A Cardiac Sound Reproduction Apparatus for Improved Stethoscope Testing

Valvular heart disease is a significant problem. The primary case physician initially does assessment through auscultation. Accuracy in classification of sounds is suboptimal (20 to 40%). Lower frequencies of heart sounds are important in classification of murmurs associated with valvular heart disease. We find stethoscope sound intensity capture falls significantly at the 1500 Hz range and lower. Strategies to improve auscultation accuracy include improving stethoscope features or developing a device that, when used with the stethoscope, augments sound capturing abilities at lower frequencies. Testing necessitated development of a reliable (without significant intra-sound variation) cardiac sound reproduction device. A sound permeable contracting polymer when used with a stethoscope signficantly increases sound intensity captured in the 625 Hz to 1500 Hz range, when tested with a reliable cardiac sound reproduction device. We prepared an air-sealed device with an amplifier, four internal speakers capable of emitting high quality, low frequency sounds, and a listening pad. An existing electronic stethoscope with, and then without, a sound permeable contracting polymer captured three sounds (normal, innocent systolic murmur, pathological systolic murmur) five times per sound. The sounds were placed in computer files. FFTs were constructed. Sound intensity within the 625 Hz to 1400 Hz range, when the sound permeable contracting polymer is used with the electronic stethoscope, relatively improves, on average, approximately 11 dB, compared to sound captured with the same electronic stethoscope without the sound permeable contracting polymer. This difference is numerically statistically significant (p<0.001). Intra-sound variability testing (standard deviation) of FFTs was not significant. A sound permeable contracting polymer used with an electronic recording stethoscope significantly improves sound intensity in an important auscultation frequency range. Intra-sound testing variation was insignificant. A study is underway to demonstrate impact using an absolute reference point. However, as amplification within existing electronic stethoscopes is commercially available, potential variation in relative reference points may be overcome with existing amplification features on electronic stethoscopes, allowing improved capture of heart sounds within the 625 Hz to 1400 Hz range. Limitations include the need for human subject study. Further testing, including human subjects testing is needed prior to application for FDA approval. FDA approval is needed before any use on humans. The methodology should not be utilized clinically without FDA approval.

Variations in behavior and condition of a Southern Ocean top predator in relation to in situ oceanographic conditions

Responses by marine top predators to environmental variability have previously been almost impossible to observe directly. By using animal-mounted instruments simultaneously recording movements, diving behavior, and in situ oceanographic properties, we studied the behavioral and physiological responses of southern elephant seals to spatial environmental variability throughout their circumpolar range. Improved body condition of seals in the Atlantic sector was associated with Circumpolar Deep Water upwelling regions within the Antarctic Circumpolar Current, whereas High-Salinity Shelf Waters or temperature/salinity gradients under winter pack ice were important in the Indian and Pacific sectors. Energetic consequences of these variations could help explain recently observed population trends, showing the usefulness of this approach in examining the sensitivity of top predators to global and regional-scale climate variability.

Size of hippocampal pyramidal neurons in schizophrenia

BACKGROUND

Meta-analyses of hippocampal size have indicated that this structure is smaller in schizophrenia. This could reflect a reduction in the size of constituent neurons or a reduced number of neurons.

AIMS

To measure the size of hippocampal pyramidal neurons in the brains of people with and without schizophrenia.

METHOD

Pyramidal neuron size in hippocampal subfields was estimated stereologically from sections taken at 5 mm intervals throughout the whole length of right and left hippocampi from the brains of 13 people with schizophrenia and 16 controls. Results were assessed using repeated-measures analysis of covariance looking for a main effect of diagnosis and gender, and interactions of these with side.

RESULTS

We were unable to detect significant differences related to diagnosis, gender or side for any hippocampal subfield for this series of cases.

CONCLUSIONS

For this series of brains, hippocampal cell size is unchanged in schizophrenia.

Synaptic pathology in prefrontal cortex is present only with severe dementia in Alzheimer disease

Synaptic pathology is proposed to be integral to the clinical expression of Alzheimer disease (AD). Most studies have assessed only the vesicle protein synaptophysin as a measure of synaptic integrity. The interrelationships of synaptophysin, other presynaptic proteins, the cholinergic system, and severity of dementia in AD remain unclear. We studied the presynaptic proteins synaptophysin, syntaxin and SNAP-25, along with choline acetyltransferase (ChAT) activity in prefrontal cortex (BA 46) samples from 18 subjects with AD and 16 controls. Mean values of presynaptic protein immunoreactivities were significantly reduced, by 21%-28%, and ChAT activity was reduced by 41% in the AD groups. Synaptic protein immunoreactivity and ChAT activity were correlated with Mini-Mental State Examination scores obtained 1 yr prior to death. When AD cases were subgrouped into mild/moderate and severe illness at time of death, all differences in presynaptic proteins and ChAT activity were significant between controls and severe cases. However, no significant differences were detected in BA 46 between controls and mild/moderate cases. Considerable synaptic reserve or plasticity remains in BA 46 until the late stages of AD. Synaptophysin and ChAT appear to be more vulnerable in severe AD than are syntaxin or SNAP-25.

A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure

BACKGROUND

Acute renal failure (ARF) requiring dialysis in critically ill patients is associated with an in-hospital mortality rate of 50 to 80%. The worldwide standard for renal replacement therapy is intermittent hemodialysis (IHD). Continuous hemodialysis and hemofiltration techniques have recently emerged as alternative modalities. These two therapies have not been directly compared.

METHODS

A multicenter, randomized, controlled trial was conducted comparing two dialysis modalities (IHD vs. continuous hemodiafiltration) for the treatment of ARF in the intensive care unit (ICU). One hundred sixty-six patients were randomized. Principal outcome measures were ICU and hospital mortality, length of stay, and recovery of renal function.

