A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis.

BACKGROUND AND STUDY AIMS: Inadvertent injection of contrast agent into the pancreatic duct is believed to be an important contributor to pancreatitis occurring after endoscopic retrograde cholangiopancreatography (post-ERCP pancreatitis, PEP). Our aim was to examine whether primary deep biliary cannulation with a guide wire is associated with a lower rate of PEP than conventional contrast-assisted cannulation. PATIENTS AND METHODS: From August 2003 to April 2006 all patients with an intact papilla who were referred for ERCP were eligible. Patients with pancreatic or ampullary cancer were excluded. Patients were randomized to undergo sphincterotomy biliary cannulation using either contrast injection or a guide wire. The ERCP fellow attempted initially for 5 minutes. If unsuccessful, the consultant attempted for 5 minutes using the same technique, followed by crossover to the other technique in the same sequence and then needle-knife sphincterotomy where appropriate. Patients were assessed clinically after the procedure, then followed up with telephone interviews after 24 hours and 30 days, and serum amylase and lipase tests after 24 hours. RESULTS: Out of 1654 patients undergoing ERCP, 413 were included in the study. PEP occurred in 29/413 (7.0 %): 16 in the guide-wire arm, 13 in the contrast arm ( P = 0.48). The overall cannulation success rate was 97.3 %. Cannulation was successful without crossover in 323/413 patients (78.2 %): 167/202 (81.4 %) in the guide-wire arm and 156/211 (73.9 %) in the contrast arm ( P = 0.03). Multivariate analysis demonstrated female sex (OR = 2.7, P = 0.04), suspected sphincter of Oddi dysfunction (OR = 5.5, P = 0.01), and complete filling of the pancreatic duct with contrast agent (OR = 3.5, P = 0.02) to be independently associated with PEP. The risk of PEP increased incrementally with each attempt at the papilla (OR 1.4 per attempt, P = 0.04) to greater than 10 % after four or more attempts. CONCLUSIONS: The guide-wire technique improves the primary success rate for biliary cannulation during ERCP but does not reduce the incidence of PEP compared to the conventional contrast technique. The incidence of PEP increases incrementally with each attempt at the papilla.

Guidepost cells.

Guidepost cells, as classically defined in the grasshopper embryo have only rarely been found in other systems. If the concept of guidepost cells is expanded, recognizing that any special role of specific cells in axon guidance is a function of the entire landscape in which axons are growing, and that growth cone--guidepost interactions may share mechanisms with many other cell--cell interactions, then numerous examples are found in both the peripheral and central nervous systems of many species.

Relationship of self-efficacy and binging to adherence to diabetes regimen among adolescents.

OBJECTIVE: To test the hypothesis that poorer adherence to diabetes care is related to four variables associated with self-concept in adolescents with diabetes: self-esteem, self-efficacy, depression, and binging behavior. In addition, we expected adolescent females to be less adherent to diabetes care. RESEARCH DESIGN AND METHODS: We recruited 193 consecutive patients (aged 13-18 yr) with insulin-dependent diabetes mellitus during their regular quarterly visit to a diabetes clinic in a large urban hospital. Participants completed the Rosenberg Self-Esteem Scale, the Children's Depression Inventory, an assessment of the frequency of binging in the past 3 mo, and parallel forms of an adherence scale and a self-efficacy scale that were developed for use in this study. RESULTS: Adolescents who reported lower adherence tended to report lower self-esteem (r = 0.45, P less than 0.001) and self-efficacy (r = 0.57, P less than 0.001), more depressive symptoms (r = -0.50, P less than 0.001), more binging (r = -0.36, P less than 0.001), and had higher HbA1c (r = -0.24, P less than 0.001) than those with higher adherence scores. Together, the psychological variables accounted for 50% of the variance in adherence. There was no sex difference in reported binging, but, as expected, adolescent females reported less adherence overall (F[7,184] = 2.5, P = 0.018). CONCLUSIONS: Treatment adherence in adolescents with insulin-dependent diabetes mellitus is associated with behavioral and psychological variables. These findings suggest that specific behavioral and cognitive interventions could be used to improve adherence in those individuals who lack confidence in their ability to perform diabetes-related tasks.

