Myocardial infarction and heart failure hospitalization rates in Maine, USA - variability along the urban-rural continuum.

INTRODUCTION: Cardiovascular disease, including myocardial infarction (MI) and heart failure (HF), remains the leading cause of death in wealthy countries and is of increasing concern in low- and middle-income countries as risk factors such as smoking and obesity become more common around the globe. Within each country the health burden of MI and HF generally falls more heavily on those who live in rural areas and on those who live in communities with lower average socioeconomic status (SES). Hospitalization rates are an important measure of community health because high rates may indicate a high burden of poor health, while inappropriately low rates (low hospitalization rates absent evidence of average good health) may indicate underutilization of health services. The objective of this study was to determine the predictors of MI and HF hospitalization rates at town level in the State of Maine, USA. Maine has large variations in wealth and along the urban-rural continuum at town level. Because our results shed light on variations in health and health-seeking behavior for different Maine populations (such as those living closer vs further from hospitals) they may be of interest to providers of healthcare to people who live in areas remote from healthcare, and to people who face other barriers to good cardiovascular health. METHODS: To determine predictors of HF and MI hospitalization in Maine, we constructed a geographic information system (GIS) for Maine's towns using publicly available electronic map layers, year 2000 census data, and electronic hospitalization records for all Maine hospitals. This GIS generated age-corrected MI and HF hospitalization rates for 1998-2002 as dependent variables and the following independent variables: poverty rate, unemployment rate, median income, educational attainment, rurality, physician density, and distance to the closest hospital. Univariable and multiple linear regression analysis were then performed to determine the significant predictors of MI and HF hospitalization rates. RESULTS: During the 5-year study period there were 24 452 hospitalizations of Maine residents to Maine hospitals for MI and 20 330 for HF. In multiple linear regression analysis, greater unemployment, a larger fraction of the population living in poverty, and proximity to a hospital predicted higher MI hospitalization rate (p = 0.000, r-sq = 19.1%) while greater unemployment and proximity to a hospital predicted higher HF hospitalization rate (p = 0.000, r-sq = 8.4%). CONCLUSIONS: Our finding that higher MI and HF hospitalization rates were predicted for towns that had lower SES is in agreement with many previous studies and shows the importance of these variables to health, even in a setting such as Maine with large variability in rurality. The negative relationship between the distance to a hospital and hospitalization rates likely does not represent better health in those living remotely from healthcare. Rather, it may indicate that people who live in communities distant from hospitals are less likely to seek hospitalization. This suggests that patient behavior as well as socioeconomic status may impact heart-related hospitalization in Maine. It highlights the importance of patient and provider education to ensure that people who live remotely from health care are hospitalized appropriately.

SCP1, a 356,023 bp linear plasmid adapted to the ecology and developmental biology of its host, Streptomyces coelicolor A3(2).

The sequencing of the entire genetic complement of Streptomyces coelicolor A3(2) has been completed with the determination of the 365,023 bp sequence of the linear plasmid SCP1. Remarkably, the functional distribution of SCP1 genes somewhat resembles that of the chromosome: predicted gene products/functions include ECF sigma factors, antibiotic biosynthesis, a gamma-butyrolactone signalling system, members of the actinomycete-specific Wbl class of regulatory proteins and 14 secreted proteins. Some of these genes are among the 18 that contain a TTA codon, making them targets for the developmentally important tRNA encoded by the bldA gene. RNA analysis and gene fusions showed that one of the TTA-containing genes is part of a large bldA-dependent operon, the gene products of which include three proteins isolated from the spore surface by detergent washing (SapC, D and E), and several probable metabolic enzymes. SCP1 shows much evidence of recombinational interactions with other replicons and transposable elements during its history. For example, it has two sets of partitioning genes (which may explain why an integrated copy of SCP1 partially suppressed the defective partitioning of a parAB-deleted chromosome during sporulation). SCP1 carries a cluster of probable transfer determinants and genes encoding likely DNA polymerase III subunits, but it lacks an obvious candidate gene for the terminal protein associated with its ends. This may be related to atypical features of its end sequences.

Complete genome sequence of the model actinomycete Streptomyces coelicolor A3(2).