RESULTS

Using intention-to-treat analysis, the overall ICU and in-hospital mortalities were 50.6 and 56.6%, respectively. Continuous therapy was associated with an increase in ICU (59.5 vs. 41.5%, P < 0.02) and in-hospital (65.5 vs. 47.6%, P < 0.02) mortality relative to intermittent dialysis. Median ICU length of stay from the time of nephrology consultation was 16.5 days, and complete recovery of renal function was observed in 34.9% of patients, with no significant group differences. Despite randomization, there were significant differences between the groups in several covariates independently associated with mortality, including gender, hepatic failure, APACHE II and III scores, and the number of failed organ systems, in each instance biased in favor of the intermittent dialysis group. Using logistic regression to adjust for the imbalances in group assignment, the odds of death associated with continuous therapy was 1.3 (95% CI, 0.6 to 2.7, P = NS). A detailed investigation of the randomization process failed to explain the marked differences in patient assignment.

CONCLUSIONS

A randomized controlled trial of alternative dialysis modalities in ARF is feasible. Despite the potential advantages of continuous techniques, this study provides no evidence of a survival benefit of continuous hemodiafiltration compared with IHD. This study did not control for other major clinical decisions or other supportive management strategies that are widely variable (for example, nutrition support, hemodynamic support, timing of initiation, and dose of dialysis) and might materially influence outcomes in ARF. Standardization of several aspects of care or extremely large sample sizes will be required to answer optimally the questions originally posed by this investigation.

Schizophrenia and the frontal lobes: post-mortem stereological study of tissue volume

BACKGROUND

It has been suggested that there is frontal lobe involvement in schizophrenia, and that it may be lateralised and gender-specific.

AIMS

To clarify the structure of the frontal lobes in schizophrenia in a post-mortem series.

METHOD

The volume of white matter and cortical components of the frontal lobes was measured in brains of controls and patients with schizophrenia using planimetry and the Cavalieri principle. The components measured were: superior frontal gyrus, middle frontal gyrus, a composite of inferior frontal gyrus and orbito-frontal cortex, as well as total frontal lobe cortex and white matter. In addition, the anterior cingulate gyrus was measured.

RESULTS

No diagnosis, gender, diagnosis x side, diagnosis x gender or diagnosis x gender x side interactions were observed in the volume of any of the components, the grey matter as a whole or the white matter. No evidence for volumetric inter-group differences was found for the anterior cingulate gyrus.

CONCLUSIONS

Such structural abnormalities as are present in the frontal lobes are more subtle than straightforward alterations in tissue volume; they may include changes in shape and the pattern of gyral folding.

Steroid responsive polyneuropathy in a family with a novel myelin protein zero mutation

OBJECTIVE

To report a novel hereditary motor and sensory neuropathy (HMSN) phenotype, with partial steroid responsiveness, caused by a novel dominant mutation in the myelin protein zero (MPZ) gene. Most MPZ mutations lead to the HMSN type I phenotype, with recent reports of Déjérine-Sottas, congenital hypomyelination, and HMSN II also ascribed to MPZ mutations. Differing phenotypes may reflect the effect of particular mutations on MPZ structure and adhesivity.

METHODS

Clinical, neurophysiological, neuropathological, and molecular genetic analysis of a family presenting with an unusual hereditary neuropathy.

RESULTS

Progressive disabling weakness, with positive sensory phenomena and areflexia, occurred in the proband with raised CSF protein and initial steroid responsiveness. Nerve biopsy in a less severely affected sibling disclosed a demyelinating process with disruption of compacted myelin. The younger generation were so far less severely affected, becoming symptomatic only after 30 years. All affected family members were heterozygous for a novel MPZ mutation (Ile99Thr), in a conserved residue.

CONCLUSIONS

This broadens the range of familial neuropathy associated with MPZ mutations to include steroid responsive neuropathy, initially diagnosed as chronic inflammatory demyelinating polyneuropathy.

Cholinergic deficits contribute to behavioral disturbance in patients with dementia

BACKGROUND

Noncognitive behavioral changes such as depression, aggressive behavior, psychosis, and overactivity occur frequently in patients with dementia, in addition to cognitive impairment, and often determine the need for institutionalization. The biochemical basis of such changes is poorly understood. Clinical trial data indicate that cholinomimetics improve noncognitive behaviors. This study investigated the relationship between markers of the cholinergic and dopaminergic neurotransmitter systems and noncognitive behavioral symptoms assessed during the course of dementing illness.

METHOD

Brains from 46 patients with dementia (36 with AD and 10 with mixed or other dementias using Consortium to Establish a Registry for AD criteria) were examined together with 32 normal controls. The patients with dementia had been evaluated every 4 months, often over several years, for cognitive performance (Mini-Mental State Examination) and behavior (Present Behavioral Examination). Concentrations of dopamine (DA) and major metabolites, choline acetyltransferase activity (ChAT), and density (Bmax) of DA D1 receptors in frontal and temporal cortex were studied by radioligand binding protocols. None of the patients was receiving cholinomimetic drugs.

RESULTS

ChAT activity, but no other neurochemical markers, was reduced in AD compared with controls. Loss of ChAT activity correlated with cognitive impairment. Lowered ChAT activity also correlated with increasing overactivity in patients with dementia in both frontal and temporal cortex whereas ChAT:DA and ChAT:D1 ratios in temporal cortex correlated negatively with aggressive behavior.

