Biomedical subjects
G Marshall
Publications and source records attributed to G Marshall.
Identification of amino acids in the N-methyl-D-aspartate receptor NR1 subunit that contribute to the glycine binding site.
The mammalian N-methyl-D-aspartate (NMDA) receptor complex is though to consist of an NR1 subunit in combination with one or more of the four NR2 subunits (A, B, C, and D). When corresponding cDNAs are expressed in Xenopus oocytes, ion channels with the characteristic profile of NMDA receptors are formed. The receptor is unique in requiring two coagonists, glutamate and glycine, for activation of the channel. We have used site-directed mutagenesis to study amino acids in the human NR1 subunit that contribute to the glycine binding site of the NMDA receptor without affecting the agonist site for glutamate. Mutations to D481 and K483 produced receptors with up to 160-fold lower affinities for glycine, as well as other agonists and partial agonists, without affecting maximum current size or the degree of agonist efficacy. The D481A mutation also led to 40-50-fold lower affinities for two structurally diverse glycine site antagonists. From these data we propose that the carboxyl group of this aspartate interacts with the amino moiety of glycine and the equivalent group contained in other agonists and antagonists.
Assessment of predictive models for binary outcomes: an empirical approach using operative death from cardiac surgery.
Predictive models in medical research have gained popularity among physicians as an important tool in medical decision making. Eight methodological strategies for creating predictive models are compared in a large, complex data base consisting of preoperative risk and operative outcome data on 12,712 patients undergoing coronary artery bypass grafting and entered into the Department of Veterans Affairs Cardiac Surgery Risk Assessment Program between April 1987 and March 1990. The models under consideration were developed to predict operative death (any death within 30 days following the surgical procedure or later if the result of a perioperative complication). The two strategies with the best predictive power among the eight examined were stepwise logistic regression alone and data reduction by cluster analysis combined with clinical judgement followed by a logistic regression model. The additive model based on unadjusted relative risks, the model based on Bayes' Theorem, and the logistic model using all candidate variables were good alternatives. Whether or not we imputed values did not have a significant impact on the predictive power of the models.
The convertases furin and PC1 can both cleave the human immunodeficiency virus (HIV)-1 envelope glycoprotein gp160 into gp120 (HIV-1 SU) and gp41 (HIV-I TM).
Intracellular proteolytic processing of human immunodeficiency virus envelope glycoprotein precursor (gp160) is an essential step for virus infectivity. Northern blot analysis provided evidence that furin and PC1, but not PC2, are expressed in the CD4+ human lymphoblastoid H9 cell line, suggesting the possible participation of these convertases in human immunodeficiency virus (HIV) gp160 proteolytic processing. Purified PC1 and furin cleaved specifically in vitro gp160 into gp120 (HIV-I SU) and gp41 (HIV-I TM). NH2-terminal sequence analysis of the produced gp41 (HIV-I TM) demonstrated that the cleavage occurred within the sequence Arg-Glu-Lys-Arg decreases Ala-Val-Gly-Ile, which is identical to the bond cleaved in vivo. Transition state analog peptides were designed and tested in vitro for their ability to inhibit the PC1- or furin-mediated gp160 cleavage. The best inhibitor was decanoyl-Arg-Lys-Arg-Arg-psi [CH2NH]-Phe-Leu-Gly-Phe-NH2.
Oral contraceptives and renal and retinal complications in young women with insulin-dependent diabetes mellitus.