Evidence for a major gene for bone mineral density in idiopathic osteoporotic families.

Although there have been a number of studies indicating a heritable component for osteoporosis in middle to late adulthood, the etiology of osteoporosis in young people is uncertain. The present study aims to evaluate the extent to which genetic factors influence familial resemblance for bone mineral density (BMD) in families ascertained on the basis of young osteoporotic probands. The sample comprises eight families (74 total individuals) that were identified through a proband under the age of 35 years with a history of two or more fractures and a spinal bone density of at least 2.5 SDs below the mean for age and sex (Z score). Secondary causes of osteoporosis were excluded in the probands. In total, 27% (18/66) of the probands' relatives had osteoporosis and an additional 30% (20/66) had osteopenia. Classical segregation analysis was performed to evaluate the extent to which a genetic etiology could account for familial resemblance in these families. The results indicate a major gene of codominant inheritance for spinal BMD. Model-fitting comparisons revealed no support for environmental effects or for polygenic inheritance.

Epidermal growth factor stimulates insulin-like growth factor-binding protein-1 expression in the neonatal rat.

Insulin-like growth factors (IGFs) and the IGF-binding proteins (IGFBPs) appear to be important in the regulation of perinatal growth. We have shown previously that administration of epidermal growth factor (EGF) to newborn rat pups inhibits growth and decreases serum IGF-I concentrations. The experiments described here were designed to investigate the effect of EGF on the IGFBPs using ligand blots of serum and Northern analysis of hepatic RNA. EGF administration caused a rapid (within 2 h) 2-fold increase in the serum IGFBP-1 concentration. Hepatic IGFBP-1 mRNA increased even more rapidly, was increased at least 2-fold at 2 h, and remained elevated 4 h after EGF. The response to EGF was specific to IGFBP-1; IGFBP-2 hepatic mRNA content was not increased over the control value, and serum IGFBP-3 and -4 concentrations were not changed by ligand blot analysis. The IGFBP-1 response to EGF was most dramatic in the first few days of life. Although EGF lowered circulating insulin levels, EGF stimulated IGFBP-1 secretion in the presence of exogenously administered insulin. Thus, the increase in IGFBP-1 did not appear to be mediated by changes in serum insulin. These results demonstrate that EGF increases serum IGFBP-1 concentrations, probably by stimulating synthesis. The association of decreased growth and increased IGFBP-1 concentrations after EGF treatment suggests that elevated IGFBP-1 concentrations may restrict IGF bioactivity in the neonatal rat.

Signal transduction pathways in constriction of the basilar artery in vivo.

We examined effects of a putative myosin light chain kinase inhibitor in the cerebral circulation in vivo. In anesthetized rats, diameter of basilar arteries was measured through a cranial window (control, 232 +/- 10 microns, mean +/- SEM). Vessel diameter was measured during topical application of agonists and antagonists. ML-7, which has been reported to compete with adenosine triphosphate for binding to the catalytic site on myosin light chain kinase, attenuated vasoconstriction in response to prostaglandin F2 alpha (10(-6) M; -22 +/- 1% before versus -14 +/- 1% and -3 +/- 2% during ML-7, 10(-7) and 10(-6) M, respectively; p less than 0.05). ML-7 (10(-6) M) did not affect baseline diameter. Responses to serotonin (10(-8) M) and phorbol 12,13-dibutyrate (10(-8) M) were not attenuated by ML-7. Thus, constriction of the basilar artery induced by prostaglandin F2 alpha in vivo is attenuated by an inhibitor of myosin light chain kinase.

Hormone replacement therapy causes a respiratory alkalosis in normal postmenopausal women.

