Variants regulating ZBTB4 are associated with age-at-onset of Alzheimer's disease.

The identification of novel genetic modifiers of age-at-onset (AAO) of Alzheimer's disease (AD) could advance our understanding of AD and provide novel therapeutic targets. A previous genome scan for modifiers of AAO among families affected by early-onset AD caused by the PSEN2 N141I variant identified 2 loci with significant evidence for linkage: 1q23.3 and 17p13.2. Here, we describe the fine-mapping of these 2 linkage regions, and test for replication in 6 independent datasets. By fine-mapping these linkage signals in a single large family, we reduced the linkage regions to 11% their original size and nominated 54 candidate variants. Among the 11 variants associated with AAO of AD in a larger sample of Germans from Russia, the strongest evidence implicated promoter variants influencing NCSTN on 1q23.3 and ZBTB4 on 17p13.2. The association between ZBTB4 and AAO of AD was replicated by multiple variants in independent, trans-ethnic datasets. Our results show association between AAO of AD and both ZBTB4 and NCSTN. ZBTB4 is a transcriptional repressor that regulates the cell cycle, including the apoptotic response to amyloid beta, while NCSTN is part of the gamma secretase complex, known to influence amyloid beta production. These genes therefore suggest important roles for amyloid beta and cell cycle pathways in AAO of AD.

PCOSMIC: a multi-centre randomized trial in women with PolyCystic Ovary Syndrome evaluating Metformin for Infertility with Clomiphene.

BACKGROUND: Ovulation induction treatment with metformin, either alone or in combination with clomiphene citrate (CC), remains controversial even though previous randomized trials have examined this. METHODS: A double blinded multi-centre randomized trial was undertaken including 171 women with anovulatory or oligo-ovulatory polycystic ovary syndrome. Women with high body mass index (BMI) > 32 kg/m(2) received placebo ('standard care') or metformin; women with BMI < or = 32 kg/m(2) received CC ('standard care'), metformin or both. Treatment continued for 6 months or until pregnancy was confirmed. Primary outcomes were clinical pregnancy and live birth. RESULTS: For women with BMI > 32 kg/m(2), clinical pregnancy and live birth rates were 22% (7/32) and 16% (5/32) with metformin, 15% (5/33) and 6% (2/33) with placebo. For women with BMI < or = 32 kg/m(2), clinical pregnancy and live birth rates were 40% (14/35) and 29% (10/35) with metformin, 39% (14/36) and 36% (13/36) with CC, 54% (19/35) and 43% (15/35) with combination metformin plus CC. CONCLUSIONS: There is no evidence that adding metformin to 'standard care' is beneficial. Pregnancy and live birth rates are low in women with BMI > 32 kg/m(2) whatever treatment is used, with no evidence of benefit of metformin over placebo. For women with BMI < or = 32 kg/m(2) there is no evidence of significant differences in outcomes whether treated with metformin, CC or both. ClinicalTrials.gov number NCT00795808; trial protocol accepted for publication November 2005: Johnson, Aust N Z Journal Obstet Gynaecol 2006;46:141-145.

A critical assessment of the role of antiphospholipid antibodies in infertility.

Antiphospholipid antibodies (aPL) are a family of autoantibodies that are associated with pregnancy complications including stillbirth and recurrent miscarriage. Infertile women, and those with recurrent IVF implantation failure, have an increased incidence of aPL (22% and 30%, respectively) compared with a healthy, fertile population (1-3%). Despite this increased incidence, aPL are not predictive of an adverse outcome from IVF. In this review we critically assess the literature in this field, which we believe to be awash with poorly designed studies. Our main criticism is that studies have not examined the fertility outcomes for individual aPL, but rather have examined outcomes for women with between one and eight different aPL. The wide range of antibodies tested and collectively analyzed means that any clinically relevant effects of a specific antibody would be undetectable, if such effects exist. It is also difficult to envisage how aPL present in the maternal blood might damage zygotes or embryos in order to induce infertility. We review the experimental data, looking at possible mechanisms by which aPL might induce infertility. Despite the multiplicity of studies we demonstrate in this review that the question of whether aPL are associated with, or cause, reduced fertility remains unanswered. We also demonstrate that there is no evidence that supposedly aPL-induced infertility or implantation failure after IVF can be treated with pharmacological interventions.

