Deletion diagnostics for the generalised linear mixed model with independent random effects.

The Generalised linear mixed model (GLMM) is widely used for modelling environmental data. However, such data are prone to influential observations, which can distort the estimated exposure-response curve particularly in regions of high exposure. Deletion diagnostics for iterative estimation schemes commonly derive the deleted estimates based on a single iteration of the full system holding certain pivotal quantities such as the information matrix to be constant. In this paper, we present an approximate formula for the deleted estimates and Cook's distance for the GLMM, which does not assume that the estimates of variance parameters are unaffected by deletion. The procedure allows the user to calculate standardised DFBETAs for mean as well as variance parameters. In certain cases such as when using the GLMM as a device for smoothing, such residuals for the variance parameters are interesting in their own right. In general, the procedure leads to deleted estimates of mean parameters, which are corrected for the effect of deletion on variance components as estimation of the two sets of parameters is interdependent. The probabilistic behaviour of these residuals is investigated and a simulation based procedure suggested for their standardisation. The method is used to identify influential individuals in an occupational cohort exposed to silica. The results show that failure to conduct post model fitting diagnostics for variance components can lead to erroneous conclusions about the fitted curve and unstable confidence intervals.

The Strain Index (SI) and Threshold Limit Value (TLV) for Hand Activity Level (HAL): risk of carpal tunnel syndrome (CTS) in a prospective cohort.

A cohort of 536 workers was enrolled from 10 diverse manufacturing facilities and was followed monthly for six years. Job physical exposures were individually measured. Worker demographics, medical history, psychosocial factors, current musculoskeletal disorders (MSDs) and nerve conduction studies (NCS) were obtained. Point and lifetime prevalence of carpal tunnel syndrome (CTS) at baseline (symptoms + abnormal NCS) were 10.3% and 19.8%. During follow-up, there were 35 new CTS cases (left, right or both hands). Factors predicting development of CTS included: job physical exposure (American conference of governmental industrial hygienists Threshold Limit Value (ACGIH TLV) for Hand Activity Level (HAL) and the Strain Index (SI)), age, BMI, other MSDs, inflammatory arthritis, gardening outside of work and feelings of depression. In the adjusted models, the TLV for HAL and the SI were both significant per unit increase in exposure with hazard ratios (HR) increasing up to a maximum of 5.4 (p = 0.05) and 5.3 (p = 0.03), respectively; however, similar to other reports, both suggested lower risk at higher exposures. Data suggest that the TLV for HAL and the SI are useful metrics for estimating exposure to biomechanical stressors. PRACTITIONER SUMMARY: This study was conducted to determine how well the TLV for HAL and the SI predict risk of CTS using a prospective cohort design with survival analysis. Both the TLV for HAL and the SI were found to predict risk of CTS when adjusted for relevant covariates.

RWJ 67657, a potent, orally active inhibitor of p38 mitogen-activated protein kinase.

Tumor necrosis factor-alpha (TNF-alpha), a cytokine secreted by activated monocytes/macrophages and T lymphocytes, has been implicated in several disease states, including rheumatoid arthritis, inflammatory bowel disease, septic shock, and osteoporosis. Monocyte/macrophage production of TNF-alpha is dependent on the mitogen-activated protein kinase p38. RWJ 67657 (4-[4-(4-fluorophenyl)-1-(3-phenylpropyl)-5-(4-pyridinyl)-1H-imidazol -2-yl]-3-butyn-1-ol) inhibited the release of TNF-alpha by lipopolysaccharide (a monocyte stimulus)-treated human peripheral blood mononuclear cells with an IC(50) of 3 nM, as well as the release of TNF-alpha from peripheral blood mononuclear cells treated with the superantigen staphylococcal enterotoxin B (a T cell stimulus), with an IC(50) value of 13 nM. This compound was approximately 10-fold more potent than the literature standard p38 kinase inhibitor SB 203580 in all p38 dependent in vitro systems tested. RWJ 67657 inhibited the enzymatic activity of recombinant p38alpha and beta, but not gamma or delta, in vitro and had no significant activity against a variety of other enzymes. In contrast, SB 203580 significantly inhibited the tyrosine kinases p56 lck and c-src (IC(50) = 5 microM). RWJ 67657 did not inhibit T cell production of interleukin-2 or interferon-gamma and did not inhibit T cell proliferation in response to mitogens. RWJ 67657 inhibited TNF-alpha production in lipopolysaccharide-injected mice (87% inhibition at 50 mg/kg) and in rats (91% inhibition at 25 mg/kg) after oral administration. Based on these favorable biological properties, RWJ 67657 may have use as a treatment for inflammatory diseases.