CONCLUSIONS

Disturbance of the cholinergic system may underlie both cognitive and some noncognitive behavioral changes in dementia, providing a basis for rational therapy.-1467

Immunocytochemical study of the dorsal and median raphe nuclei in patients with Alzheimer's disease prospectively assessed for behavioural changes

The dorsal and median raphe nuclei were examined with immunocytochemistry to display the 5-HT neurones in 16 cases of post-mortem-proven Alzheimer's disease (AD) and 12 age and sex-matched controls. The AD cases had been prospectively assessed during life for expression of behavioural changes as well as for cognitive decline. A significant (P < 0.001) 41% reduction in density of dorsal raphe neurones was found along with a significant (P < 0.02) 29% reduction in density of median raphe neurones in AD. There were significantly more neurofibrillary tangles in both dorsal and median raphe nuclei in AD than in controls (P < 0.001). There was no correlation between reduction in neurone density in these nuclei and behavioural change, cognitive decline, neurofibrillary tangle counts in these nuclei or plaque and tangle pathology in frontal and temporal cortex. It was concluded from these findings that the raphe nuclei are significantly affected by the pathology of AD and that plasticity in the 5-HT system is the probable reason for the lack of correlation of reduced 5-HT neurone density and clinical disease parameters.

Anomalous asymmetry of fusiform and parahippocampal gyrus gray matter in schizophrenia: A postmortem study

OBJECTIVE

Anomalies of structure and asymmetry of the parahippocampal gyrus (origin of the perforant path input to the hippocampal formation in the medial temporal lobe) have been shown in some postmortem studies of schizophrenia, but previous studies have not included the fusiform gyrus (which may have a role in facial recognition and naming), adjacent to the parahippocampal gyrus on the ventral occipitotemporal surface.

METHOD

The volumes of gray matter in the left and right parahippocampal and fusiform gyri were assessed with a stereological point-counting technique in the temporal lobes from formalin-fixed brains of 27 comparison subjects and 31 patients with schizophrenia. Age was a covariate and gender was a factor in the analysis.

RESULTS

In relation to the comparison subjects, the schizophrenic patients (both sexes) had lower volumes of both the parahippocampal and fusiform gyri on the left side. For both structures a left-greater-than-right volume asymmetry was present in the comparison subjects, but this asymmetry was reversed in the parahippocampal and fusiform gyri of the schizophrenic patients. A sex difference was present with respect to age at onset-degree of anomaly of asymmetry for both gyri increased with age at onset in men but not in women.

CONCLUSIONS

The findings add substance to the view that the sex-related dimension of symmetry/asymmetry is integral to the disease process in schizophrenia and draw attention to the fusiform gyrus as a structure of particular interest in relation to disturbances of identification and naming in psychosis.

Optimising imaging parameters for post mortem MR imaging of the human brain

PURPOSE

MR imaging of post mortem brains has the potential to yield volumetric information and define the extent of structural changes prior to pathological examination. Although standard T2-weighted clinical imaging sequences have been used for the examination of formalin-fixed brains, these protocols may not yield optimum contrast. We examined the effect of varying durations of formalin fixation on the transverse relaxation time (T2) and the tissue spin density.

MATERIAL AND METHODS

Three post mortem brains were examined weekly during formalin fixation from the unfixed state to 35 days fixation. Standard MR spin-echo imaging was used at 5 echo times (20-100 ms) to calculate transverse relaxation time (T2) and spin density.

RESULTS

T2 decreased significantly (ANOVA, p<0.001) in both grey and white matter by 7 days fixation and there was a further (but non-significant) trend towards lower values between 7 and 35 days. Grey and white matter T2 times converged with fixation. Conversely, the grey to white matter spin density ratio increased from 1.19+/-0.01 to 1.54+/-0.06 over five weeks of fixation.

CONCLUSION

Our results suggest that spin density-weighted imaging sequences would provide improved grey to white matter contrast over T2-weighted sequences.

Mesenchymal chondrosarcoma associated with Goldenhar's syndrome

Goldenhar's syndrome is characterised by bony abnormalities of the face, jaw and vertebral column. We report the first case of the development of a primary malignant neoplasm (mesenchymal chondrosarcoma) initially misdiagnosed as a meningioma, occurring in association with this syndrome.

Schizophrenia and temporal lobe asymmetry. A post-mortem stereological study of tissue volume

BACKGROUND

A previous report by Crow of a left-sided increase in temporal horn volume in schizophrenia implies a left-sided loss of tissue.

AIMS

To elucidate the structural nature of schizophrenia.

METHOD

The volume of grey matter in the temporal pole and inferior, middle and superior temporal gyri was measured, in addition to the total volume of grey and white matter, in the temporal lobes of the brains of 29 patients with schizophrenia and 27 controls.

RESULTS

We found a significant left-sided reduction in the superior temporal gyrus in both males and females with schizophrenia, which was related to increasing age of onset in the males. The total volume of temporal lobe grey and white matter was also significantly reduced. Although being more marked on the left than the right, the lateralisation for these total grey and white measures (by contrast with the superior temporal gyrus alone) did not attain formal statistical significance.

CONCLUSIONS

Confirmation of a lateralised reduction in the superior temporal gyrus, which is differentially related to age of onset according to gender, adds to evidence that the changes in schizophrenia are in systems that are lateralised. The findings implicate language as the relevant function.

The size and fiber composition of the anterior commissure with respect to gender and schizophrenia

BACKGROUND

In light of evidence for deviations in asymmetry and alterations in the anatomy of the corpus callosum in schizophrenia, this study examined the anterior commissure in post mortem brains (n = 14 female control patients, 15 male control patients, 11 female schizophrenic patients, 15 male schizophrenic patients).

METHODS

Measures were made of the cross-sectional area of the anterior commissure in the midsagittal plane. In addition, the fiber density and fiber number were measured in a subset of cases (n = 10 female control subjects, 10 male control subjects, 8 female schizophrenic patients, 9 male schizophrenic patients), using the Palmgren silver stain and stereological methods.