Exercise Evaluation Randomised Trial (EXERT): a randomised trial comparing GP referral for leisure centre-based exercise, community-based walking and advice only.

OBJECTIVES: To evaluate and compare the effectiveness and cost-effectiveness of a leisure centre-based exercise programme, an instructor-led walking programme and advice-only in patients referred for exercise by their GPs. DESIGN: A single-centre, parallel-group, randomised controlled trial, consisting of three arms, with the primary comparison at 6 months. SETTING: Assessments were carried out at Copthall Leisure Centre in Barnet, an outer London borough, and exercise programmes conducted there and at three other leisure centres and a variety of locations suitable for supervised walking throughout the borough. PARTICIPANTS: Participants were aged between 40 and 74 years, not currently physically active and with at least one cardiovascular risk factor. INTERVENTIONS: The 943 patients who agreed to participate in the trial were assessed in cohorts and randomised to one of the following three arms: a 10-week programme of supervised exercise classes, two to three times a week in a local leisure centre; a 10-week instructor-led walking programme, two to three times a week; an advice-only control group who received tailored advice and information on physical activity including information on local exercise facilities. After 6 months the control group were rerandomised to one of the other trial arms. Assessments took place before randomisation, at 10 weeks (in a random 50% subsample of participants), 6 months and 1 year in the leisure centre and walking arms. The control participants were similarly assessed up to 6 months and then reassessed at the same intervals as those initially randomised to the leisure centre and walking groups. MAIN OUTCOME MEASURES: The primary outcome measures were changes in self-reported exercise behaviour, blood pressure, total cholesterol and lipid subfractions. Secondary outcomes included changes in anthropometry, cardiorespiratory fitness, flexibility, strength and power, self-reported lifestyle behaviour, general and psychological health status, quality of life and health service usage. The costs of providing and making use of the service were quantified for economic evaluation. RESULTS: There was a net increase in the proportion of participants achieving at least 150 minutes per week of at least moderate activity in the sport/leisure and walking categories in all three study groups: at 6 months, the net increases were 13.8% in the leisure centre group, 11.1% in the walking group and 7.5% in the advice-only group. There were significant reductions in systolic and diastolic blood pressure in all groups at each assessment point compared with baseline. There were also significant and sustained improvements in cardiorespiratory fitness and leg extensor power, and small reductions in total and low-density lipoprotein cholesterol in all groups, but there were no consistent differences between the groups for any parameter over time. All three groups showed improvement in anxiety and mental well-being scores 6 months after the beginning of the trial. Leisure centre and walking groups maintained this improvement at 1 year. There were no differences between groups. Costs to the participants amounted to pound 100 for the leisure centre scheme and pound 84 for the walking scheme, while provider costs were pound 186 and pound 92, respectively. Changes in overall Short Form 36 scores were small and advice only appeared the most cost-effective intervention. CONCLUSIONS: The results of this trial suggest that referral for tailored advice, supported by written materials, including details of locally available facilities, supplemented by detailed assessments may be effective in increasing physical activity. The inclusion of supervised exercise classes or walks as a formal component of the scheme may not be more effective than the provision of information about their availability. On cost-effectiveness grounds, assessment and advice alone from an exercise specialist may be appropriate to initiate action in the first instance. Subsidised schemes may be best concentrated on patients at higher absolute risk, or with specific conditions for which particular programmes may be beneficial. Walking appears to be as effective as leisure centre classes and is cheaper. Efforts should be directed towards maintenance of increased activity, with proven measures such as telephone support. Further research should include an updated meta-analysis of published exercise interventions using the standardised mean difference approach.

Ultrasound versus 'clinical touch' for catheter guidance during embryo transfer in women.