A patient with mental retardation and possible panic disorder.

The limited communication skills and varying behavior patterns of people with mental retardation make the diagnosis of psychiatric disorders a challenging task. The authors present the case of a patient with mild mental retardation and possible panic disorder whose panic symptoms were missed by clinicians until a structured questionnaire to screen for those symptoms was administered. In assessing people with mental retardation for psychiatric disorder, clinicians should be alert to the possibility of panic disorder if patients show avoidant behaviors and report vague somatic complaints. A simplified structured format for assessment may lead to more accurate diagnosis.

Evaluation of the antiinflammatory activity of a dual cyclooxygenase-2 selective/5-lipoxygenase inhibitor, RWJ 63556, in a canine model of inflammation.

Sterile perforated polyethylene spheres (wiffle golf balls) were implanted s.c. in beagle dogs. A local inflammatory reaction was elicited within the spheres by injecting carrageenan. Changes in leukocyte count, prostaglandin E2, thromboxane B2 and leukotriene B4 levels were monitored in fluid samples collected over a 24-hr period. Blood samples were also collected at various time points and analyzed for prostaglandin E2 and leukotriene B4 production after ex vivo calcium ionophore treatment. Effects of standard antiinflammatory agents (aspirin, indomethacin, dexamethasone, tenidap and zileuton) and newer cyclooxygenase-2 (COX-2) selective agents (nimesulide, nabumetone and SC-58125) were determined after oral administration. Ex vivo inhibition of cyclooxygenase product synthesis (prostaglandin E2, thromboxane B2) in whole blood was used as an indicator of activity for the constitutive COX-1 isoform, although inhibition of the synthesis of these mediators in the chamber exudate during an inflammatory process is believed to represent COX-2 inhibition. Treatment effects on leukotriene B4 production were also determined both ex vivo in whole blood and in the fluid. All of the compounds tested, except aspirin, inhibited leukocyte infiltration into the fluid exudate. Inhibitors that exert their effects on both isozymes of cyclooxygenase attenuate production of cyclooxygenase metabolites in both the inflammatory exudate and in peripheral blood ex vivo, although COX-2 selective inhibitors only demonstrated activity in the exudate. A 5-lipoxygenase inhibitor (zileuton), a corticosteroid (dexamethasone) and a dual COX-2 selective/5-lipoxygenase inhibitor (RWJ 63556) had similar profiles in that they all inhibited cell infiltration and eicosanoid production in the fluid and also attenuated leukotriene B4 production in both the fluid and blood.

N-(5-substituted) thiophene-2-alkylsulfonamides as potent inhibitors of 5-lipoxygenase.

Compound 4k N-[5-(4-fluoro)phenoxythien-2-yl]methanesulfonamide is representative of a new class of potent inhibitors of 5-lipoxygenase (5-LO). These versatile compounds exhibit dose-dependent inhibition of 5-LO with IC50s ranging from 20-100 nM in the rat basophilic leukemia (RBL-1) cell homogenate assay and submicromolar IC50s in both the RBL-1 and human peripheral blood leukocyte (PBL) whole cell assays. Compound 4k also showed significant anti-inflammatory activity in the adjuvant arthritic rat at an oral dose of 3 mg/kg.

Nitroarylhydroxymethylphosphonic acids as inhibitors of CD45.

A series of nitroarylhydroxymethylphosphonic acids was synthesized and evaluated as inhibitors of CD45. It was discovered that both the alpha hydroxy and nitro groups are essential for activity. Potency is enhanced by the addition of a large lipophilic group on the aryl ring adjacent to the phosphonic acid moiety. Kinetics studies have shown that these compounds are competitive inhibitors and thus bind at the active site of this enzyme.

Phosphatase inhibitors--III. Benzylaminophosphonic acids as potent inhibitors of human prostatic acid phosphatase.