Streptomyces coelicolor is a representative of the group of soil-dwelling, filamentous bacteria responsible for producing most natural antibiotics used in human and veterinary medicine. Here we report the 8,667,507 base pair linear chromosome of this organism, containing the largest number of genes so far discovered in a bacterium. The 7,825 predicted genes include more than 20 clusters coding for known or predicted secondary metabolites. The genome contains an unprecedented proportion of regulatory genes, predominantly those likely to be involved in responses to external stimuli and stresses, and many duplicated gene sets that may represent 'tissue-specific' isoforms operating in different phases of colonial development, a unique situation for a bacterium. An ancient synteny was revealed between the central 'core' of the chromosome and the whole chromosome of pathogens Mycobacterium tuberculosis and Corynebacterium diphtheriae. The genome sequence will greatly increase our understanding of microbial life in the soil as well as aiding the generation of new drug candidates by genetic engineering.

Mortality impact of an integrated community cardiovascular health program.

BACKGROUND: Preventing cardiovascular disease through community interventions makes theoretical sense but has been difficult to demonstrate. We set out to determine whether a community cardiovascular health program had an impact on mortality. DESIGN: Program evaluation plus ecologic observational analysis of program encounters and mortality rates with external comparisons. SETTING: Franklin County and two comparison counties in rural Maine. PARTICIPANTS: Program encountered >50% of regional adults, broadly distributed by site, gender, and age. INTERVENTIONS: From 1974 to 1994, a community program, integrated with primary medical care and staffed by professional nurses, provided education, screening, counseling, referral, tracking, and follow-up for cardiovascular risk factors. MAIN OUTCOME MEASURES: Age-adjusted mortality rates (total, heart, coronary, cerebrovascular, cancer) for three counties and Maine, plus annual program encounters. RESULTS: Relative to Maine, the Franklin heart disease death rate was 0.97 at baseline (1960-1969; 95% confidence interval, 0.91 to 1.03), 0.91 during the program (0.85 to 0.97), 0.83 during the 11 years of program growth (0.78 to 0.88), but 1.0 during the 10 years of decreasing encounters. Franklin's total death rate was 1.01 at baseline, 0.95 during the program (0.92 to 0.98), and 0.90 during program growth (0.86 to 0. 94). Results were similar for coronary disease, stroke, and cancer. Relative death rates did not fall in either comparison county. Nurse-client encounters totaled 120,280 over 21 years. Relative to Maine, heart disease death rates correlated inversely with program encounters (r = -0.53) but not with unemployment or physician supply. CONCLUSIONS: Integrated with primary medical care, a comprehensive, nurse-mediated community cardiovascular health program in rural Maine has been associated with significant time-dependent and dose-dependent reductions in cardiovascular and total mortality.

The C termini of constitutive nitric-oxide synthases control electron flow through the flavin and heme domains and affect modulation by calmodulin.

The sequences of nitric-oxide synthase flavin domains closely resemble that of NADPH-cytochrome P450 reductase (CPR). However, all nitric-oxide synthase (NOS) isoforms are 20-40 residues longer in the C terminus, forming a "tail" that is absent in CPR. To investigate its function, we removed the 33 and 42 residue C termini from neuronal NOS (nNOS) and endothelial NOS (eNOS), respectively. Both truncated enzymes exhibited cytochrome c reductase activities without calmodulin that were 7-21-fold higher than the nontruncated forms. With calmodulin, the truncated and wild-type enzymes reduced cytochrome c at approximately equal rates. Therefore, calmodulin functioned as a nonessential activator of the wild-type enzymes and a partial noncompetitive inhibitor of the truncated mutants. Truncated nNOS and eNOS plus calmodulin catalyzed NO formation at rates that were 45 and 33%, respectively, those of their intact forms. Without calmodulin, truncated nNOS and eNOS synthesized NO at rates 14 and 20%, respectively, those with calmodulin. By using stopped-flow spectrophotometry, we demonstrated that electron transfer into and between the two flavins is faster in the absence of the C terminus. Although both CPR and intact NOS can exist in a stable, one-electron-reduced semiquinone form, neither of the truncated enzymes do so. We propose negative modulation of FAD-FMN interaction by the C termini of both constitutive NOSs.