Menopause is associated with an increase in venous bicarbonate concentrations that is reversible with hormone replacement therapy (HRT). However, the mechanism underlying this effect is not known. To address this question, we studied the changes in acid-base indexes in the arterialized venous blood of normal postmenopausal women commencing conjugated equine estrogen (0.625 mg/day), medroxyprogesterone acetate (MPA; 5 mg/day), their combination, or placebo, in a double blind randomized controlled study over 3 months. Serum bicarbonate concentrations decreased significantly in the groups receiving either MPA or estrogen plus MPA (P = 0.008). This trend was apparent as early as 2 days and reached 2.7 and 2.3 mmol/L in the respective groups by 3 months. Similar changes were seen with partial pressure of carbon dioxide (P = 0.04); a change of -0.7 kPa occurred in the estrogen plus MPA group at 3 months. There were no changes in bicarbonate concentrations or partial pressure of carbon dioxide in those receiving estrogen alone or placebo. Accompanying changes in blood pH were apparent in the estrogen plus MPA group, where there was an upward trend at 1 week (P = 0.056) and a significant change from baseline (+0.013) at 3 months (P = 0.03). In the whole group, the changes in pH were inversely correlated with those in urinary excretion of hydroxyproline (r = -0.44; P = 0.01). We conclude that HRT using conjugated estrogens and MPA produces small, but sustained, changes in acid-base status. These may contribute to the effects of HRT and menopause on many tissues and disease processes, including the development of osteoporosis.

Changes in mitochondrial DNA during aging.

Mitochondrial DNA (mtDNA) was isolated from liver mitochondria of rats between 2 and 24 months of age. The mtDNA was purified by cesium chloride--ethidium bromide isopycnic density gradient centrifugation. In the gradients, in addition to the two expected bands of ethidium--DNA complex, there was observed a third, more dense band (d = 1.69 g/cm3). This novel band, rarely observed in preparations from younger animals, was present in most preparations from older animals. The latter was characterized using the diphenylamine assay(s) and ascertained to contain DNA and carbohydrate components. Agarose gel electrophoresis revealed the DNA of the novel band to have a migration identical to form I mtDNA. Digestion of the novel band with the restriction endonuclease Bam HI yielded products identical to those obtained upon treatment of form I mtDNA with Bam HI. The observation of mtDNA at a density of 1.69 g/cm3 indicates the presence, predominantly in older animals, of a subclass of mtDNA molecules with altered ethidium binding properties. The significance of this mtDNA and its position in the gradient is unclear at this time.

Hydrochlorothiazide reduces loss of cortical bone in normal postmenopausal women: a randomized controlled trial.

PURPOSE: Thiazide diuretics reduce urine calcium excretion and might therefore reduce postmenopausal bone loss. In some, but not all, case-control studies, their use has been associated with a reduced incidence of hip fractures. We studied the effects of hydrochlorothiazide on bone loss in normal postmenopausal women. SUBJECTS AND METHODS: We performed a randomized, double-blind, 2-year trial of the effects of hydrochlorothiazide (50 mg per day) and placebo on bone mineral density in normal postmenopausal women. Participants were not required to have either low bone mineral density or hypertension. Bone mineral density was measured using dual-energy x-ray absorptiometry. RESULTS: One hundred eighty-five women entered the study, of whom 138 completed 2 years of follow-up. In an intention-to-treat analysis, hydrochlorothiazide produced significant benefits on bone mineral density of the total body (between-group difference at 2 years of 0.8%, 95% confidence interval [CI]: 0.3% to 1.3%, P <0.0001), legs (0.9%, 95% CI: 0.2% to 1.7%, P <0.0001), mid-forearm (1.2%, 95% CI: 0.2% to 2.2%, P = 0.02), and ultradistal forearm (1.7%, 95% CI: 0.1% to 3.2%, P = 0.04). There was no effect in the lumbar spine (0.5%, 95% CI: -0.5% to 1.6%) or femoral neck (0.2%, 95% CI: 1.3% to 1.7%). The between-group changes tended to be greatest during the first 6 months, except in the mid-forearm where there appeared to be a progressive divergence. An as-treated analysis produced similar results. Urine calcium excretion and indices of bone turnover decreased in the thiazide group, but parathyroid hormone concentrations did not differ between the groups. Treatment was tolerated well. CONCLUSIONS: Hydrochlorothiazide (50 mg per day) slows cortical bone loss in normal postmenopausal women. It may act directly on bone as well as on the renal tubule. The small size of the effect suggests that thiazides may have a role in the prevention of postmenopausal bone loss, but that they are not an appropriate monotherapy for treating osteoporosis.