RESULTS

In control subjects, fiber numbers were greater (p = .024) in women than men. In schizophrenia, the cross-sectional area was unaffected, but for fiber density there was a significant gender x diagnosis interaction (p = .026), corresponding to a reduction in female, but not male patients with schizophrenia.

CONCLUSIONS

The reduction in density of fibers in the anterior commissure is consistent with an alteration of interhemispheric connectivity in schizophrenia, but the restriction of the finding to women emphasizes the relevance of gender to understanding the nature of the hemispheric interaction.

Investigation of a unique male and female sibship with Kallmann's syndrome and 46,XX gonadal dysgenesis with short stature

A sibship is described where the brother and a sister both have Kallmann's syndrome (anosmia and deficiency of gonadotrophin releasing hormone) and the woman also has streak ovaries. Although there are several conditions that may occur with Kallmann's syndrome, there are no known reports of ovarian dysgenesis being associated with this disorder. Cytogenetic analysis showed no rearrangement or major deletions of the chromosomes. Linkage analysis using informative microsatellite markers predicts that a gene other than KAL1 (at Xp22.3) is implicated in the Kallmann's syndrome manifesting concurrently with ovarian dysgenesis found in this family.

The size and fibre composition of the corpus callosum with respect to gender and schizophrenia: a post-mortem study

In this study the cross-sectional area (in n = 14 female controls, 15 male controls, 11 female patients with schizophrenia, 15 male patients with schizophrenia) and fibre composition (in n = 11 female controls, 10 male controls, 10 female patients with schizophrenia, 10 male patients with schizophrenia) of the corpus callosum in post-mortem control and schizophrenic brains was examined. A gender x diagnosis interaction (P = 0.005) was seen in the density of axons in all regions of the corpus callosum except the posterior midbody and splenium. Amongst controls, females had greater density than males; in patients with schizophrenia this difference was reversed. A reduction in the total number of fibres in all regions of the corpus callosum except the rostrum was observed in female schizophrenic patients (P = 0.006; when controlling for brain weight, P = 0.053). A trend towards a reduced cross-sectional area of the corpus callosum was seen in schizophrenia (P = 0.098); however, this is likely to be no more than a reflection of an overall reduction in brain size. With age, all subregions of the corpus callosum except the rostrum showed a significant reduction in cross-sectional area (P = 0.018) and total fibre number (P = 0.002). These findings suggest that in schizophrenia there is a subtle and gender-dependent alteration in the forebrain commissures that may relate to the deviations in asymmetry seen in other studies, but the precise anatomical explanation remains obscure.

Analysis of a human cDNA containing a tissue-specific alternatively spliced LIM domain

A unique clone, isolated from a human pancreatic cDNA library, was sequenced and characterized. Northern blot analysis showed that the gene is active in a number of fetal and adult tissues, and immunoblots showed expression in nuclear and cytosolic cell fractions. The gene corresponding to the clone was localized to chromosome 13 by human/rodent somatic cell hybrid panels. The largest open reading frame contains a LIM domain, and the deduced peptide from the open reading frame appears to have the characteristics of a LIM-only protein, designated LMO7. RT-PCR and genomic sequence analyses indicate that expression of this gene product is subject to tissue-specific modulation by elimination of the LIM domain by alternative splicing in neural tissues.

Anomalies of cerebral asymmetry in schizophrenia interact with gender and age of onset: a post-mortem study

In a post-mortem study of cerebral asymmetry in schizophrenia it was found that asymmetry of the length from the frontal pole to the central sulcus measured dorsally over the external surface of the brain on both hemispheres, showed a gender x diagnosis interaction (p = 0.002). Female controls had a left-greater-than-right asymmetry, and the male controls had a right-greater-than-left asymmetry. This pattern was reversed in schizophrenia. The converse effect was observed on a similar measure of the occipito-parietal lobes (p = 0.028). Significant changes were not seen in measures taken around the lateral surface of the hemispheres. Further, within the patient group, the frontal lobe asymmetry was related to age of onset such that leftward asymmetrical brains were associated with a later age of onset than rightward asymmetrical brains (p = 0.0463 for the females; p = 0.0162 for the males). The occipito-parietal asymmetry was not related to age of onset. We conclude that the asymmetry of the relative distribution of tissue between frontal and posterior regions of the hemispheres is altered in schizophrenia. The findings also suggest that there is an interaction between gender and cerebral asymmetry that is critical in determining age of onset.

Temporal-lobe length is reduced, and gyral folding is increased in schizophrenia: a post-mortem study

This post-mortem study of the brains of 29 controls and 25 patients with schizophrenia investigated the length and gyral folding of the temporal lobes, and the asymmetries and inter-relationships of these two measures. The degree of gyral folding was significantly increased in schizophrenia (p = 0.002), but the orientation of the sulci was not changed (p = 0.420). Neither gender nor side affected any of the measures of gyral anatomy, nor were there any significant interactions of these variables with diagnosis. The temporal lobes were significantly shortened in schizophrenia, on two different measures (p = 0.009, and p = 0.001), and on one of these, females had shorter temporal lobes than males (p < 0.0005). No diagnosis x side interactions were found. The temporal-lobe shortening remained after controlling for brain weight and was not statistically related to gyral folding. These two structural changes may reflect an alteration of the cortico-cortical connectivity of the brain in schizophrenia.