OBJECTIVE: To evaluate the effects of oral contraceptives (OCs) as a possible risk factor for early diabetic renal and/or retinal complications. DESIGN: A retrospective case-control study. SETTING: A university hospital diabetes clinic. PARTICIPANTS: Forty-three diabetic women who used OCs for 1 year or longer (mean, 3.4 years; range, 1.0 to 7.0 years) were compared with a computer-matched control group of 43 diabetic women who never used OCs. MAIN OUTCOME MEASURES: Hemoglobin A1c levels, albumin excretion rates, and mean retinopathy scores. RESULTS: The mean +/- SEM age and duration of diabetes were 22.7 +/- 0.5 years (range, 17.1 to 30.5 years) and 13.8 +/- 0.8 years, respectively, for the study group. The mean longitudinal hemoglobin A1c values were similar for study subjects and control subjects. The final mean albumin excretion rates, reflecting diabetic renal damage, and the mean eye grades were not significantly different between the groups. CONCLUSIONS: The use of OCs among young women with insulin-dependent diabetes mellitus does not pose an additional risk for the development of early diabetic retinopathy and/or nephropathy.
Bayesian-logit model for risk assessment in coronary artery bypass grafting.
Predictive models for the assessment of operative risk using patient risk factors have gained popularity in the medical community as an important tool for the adjustment of surgical outcome. The Bayes' theorem model is among the various models used to predict mortality among patients undergoing coronary artery bypass grafting procedures. Comparative studies of the various classic statistical techniques, such as logistic regression, cluster of variables followed by a logistic regression, a subjectively created sickness score, classification trees model, and the Bayes' theorem model, have shown that the Bayes' model is among those with the highest predictive power. In this study, the Bayes' theorem model is reformulated as a logistic equation and extended to include qualitative and quantitative risk factors. We show that the resulting model, the Bayesian-logit model, is a mixture of logistic regression and linear discriminant analysis. This new model can be created easily without complex computer programs. Using 12,712 patients undergoing coronary artery bypass grafting procedures at the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Study between April 1987 and March 1990, the predictive power of the Bayesian-logit model is compared with the Bayes' theorem model, logistic regression, and discriminant analysis. The ability of the Bayesian-logit model to discriminate between operative deaths and operative survivors is comparable with that of logistic regression and discriminant analysis.
Impact of mammary grafts on coronary bypass operative mortality and morbidity. Department of Veterans Affairs Cardiac Surgeons.
The internal mammary artery is frequently used as a coronary artery bypass graft conduit because of superior long-term patency. The purpose of this study was to determine if there was also an advantage to the internal mammary artery in terms of operative mortality and morbidity. The Department of Veterans Affairs Cardiac Surgery Database was reviewed for two separate time periods, April 1987 through March 1989 and October 1990 through September 1991. During these periods, 14,172 patients underwent coronary artery bypass grafting. Univariate and multivariate logistic regression analyses were used to determine preoperative variables predictive of operative mortality and morbidity, with the independent variable of use of the internal mammary artery added to previously determined indicators. The total group was analyzed in risk quartiles according to expected mortality. Univariate analysis revealed an operative mortality of 6.8% in the early period and 6.5% in the latter period for the saphenous vein groups compared with 3.7% and 3.2%, respectively, for the internal mammary artery groups (p = 0.000). Multivariate analysis revealed an odds ratio of operative death with use of the internal mammary artery graft versus use of vein grafts of 0.78 during the first period and 0.72 during the second period, reductions of 22% and 28%, respectively. There were 29% and 37% reductions in the odds of operative mortality in the highest-risk quartile group of patients using the internal mammary artery graft. The odds ratio of developing mediastinitis with one internal mammary artery graft was 1.84 (p < 0.01) in the first time period and 1.11 in the second time period (p = not significant). However, with multiple mammary bypass grafts, the odds ratios were 3.70 (p < 0.01) and 2.96 (p < 0.01) in the respective time periods. On the basis of this study, it is concluded that internal mammary artery grafts in addition to providing superior long-term patency also decreased operative mortality after adjustment for patient risk factors. Use of the mammary artery does not consistently increase operative complications with the exception of mediastinitis when both internal mammary arteries are employed.
The Veterans Affairs Continuous Improvement in Cardiac Surgery Study.