Cell proliferation in denervated muscle: time course, distribution and relation to disuse.

The effects of denervation on skeletal muscle fibers have been intensively investigated, but the effects on other cell types within muscle tissue are not well understood. In the present experiments, cell proliferation was analyzed in mouse extensor digitorum longus muscles denervated for periods of one day to six weeks. Incorporation of tritiated thymidine into DNA increased 36 h after denervation, reached a maximum at a level twenty times control at 4 days, and returned towards control values by 7 days. Incorporation first increased in the endplate area, but 12 h later involved the entire muscle. Six weeks after denervation, muscles labeled at 4 days had lost 90% of the total label. Muscle disuse, produced by tetrodotoxin block of the nerve for up to 4 days, did not result in a proliferative response. Thus, cell proliferation after denervation is not a response to simple disuse, but rather to a nerve- or muscle-related mitogen. Since the response is mostly distributed throughout the entire muscle, the mitogen probably emanates from muscle fibers.

Cell proliferation in denervated muscle: identity and origin of dividing cells.

DNA synthesis in skeletal muscle increases dramatically during the first week after denervation. In the present study, we have characterized the dividing cells in order to assess the specificity and significance of this response to denervation. Autoradiography of [3H]thymidine-labeled denervated muscles revealed that many classes of cells were dividing, including fibroblasts (the most numerous of the labeled cells), macrophages, vascular cells, muscle satellite cells, spindle capsule cells, perineurial cells and Schwann cells. The number of labeled satellite cells accounted for no more than 10% of the dividing cells. Labeling indices of spindle capsule, perineurial and Schwann cells reached a maximum 3 days after denervation, while those of fibroblasts and macrophages peaked at 4 days. The former group of cells, which are in close contact with nerve trunks, accounted for 28% of cell division on day 3 (but only 5% on day 4) and were apparently responding to a local influence from degenerating axons. Connective tissue cells, making up the largest class of dividing cells (80% on day 4) were found throughout the muscle and appeared to proliferate in response to changes occurring along the entire length of the muscle fibers. Macrophages involved in the response were mostly resident histiocytes, since prior labeling of blood cells showed that leukocytes did not enter the muscle in substantial number after denervation. Both muscle satellite cells and connective tissue cells are essential for the functional regeneration of muscle. Thus, on the basis of overall cytologic characterization, cell division after denervation seems to represent a limited regenerative response.

Cromakalim-induced relaxation of guinea-pig isolated trachealis: antagonism by glibenclamide and by phentolamine.

1. Tested against the spontaneous tone of guinea-pig isolated trachealis, cromakalim (0.1-100 microM), isoprenaline (1 nM-1 microM) and theophylline (1 microM-1 mM) each produced concentration-dependent relaxation. 2. Glibenclamide (0.1-10 microM) did not itself alter the spontaneous tone of the trachea nor did it modify the relaxant actions of isoprenaline or theophylline. In contrast, glibenclamide (0.1 and 1 microM) caused a concentration-dependent rightward shift of the log concentration-effect curve of cromakalim. Glibenclamide (10 microM) reduced the slope of the log concentration-effect curve of cromakalim and moved the foot of the curve back towards the control position. 3. Phentolamine (1, 10 and 100 microm) did not itself alter the spontaneous tone of the trachea nor did it modify the relaxant actions of isoprenaline or theophylline. In contrast phentolamine caused concentration-dependent depression of the log concentration-effect curve of cromakalim. 4. Neither prazosin (1 microM) nor yohimbine (10 microM) modified the spontaneous tone of the trachea. Prazosin and yohimbine each failed to antagonise the effects of cromakalim, isoprenaline and theophylline. 5. Intracellular electrophysiological recording showed that glibenclamide (1 microM) and phentolamine (100 microM) caused minor change in the resting membrane potential of trachealis cells. Slow wave activity was slightly depressed by these agents. In contrast tetraethylammonium (TEA; 8 mM) caused marked depolarisation, and promoted the conversion of slow waves into regenerative action potentials. These electrical changes were accompanied by tonic tension development. 6. Phentolamine (100 microM) and glibenclamide (1 microM) reduced and reversed both the relaxation and the hyperpolarisation induced by cromakalim (10 microM). 7. It is concluded that glibenclamide and phentolamine each provide selective antagonism of the relaxant action of cromakalim in guinea-pig trachealis. These agents also inhibit the plasmalemmal hyperpolarisation induced by cromakalim. The effect of phentolamine is unrelated to the blockade of alpha 1- or alpha 2-adrenoceptors. If either glibenclamide or phentolamine act to block the K+ channels opened by cromakalim, then such channels are not identical to those which endow the trachealis plasmalemma with its powerful rectifying behaviour.