Comparison of pathological diagnostic criteria for Alzheimer disease

Because the clinical picture of Alzheimer disease (AD) is often difficult to discriminate from other dementing illnesses, the diagnosis of AD requires neuropathological confirmation. However, for the pathological diagnosis of AD, there are no unanimously accepted criteria. The three currently used sets of pathological criteria (Khachaturian: Khachaturian, Arch Neurol 1985;42:1097-105; Tiemy: Tierney et al., Can J Neurol Sci 1986; 13:424-6; CERAD: Mirra et al., Neurology 1991;41:479-86) for the disease differ from each other considerably. We applied these criteria to the first 43 consecutive subjects (37 demented) with no neuropathology other than AD-type pathology from autopsies after longitudinal prospective clinical study in the Oxford Project to Investigate Memory and Ageing (OPTIMA). The results show that the CERAD category of definite AD corresponds closely with the cases that fulfill Tierney A3 inclusion criteria for AD. The combined CERAD categories of possible, probable, and definite AD correspond closely to cases fulfilling Khachaturian criteria forAD. The influence of a clinical diagnosis of dementia when Khachaturian and CERAD criteria were applied was considerable because between 9.3% and 90.7% of patients would have been categorized differently depending on whether clinical dementia was present or absent.

Electron microscopy study of explanted intraocular lenses from clinically noninfected eyes

PURPOSE

To determine whether intraocular lenses (IOLs) in clinically noninfected eyes are coated with a significant, bacteria-containing biofilm.

SETTING

The Oxford Eye Hospital, Oxford, United Kingdom.

METHODS

Twenty-six IOLs, removed for reasons other than endophthalmitis from 26 patients attending the Oxford Eye Hospital over a 3 year period, were examined by electron microscopy. Immediately following explantation, the IOL was placed in glutaraldehyde 4% in 0.1 M phosphate buffer solution and processed for scanning electron microscopy (SEM). Areas of interest were reprocessed for transmission electron microscopy (TEM).

RESULTS

There was no evidence of a bacterial biofilm on any IOL. In 5 IOLs, significant host cellular debris was seen at the tip of the haptic or at the optic-haptic junction. In 4 of them, clusters of coccoid-shaped structures were seen at the optic-haptic junction on SEM, but examination by TEM showed these structures to be melanosomes, not bacteria.

CONCLUSION

We found no evidence to suggest that a significant number of IOLs are coated with a bacterial biofilm in clinically noninfected cases. We advocate the use of TEM to distinguish between coccoid bacteria and melanosomes.

Accuracy of clinical operational diagnostic criteria for Alzheimer's disease in relation to different pathological diagnostic protocols

In this study we analysed the accuracy of two sets of clinical diagnostic criteria, the NINCDS/ADRDA and DSM-III-R, in relation to the currently used pathological diagnostic criteria for Alzheimer's disease (AD), the Khachaturian criteria, the Tierney A3 criteria and the CERAD protocol. The sensitivity of the individual clinical diagnostic criteria, NINCDS/ADRDA and DSM-III-R, is poor (34-58%) irrespective of the pathological diagnostic criteria applied for the definite diagnosis of AD. The combination of the NINCDS/ ADRDA 'possible' and 'probable dementia of the Alzheimer type' (DAT) categories has a high sensitivity (91-98%). However the combination resulted in very poor specificity (40-61 %). Thus, none of the clinical diagnostic criteria is satisfactory. We found similar results when we analysed the predictive value of these clinical diagnostic criteria. The positive predictive value of NINCDS 'probable DAT' category and that of the DAT diagnosis by DSM-III-R is very high (89-100%). This makes the use of these categories suitable for research purposes. However, the negative predictive value of both diagnoses is poor (33-63%), making these criteria unsuitable for diagnostic purposes in clinical practice.

Electron microscopy findings on an intraocular lens in the uveitis, glaucoma, hyphaema syndrome

PURPOSE

To report the electron microscopic findings on an explanted intraocular lens in a patient with the uveitis, glaucoma, hyphaema syndrome.

METHODS

Scanning and transmission electron microscopy were undertaken on a coccoon of cellular material from the tip of the intraocular lens haptic.

RESULTS

Scanning electron micrographs showed densely packed coccoid-like structures on the haptic surface. By transmission electron microscopy these structures proved to be melanosomes.

CONCLUSIONS

The scanning electron micrographs described in this report are similar to those reported in patients with chronic post-operative uveitis, but to our knowledge have not been shown before in association with the uveitis, glaucoma, hyphaema syndrome. Transmission electron microscopy determined that the coccoid-like structures were melanosomes. The melanosomes are probably derived from damaged pigment epithelial cells or iris stromal melanocytes secondary to recurrent chafing of the haptic against the posterior surface of the iris.

Temporal cortex synaptophysin mRNA is reduced in Alzheimer's disease and is negatively correlated with the severity of dementia

We measured synaptophysin mRNA in neocortical tissue from 7 prospectively assessed, pathologically verified normal individuals, 17 subjects with Alzheimer's disease (AD), and 13 subjects with a non-AD dementia. In temporal cortex (Brodmann area 21), synaptophysin mRNA was decreased in AD and non-AD dementia groups compared to controls. The loss was also present relative to polyadenylated mRNA content. Synaptophysin mRNA signal correlated negatively with the degree of dementia and negatively with the pathological severity of AD. In occipital cortex (Brodmann area 17) there were no differences between groups nor clinicopathological correlations. These data extend the evidence for a regional synaptic pathology in AD which affects synaptic protein gene expression by temporal cortex neurons.

Worker health and safety training: assessing impact among responders

A mail survey was conducted among emergency responders who received training at the New Jersey/New York Hazardous Materials Worker Training Center. Responses indicate that technical topics are extremely important (i.e., decontamination, personal protection); that the vast preponderance of trainees felt confident in their ability to recall specific critical concepts in a crisis; and that 42% of respondents (75) had experienced an incident that would have resulted in injury or death without training. Phone surveys for details of specific incidents reported by 43 of the 75 mail survey respondents revealed that anecdotal data provide powerful evidence of the value of training; that extensive and uniform training is needed across jurisdictions; that training should emphasize the technical aspects of health and safety, and should include demonstration and hands-on techniques; and that integrated organizational support for implementation of health and safety practices is critical.