BACKGROUND: Many women undergoing an Assisted Reproductive Technology (ART) cycle will not achieve a live birth. Failure at the embryo transfer stage may be due to poor embryo quality, lack of uterine receptivity, or the transfer technique itself. Numerous methods, including the use of ultrasound guidance for proper catheter placement in the endometrial cavity, have been suggested as a means of improving the technique of embryo transfer. This review evaluates the effectiveness of ultrasound (UGET) in comparison with 'clinical touch' embryo transfer (CTET) the traditional method of embryo transfer. OBJECTIVES: :To determine whether ultrasound guidance influences treatment outcomes in women undergoing embryo transfer (ET) during assisted reproductive technology (ART) cycles. SEARCH STRATEGY: All electronic databases were searched on 20 th August 2006. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched August 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2006), MEDLINE (1970-2006), EMBASE (1985-2006), BIO Extracts (1980-2006). Relevant conference proceedings were also hand searched (ASRM, ESHRE and FIGO). SELECTION CRITERIA: Only randomised controlled trials were included. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility and quality of trials and extracted data from those selected. MAIN RESULTS: Thirteen out of fifteen identified studies were eligible for analysis. No study reported live births, however, personal communication resulted in data relating to this outcome being obtained in two of the studies. Six studies reported on ongoing pregnancies. The live birth/ ongoing pregnancies per woman randomised associated with UGET (452/1376) was significantly higher than for clinical touch (353/1338) OR 1.40, 95%CI 1.18 to 1.66, P<0.0001). This means, for example, that for a population of women with a 25% chance of pregnancy using clinical touch this would be increased to 32% (28% to 46%) by using UGET. There were no statistically significant differences in the incidence of adverse events between the two comparison groups with the exception of blood on the catheter. AUTHORS' CONCLUSIONS: The studies are limited by their quality with only one of the thirteen studies reporting details of both computerised randomisation techniques and adequate allocation concealment. Ultrasound guidance does appear to improve the chances of live/ongoing and clinical pregnancies compared with clinical touch methods. The quality of future studies should be improved with adequate reporting of randomisation, allocation concealment, and power calculations. The primary outcome measure of future studies should be the reporting of live births per woman randomised.

Antiphospholipid antibodies in serum and follicular fluid--is there a correlation with IVF implantation failure?

BACKGROUND: Antiphospholipid antibodies (aPLs) are associated with infertility, but the mechanism underlying this statistical association is currently obscure. We aimed to investigate the finding that aPLs are concentrated in follicular fluid and to establish if this is associated with a poorer outcome from IVF. METHODS AND RESULTS: In 19.2% of 99 women undergoing IVF, at least one aPL was detected in their serum and/or follicular fluids, but the antibody levels in follicular fluid were not higher than in serum. Women with aPLs had a lower implantation rate (14%) than women without these antibodies (24.1%), but this difference was not significant (P=0.127). There was also a non-significant reduction in the live birth rate for women with aPLs. In a parallel investigation, 10 sheep immunized with beta2 glycoprotein I (beta2GPI) or irrelevant control antigens showed strong immune responses, but there were no significant differences between the levels of antibodies in the follicular fluid or serum from beta2GPI or control immunized sheep. CONCLUSION: aPLs do not appear to be selectively concentrated in follicular fluids and, when present, do not adversely affect the reproductive outcome of women undergoing IVF.

Morbidity, deprivation, and antidepressant prescribing in general practice.

BACKGROUND: Although the link between depression, unemployment, and measures of deprivation and morbidity has been previously documented, the relationship between general practice prescribing of antidepressants, morbidity, and the social demography of general practice populations is poorly understood. AIM: To consider whether morbidity and the social demography of general practice populations influence the prescribing costs of individual practices. METHOD: Data were analysed, using a forward stepwise regression procedure, of all 78 practices served by the Cornwall and Isles of Scilly Health Authority. Data on prescribing for antidepressants were provided by the Prescription Pricing Authority for the period from July to December 1995 and converted into defined daily doses (DDDs) to standardize for the variation in prescribing practice between general practitioners. RESULTS: A significant positive correlation exists between the rates of prescribing DDDs of antidepressants by general practices and the prevalence of permanent sickness in the areas in which these practices serve. CONCLUSION: Demonstrating an association between morbidity and prescribing rates for depression may prove helpful in setting prescribing budgets.

Sociodemographic and morbidity indicators of need in relation to the use of community health services: observational study.

