Occurrence of amyotrophic lateral sclerosis among Gulf War veterans

BACKGROUND

In response to Gulf War veterans' concerns of high rates of ALS, this investigation sought to determine if Gulf War veterans have an elevated rate of ALS.

METHODS

A nationwide epidemiologic case ascertainment study design was used to ascertain all occurrences of ALS for the 10-year period since August 1990 among active duty military and mobilized Reserves, including National Guard, who served during the Gulf War (August 2, 1990, through July 31, 1991). The diagnosis of ALS was confirmed by medical record review. Risk was assessed by the age-adjusted, average, annual 10-year cumulative incidence rate.

RESULTS

Among approximately 2.5 million eligible military personnel, 107 confirmed cases of ALS were identified for an overall occurrence of 0.43 per 100,000 persons per year. A significant elevated risk of ALS occurred among all deployed personnel (RR = 1.92; 95% CL = 1.29, 2.84), deployed active duty military (RR = 2.15, 95% CL = 1.38, 3.36), deployed Air Force (RR = 2.68, 95% CL = 1.24, 5.78), and deployed Army (RR = 2.04; 95% CL = 1.10, 3.77) personnel. Elevated, but nonsignificant, risks were observed for deployed Reserves and National Guard (RR = 2.50; 95% CL = 0.88, 7.07), deployed Navy (RR = 1.48, 95% CL = 0.62, 3.57), and deployed Marine Corps (RR = 1.13; 95% CL = 0.27, 4.79) personnel. Overall, the attributable risk associated with deployment was 18% (95% CL = 4.9%, 29.4%).

CONCLUSIONS

Military personnel who were deployed to the Gulf Region during the Gulf War period experienced a greater post-war risk of ALS than those who were not deployed to the Gulf.

Aberrant expression of minichromosome maintenance protein-2 and Ki67 in laryngeal squamous epithelial lesions

Histological classification of laryngeal epithelial lesions is highly subjective, and methods of cytological detection are not well developed. Improved determination of aberrant cell cycle entry may allow increased objectivity in histological assessment and enable the development of less invasive diagnostic cytology tests. Sections of normal larynx (n=10), laryngeal dysplasia (n=20) and laryngeal squamous cell carcinoma (SCC) (n=10) were classified according to the Ljubljana classification and stained for markers of cell cycle entry, minichromosome maintenance protein-2 (Mcm-2) and Ki67. Expression patterns were compared using double labelling confocal microscopy. There was a correlation between Mcm-2 and Ki67 labelling indices (rho=0.93; 95% CI [0.84, 0.97]) and both markers showed increased expression from normal epithelium to SCC (Mcm-2, P=0.001; Ki67, P=0.0002). Importantly, there was minimal expression of Mcm-2 or Ki67 in the most superficial layers of normal larynx and abnormal or atypical hyperplasia, in contrast to carcinoma in situ and SCC. Clusters of Mcm-2/5-positive cells were present in cytological preparations from SCC, but not from those showing atypical hyperplasia or inflammation in non-neoplastic tissue. Minichromosome maintenance protein-2 staining may increase the objectivity and reliability of histological grading of laryngeal epithelial lesions. Laryngeal brushings, combined with immuno-enhanced liquid-based cytology, could be useful, as a less invasive approach, to the detection of laryngeal malignant and premalignant lesions.

The effect of maternal undernutrition on ovine fetal growth

Modifications in maternal nutrition during pregnancy can significantly disrupt fetal growth and subsequent post-natal health and survival. This study investigated the effects of undernutrition on fetal growth and the potential mechanisms involved. Tissue from pregnant ewes (n=27) was investigated on days 45, 90 and 135 of gestation (term = approximately 150 days). The thoracic girth (P<0.05) was greater in fetuses from nutrient restricted ewes on day 45 and there was also a trend towards an increased gut weight (P<0.08). By day 90, the fetal brain and thymus weight were lighter in underfed than in well-fed animals whilst the weight of the fetal ovaries was heavier (P<0.05). On day 135 the fetal heart, pancreas, thymus, gut and kidney weights were lighter in undernourished ewes (P<0.05). When expressed as a percentage of fetal body weight, significance was retained in the heart, pancreas and thymus (P<0.05). Bone growth was also affected. At day 90 the fetal femur and metatarsal were longer in underfed mothers (P<0.05). In contrast, the fetal humerus and scapula were shorter in underfed than in well-fed animals on day 135 (P<0.05) when the weight of the semitendinosus muscle (P<0.05) was also reduced. The fall in fetal glucose (P<0.1), insulin (P<0.01) and IGF-I (P<0.01) levels in underfed ewes on day 135 may have compromised fetal growth. Fetal plasma IGF binding protein-2 also increased between days 90 and 135 in underfed ewes (P<0.03), whilst levels were unaltered in well-fed animals. Although maternal and fetal plasma IGF-I levels increased with gestation (P<0.01) and the placentome morphology altered in all ewes (P<0.05), the fall in placental mass (P<0.05), amniotic and allantoic glucose concentrations (P<0.05) and maternal plasma glucose and insulin levels (P<0.05) in underfed ewes in late gestation may have compromised fetal substrate delivery. These perturbations in fetal development may have significant implications on adult health and carcass conformation, raising important health and economic issues in medical and agricultural sectors.