Exon scrambling of MLL transcripts occur commonly and mimic partial genomic duplication of the gene

The MLL gene is frequently rearranged in acute human leukemia of both the myeloid and lymphoid lineages. Using a sensitive reverse transcriptase-polymerase chain reaction (RT-PCR) assay, we identified several abnormally spliced transcripts in which MLL exons were joined in an order different from the genomic orientation (scrambled exons). Mis-splicing of MLL was present in both normal and malignant tissues. Although the majority of these scrambled transcripts were joined accurately at consensus splice sites, there were several examples in which the junctions of exons spliced in aberrant order were at non-consensus sites. A number of features differentiate mis-splicing of MLL from the previously described cases of scrambled exons and circular RNAs. Some scrambled transcripts appear to be present in the polyadenylated fraction of RNA. No correlation of exon scrambling with exon skipping was found, and there was no particular tendency for the exons involved to be near large introns. Our data show that splicing of MLL is extremely complex. The presence of scrambled transcripts in both normal and leukemic cells, indistinguishable from transcripts resulting from genomic MLL rearrangements, precludes the use of nested RT-PCR as a screening method for detection of tandem duplication of tandem duplication of MLL.

Primary (localised non-familial) conjunctival amyloidosis: three case reports

Conjunctival amyloidosis is an uncommon condition which usually arises secondary to chronic infection or trauma to the eye. It is rare to find significant deposits of amyloid involving the conjunctiva alone in the absence of a known antecedent infective, traumatic or hereditofamilial disorder. We report three patients with primary localised conjunctival amyloidosis. Each patient presented with a painless swelling in the lower fornix; in two this gradually extended to involve the bulbar and palpebral conjunctiva of both eyes with friable yellow deposits. Detailed clinical photographs illustrate the specific features of the disease. None of the patients had previous ocular pathology and bacterial, viral and fungal cultures of the conjunctiva were negative. There were no signs of inflammation. Conjunctival biopsies in each case showed large amorphous nodular deposits of amyloid within the substantia propria. Extensive systemic investigations including serum and urinary protein immunoelectrophoresis were normal. Follow-up ranged from 2 to 15 years after presentation. Treatment was symptomatic. As the typical features of amyloidosis present late in the course of conjunctival disease a diagnostic biopsy is often delayed. Once there is histopathological verification plasma cell disease must be excluded, although if the amyloid is limited to the conjunctiva systemic involvement is unlikely.

Gene expression studies of mRNAs encoding the NMDA receptor subunits NMDAR1, NMDAR2A, NMDAR2B, NMDAR2C, and NMDAR2D following long-term treatment with cis-and trans-flupenthixol as a model for understanding the mode of action of schizophrenia drug treatment

It has been hypothesized that glutamate receptor function is important in both the aetiology and treatment of schizophrenia. In order to understand how specific glutamate receptor genes are involved in the treatment of schizophrenia we have used a multiprobe oligonucleotide solution hybridization (MOSH) technique to examine the regulation of gene express of the NMDAR1, 2A, 2B, 2C, 2D receptor subunits in the left rat brain following treatment with the optical isomers of flupenthixol. cis- and trans-flupenthixol are both present in the commonly used oral and depot treatments for schizophrenia and a controlled trial showed that cis-flupenthixol had a significantly superior ability to ameliorate the positive symptoms of schizophrenia compared to its trans-isomer. At a dose of 0.2 mg/kg/day over a period of 1, 2, 4, 8, 12 and 24 weeks, we found that both isomers down regulated the expression of NMDAR1 mRNA in most regions of the brain. NMDAR2A, 2B and 2C receptor subunits showed a significantly decreased expression from 12 to 24 weeks but after 2 weeks NMDAR2B, 2C, 2D expression was increased in several brain regions. The NMDAR1 receptor subunit immunoreactivity in the right brain following 4 and 24 weeks of drug treatment was also examined by Western blotting. Both trans- and cis-flupenthixol significantly decreased the NR1 immunoreactivity in the right cerebellum after 24 weeks of treatment. These results suggest that NMDA receptor subunits may have a role in the action of antipsychotic drugs. If we assume that the NMDA receptor expression changes reflect a beneficial and significant mechanism in the treatment of schizophrenia, it could be argued that NMDA receptor changes are more related to the negative or non-specific symptoms of schizophrenia.

Absence of aluminium in neurofibrillary tangles in Alzheimer's disease

Using the new technique of nuclear microscopy, aluminium is not detected in pyramidal neurons in brain tissue from Alzheimer's disease (AD) patients. The analytical technique of nuclear microscopy can simultaneously image and analyse features in unstained and untreated tissue sections. In tissue which had been previously subjected to conventional procedures such as fixation and osmication, aluminium was observed in both neurons and surrounding tissue. This result shows that the analysis of tissue prepared using conventional chemical techniques may produce contamination or elemental redistribution, and supports our previous investigations which implied that aluminium is not involved in the aetiology of AD. In addition, significant increases in iron, phosphorus and sulphur concentrations were noted between neurons from Alzheimer tissue and neurons from age-matched controls, and between the supporting Alzheimer tissue and supporting control tissue, implying an overall increase in these elements. No significant increase in calcium was observed between neurons from Alzheimer tissue and neurons from age-matched controls.

Benign intracerebral cysts with ependymal lining: pathological and radiological features

Cerebral intraparenchymal cysts without communication with the ventricles are very rare. We report four such cases with no relevant past history or evidence of infection, haemorrhage, trauma, tumour or congenital neural tube defect. At operation smooth wailed cysts with an ependymal-type lining were found. To the best of our knowledge, we present the first correlation of their pathological and radiological features (including magnetic resonance imaging). We also review the literature on these cysts.