OBJECTIVE: To examine whether the sociodemographic and morbidity characteristics of populations influence their use of the following community heath services: district nursing, health visiting, chiropody, community maternity, community mental illness, and the professions allied to medicine. DESIGN: Observational study. SETTING: Nationally representative sample of provider trusts in England. MAIN OUTCOME MEASURES: Activity levels for each service calculated for enumeration districts within the catchment areas of the sample of trusts and standardised to allow for differences in age structure. Regression analysis to determine whether the standardised activity rates for each service could be predicted by a range of socio-demographic and morbidity proxies. RESULTS: Morbidity or deprivation, or both, seemed to influence the use of services in each of the care programmes examined. CONCLUSIONS: The allocation of funds for community health services should allow for differences in the health and socio-demographic characteristics of health authorities.

A cost comparison of hysterectomy and hysteroscopic surgery for the treatment of menorrhagia.

OBJECTIVES: To estimate and compare the costs of treating women with menorrhagia by hysterectomy or hysteroscopic surgery, in the form of transcervical resection of the endometrium (TCRE) or endometrial laser ablation (ELA). STUDY DESIGN: Randomised controlled trial set in the gynaecological department of a large British teaching hospital. Under usual circumstances, 204 women who would have undergone hysterectomy for menorrhagia were randomly allocated to either hysterectomy (n = 99) or hysteroscopic surgery in the form of TCRE (n = 52) or ELA (n = 53). National Health Service (NHS) costs and costs to patients per patient occurring up to 1 year following surgery were estimated. Theatre times and length of hospital stay were recorded during the trial. Costs were obtained from the health board finance department and relevant suppliers of technical equipment. One year after treatment patients completed questionnaires on personal costs incurred. RESULTS: The NHS costs of treating women with hysteroscopic surgery were 24% (TCRE) or 20% (ELA) less than treating women by hysterectomy (1001 pounds/1046 pounds vs. 1315 pounds). On average, women undergoing hysteroscopic surgery incurred 71% less costs to themselves than those who underwent hysterectomy (21 pounds vs. 73.40 pounds). CONCLUSIONS: Hysteroscopic endometrial ablation incurs less costs than hysterectomy both to the National Health Service and to women alike, up to 1 year after surgery.

Using census information to estimate GP practice morbidity.

This paper shows how small area census data can be used to estimate the socio-demographic characteristics of GP practices. It provides information on the likely accuracy of the technique by applying it to estimates of the proportion of elderly patients within a practice (a statistic known from other sources) and produces evidence which suggests that the method is most successful where practices serve a high proportion of patients within their catchment.

The effect of allowing clinical discretion in ordering biochemical tests. Evaluation by complementary methods.

We describe the effects on costs, working patterns, and clinical behavior of installing a DAX "discretionary" biochemistry analyzer. Use of the new analyzer encouraged doctors to be more specific in requesting biochemical tests, which substantially reduced the number of tests requested and slightly reduced overall costs. Doctors preferred being able to order tests in this more specific way.

Costing shared care.

Growing interest in shared health care schemes over the last decade has received additional impetus with the introduction of GP fund holding and the internal market in health care provision. Ken Buckingham and colleagues report on the relative costs of such a scheme for asthma in comparison with the costs of conventional outpatient care. Data was collected during a randomised controlled trial of shared or integrated care for patients with chronic asthma, who had been referred to a hospital outpatient clinic.

A note on HYE (healthy years equivalent)

This note presents a simplified description of the Healthy Years Equivalent (HYE) health outcome measure. I examine the claims made for the HYE and discuss their theoretical validity. The HYE is shown to be conceptually flawed because of confusions between the measures of value and the things being valued. Under close inspection the unnecessarily complicated multiple stage valuation used to determine the HYE is seen to be no more than an indirect way of asking the Time Trade-Off. For this reason the claimed superiority of the method over the Quality Adjusted Life Year (QALY) is rejected.

Biotin-containing protein as a cause of false positive clones in gene probing with streptavidin/biotin.

Using a streptavidin/biotin labeling technique, we unintentionally cloned a gene encoding a biotin carboxyl carrier protein, a subunit of biotin-dependent enzymes, from a genomic library of Streptococcus mutans strain UT-041. In colony lifts, the clone reacted positively to the streptavidin-containing detection system but could not be detected in Southern blot analysis. The amino acid sequence of the gene product, deduced from its nucleotide sequence, demonstrated all the features common to biotin carboxyl carrier proteins from other bacteria, indicating that the biotin carboxyl carrier protein in the clone had produced a "false-positive" (DNA probe-independent) reaction by binding to the streptovidin. To circumvent this problem with the detection system in gene probing in the future, we recommend that all positive clones be screened by direct incubation with streptavidin-alkaline phosphatase (SA-AP) in the absence of biotin-labeled probe DNA. Clones binding to SA-AP would be considered false positives.