Guinea-pig isolated trachealis: the effects of charybdotoxin on mechanical activity, membrane potential changes and the activity of plasmalemmal K(+)-channels.

1. A study has been made, in guinea-pig isolated trachealis, of the effects of charybdotoxin in modulating (a) the activity of large conductance K(+)-channels, (b) the spontaneous electrical activity of intact cells and (c) the mechanical effects of some bronchodilator drugs. 2. Single smooth muscle cells were isolated from guinea-pig trachealis by enzymic digestion and were studied by the patch clamp recording technique. Recordings were made from outside-out plasmalemmal patches when the medium bathing the external surface of the patches contained 1.2 mM Ca2+ and 6 mM K+ while that bathing the cytosolic surface contained 0.1 microM Ca2+ and 140 mM K+. Charybdotoxin (100 nM), applied to the external surface of patches held at 0 mV, abolished the unitary currents associated with the opening of large conductance K(+)-channels. 3. Opened segments of guinea-pig trachea were used for the simultaneous recording of membrane potential and tension changes. In these experiments charybdotoxin (100 nM) caused the conversion of spontaneous electrical slow waves into spike-like action potentials. This effect was accompanied by a very small reduction in resting membrane potential. 4. Tissue bath recording showed that charybdotoxin (100 nM) increased the spontaneous mechanical tone of the tissue, antagonized (2.8 fold in each case) the relaxant actions of isoprenaline and theophylline but did not antagonize the relaxant actions of cromakalim or RP 49356. 5. It is concluded that charybdotoxin is an effective inhibitor of large conductance K(+)-channels in guinea-pig trachealis cells. The ability of charybdotoxin to convert spontaneous slow waves into spike-like action potentials suggests that the large, charybdotoxin-sensitive, K+-channels play an important role in determining the strong outward rectifying behaviour of the cells. The ability of charybdotoxin to antagonize isoprenaline and theophylline, but not to antagonize cromakalim and RP 49356, suggests that opening of the large conductance, charybdotoxin-sensitive K+-channel is implicated in the action of the former but not the latter pair of bronchodilator drugs.

Endocrine changes in male sexual deviants after treatment with anti-androgens, oestrogens or tranquillizers.

The endocrine effects of drugs on two groups of 12 male sexual offenders in a special hospital were studied. In the first study benperidol, chlorpromazine and placebo were compared and in the second ethynyl oestradiol and cyproterone acetate were compared with no treatment. In the first study there was no difference between the three drugs in their effects on plasma testosterone or luteinizing hormone (LH). In the second study cyproterone acetate produced a reduction in plasma testosterone, LH and follicle-stimulating hormone (FSH). Ethynyl oestradiol produced a rise in plasma testosterone and LH, and no change in FSH. Neither drug changed total plasma oestrogen levels. The unexpected effects of ethynyl oestradiol were attributed to an increase in sex hormone-binding globulin (SHBG) leading to a rise in bound, inactive testosterone. Direct measurement showed a two- to threefold increase in SHBG with ethynyl oestradiol treatment and no change in SHBG with cyproterone acetate treatment. In spite of these contrasting endocrine effects, ethynyl oestradiol, cyproterone acetate and benperidol produced similar behavioural changes.