Further investigation of the structural requirements of a series of benzylphosphonic acid inhibitors of human prostatic acid phosphatase has led to the highly potent series of alpha-aminobenzylphosphonic acids. The alpha-benzylaminobenzylphosphonic acid, with an IC50 = 4 nM, exhibited a 3500-fold improvement in potency over the carbon analogue, alpha-phenylethyl. The enhanced potency may be due to a combination of four favorable interactions including those with the phosphate binding region, the presence the hydrophobic moieties of the benzylamino and phenylphosphonic acid, and a rigid conformer produced by an internal salt bridge between the phosphonate and the alpha-amino group. Replacement of the phosphonic acid moiety with a phosphinic or carboxylic acid as well as deletion of the benzyl substitution of the alpha-amino group led to great reductions in potency.

Piperazinylalkyl heterocycles as potential antipsychotic agents.

We recently reported on a series of pyrrole Mannich bases orally active in inhibiting the conditioned avoidance response (CAR) in rats. These compounds exhibit affinity for both D2 and 5-HT1A receptors, and some are noncataleptogenic. Such a profile suggests that they may be potential antipsychotic agents which lack the propensity for causing extrapyramidal side effects and tardive dyskinesias in humans. One of these compounds, 1-[[1-methyl-5-[[4-[2-(1-methylethoxy)phenyl]- 1-piperazinyl]methyl]-1H-pyrrol-2-yl]methyl]-2-piperidinone (RWJ 25730, 1), was chosen for further development but found to be unstable in dilute acid. In order to improve stability, we replaced the pyrrole methylene linkage to the piperazine ring with ethylene, employed ethylene and dicarbonyl as linkers between the lactam and the pyrrole ring, placed electron-withdrawing groups on the pyrrole ring, and substituted acyclic amide for lactam. In addition, we replaced the pyrrole segment with other heterocycles including thiophene, furan, isoxazole, isoxazoline, and pyridine. Generally, replacement of the N-methylpyrrole segment with thiophene, furan, isoxazoline, or pyridine afforded compounds equipotent with 1 in CAR, which were more stable in dilute acid. In the case of side chain or lactam modifications, CAR activity was significantly decreased or abolished, with the exception of 6. For the most part, the modifications to 1 resulted in the decrease or loss of D2 receptor binding. However, within this series, 5-HT1A receptor binding was greatly increased, with thiophene 40 exhibiting an IC50 of 0.07 nM. The CAR activities of pyrroles 6 and 12, thiophene 40, furans 44-47, isoxazolines 49 and 50, and pyridine 54 coupled with their weak or nonexistent D2 binding and strong 5-HT1A binding suggest that they may be acting via a nondopaminergic mechanism or that dopaminergic active metabolites are responsible. Pyrrole 6 and furans 44 and 47 show promise as antipsychotic agents based on their CAR activity, receptor-binding profile, and solution stability.

N-aryl-N'-benzylpiperazines as potential antipsychotic agents.

N1-(2-Alkoxyphenyl)piperazines additionally containing an N4-benzyl group bearing alcohol, amide, imide, or hydantoin functionalities were prepared and evaluated in the conditioned avoidance response (CAR) test predictive of clinical antipsychotic activity and in in vitro receptor-binding assays. Certain of the compounds display high affinity for the D2, 5-HT1A, and alpha 1-adrenergic receptors. Structures bearing acyclic amide, lactam, and imide functionalities display good biological activity, with a preference for the 1,3-disubstituted phenyl ring relative to the 1,4- and 1,2-congeners (7 vs 10 and 12). Every possible position of hydantoin attachment was investigated (e.g., substitution at N1, N3, and C5). The hydantoin involving attachment to N1 (24) was found to have good biological activity, whereas those hydantoins with attachment to N3 or C5 (22, 23, and 25) were inactive. Several of the smaller acetylated derivatives (30 and 33) have fair in vivo activity, which was lost in the case of the larger benzoyl analog 31. Uracil congener 34 had modest affinity for the D2 receptor (65 nM) as well as excellent in vivo activity. Benzylamino compounds display (viz. 27 and 35-38) moderate CAR activity but have surprising receptor affinity, often greater than those of comparable structures bearing a carbonyl (36 vs 7). Benzyl and benzhydryl alcohol compounds 40-48 are more active than amino structures 27 and 35-38 and also exhibit excellent in vivo activity in the CAR test with modest D2 and 5-HT1A receptor binding.

