higher with the SB than with the TB method in nonsmoking and in smoking asthmatics and especially so with the higher NO values. Furthermore, NO values with both methods were higher in nonsmoking asthmatics than in nonsmoking healthy subjects. NO was not significantly different between exsmokers with COPD and healthy exsmokers. In conclusion nitric oxide values of the single-breath and tidal-breathing methods are not interchangeable. Both methods can be used to measure differences between groups.

Milk proteins are hydrolyzed to prevent immunological reactions, but immunoreactive epitopes, including the ABBOS epitope of bovine serum albumin (BSA), can still be detected in commercially available milk protein hydrolysates. We used lactococcal cell-envelope proteinase (CEP) for the hydrolysis of the individual milk proteins and of mixtures thereof, or for the hydrolysis of sodium caseinate (contaminated with whey proteins). CEP exclusively degraded casein, leaving the four major whey proteins intact. This property facilitated the removal of the intact whey proteins from the casein fragments by ultrafiltration. Depending on the molecular mass of the whey protein to be removed, membranes with cutoff values between 3 and 30 kDa were used, resulting in casein hydrolysates free of protein fragments with cross-reactive whey-protein-specific IgE (immunoglobulin E) or ABBOS antibody-binding sites. Even the casein itself was degraded in such a way by CEP that cross-reactive casein-specific IgE antibody-binding sites could be eliminated. The product could find application in infant formulas for therapeutic and preventive treatment of children with cow's milk allergy; in addition, the preventive use of such formulas in children genetically susceptible to the development of insulin-dependent diabetes mellitus (IDDM) should be considered if a relationship between the consumption of BSA and IDDM were to become more apparent. The method is also applicable for preparing casein-free whey protein preparations.

Measurement of nitric oxide levels in exhaled air is commonly performed using a chemiluminescence detector. However, water vapour and carbon dioxide affect the chemiluminescence process. The influence of these gases at the concentrations present in exhaled air, has not yet been studied. For this in vitro study, mixtures of 50, 100 and 200 parts per billion (ppb) NO in air were prepared and fed into the NO analyser either directly or bubbled through water. Mixtures with CO2 were prepared by adding 0-10% CO2 to the diluent air. We found a significant decrease in NO readings in the water-saturated samples compared to the dry gas (p < 0.001), strongly dependent on the partial pressure of water. NO levels in exhaled air (mean 10 +/- 2 ppb) showed a decrease of 17 +/- 3% when water vapour was not absorbed. From the experiments with CO2 we found a decrease in NO reading of 1.04 +/- 0.07% per volume CO2 (%). Presence of water vapour, thus, leads to a systematic underestimation of NO levels. Insertion of a water absorber might, therefore, be advantageous. The influence of CO2 concentrations in the normal respiratory range is negligible. With high expiratory CO2 levels as applied in permissive hypercapnia, the effects may be substantial.

Since the rise in asthma mortality and morbidity, many guidelines and self-management plans have been published. Many of these guidelines and self-management plans are not, however, based on results of previous studies but on the opinion of experts. We compared the five most frequently cited asthma guidelines concerning treatment steps and self-management plans with special regard to peak expiratory flow (PEF)-guided plans in asthma. We also compared results of published studies with asthma-management in the context of the guidelines. Classification of asthma severity differed considerably between the guidelines. This was also true for PEF-guided patient self-management plans. Although there was agreement on the type of drug to be used, guidelines varied with respect to when to use the drug, the "best" strategy to increase the dose, and the maximum dose. The studies available on self-management do not make it possible to determine which part of the programme is most important or cost-effective. The latter is an important issue.

Objective: Because the bovine serum albumin residues 126-144 (ABBOS) have been reported to be responsible for the autoimmune reaction directed against pancreatic islet cells, it was our aim to study the potential survival of the ABBOS epitope during digestion in the gastrointestinal tract., Research Design and Methods: Either nontreated (commercially available) or heat-treated bovine serum albumin (BSA) was hydrolyzed in vitro with pepsin at a pH of 2.0, 3.0, and 4.0 and subsequently with pancreatic enzymes at a pH of 7.5. Cross-reactivity between the ABBOS peptide and the BSA hydrolysates was determined by competitive enzyme-linked immunosorbent assay (ELISA) using a rabbit polyclonal antibody raised against the ABBOS peptide in BSA., Results: Biochemical findings clearly showed that the degradation of BSA during simulated physiological digestion depended on its conformation and on the pH of its pepsin-catalyzed hydrolysis. Raising the pH of the pepsin-catalyzed hydrolysis from 2.0 to 4.0 decreased the efficiency of the process, especially when BSA had first been denatured by heat treatment. As a consequence, a large proportion of the cross-reactive anti-ABBOS antibody-binding sites was still intact in the final hydrolysates., Conclusions: The present results suggest that the ABBOS epitope of BSA will not be completely eliminated during digestion under conditions that prevail in the stomach of infants (pH 3-4).

Projections from the hippocampal formation to the medial prefrontal cortex are well known. In this report we used two retrogradely transported tracers to show that a small but significant subpopulation of pyramidal neurons in area CA1 and subiculum of the hippocampal formation projects to the lateral prefrontal cortex. About half of these neurons also possess collateral projections to the medial prefrontal cortex. The neurons projecting only to the lateral PFC are found in the intermediate hippocampal formation and in the most ventral part of the temporal subdivision. On the other hand, most of the neurons projecting to the medial prefrontal cortex only are present in the temporal and ventral intermediate hippocampal formation, and their number decreases in the dorsal intermediate subdivision. The distribution of neurons having collateral projections is comparable to that of neurons projecting to the medial prefrontal cortex only. In view of proposed functional differences between the septal one-third and the temporal two-third of the hippocampal formation, it is of interest that the neurons projecting to the prefrontal cortex are only present in the temporal two-thirds.