Systemic administration of adrenomedullin(27-52) increases bone volume and strength in male mice.

Adrenomedullin is a 52-amino acid peptide first described in a human phaeochromocytoma but since been found to be present in many tissues, including the vascular system and bone. Because of its structural similarity to amylin and calcitonin gene-related peptide, both of which have actions on bone cells, we have previously assessed the effects of adrenomedullin on the skeleton, and found that it increases osteoblast proliferation in vitro and bone formation following local injection in vivo. The present study carries this work forward by assessing the effects on bone of the systemic administration of a fragment of this peptide lacking the structural requirements for vasodilator activity. Two groups of 20 adult male mice received 20 injections of human adrenomedullin(27-52) 8.1 microg or vehicle over a 4-week period and bone histomorphometry and strength were assessed. In the tibia, adrenomedullin(27-52) produced increases in the indices of osteoblast activity, osteoid perimeter and osteoblast perimeter (P<0.05 for both using Student's t-test). Osteoclast perimeter was not affected. There was a 21% increase in cortical width and a 45% increase in trabecular bone volume in animals treated with adrenomedullin(27-52) (P<0.002 for both). Assessment of bone strength by three-point bending of the humerus showed both the maximal force and the displacement to the point of failure were increased in the animals treated with adrenomedullin(27-52) (P<0.03 for both). There was also a significant increase in the thickness of the epiphyseal growth plate. No adverse effects of the treatment were noted. It is concluded that adrenomedullin(27-52) acts as an anabolic agent on bone. These findings may be relevant to the normal regulation of bone mass and to the design of agents for the treatment of osteoporosis.

Inhibitory effect of dibenzofuran and dibenzosuberol derivatives on rhinovirus replication in vitro; effective prevention of viral entry by dibenzosuberenone.

A series of derivatives of dibenzofuran and dibenzosuberol block rhinovirus replication in vitro as judged by their ability to hinder the cytopathic effect in cells infected with HRV14 or HRV16. Both the number and the size of viral plaques were reduced effectively by treatment with these compounds in a dose-dependent fashion, thus affecting viral spread. The compound 2-hydroxy-3-dibenzofuran carboxylic acid was equally effective against HRV16 and HRV14, with IC50 values of 25 microM in cytopathy assays. Dibenzosuberenone showed minor differences in selectivity, with IC50 values of 10 and 30 microM for HRV16 and HRV14 cytopathy, respectively. Likewise, dibenzosuberenone effectively prevented the production of HRV16 proteins, viral RNA, and infectious virus particles when present at concentrations above 30 microM. Time-of-addition experiments show that compounds must be administered before or during the viral adsorption step in order to be effective antivirals. Dibenzosuberenone can block the adsorption of viral particles on to cells, preventing further steps in the replication cycle, but is not effective as a direct inactivating agent. These compounds likely interact with viral capsid proteins, affecting receptor interactions required for attachment and subsequent entry into cells.

Expression of insulin-like growth factor binding protein-4 (IGFBP-4) by rat neural cells--comparison to other IGFBPs.