The health of Filipinas in the Hunter region

An interview survey found life-style behaviours (including risk factors and screening), social support and psychological health (GHQ-12) among a sample of 198 Filipina-Australians to be conducive to good health. Knowledge of local health services was good, and most women expressed general satisfaction with all aspects of life in Australia, except in the area of employment prospects. Despite these indications of good health in the group, there remains a need for health service providers to be aware of the difficulties faced by a proportion of Filipina migrants to Australia.

Adaptation to the mental health setting: the lived experience of comprehensive nurse graduates

The aim of this qualitative descriptive study was to explore the experience of new comprehensive nurse graduates as they adapted to working in the acute psychiatric setting. Interviews were conducted with four participants, focusing on their current work experiences and how the philosophical beliefs and values derived from their educational preparation fit with those they encountered within the practice setting. The data were analysed by noting common experiences, values and meanings and identifying the themes that emerged. The themes were: transition to practice, conflict, contradiction, structural constraints, and the 'reality' of the psychiatric setting. The results of the study confirm the concern that has been voiced by new graduates about the quality and quantity of current orientation programs. Conflicting values and beliefs concerning the nature of mental health/psychiatric nursing also became evident. It appears that the graduates' Comprehensive nursing preparation may have contributed to their feelings of unease as they attempted to fit their own values and beliefs about nursing with those of the acute psychiatric setting.

Surface and percentage depth doses for secondary blocking using a multileaf collimator and cerrobend-alloy blocks

Percentage depth doses from the surface to a depth of 30 cm have been measured for a number of square fields using 6 MV and 15 MV X-rays as part of the commissioning procedure for a commercially available MLC. Factors such as changing SSD, presence of a secondary blocking tray in the beam, and radiation transmission between the MLC leaves were investigated.

The effects of additional pathology on the cognitive deficit in Alzheimer disease

The diagnosis of Alzheimer disease (AD) according to current criteria is a combined clinical and pathological exercise. The clinical discrimination of AD from other types of dementia may be complicated when the patient suffers from more than one disease. In particular the concomitant presence of other neurological conditions may significantly influence the severity of cognitive deficit. In this study we analyze the extent of the influence of vascular and other neurodegenerative pathology on the cognitive deficit in a consecutive series of 88 prospectively assessed elderly subjects. We find that, for any given level of cognitive deficit, the densities of either all plaques or neuritic plaques alone in the neocortex are significantly lower in cases of AD mixed with other CNS pathology than in cases of AD with no other CNS pathology. In AD combined with cerebrovascular disease, the total plaque density makes a significant contribution to cognitive deficit, while neurofibrillary tangle (NFT) densities do not. In contrast, in pure AD tangle density is the major determinant of cognitive deficit. Our findings draw attention to the influence of coexisting brain pathologies on the clinical manifestation of dementia in subjects with AD. These findings indicate that pathological diagnostic criteria for AD should take into account such additional pathology in demented subjects. They also improve understanding of the circumstances in which the amyloid component of AD can play a decisive role in precipitating clinical dementia.

Characterisation of human 5-hydroxytryptamine2A and 5-hydroxytryptamine2C receptors expressed in the human neuroblastoma cell line SH-SY5Y: comparative stimulation by hallucinogenic drugs

Stable transfection of the human neuroblastoma cell line SH-SY5Y with the human 5-hydroxytryptamine2A (5-HT2A) or 5-HT2C receptor cDNA produced cell lines demonstrating ligand affinities that correlated closely with those for the corresponding endogenous receptors in human frontal cortex and choroid plexus, respectively. Stimulation of the recombinant receptors by 5-HT induced phosphoinositide hydrolysis with higher potency but lower efficacy at the 5-HT2C receptor (pEC50 = 7.80 +/- 0.06) compared with the 5-HT2A receptor (pEC50 = 7.30 +/- 0.08). Activation of the 5-HT2A receptor caused a transient fourfold increase in intracellular Ca2+ concentration. Whole-cell recordings of cells clamped at -50 mV demonstrated a small inward current (2 pA) in response to 10 microM 5-HT for both receptors. There were no differences in potency or efficacy of phosphoinositide hydrolysis among four hallucinogenic [d-lysergic acid diethylamide (LSD), 1-(4-iodo-2,5-dimethoxyphenyl)-2-aminopropane (DOI), 5-methoxy-N,N-dimethyltryptamine, and mescaline] and three nonhallucinogenic drugs (m-chlorophenylpiperazine, quipazine, and ergotamine). Comparison of equipotent doses producing 20% of the maximal response induced by 5-HT revealed selective activation of the 5-HT2A receptor by LSD and to a lesser degree by DOI, mescaline, and ergotamine. Quipazine and 5-methoxy-N,N-dimethyltryptamine were relatively nonselective, whereas m-chlorophenylpiperazine selectively activated the 5-HT2C receptor. It is unlikely therefore that hallucinosis is mediated primarily by activity at the 5-HT2C receptor, whereas activity at the 5-HT2A receptor may represent an important but not unique mechanism associated with hallucinogenic drug action.

Flatness characteristics for diagonal scans from Varian and Siemens linear accelerators

The advent of 3D treatment planning systems whose algorithms utilize diagonal scan data to perform dose calculations has made the collection of diagonal profile data essential. Manufacturers' specifications (MS) on beam flatness and symmetry apply to both the radial and transverse axes of all square field sizes from 10 X 10 cm2 to the largest field available. Beam profile measurements were obtained for both diagonal axes over a range of field sizes and depths for two units, a Varian 2100C and a Siemens KD. In this note the International Electrotechnical Commission (IEC) flatness definition was used to characterize the diagonal flatness of each beam.