The Department of Veterans Affairs Cardiac Surgery Consultants Committee is responsible for reviewing the quality of cardiac surgical treatment at the 43 Veterans Affairs cardiac surgical centers where these procedures are performed. It does so by reviewing both the unadjusted and risk-adjusted operative mortality data and the incidence of perioperative complications. These data are reviewed by the committee semiannually, and the overall summary and hospital-specific data are shared with the individual cardiac surgical program directors. Paper audits and site visits are performed when indicated by increased unadjusted and risk-adjusted operative mortality. Constructive criticism is shared with the program director and medical center administration. The relative risk of death for numerous patient risk factors has been estimated, and is now used in prospective clinical decision making. During the 7-year period that risk-adjusted outcomes have been utilized, there has been an overall significant reduction in the observed-to-expected operative mortality ratio. Although many factors could have contributed to this, including continually improving surgical techniques, it is also likely that part of this improvement has occurred because of the continuous feedback of these quality improvement data to our cardiothoracic surgeons and cardiologists.
Cloning, functional coexpression, and pharmacological characterisation of human cDNAs encoding NMDA receptor NR1 and NR2A subunits.
Using expression cloning, and more recently using polymerase chain reaction cloning approaches, a family of rat N-methyl-D-aspartate (NMDA) receptor subunit cDNAs has been described (NR1, NR2A, NR2B, NR2C, and NR2D). Here we report cloning and sequencing of cDNAs encoding isoforms of the human NR1 subunit (NR1a, NR1d, and NR1e) that differ at their C-terminal end as a result of alternative splicing and also of a cDNA encoding the human NR2A subunit. The deduced amino acid sequences of the human NR1 subunit isoforms differed from the published rat NR1 subunit sequences at only eight positions, all of which were N-terminal to the alternatively spliced domains. The human NR2A subunit deduced amino acid sequence differed from the published rat NR2A subunit sequence at 81 of the 1,464 amino acids, with most of the substitutions being located in the C-terminal half of the subunit. The gene for NR2A has been localised to human chromosome 16. We also report the expression and pharmacological characterisation of recombinant human NR1a/NR2A heteromeric receptors in Xenopus oocytes. These receptors had EC50 values of 2.14 and 2.05 microM for glutamate and glycine, respectively, and an IC50 of 46.8 microM for Mg2+. Responses were antagonised by D-2-amino-5-phosphonovalerate, L-689,560, pH 6.3, zinc, and MK-801. No modulatory effect was observed on application of ifenprodil, confirming previous observations with rat NR1 + NR2A recombinant receptors.
Daily variation in plasma zinc concentrations in women fed meals at six-hour intervals.
Ten pre-menopausal women participated in two studies to measure the daily variations in plasma zinc when meals were fed at 6-h intervals and to determine if the response was related to shifts in serum insulin, glucose, calcium, or phosphorus concentrations. In Study 1, identical meals were fed at 6-h intervals for 2 d, and blood was sampled 8 times between each meal. In Study 2, the women fasted from 1800 h on d 1 to noon the next day, and blood was sampled hourly from 0700-1200 on d 2. The postprandial plasma zinc response was similar following all four meals and accounted for 50% of the total within subject variation in plasma zinc. A small (2-6%) increase occurred within the first 60 min; then plasma zinc declined to a low point at 4 h after the meal. This characteristic pattern was not observed during the fasting study. Serum phosphorus varied consistently after each meal with a net efflux from circulation that preceded an efflux of zinc by 2 h. The postprandial response of serum glucose and insulin were related to the postprandial plasma zinc response measured 6 h earlier; the variables were not correlated at concurrent time points. The data show that food intake is a determinant of the daily variations in plasma zinc. The net efflux of zinc from circulation following meals may reflect hepatic zinc uptake in association with an increase in postprandial liver metabolism.
A comparative study of re-attenders and non-re-attenders for second triennial National Breast Screening Programme appointments.