In vivo native cellular fluorescence and histological characteristics of head and neck cancer.

Native cellular fluorescence (NCF) represents the innate capacity of tissues to absorb and emit light of a specified wavelength. The ability to define the relationship of in vivo NCF with biological characteristics of neoplastic disease may allow for an improved understanding of the clinical course of disease. Head and neck cancers from 35 patients were evaluated in vivo for NCF characteristics using a xenon lamp-based spectrometer coupled to a handheld fiberoptic probe. Spectral assessment was limited to lambda 450-nm emission characteristics, in which tissues were excited at various wavelengths, ranging from lambda 290 nm to lambda 415 nm, and the intensity of lambda 450 nm emission was recorded. Each cancer was subsequently biopsied and assessed for histological differentiation by a pathologist who was blinded to NCF analysis. Considerable variation in spectral characteristics between head and neck cancers was identified, which was determined, in part, by NCF characteristics of the normal mucosa from the same patient. Poorly differentiated tumors were more likely than well- or moderately differentiated tumors to have lower excitation maxima (P < 0.05 by ANOVA). Most significantly, the tumor differentiation status, as well as the probability of demonstrating recurrent disease, could also be related to the NCF characteristics of the patient's normal mucosa from the same site within the upper aerodigestive tract. NCF analysis may represent an effective tool to identify biological characteristics of head and neck tumors in vivo without the need for invasive biopsies. Results suggest the need to explore the determinants of NCF characteristics expressed by clinically normal mucosa.

Lipid lowering in a multidisciplinary clinic compared with primary physician management.

A multidisciplinary lipid reduction clinic achieved greater reduction of serum cholesterol when compared with primary physicians among patients with coronary heart disease. The lipid clinic was more likely than the primary physicians to prescribe lipid-lowering medication, to prescribe multiple medications, and to use drug doses in excess of the "starting dose."

An autoinhibitory control element defines calcium-regulated isoforms of nitric oxide synthase.

Nitric oxide synthases (NOSs) are classified functionally, based on whether calmodulin binding is Ca2+-dependent (cNOS) or Ca2+-independent (iNOS). This key dichotomy has not been defined at the molecular level. Here we show that cNOS isoforms contain a unique polypeptide insert in their FMN binding domains which is not shared with iNOS or other related flavoproteins. Previously identified autoinhibitory domains in calmodulin-regulated enzymes raise the possibility that the polypeptide insert is the autoinhibitory domain of cNOSs. Consistent with this possibility, three-dimensional molecular modeling suggested that the insert originates from a site immediately adjacent to the calmodulin binding sequence. Synthetic peptides derived from the 45-amino acid insert of endothelial NOS were found to potently inhibit binding of calmodulin and activation of cNOS isoforms. This inhibition was associated with peptide binding to NOS, rather than free calmodulin, and inhibition could be reversed by increasing calmodulin concentration. In contrast, insert-derived peptides did not interfere with the arginine site of cNOS, as assessed from [3H]NG-nitro-L-arginine binding, nor did they potently effect iNOS activity. Limited proteolysis studies showed that calmodulin's ability to gate electron flow through cNOSs is associated with displacement of the insert polypeptide; this is the first specific calmodulin-induced change in NOS conformation to be identified. Together, our findings strongly suggest that the insert is an autoinhibitory control element, docking with a site on cNOSs which impedes calmodulin binding and enzymatic activation. The autoinhibitory control element molecularly defines cNOSs and offers a unique target for developing novel NOS activators and inhibitors.

Neuroimaging of AIDS. I. Fungal infections of the central nervous system.

Fungal infections of the central nervous system are quite uncommon and most frequently occur in immunocompromised patients, such as those with AIDS. This article outlines the most common fungal infections that occur in the central nervous system. Even though fungal infections of the central nervous system, other than cryptococcosis, are rare in the AIDS population, one should recognize the findings and consider the diagnosis.

Neurosyphilis in patients with AIDS.

Syphilis has become much more prevalent because of the dramatic increase in immunocompromised patients. The increase in immunocompromised patients is mainly secondary to AIDS. This article is put forth to refamiliarize the reader with syphilis, specifically neurosyphilis. The neurologic symptomatology and neuroimaging characteristics are presented so that one can recognize the findings and consider the diagnosis of neurosyphilis when confronted with a patient with AIDS.