CT guided percutaneous fixation of sacroiliac fractures in trauma patients

BACKGROUND

Open reduction and internal fixation of unstable pelvic fractures has been advocated to minimize complications and avoid further injury. We have recently performed CT guided percutaneous fixation of sacroiliac joints as an alternative to open repair.

METHODS

From May 1, 1998 to April 30, 1999, our Level II trauma center admitted 76 patients with pelvic fractures, all due to blunt trauma. Twenty patients with unstable sacroiliac fracture-distractions underwent 22 percutaneous fixation procedures under general anesthesia in the radiology department by the third hospital day. Procedure times averaged 82 minutes. Localization with CT guidance was performed by the radiologist using 3-D images followed by percutaneous screw placement by the orthopaedic surgeon.

RESULTS

There was minimal procedural blood loss and no post-procedural wound complications. There was one operative delay due to respiratory difficulties and one postoperative death unrelated to the pelvic fracture. All patients were mobilized on the first post-procedural day.

CONCLUSION

CT guided fixation of unstable pelvic fractures minimizes blood loss during a short procedure with few subsequent complications and allows early mobilization of the patients.

MDM2 can promote the ubiquitination, nuclear export, and degradation of p53 in the absence of direct binding

MDM2 can bind the N terminus of p53 and promote its ubiquitination and export from the nucleus to the cytoplasm, where p53 can then be degraded by cytoplasmic proteasomes. Several studies have reported that an intact MDM2 binding domain is necessary for p53 to be targeted for ubiquitination, nuclear export, and degradation by MDM2. In the current study, we examined whether the MDM2 binding domain of p53 could be provided in trans through oligomerization between two p53 molecules. p53 proteins mutated in their MDM2 binding domains were unable to bind MDM2 directly and were resistant to MDM2-mediated ubiquitination, nuclear export, and degradation when expressed with MDM2 alone. However, these same p53 mutants formed a complex with MDM2 and were efficiently ubiquitinated, exported from the nucleus, and degraded when co-expressed with MDM2 and wild-type p53. Moreover, this effect required MDM2 binding by wild-type p53 as well as oligomerization between wild-type p53 and the MDM2 binding-deficient p53 mutants. Taken together, these results support a model whereby MDM2 binding-deficient forms of p53 can bind MDM2 indirectly through oligomerization with wild-type p53 and are subsequently targeted for ubiquitination, nuclear export, and degradation. These findings may have important implications regarding the DNA damage response of p53.

Measuring the economic costs of antimicrobial resistance in hospital settings: summary of the Centers for Disease Control and Prevention-Emory Workshop

Health systems administrators and clinicians need refined calculations of the attributable cost of infections due to drug-resistant microorganisms to develop and assess cost-effective prevention strategies that deal with these infections. To date, however, efforts to provide this information have yielded widely variable and often conflicting estimates. This lack of reproducibility is largely attributable to problems in study design and in the methods used to identify and measure costs. Addressing these methodological issues was the focus of a workshop that included participants from a broad range of backgrounds, including economics, epidemiology, health care management, health care outcomes research, and clinical care. This workshop summary presents the advantages and disadvantages of various research designs as well as particular methodological issues related to the measurement of the economic cost of resistance in health care settings. Suggestions are made for needed common definitions and approaches, study areas for future research are considered, and priority investigations are identified.

Student nurses' experiences of Project 2000

AIM

The aim of the study was to investigate student nurses' experiences of Project 2000.

METHOD

A sample of 76 students completed a questionnaire twice, once at the beginning of the course and again after one year. A second questionnaire comprising rating scales of how stressed they felt, was completed by a sample of 30 students weekly for the first year of the course.

RESULTS

Seven areas of concern were identified: the theory component of the course, assessments, clinical practice, financial pressures, time management, personal development and personal difficulties.

CONCLUSION

Sufficient data were generated to suggest that the experiences of Project 2000 students in other institutions are likely to be similar to those reported in the study. Recommendations for teachers, clinical staff and students are made.