Clustering of pathological features in Alzheimer's disease: clinical and neuroanatomical aspects

We have analyzed the tendency of amyloid load, neuritic plaques and neurofibrillary tangles (NFT) in the hippocampus and neocortex to occur in clusters in 49 consecutive cases of Alzheimer's disease (AD). This clustering tendency of the pathology was analysed in relation to severity of clinical disease assessed within 6 months before death, duration and age at onset of disease and at death. Amyloid plaques showed only a slight tendency to cluster together while neuritic plaques and, even more, NFT were clearly clustered. A greater clustering tendency was associated with more severe clinical impairment with particularly strong correlations being found between the clustering tendency of NFT in the hippocampus and clinical memory deficit, and between the clustering tendency of NFT in the parietal neocortex and overall cognitive deficit. Neuritic plaques showed similar but less pronounced and robust correlations between clustering and cognitive status. In the hippocampus NFT clustering was also negatively correlated with age at death, but not duration of disease nor age of disease onset. We conclude that clustering characterises neuritic pathology but not diffuse amyloid deposits and significantly affects cognition. The discrepancies between the group diagnosed as AD-only and the patient group that contained all patients, including the ones with mixed pathology, lead us to believe that any additional pathology might have a significant effect on the cognitive status of AD patients.

Presynaptic serotonergic markers in community-acquired cases of Alzheimer's disease: correlations with depression and neuroleptic medication

Presynaptic serotonergic markers, serotonin uptake sites, and concentrations of serotonin and 5-hydroxyindoleacetic acid were studied in the frontal and temporal cortex of 20 community-acquired cases of Alzheimer's disease and 16 controls matched for age, sex, postmortem delay, and storage. Clinical assessments, including behavioural symptoms, of the Alzheimer patients were made at 4-month intervals during life. There was significant reduction in the number of serotonin uptake sites in Alzheimer cases in temporal but not frontal cortex. There was no significant alteration in the concentrations of serotonin or 5-hydroxyindoleacetic acid in either region. Alzheimer patients who had persistent depressive symptoms during life had significantly fewer serotonin uptake sites in both cortical areas compared with Alzheimer patients without these symptoms. In addition, Alzheimer patients who were receiving chronic neuroleptic medication had significantly lower concentrations of serotonin in frontal cortex and 5-hydroxyindoleacetic acid in temporal cortex than those patients not receiving such treatment. These data suggest previous studies that reported uniform serotonergic dysfunction may have been subject to unintentional selection of behaviourally disturbed Alzheimer cases or those receiving chronic neuroleptic medication. This study also provides a basis for the treatment of behaviourally disturbed Alzheimer patients with serotonomimetics.

Ultrastructural study of the cornea in a bone marrow-transplanted Hurler syndrome patient

This case report describes a 14-year-old girl with Hurler syndrome, who had received a successful bone marrow-transplant at the age of two. Corneal clouding was present at the time of transplant and has only partially cleared. A right penetrating keratoplasty was performed and the corneal specimen was examined by light microscopy, transmission electron microscopy with Cuprolinic blue staining for proteoglycans, and low-angle X-ray diffraction. The results show the corneal stroma to be disrupted by vacuolated stromal cells. There is abnormal accumulation of proteoglycans in the vacuolated stromal cells and nearby stroma. These proteoglycans mainly contain chondroitin/dermatan sulphate glycosaminoglycans since they are susceptible to chondroitinase ABC. There are a large range of fibril diameters (12.5-50.1 nm) and there is an abnormal distribution of the fibril diameters measured from micrographs. Both are confirmed by X-ray diffraction results (the mean collagen fibril diameters are in a range between 29.7 and > 51.1 nm). X-ray diffraction also shows that the mean centre-to-centre distance of the fibrils slightly increases. These findings suggest that proteoglycans play a role in modelling the stromal structure and can also explain the corneal clouding. Many long-spacing collagen structures with a mean periodicity of 91.8 nm are observed in the corneal stroma. The finding that the long-spacing collagen consists of fine collagen fibrils and that very few proteoglycans filaments bind to them suggests that some change in the interaction of proteoglycans and collagen is responsible for the formation of long-spacing collagen. To our knowledge, this is the first ultrastructural study of the cornea from a bone marrow-transplant patient with Hurler syndrome. The structural features documented here relate to a cornea incompletely corrected by bone marrow transplantation.

The palliative care quiz for nursing (PCQN): the development of an instrument to measure nurses' knowledge of palliative care

This paper describes the process and outcomes of a study to develop a tool to measure nurses' knowledge of palliative care. The development of the palliative care quiz for nursing (PCQN) entailed the convening of an advisory committee, a wide process of consultation, the development of a conceptual framework, determination of format, generating of items and pre-testing, piloting and further testing of the quiz. The PCQN is a 20-item true, false and 'I don't know' test of knowledge that is easily administered and has utility for assessing knowledge, stimulating discussion and identifying misconceptions about palliative care nursing.

Betel nut and smoking. Are they both protective in ulcerative colitis? A pilot study

Two-hundred and twenty-three Asian patients with inflammatory bowel disease were sent a questionnaire about smoking and betel nut chewing habits. The 116 responses from patients with ulcerative colitis were compared with answers from 79 healthy members of the community. Twelve per cent of male patients were currently smokers compared with 31% of healthy controls (chi 2 = 20.9 P < 0.05). No such differences existed between female patients and controls. Thirteen per cent of male patients regularly used betel nut compared with 20% (chi 2 = 3.9 P < 0.05). Both smoking and betel nut chewing appear to reduce the risk of developing ulcerative colitis, although these effects may be linked.