Thiophosphorylation independently activates each head of smooth muscle myosin in vitro.

To determine whether thiophosphorylation of the 20-kDa myosin light chain activates each head of smooth muscle myosin independently of the head with which it is paired, chicken gizzard smooth muscle myosin was randomly thiophosphorylated, producing a mixture of unphosphorylated and singly and doubly thiophosphorylated myosin. Thiophosphorylation levels were measured by glycerol-urea gels, and the activity of this myosin was determined by actin-activated adenosinetriphosphatase measurements and in an in vitro motility assay, where the velocity of actin filaments moving over a myosin-coated surface is measured. Activity at each thiophosphorylation level was similar to that previously observed for mixtures of unphosphorylated and doubly thiophosphorylated myosin (D. E. Harris, S. S. Work, R. K. Wright, N. R. Alpert, and D. M. Warshaw. J. Muscle Res. Cell Motil. 15: 11-19, 1994). All doubly thiophosphorylated myosin was then formed into filaments and removed from randomly thiophosphorylated myosin by centrifugation. The remaining myosin (mixture of unphosphorylated and singly phosphorylated myosin), which could not polymerize because of their conformation, retained approximately 70% activity compared with mixtures of unphosphorylated and doubly thiophosphorylated myosin. Thus a thiophosphorylated smooth muscle myosin head can produce substantial biochemical and mechanical activity, even when it is paired with an unphosphorylated partner.

Cardiac V1 and V3 myosins differ in their hydrolytic and mechanical activities in vitro.

The two mammalian cardiac myosin heavy chain isoforms, alpha and beta, have 93% amino acid homology, but hearts expressing these myosins exhibit marked differences in their mechanical activities. To further understand the function of these cardiac myosins as molecular motors, we compared the ability of these myosins to hydrolyze ATP and to both translocate actin filaments and generate force in an in vitro motility assay. V1 myosin has twice the actin-activated ATPase activity and three times the actin filament sliding velocity when compared with V3 myosin. In contrast, the force-generating ability of these myosins is quite different when the total force produced by a small population of myosin molecules (> 50) is examined. V1 myosin produces only one half the average cross-bridge force of V3 myosin. With discrete areas of primary structural heterogeneity known to exist between alpha and beta heavy chains, the differences we report in the hydrolytic and mechanical activities of the motors are explored in the context of potential structural and kinetic differences between the V1 and V3 myosins.

The essential light chain is required for full force production by skeletal muscle myosin.

Myosin, a molecular motor that is responsible for muscle contraction, is composed of two heavy chains each with two light chains. The crystal structure of subfragment 1 indicates that both the regulatory light chains (RLCs) and the essential light chains (ELCs) stabilize an extended alpha-helical segment of the heavy chain. It has recently been shown in a motility assay that removal of either light chain markedly reduces actin filament sliding velocity without a significant loss in actin-activated ATPase activity. Here we demonstrate by single actin filament force measurements that RLC removal has little effect on isometric force, whereas ELC removal reduces isometric force by over 50%. These data are interpreted with a simple mechanical model where subfragment 1 behaves as a torque motor whose leyer arm length is sensitive to light-chain removal. Although the effect of removing RLCs fits within the confines of this model, altered crossbridge kinetics, as reflected in a reduced unloaded duty cycle, probably contributes to the reduced velocity and force production of ELC-deficient myosins.

Smooth, cardiac and skeletal muscle myosin force and motion generation assessed by cross-bridge mechanical interactions in vitro.

Differences in the mechanical properties of mammalian smooth, skeletal, and cardiac muscle have led to the proposal that the myosin isozymes expressed by these tissues may differ in their molecular mechanics. To test this hypothesis, mixtures of fast skeletal, V1 cardiac, V3 cardiac and smooth muscle (phosphorylated and unphosphorylated) myosin were studied in an in vitro motility assay in which fluorescently-labelled actin filaments are observed moving over a myosin coated surface. Pure populations of each myosin produced actin filament velocities proportional to their actin-activated ATPase rates. Mixtures of two myosin species produced actin filament velocities between those of the faster and slower myosin alone. However, the shapes of the myosin mixture curves depended upon the types of myosins present. Analysis of myosin mixtures data suggest that: (1) the two myosins in the mixture interact mechanically and (2) the same force-velocity relationship describes a myosin's ability to operate over both positive and negative forces. These data also allow us to rank order the myosins by their average force per cross-bridge and ability to resist motion (phosphorylated smooth > skeletal = V3 cardiac > V1 cardiac). The results of our study may reflect the mechanical consequence of multiple myosin isozyme expression in a single muscle cell.