We recently isolated and characterized the 24 kDa and N-glycosylated 28 kDa insulin-like growth factor binding protein-4 (rIGFBP-4) from the B104s rat neuronal cell line (Endocrinology, 129 (1991) 1009-1115). To examine the prevalence of IGFBP-4 secretion by cells of neural origin, we assessed the expression of IGFBP-4 in different neural cell types using ligand blotting, immunoblotting and blot hybridization with relevant cDNAs. A specific IGFBP-4 antibody raised against a synthetic 20 amino acid peptide was used for immunologic recognition. In all the neural cells tested (B104s, C6 astrocytoma, primary neonatal astrocytes and primary fetal neurons), IGFBP-4 was definitively identified by immunoblotting. Blot hybridization using a rat cDNA probe revealed expression of IGFBP-4 mRNA transcripts by all these cells. Using a combination of the same techniques, expression of IGFBP-1, -2, and -3 were also examined. The B104s cells secreted primarily IGFBP-4; C6 cells secreted predominantly IGFBP-3 and small amount of IGFBP-4; both primary neonatal astrocytes and fetal neurons secreted IGFBP-2 as the major IGFBP accompanied by a small quantity of IGFBP-4. IGFBP-1 was not identified in any of the cell media. When probed with the respective IGFBP cDNAs, the mRNA abundance generally reflected the media IGFBP content. The expression of IGFBP-4 mRNA in vivo was examined as well and compared to that of IGFBP-1 and IGFBP-2. Transcripts for both IGFBP-2 and IGFBP-4 were found in all gross anatomical divisions of the rat brain from embryonic day 15 until adulthood, whereas IGFBP-1 was not detected at any time. IGFBP-4 mRNA tended to be more abundant at the youngest ages whereas IGFBP-2 increased during development. These data indicate that IGFBP-4 is produce by a variety of neural cell types and suggest that it may play a role in brain development.

Global budgeting in Germany: lessons for the United States.

In 1993 Germany implemented significant health reform legislation that, among other things, strengthened the global budgeting of physicians and instituted global budgeting of pharmaceutical expenditures. German physician expenditures are now capped at the growth in income of members of the sickness funds, in contrast to prior years, in which some growth above a targeted level was allowed. For the first time, dental services also are subject to the budget cap. The new reform legislation also limits growth in pharmaceutical expenditures by increasing the level of copayments and by placing physicians as a group at financial risk for growth over the limit. This paper examines the effect of these reforms during the first year and offers lessons for reform of the U.S. system.

Influence of functional impairment and social support on depressive symptoms in persons with diabetes.

Tested the buffering model of social support among 158 adults with diabetes. We predicted that, among patients with higher levels of illness-related impairment, adequate social support would act as a buffer against depression. Measures included the Beck Depression Inventory; the Sickness Impact Profile; and an assessment of the adequacy of social support to enable the patient to deal with illness-related tasks, domestic chores, financial responsibilities, and emotional needs. Depressive symptoms correlated positively with functional impairment (r = .58, p less than .001) and negatively with the adequacy of social support (r = -.31, p less than .001). In addition, social support moderated depression in the face of greater impairment such that, among patients who reported the most illness-related functional disabilities, adequate support provided a relative protection from depression. The findings suggest that individuals with inadequate support are most at risk to become depressed when disability related to illness increases.

Peptidyl diazomethyl ketones inhibit the human rhinovirus 3C protease: effect on virus yield by partial block of P3 polyprotein processing.

The efficacy of a series of diazomethyl ketones (DMKs) was measured in rhinovirus-infected cultures and against the HRV14 3C protease. Their specificity and potency were confirmed against purified recombinant enzyme expressed in a yeast secretion system. An internally quenched fluorescent peptide substrate was used to assess the potency against the enzyme, obtaining a 50% inhibitory concentration (IC50) of 1 microM for both Z-L-F-Q-CHN2 and Z-V-L-F-Q-CHN2, while a lower affinity was observed for Z-F-Q-CHN2. The tripeptide Z-L-F-Q-CHN2 blocked viral replication with an IC50 value of 30 microM as judged by the reduction in viral induced cytopathy of HeLa-H1 cells, as well as a marked reduction in viral plaque formation (50% effective concentration=20 microM). Western blot analysis of viral proteins from infected cells indicates that this inhibitor works specifically by blocking viral polyprotein maturation, displaying a reduction of detectable 3C protease and an accumulation of the 3CD polypeptide. These results indicate that DMK inhibitors of the 3C protease have antiviral potency. Furthermore, the pattern of viral protein processing observed suggests that reducing the concentration of mature HRV 3C protease even in the presence of increased 3CD protein is sufficient to block proper viral processing and significantly reduce virus yield.