Objective: Our aim was to determine whether currently available products based on hydrolyzed milk protein and a small peptide (ABBOS) in bovine serum albumin (BSA) (positions 126-144) share common antigenic sites. The commercial products are primarily developed to reduce cow's milk protein-associated allergenicity, but whether they also could be used in intervention trials to elucidate the role of BSA in the etiology of IDDM is not known., Research Design and Methods: A sensitive competitive enzyme-linked immunosorbent assay (ELISA) using a rabbit polyclonal antibody raised against the ABBOS peptide in BSA was developed. With this method, we determined cross-reactivity between the ABBOS peptide and commercially available products: four milk protein hydrolysates and eight infant formulas based on hydrolyzed milk protein. The products were further characterized by physicochemical techniques., Results: Hydrolyzed milk protein products are found to inhibit competitively the binding of ABBOS peptide to antibody. The number of residual reactive sites varied considerably among products and was not strongly related to the degree of hydrolysis (DH) or the molecular mass distribution of the hydrolysates., Conclusions: The presence of possible immunoreactive peptides in infant formulas based on hydrolyzed cow's milk protein cannot be adequately predicted by the DH or molecular mass distribution of the hydrolysates. Its specific determination is needed to ensure infant formulas free of cross-reactive ABBOS antibody binding sites for use in ongoing and forthcoming intervention trials to elucidate the role of BSA as a possible environmental triggering agent of IDDM.

Background: The efficacy of dry powder inhalers depends on the patient's inspiratory flow. Drug delivery from the Turbohaler (Turbuhaler in some countries), a multidose powder inhaler, is optimal at flows of > 40 l/min. The aim of this study was to investigate the peak inspiratory flow that can be generated by asthmatic patients through the budesonide Turbohaler (PIFTBH) during maintenance treatment at home., Methods: Thirty asthmatic patients, consecutively recruited from the outpatient clinic, inhaled their maintenance dose of 800 (n = 16) or 1600 micrograms/day (n = 14) for two months or one month, respectively. The Turbohaler was connected to a modified Vitalograph Compact installed at home to obtain printed PIFTBH values for all inhalations. Peak expiratory flow (PEF) was measured twice daily., Results: Flows were remarkably constant with individual mean PIFTBH values ranging from 55 l/min to 95 l/min. Only 13 of the 5248 PIFTBH recordings taken at home (three patients) were < 40 l/min and all were > 30 l/min. Weekly mean morning PEF values ranged from 114 l/min to 733 l/min. PIFTBH values could not be accurately predicted from lung function parameters in individual patients., Conclusions: In a group of stable asthmatic patients inspiratory flow rates rarely fell below the 40 l/min needed to operate a Turbohaler.

Background: Hypersensitivity to cow milk protein is frequently observed in infancy. Since the pH in the infant's stomach is relatively high (pH 3-4) compared with adults (pH 2), an incomplete digestion of the milk proteins is expected to occur., Objective: The determination of the degree of hydrolysis by pepsin of the four main proteins of bovine whey, i.e. alpha-lactalbumin (alpha La), beta-lactoglobulin (beta Lg), bovine serum albumin (BSA) and bovine immunoglobulin G (B-IgG), in the pH range 2.0-4.0 and of the antigenic properties of the resulting hydrolysates., Methods: Whey proteins were successively hydrolysed with pepsin at pH values ranging from 2.0 to 4.0 and with pancreatic enzymes at pH 7.5 using a pH-stat. The resulting hydrolysates were characterized by their degree of hydrolysis, and analysed by sodium dodecyl sulfate polyacrylamide gel electrophoresis, gel permeation chromatography and immunologically by competitive enzyme-linked immunosorbent assay., Results: In general, the degree of hydrolysis, the gel electrophoretic patterns, the contents of peptides of molecular mass > 5 kDa and the residual human-immunoglobulin E and G antigenicities of the hydrolysates did not differ much whether the pepsin incubation was done at pH 2.0 or 3.0. Pepsin incubation at pH 4.0, however, resulted in a decreased hydrolysis and enhanced residual antigenicity of alpha La, BSA and B-IgG, but not of beta Lg., Conclusion: The poor and slow degradation of the antigenic epitopes of whey proteins when pepsin digestion occurs under conditions that prevail in the stomach of infants could be of much importance for the development of cow milk hypersensitivity. The immature gastrointestinal mucosal barrier of infants allows large antigenic fragments of these proteins to pass into the systemic circulation.

Background: Milk protein hydrolysates are frequently used in milk substitutes for children with cow's milk allergy. However, cases of hypersensitivity to commercially available hypoallergenic infant formulas based on milk protein hydrolysates have been reported., Objective: Our purpose was to determine the immunologic response of milk protein-specific IgE and IgG in the serum of patients allergic to cow's milk against four commercially available hypoallergenic milk protein hydrolysates and eight infant formulas., Methods: Antibody levels in patients' serum and milk protein-specific residual antigenicity of the hypoallergenic products were determined by indirect and competitive ELISA., Results: Patients allergic to cow's milk had IgE and IgG antibodies to several protein fractions of cow's milk; intraindividual and interindividual variation in the concentrations of these antibodies was considerable. In general, IgE and IgG residual antigenicity of individual milk proteins in the hypoallergenic products was lower compared with that of the intact milk protein, but immunoreactive epitopes could still be detected in all products. Their number varied considerably among the individual milk proteins and also differed among products., Conclusions: The individual sensitization pattern of the patient allergic to cow's milk and the milk protein-specific residual antigenicity might be considered as possible laboratory predictors of adverse reactions to hypoallergenic products. Their determination could be a useful preclinical screening test for pediatricians to select a formula adapted to the individual patient.