Clinical effectiveness of behavioral signs for screening chronic low-back pain patients in a work-oriented physical rehabilitation program.

This prospective study investigated the relationship between behavioral sign scores (from Waddell) and the return to work status of chronic low-back pain patients who completed a work-oriented physical rehabilitation program without formal facility-related psychologic or social services. Further, the authors monitored the effect of this program on changing these scores. The program consisted of physical reconditioning through resistive exercises, flexibility and aerobic training, posture and body mechanics education, and progressive work simulation tasks and activities of daily living. One hundred eighty-three nonworking or partially disabled low-back pain patients with an average duration of 8.7 months' disability were included in the study. The presence of each of eight behavioral signs was tested for on entry and again on completion of the program. Analysis showed a significant drop in behavioral sign scores for patients who successfully returned to work. There was no significant reduction in scores for patients who did not return to work. The results suggest these signs may predict the effectiveness of treating chronic low-back pain patients in a return-to-work physical rehabilitation program. Conversely, screening for behavioral signs may identify low-back pain patients who would benefit from intensive behavioral and psychiatric testing and intervention efforts.

Smooth and skeletal muscle myosin both exhibit low duty cycles at zero load in vitro.

Smooth muscle's stress equals that of skeletal muscle with less myosin. Thus, under isometric conditions, smooth muscle myosin may spend a greater fraction of its cycle time attached to actin in a high force state (i.e. higher duty cycle). If so, then smooth muscle myosin may also have a higher duty cycle under unloaded conditions. To test this, we used an in vitro motility assay in which fluorescently labeled actin filaments move freely over a sparsely coated (5-100 micrograms/ml) myosin surface. Actin filament velocity (V) was a function of the number of cross-bridges capable of interacting with an actin filament (N) and the duty cycle (f), V = (a x Vmax) x (1-(1-f)N) (Uyeda et al., 1990; Harada et al., 1990). N was estimated from the myosin density on the motility surface and the actin filament length. Data for V versus N were fit to the above equation to predict f. The duty cycle of smooth muscle myosin (4.0 +/- 0.7%) was not significantly different from that of skeletal muscle myosin (3.8 +/- 0.5%) in agreement with values estimated by Uyeda et al. (1990) for skeletal muscle myosin under unloaded conditions. The duty cycles of smooth and skeletal muscle myosin may still differ under isometric conditions.

Smooth and skeletal muscle actin are mechanically indistinguishable in the in vitro motility assay.

Smooth muscle produces as much stress as skeletal muscle with less myosin. To determine if the actin isoforms specific to smooth muscle contribute to the enhanced force generation, the motility of actin filaments from smooth and skeletal muscle were compared in an in vitro assay in which single fluorescently labeled actin filaments slide over a myosin-coated coverslip. No difference was observed between the velocity of smooth versus skeletal muscle actin filaments over either smooth or skeletal muscle myosin over a large range of assay conditions (changes in pH, ionic strength, and [ATP]). Similarly, no difference was observed between the two actins when the filaments moved under load over mixtures of phosphorylated smooth and skeletal muscle myosin. Thus, it appears that the actin isoforms of smooth and skeletal muscle are mechanically indistinguishable in the motility assay and that smooth muscle's enhanced force generation may originate within the myosin molecule specific to smooth muscle.

Nucleotide sequences of the rabbit alpha-smooth-muscle and beta-non-muscle actin mRNAs.

We report the characterization of cDNAs encoding two actin isoforms (alpha-smooth muscle and beta-non-muscle) from the rabbit uterus. These isoforms have extensive amino acid and nucleotide sequence homology to the corresponding mouse and human isoforms.