An investigation of the interaction between thematic and phrasal structure in nonfluent agrammatic subjects

Garrett (1982) developed a model of normal sentence production which has been used in the description of aphasic language (Schwartz, 1987). This study investigated the effects of the thematic representation specified at the functional level on the complexity of the phrases produced at the positional level. A group of 14 nonfluent, agrammatic subjects were compared to 20 normal controls in their production of the story of Cinderella. The agrammatic subjects produced fewer argument structures than the normal control subjects. Their phrasal realization of the arguments, however, was not qualitatively different from that of the normal subjects. In both cases, with an increase in the number of arguments, there was a concurrent increase in the mean complexity of the phrases used to realize those arguments and in the total phrasal complexity of the utterances. The complexity of noun phrases differed according to the thematic roles expressed; this seemed to be a consequence of their different locations in the sentence. Preverbal noun phrases were much less complex than postverbal noun phrases. There was no evidence to suggest that there was a trade-off between the production of thematic structure and subsequent phrasal production. Neither was there evidence to suggest that production differed according to whether the phrase was an argument of the verb or a nonargument. The complexity of a phrase was determined by the type of information it conveyed.

The effects of age on accident severity and outcome in Irish road traffic accident patients

Road traffic accidents (RTA's) are the leading cause of fatal trauma in Ireland. Although older drivers are the safest group of drivers in the population, once involved in a crash they are more likely to sustain a severe injury or death. The experiences of Irish elderly RTA victims has not been previously documented. We studied older RTA patients admitted to two Irish trauma centres in 1995. Of 525 patients, 39 (7%) were aged over 65. We compared 38 patients aged 16-64 years for comparison and reviewed the notes in detail. Elderly patients were mostly pedestrians (23/38 - 61%) though 21% (8/38) were drivers with 8% (3/38) on public transport. Younger patients were mostly drivers (14/37 - 38%), cyclists (9/37 - 24%) or motorcyclists (7/37 - 19%). Older patients had a higher median Injury Severity Score, p < 0.05, were more likely to be female (p<0.01), involved in RTA's between 9am-5pm (p<0.05) and have pre-existing medical conditions (p<0.01). The following were significantly increased in older patients (p values): surgical (<0.01), medical (<0.01) and therapist workload (p<0.05), complications (<0.0001), length of stay (<0.01). Less elderly were discharged directly to home (p<0.001). Strategies to reduce the mortality and morbidity associated with RTA in the elderly should emphasise a) older pedestrians during daytime hours, b) attention to safety in public transport. Treatment must ensure adequate medical and therapist input to anticipate higher complication rates.

MIRABEL: models for integrated review and assessment of biodiversity in European landscapes

In this paper, we present the methodology and some results from the application of an integrating conceptual framework, MIRABEL, to analyze the consequences of environmental change for biodiversity. For 28 European countries, MIRABEL tabulates changes in the status of threatened habitats predicted to result from 10 environmental pressures. Regional variations in the severity of the pressures and impacts are taken into account by compiling separate impact tables for each of 13 Ecological Regions. Results suggest that agricultural intensification is one of the main threats, however, differences recorded by MIRABEL in the intensity of the pressures, their rate of change and their past and expected impacts on biodiversity in the various Ecological Regions is telling evidence of Europe's biogeographical variety, and of the need to take this into consideration when assessing environmental change.

MIRABEL: models for integrated review and assessment of biodiversity in European landscapes

In this paper, we present the methodology and some results from the application of an integrating conceptual framework, MIRABEL, to analyze the consequences of environmental change for biodiversity. For 28 European countries, MIRABEL tabulates changes in the status of threatened habitats predicted to result from 10 environmental pressures. Regional variations in the severity of the pressures and impacts are taken into account by compiling separate impact tables for each of 13 Ecological Regions. Results suggest that agricultural intensification is one of the main threats, however, differences recorded by MIRABEL in the intensity of the pressures, their rate of change and their past and expected impacts on biodiversity in the various Ecological Regions is telling evidence of Europe's biogeographical variety, and of the need to take this into consideration when assessing environmental change.

On the differences between conventional and auditory spectrograms of English consonants

A new tool for speech analysis is presented, operating in real-time and incorporating the analysing power of a contemporary auditory model to produce the familiar display of the speech spectrograph. This "auditory spectrograph" is used to analyse English consonant sounds and the results are compared with conventional wide and narrow band spectrograms. The auditory analyses are found to attach more visual weight to the acoustic cues associated with speech production and perception, and features that are either difficult or impossible to distinguish on conventional spectrograms are clarified.