This study, funded by the National Breast Screening Programme, was undertaken in 1992 at the Helen Garrod Breast Screening Unit, Nottingham. In a sample of 400 women who attended first round screening in 1989 and remained eligible for screening 10 per cent failed to attend triennial recall. A sample of a further 400 women who had been screened previously containing 200 women who re-attended for second round screening and 200 who failed to re-attend were studied anonymously by questionnaire. No significant difference existed between re-attenders and non-re-attenders in their perceived personal risk of breast cancer. A significant difference existed between the two groups in (1) their knowledge of breast cancer, (2) their ease of attending for screening, and (3) their previous experience of breast screening. Half of the women who failed to return implicated their initial visit in this decision--41 per cent implicating pain, 6 per cent stress and 3 per cent embarrassment. Hence a small percentage (5 per cent) of women do not re-attend for screening because of a negative experience at their initial visit. Every effort should therefore be made to make screening as acceptable as possible.
Continuous assessment and improvement in quality of care. A model from the Department of Veterans Affairs Cardiac Surgery.
OBJECTIVE: The authors organized the Department of Veterans Affairs (VA) Continuous Improvement in Cardiac Surgery Study (CICSS) to provide risk-adjusted outcome data for the continuous assessment and improvement of quality of care for all patients undergoing cardiac surgery in the VA. BACKGROUND: The use of risk-adjusted outcomes to monitor quality of health care has the potential advantage over consensus-derived standards of being free of preconceived biases about how health care should be provided. Monitoring outcomes of all health care episodes, as opposed to review of selected cases (e.g., adverse outcomes), has the advantages of greater statistical power, the opportunity to compare processes of care between good and bad outcomes, and the positive psychology of treating all providers equally. These two concepts, together with a pre-existing peer committee (the VA Cardiac Surgery Consultants Committee) to review, interpret, and act on the risk-adjusted outcome data, form the primary design considerations for CICSS. METHODS: Patient-level risk and outcome (operative mortality and morbidity) data are collected prospectively on each of the approximately 7000 patients undergoing cardiac surgery in the VA each year. These outcomes, adjusted for patient risk using logistic regression, are provided every 6 months to each cardiac surgery program and to a national peer review committee for internal and external quality assessment and improvement. RESULTS: For the most recent 12-month period with complete data collection, observed-to-expected (O/E) ratios ranged from 0.2 to 2.2, with eight centers falling outside of the 90% confidence limits for an O/E ratio equaling 1.0. The O/E ratio for all centers has fallen by 14% over the 4.5-year period of this program (p = 0.06). CONCLUSIONS: A large-scale, low-cost program of continuous quality improvement using risk-adjusted outcome is feasible. This program has been associated with a decrease in risk-adjusted operative mortality.
Dose-response of chronic beta-blocker treatment in heart failure from either idiopathic dilated or ischemic cardiomyopathy. Bucindolol Investigators.
BACKGROUND: Small-scale clinical investigations have demonstrated that single doses of beta-blocking agents can improve left ventricular function in heart failure from idiopathic dilated cardiomyopathy (IDC). The purpose of this multicenter clinical trial was to determine the dose-effect characteristics of beta-blockade in a heart failure population that includes ischemic dilated cardiomyopathy (ISCD). METHODS AND RESULTS: Bucindolol is a nonselective beta-blocking agent with mild vasodilatory properties. One hundred forty-one subjects with class II or III heart failure, left ventricular ejection fraction (LVEF) < or = 0.40, and background therapy of angiotensin-converting enzyme inhibitors, digoxin, and diuretics were given an initial challenge dose of bucindolol 12.5 mg. One hundred thirty-nine subjects (99 with IDC, 40 with ISCDC) tolerated challenge and were randomized to treatment with placebo or bucindolol 12.5 mg/d (low dose), 50 mg/d (medium dose), or 200 mg/d (high dose). At the end of 12 weeks, left ventricular function and other parameters were measured and compared with baseline values. There was a dose-related improvement in left ventricular function in bucindolol-treated subjects. In the high-dose bucindolol group, radionuclide-measured LVEF improved by 7.8 EF units (%) compared with 1.8 units in the placebo group (P < .05), and compared with the placebo group, a greater percentage of subjects had an increase in LVEF by > or = 5 units. In contrast, all three bucindolol doses prevented deterioration of myocardial function as defined by an LVEF decline of > or = 5 units. CONCLUSIONS: In heart failure from systolic dysfunction, beta-blockade with bucindolol produces a dose-related improvement in and prevents deterioration of left ventricular function.