Difficulties in symptom recognition in infants.

The subject of symptom recognition in infants is just beginning to be explored in nursing literature; the process may be more difficult that it originally appears. Because symptoms are subjective and their identification is dependent on communication between the client and the nurse or caretaker, it becomes important to assist nurses, parents, and other health care providers in this process. This article discusses the impact of cues, developmental aspects, and inferences as they influence the identification of symptoms experienced by infants.

Synthesis and cardiotonic activity of a series of substituted 4-alkyl-2(1H)-quinazolinones.

The synthesis, cardiac fraction III cyclic nucleotide phosphodiesterase (PDE-III) inhibition, and positive inotropic activity of a series of 2(1H)-quinazolinones are reported. A general synthesis of the series involved the cyclization of 2-aminoacetophenones with potassium cyanate in acetic acid. Modifications at the 4-position of the quinazoline nucleus were best achieved by formation of the intermediate N1-acyl-N3-phenylurea from the substituted phenyl isocyanate and appropriate carboxamide. PPA was used to ring close to the quinazoline product. Generally the SAR for the series paralleled the five-point model previously published for PDE-III inhibition. The most active analogue of the series was 5,6-dimethoxy-4-methyl-2(1H)-quinazolinone (1) (ORF 16600), which had about twice the intravenous potency of amrinone. Compound 1 is currently under development as an orally active cardiotonic.

Interactions between oncologists and patients during rounds.

Physician behavior during inpatient rounds was observed and quantified for 394 interactions between patients with cancer and physicians. Most patients had solid tumors (90%) and a limited prognosis despite treatment (61%). The physicians spent 1.45 +/- 0.58 h on morning rounds seeing an average of 9.3 +/- 3.39 patients. For each patient an average of 3.61 +/- 2.83 min was spent in the room. The rest of the time was involved in reviewing the results of diagnostic tests, discussing treatment plans, and updating patient's charts. Time spent in the room was significantly related to the patient's sex and diagnosis. Physicians spent more time with patients having the poorest prognosis (p = 0.009). Specific behaviors were analyzed using a Physician Behavior Check List that allows accurate recording of behavior during a brief patients-physician encounter. Factor analysis of responses to the check list resulted in four factors that explained 58.7% of the variance. The physician behavior factor scores failed to correlate with factor scores from the responses of the same physicians to the Cancer Attitude Survey. In addition, the physicians were unable to accurately estimate the time they actually spent with patients or the frequency of specific behaviors that occurred during these interactions.

Kinetic studies of a tumor-induced leukemoid reaction in mice.

A transplantable murine breast carcinoma in mice was associated with marked leukemoid reaction. Within 1 week of subcutaneous implantation of tumor the leukocyte count began to increase and reached average levels of 165,000 leukocytes per cubic millimeter within 18 days. This represented an increase in mature neutrophils primarily, although other blood leukocytes were modestly increased as well. The total number of neutrophils per humerus was increased but no increase was detected in the number of myloblasts, promyelocytes, or myelocytes. The tritiated thymidine-labeling index of the latter three cells was not significantly changed during tumor growth. The number of progenitor cells forming granulocytic and mononuclear cells in vitro was decreased in the marrow during tumor growth. Colony-stimulating activity in plasma was slightly increased during the early phase of tumor growth and decreased during later phases. Emergence time of blood neutrophils was normal, as measured by labeling with tritiated thymidine, but decline in labeled cells was abnormally slow in tumor-bearing mice. There was a shift of erythropoiesis to the spleen, but total erythropoiesis appeared to be normal in most mice. Surgical excision of the tumor resulted in prompt reversal of the leukemoid reaction. In the aggregate these results are consistent with a hypothesis that the leukemoid reaction was the result of increased blood transit time of neutrophils primarily, rather than increased neutrophil production.

Family photographs: in treatment and training.

The universal appeal of nostalgia and reminiscence makes photographs a natural instrument for studying the impact of the past upon the present. This paper explores photography as a medium for facilitating reminiscence to discover individual roles, interpersonal relationships, and family dynamics. A method is described for using family photographs in treatment and training of clinicians at a Family Therapy Clinic.