Semantic memory is impaired in both dementia with Lewy bodies and dementia of Alzheimer's type: a comparative neuropsychological study and literature review

OBJECTIVE

To test the hypothesis that semantic impairment is present in both patients with dementia with Lewy bodies (DLB) and those with dementia of Alzheimer's type (DAT).

METHODS

A comprehensive battery of neuropsychological tasks designed to assess semantic memory, visuoperceptual function, verbal fluency, and recognition memory was given to groups of patients with DLB (n=10), DAT (n=10) matched pairwise for age and mini mental state examination (MMSE), and age matched normal controls (n=15).

RESULTS

Both DLB and DAT groups exhibited impaired performance across the range of tasks designed to assess semantic memory. Whereas patients with DAT showed equivalent comprehension of written words and picture stimuli, patients with DLB demonstrated more severe semantic deficits for pictures than words. As in previous studies, patients with DLB but not those with DAT were found to have impaired visuoperceptual functioning. Letter and category fluency were equally reduced for the patients with DLB whereas performance on letter fluency was significantly better in the DAT group. Recognition memory for faces and words was impaired in both groups.

CONCLUSIONS

Semantic impairment is not limited to patients with DAT. Patients with DLB exhibit particular problems when required to access meaning from pictures that is most likely to arise from a combination of semantic and visuoperceptual impairments.

Noun-verb differences? a question of semantics: a response to shapiro and caramazza

We presented a new model using the sensory/functional theory of semantic category deficits to explain noun/verb deficits in aphasia. The predictions arising from this model were tested on a small number of patients exhibiting grammatical and/or semantic category specific deficits in picture naming. The results lent support for the theory presented. Shapiro and Caramazza (this issue) raised several objections to this theory (which they call the "extended sensory functional theory," or ESFT). In this article we address their concerns about the validity of the ESFT and conclude that it is indeed a useful model that provides a parsimonious explanation for many diverse patterns of deficits.

Age of acquisition and imageability ratings for a large set of words, including verbs and function words

Age of acquisition and imageability ratings were collected for 2,645 words, including 892 verbs and 213 function words. Words that were ambiguous as to grammatical category were disambiguated: Verbs were shown in their infinitival form, and nouns (where appropriate) were preceded by the indefinite article (such as to crack and a crack). Subjects were speakers of British English selected from a wide age range, so that differences in the responses across age groups could be compared. Within the subset of early acquired noun/verb homonyms, the verb forms were rated as later acquired than the nouns, and the verb homonyms of high-imageability nouns were rated as significantly less imageable than their noun counterparts. A small number of words received significantly earlier or later age of acquisition ratings when the 20-40 years and 50-80 years age groups were compared. These tend to comprise words that have come to be used more frequently in recent years (either through technological advances or social change), or those that have fallen out of common usage. Regression analyses showed that although word length, familiarity, and concreteness make independent contributions to the age of acquisition measure, frequency and imageability are the most important predictors of rated age of acquisition.

Semantic memory is impaired in both dementia with Lewy bodies and dementia of Alzheimer's type: a comparative neuropsychological study and literature review

OBJECTIVE

To test the hypothesis that semantic impairment is present in both patients with dementia with Lewy bodies (DLB) and those with dementia of Alzheimer's type (DAT).

METHODS

A comprehensive battery of neuropsychological tasks designed to assess semantic memory, visuoperceptual function, verbal fluency, and recognition memory was given to groups of patients with DLB (n=10), DAT (n=10) matched pairwise for age and mini mental state examination (MMSE), and age matched normal controls (n=15).

RESULTS

Both DLB and DAT groups exhibited impaired performance across the range of tasks designed to assess semantic memory. Whereas patients with DAT showed equivalent comprehension of written words and picture stimuli, patients with DLB demonstrated more severe semantic deficits for pictures than words. As in previous studies, patients with DLB but not those with DAT were found to have impaired visuoperceptual functioning. Letter and category fluency were equally reduced for the patients with DLB whereas performance on letter fluency was significantly better in the DAT group. Recognition memory for faces and words was impaired in both groups.

CONCLUSIONS

Semantic impairment is not limited to patients with DAT. Patients with DLB exhibit particular problems when required to access meaning from pictures that is most likely to arise from a combination of semantic and visuoperceptual impairments.