Synergistic induction of thermotolerance in murine natural killer cells by interferon alpha and mild heat shock.
Splenic lymphocytes from C3H/HeN mice were primed in vivo or in vitro with the interferon inducer poly inosine:cytosine (Poly IC) or in vitro with interferon alpha (IFN alpha) and evaluated for their natural killer (NK) activity after exposure to hyperthermia for defined periods. Lytic activity against cells of the NK-susceptible Moloney lymphoma cell line YAC by Poly I:C- or IFN alpha-primed spleen cells exhibited thermotolerance to 41, 42 and 43 degrees C exposure compared to unprimed cells. Spleen cells were also incubated for 1 h at 40 or 37 degrees C prior to exposure to 42 degrees C. Incubation at 40 degrees C produced a modest increase in thermal resistance to 42 degrees C by otherwise unprimed spleen cells. Spleen cells that had been primed by Poly I:C or IFN alpha followed by 1 h at 40 degrees C were rendered even more resistant to hyperthermia at 42 degrees C. These data suggest that two host responses to viral infection, fever and production of IFN alpha, may endow cells involved in the inflammatory response (in this case NK cells) with resistance to more severe stress. Further, IFN alpha and fever may synergize in this protective mechanism.
The experience of a single Australian paediatric oncology unit. 1000 patients 1964-1987.
OBJECTIVE: To determine the survival for children with malignant disease diagnosed in the period 1964-1987 and treated in a single paediatric oncology unit. DESIGN: Records of patients treated by the Department of Haematology and Oncology at the Prince of Wales Children's Hospital were reviewed to determine the survival of children with cancer according to decade of diagnosis and diagnostic group. PATIENTS: Patients were eligible for the study if referred for treatment at or soon after diagnosis of malignancy. One thousand patients were treated during the study period. There were 363 with acute lymphoblastic leukaemia (ALL), 126 with tumours of the central nervous system (CNS), 86 with acute non-lymphoblastic leukaemia (ANLL), 81 with lymphoma, 79 with neural crest tumours, 69 with renal tumours, 66 with bone sarcomas, 53 with soft tissue sarcomas, and 77 with various other diagnoses. Age range was one day to 20.75 years. INTERVENTIONS: Treatment included surgery, radiotherapy and chemotherapy in a variety of protocols. RESULTS: Ten-year survival for the 1960s, 1970s and 1980s was 15%, 51% and 64% respectively (P < 0.001), excluding tumours of the CNS. From 1985 onwards, actual survival at five years has been 79%. Survival from Wilms' tumour and Hodgkin's disease remained high throughout the study period, and significant improvement in survival occurred with ALL, non-Hodgkin's lymphoma (NHL) and osteogenic sarcoma. Survival remained poor with neuroblastoma and ANLL. CONCLUSIONS: Significant improvement in outcomes for childhood malignancy has been achieved over the last three decades, with five-year survival currently at 79% (excluding tumours of the CNS). Some diagnostic groups have had only small improvements in outcome and require new strategies.
Factors predictive of operative mortality among coronary artery bypass subsets.