Hormonal regulation of insulin-like growth factor (IGF)-binding proteins secreted by isolated sheep thyroid epithelial cells: relationship with iodine organification.

Isolated sheep thyroid follicles release specific insulin-like growth factor-binding proteins (IGFBPs). Since IGFBPs can modulate IGF bioactivity, at least in vitro, their presence in thyroid tissue may influence synergistic interactions between TSH and endogenous IGF-I or -II which are known to control both thyroid growth and function. We have examined the hormonal control of IGFBP release in relation to iodine organification. Sheep thyroid follicles were isolated by incubation with collagenase and differential centrifugation, grown in Coon's modified Ham's F12M medium with the addition of transferrin, glycylhistidyl-lysine, somatostatin (3H), TSH, cortisol and insulin (6H), and maintained in OH (hormone-free) or 3H medium with or without further supplements for 48 h. Conditioned culture medium was separated by 8% sodium dodecyl sulphate (SDS)-polyacrylamide gel electrophoresis, transferred to nitrocellulose and incubated with 125I-labelled IGF-II followed by autoradiography (ligand blot). Additionally, the radioactive bands were cut from the filters and quantified by gamma-spectrometry. Iodine organification was assessed by incubation of follicles with 10(6) c.p.m. Na125I for 3 h before washing, solubilization in 0.1 mol NaOH/l and the precipitation of organified radioisotope with 10% (v/v) trichloroacetic acid. Cells conditioned in OH or 3H medium released specific IGFBPs of 46, 34, 28 and 19 kDa on ligand blot analysis. The proteins of 34 and 19 kDa were immunopositive on Western blot analysis using anti-bovine IGFBP-2 antiserum. The 46-kDa IGFBP was retained by Concanavalin A-Sepharose chromatography and demonstrated to be glycoprotein. This is probably ovine IGFBP-3. The addition of TSH, or TSH plus cortisol to OH or 3H medium significantly decreased the 125I-labelled IGF-II associated with the 34- and 28-kDa IGFBP species. All IGFBP species were substantially reduced in 6H medium, which was predominantly due to the effects of TSH and cortisol. When total 125I-labelled IGF-II associated with IGFBPs was considered, a significant (P less than 0.01) inverse correlation existed between IGFBP activity and iodine organification in the same cultures; the latter being greatest in OH or 3H medium supplemented with TSH and cortisol. None of these hormone additions altered the endogenous release of IGF-II by the cells. These results suggest that endogenous IGFs, under hormonal control, may modulate the action of endogenous IGF in the regulation of thyroid function.

A radioimmunoassay for the regulatory allylic steroid, 3 alpha-hydroxy-4-pregnen-20-one (3 alpha HP).

The allylic steroid, 3 alpha-hydroxy-4-pregnen-20-one (3 alpha HP), found in gonadal and brain tissues by radiotracer and chemical methods, had been shown to play a role in gametogenesis, gonadotropin secretion and brain excitability. Since no simple assay was available, a radioimmunoassay for 3 alpha HP was developed using [3H]3 alpha HP and an antiserum raised against 3 alpha HP-20-CMO conjugated to bovine serum albumin. The specificity of the assay for the 3 alpha allylic configuration of 3 alpha HP was confirmed by examining 32 other steroids; cross-reaction with steroids containing different configurations (including metabolites of 3 alpha HP such as progesterone) was less than 0.9%. A Scatchard plot indicated a Ka of 1.56 X 10(9) M-1. Inter- and intra-assay coefficients of variation were 13.1 and 4.5%, respectively. The sensitivity of the assay was 6 pg and the 50% intercept of the standard curve was approx. 123 pg. The measurement by RIA of 3 alpha HP from standard solutions and HPLC purified tissue extracts was confirmed qualitatively and quantitatively by GC/MS methods. The RIA method was employed to determine 3 alpha HP levels in cultured Sertoli cells and in serum of intact and ovariectomized adult rats. Although for most uses, chromatography would not be necessary, two possible methods are presented to enable the separation of 3 alpha HP from other interfering steroids prior to RIA.