Exposure to febrile temperature modifies endothelial cell response to tumor necrosis factor-alpha

Fever is an important regulator of inflammation that modifies expression and bioactivity of cytokines, including tumor necrosis factor (TNF)-alpha. Pulmonary vascular endothelium is an important target of TNF-alpha during the systemic inflammatory response. In this study, we analyzed the effect of a febrile range temperature (39.5 degrees C) on TNF-alpha-stimulated changes in endothelial barrier function, capacity for neutrophil binding and transendothelial migration (TEM), and cytokine secretion in human pulmonary artery endothelial cells (EC). Permeability for [(14)C]BSA tracer was increased by treatment with TNF-alpha, and this effect was augmented by incubating EC at 39.5 degrees C. Treating EC with 2. 5 U/ml TNF-alpha stimulated an increase in subsequent neutrophil adherence and TEM. Incubating EC at 39.5 degrees C caused a 30% increase in TEM but did not modify the enhancement of neutrophil adherence or TEM by TNF-alpha treatment. Analysis of cytokine expression in EC cultures exposed to TNF-alpha at either 37 degrees or 39.5 degrees C revealed three patterns of temperature and TNF-alpha responsiveness. Granulocyte-macrophage colony stimulating factor (GM-CSF) and interleukin (IL)-8 were not detectable in untreated EC but were increased after TNF-alpha exposure, and this increase was enhanced at 39.5 degrees C. IL-6 expression was also increased with TNF-alpha exposure, but IL-6 expression was lower in 39.5 degrees C EC cultures. Transforming growth factor-beta(1) was constitutively expressed, and its expression was not influenced either by TNF-alpha or exposure to 39.5 degrees C. These data demonstrate that clinically relevant shifts in body temperature might cause important changes in the effects of proinflammatory cytokines on the endothelium.

The functional anatomy of the female pelvic floor and stress continence control system

This paper provides an overview of the functional anatomy of the structures responsible for controlling urinary continence under stress. The stress continence control system can be divided into two parts: the system responsible for bladder neck support, and the system responsible for sphincteric closure. Age- and injury-related changes in each of these systems are discussed. Understanding the pathophysiology of incontinence on the anatomical level will help to lead to identification of specific defects, thereby allowing better individualized treatment for the incontinent patient.

Treatment of word retrieval in aphasia: generalisation to conversational speech

The question of whether treatment gains in picture naming generalise to conversation remains relatively unexplored. Several difficulties surround data collection and analysis. A quantitative measure of word retrieval in aphasia is presented along with relevant details relating to the reliability of the measure, and the relationship between word retrieval in picture naming and noun retrieval in conversation. We discuss the clinical application of the measure and its applicability outside the field of aphasia.

Phonological and orthographic approaches to the treatment of word retrieval in aphasia

We present a preliminary report on a study of the treatment of word finding difficulties in aphasia using phonological and orthographic cues. These techniques although often used to cue word finding in the immediate term have been little evaluated in terms of therapy designed to improve word retrieval in the long term. The first phase using cued word retrieval in a picture naming task was followed by a second phase designed to facilitate use of treated words in real-life contexts. The results from both phases were encouraging with improved word retrieval for three out of the four participants. The implications for clinical practice are discussed.

Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhoea

Imaging is an important component in the investigation of unilateral watery rhinorrhoea suspicious of cerebrospinal fluid (CSF). Whilst the demonstration of the presence of beta 2 transferrin confirms that CSF is present it may prove difficult to demonstrate the exact site of origin. Fine detail coronal computed tomography (CT) with sections of 1-2 mm thickness through the anterior skull base may show small dehiscences and fractures. The commonest site for congenital dehiscences is the cribriform niche adjacent to the vertical attachment of the middle turbinate anteriorly and the superior and lateral walls of the sphenoid posteriorly. In the presence of frequent or constant CSF rhinorrhoea a CT cisternogram can be helpful in defining the exact site of the leak. Magnetic resonance imaging (MRI) is reserved for defining the nature of soft tissue i.e. inflammatory tissue, meningoencephalocele or tumour. Finally, per-operative intrathecal fluorescein is helpful when imaging does not prove positive. A management algorithm for CSF rhinorrhoea is presented.

The impact of waiting time on liver transplant outcomes

OBJECTIVE

To measure the impact of patient waiting time on the probability of graft failure following liver transplantation.

DATA SOURCES

Observations on all patients receiving transplants between 1995 and 1997 collected by the United Network for Organ Sharing.

STUDY DESIGN

This study uses a two-stage probit algorithm. The first stage is an ordinary least squares regression of controls and indicators of patient blood type (the instrument set) on waiting time. The second uses the predicted value from the first regression in a probit analysis where the dependent variable is graft failure.

PRINCIPAL FINDINGS

Waiting time has a statistically and clinically significant effect on the probability of graft failure following transplantation. Waiting 50 additional days for a transplant increases the probability of graft failure at one year by between one and two percentage points.

CONCLUSIONS

Policies to reduce waiting times will yield clinical benefits beyond decreasing the length of time patients spend in poor health.