As risk-adjusted outcome is increasingly being used to make clinical decisions and to assess and improve quality of care, it is important to develop simple, stable models for predicting outcome. Here we address the hypothesis that a risk factor for increased operative mortality at coronary artery bypass grafting may have differential effects in subgroups of patients defined by the presence or absence of other risk variables. We used a series of univariate and multivariate analyses to identify a group of ten patient-related preoperative characteristics independently predictive of operative death in the total population of 12,712 patients undergoing coronary artery bypass grafting at 43 Department of Veterans Affairs medical centers participating in the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Study. Separate logistic regression models were then developed for each of 14 clinically important subgroups defined by the presence or absence of seven risk variables. Odds ratios for operative death and estimated operative mortality were calculated from these subgroup regression models. Of 65 comparisons of pairs odds ratios of preoperative risk variables between the subgroups with and without a second risk variable, only five were found to be significant (p < 0.05 without adjustment for multiple comparisons); this is only slightly more than would be expected by chance alone. Risk factors for increased operative death appear to have similar odds ratios for subgroups of patients defined by a second risk variable. This finding greatly simplifies the use of predicted operative mortality in clinical decision making and quality assessment and improvement in coronary artery bypass grafting.
Factors influencing the onset and progression of diabetic retinopathy in subjects with insulin-dependent diabetes mellitus.
BACKGROUND: The etiology of diabetic retinopathy is poorly understood. In the current study, factor associated with the onset and the progression or regression of retinopathy are evaluated. METHODS: Two hundred seventy-seven subjects with insulin-dependent (type I) diabetes mellitus (IDDM) were evaluated longitudinally for retinal changes over a mean of 2.7 years. The multistate Markov model was used to analyze the influences of the duration of diabetes, a family history of hypertension, age, sex, cigarette smoking, systolic blood pressure, diastolic blood pressure, cholesterol levels, and longitudinal glycohemoglobin (GHb) values on the development and the progression or regression of retinopathy. RESULTS: Univariate analysis confirmed that four factors were significantly associated with the etiology and the progression or regression of diabetic retinopathy: age, duration of diabetes, mean longitudinal GHb levels (all at P < 0.01), and diastolic blood pressure (P < 0.04). However, age was no longer significant when controlled by duration of diabetes. Cigarette smoking was only associated significantly with background retinopathy (stages 2 and 3). Systolic blood pressure, sex, a family history of hypertension, and cholesterol levels were not significantly associated with retinopathy. CONCLUSIONS: The onset of diabetic retinopathy is associated with the duration of diabetes, mean longitudinal GHb levels, smoking, and diastolic blood pressure. A longer duration of diabetes, higher GHb values, and higher diastolic blood pressure levels are associated with an increased risk of progression and a decreased chance of regression of diabetic retinopathy.
Detection of two early gene products of Epstein-Barr virus by fluorescence flow cytometry.
The intracellular expression of two early gene products of Epstein-Barr virus (EBV) was evaluated by fluorescence flow cytometry. Two Burkitt's lymphoma cell lines were superinfected by EBV from the P3HR-1 cell line. Twelve to 96 hr after superinfection the cells were fixed with paraformaldehyde and made permeable by saponin treatment. Monoclonal antibodies to the diffuse (D) and restricted (R) components of the early antigen (EA) complex were applied to the cells followed by fluorochrome-conjugated goat antibodies specific for the heavy chain isotypes of the monoclonal antibodies. Fluorescence flow cytometry revealed a clear separation in fluorescence intensity between cells containing EA-R or EA-D and negative cells. A major proportion of EA-positive cells displayed both antigens. In addition, a significant fraction expressed either EA-R or EA-D but not both. Expression of EA occurred more rapidly and peaked earlier in Daudi cells than in Raji cells. This apparent difference in EA expression between the two cell lines, however, was much less pronounced when one considered the proportion of cells expressing EA-R only, EA-D only, or both EA-R and EA-D, as a percentage of the total EA expression. Parallel fluorescence microscopy experiments revealed that the variation of the ratio of EA-R to EA-D expression with time correlated well between the two methods.