Quality assurance and quality management in the National Health Service

This review deals with current views on quality assurance as relevant to both health care professionals and health service managers. The concept of quality is defined and a brief history of quality in the health service presented. The paper then explores political, social and economic factors which govern the provision of quality assurance in the modern health service. The possible effects of the health service reforms on quality management is discussed.

Recurrent gastrointestinal bleeding associated with chronic pancreatitis

A 52 year old man with chronic pancreatitis presented with recurrent upper gastrointestinal bleeding. Gastroscopy was normal, but visceral angiography suggested that there were gastric varices. Despite treatment with propranolol he had further episodes of bleeding and so underwent splenectomy to decompress the gastric varices. When the spleen was removed, however, an inflammatory mass in the head of the pancreas adherent to the posterior gastric wall was noted. Within it the splenic artery was visible and communicated with the gastric lumen through a small opening in the gastric wall. The artery was ligated and the patient has since had no further bleeding. Thus, chronic pancreatitis should be considered as a cause of recurrent upper gastro-intestinal bleeding, especially when gastroscopy is normal.

Casein kinase II is the P protein phosphorylating cellular kinase associated with the ribonucleoprotein complex of purified vesicular stomatitis virus

Protein kinase activities associated with a highly purified transcriptionally active ribonucleoprotein complex from the virions of vesicular stomatitis virus (VSV) were isolated and characterized. Based upon several biochemical and immunological criteria, the protein kinase activity, which phosphorylated the bacterially expressed unphosphorylated (Po) protein, was shown to be cellular casein kinase II (CKII). These studies included inhibition of the protein kinase by specific inhibitors, phosphorylation of mutant phosphoproteins (P), immunoprecipitation by CKII antibody and Western blot analyses, and finally its ability to activate Po to synthesize RNA in a transcription-reconstitution reaction. The P protein is phosphorylated intracellularly by cellular CKII. The present study demonstrates that VSV specifically packages CKII which remains strongly associated with the ribonucleoprotein complex during morphogenesis.

Incidence of malignancy in Bankura (a retrospective study)

A retrospective study on pattern of malignant lesions in a rural district of West Bengal from 1981-1990 was conducted in the department of pathology, BS Medical College, Bankura, West Bengal. A total number of 17,130 cases were received out of which 1976 were malignant lesions (11.53%). The peak incidence of cancer in both sexes was found between the 4th, 5th and 6th decades, ie, 31-60 years of age. Sex-wise distribution showed more incidence in female (1246-62.17%) than in male (730-37.83%). Cancer of the cervix (35.62%) showed the highest incidence in this series. Cancer of the larynx (11.94%) was the commonest cancer in males. Malignancy of the lymph node was observed in 11.43% cases. Malignancy of the lungs and vagina (< 0.5%) showed very low incidence.

Case report: prolonged contrast enhancement of the inner ear on magnetic resonance imaging in Ramsay Hunt syndrome

There have been recent reports of enhancement of the inner ear in acute labyrinthitis on gadolinium enhanced magnetic resonance imaging (MRI). However, none has described persistence of enhancement beyond 6 weeks. We report a case of Ramsay Hunt syndrome with labyrinthitis, sensorineural hearing loss and facial nerve palsy in which marked enhancement of the inner ear structures was observed on MRI 6 months after the onset of symptoms. Enhancement on delayed or repeated imaging after a period of months does not exclude labyrinthitis from the differential diagnosis of the small intracanalicular acoustic neuroma, and care should be taken not to confuse them.

Experimental models of acute pancreatitis

Various models of experimental acute pancreatitis are described. An ideal model would be reproducible, have a similar natural history to that of the human disease and a similar response to treatment. Furthermore, it should be relatively cheap and simple. Few, if any, of the available experimental models completely satisfy these criteria. The appropriate choice of model is discussed, as are possible future developments in this field.

Synthesis and anthelmintic activity of 3-substituted 5-methylthio-isoxazoles

Isoxazole derivatives have been shown to possess antiparasitic activity. In the present study, 3-substituted 5-methylthio-isoxazoles were synthesized and tested for anthelmintic activity, along with some other isoxazoles which have been reported but not tested earlier. Nine compounds (2a, 2b, 2e, 2g, 2u, 3a, 3b, 3e and 3f) showed activity against both A. ceylanicum and N. dubius in vitro. Twelve compounds (2a, 2b, 2d, 2e, 2f, 2h, 2l, 2n, 2o, 2u, 3d and 3e) showed activity against N. dubius in vivo, a parasite of veterinary importance.

Vasovasostomy: 10 years' experience in a district general hospital showing improved results with luminal dilatation

We report a simple and effective technique for vasovasostomy. Over 105 procedures have been performed over a 10-year period by a single consultant and his registrars with results comparable to those obtained with more time-consuming formal microsurgical techniques when routine luminal dilatation of the vas was adopted. Additionally, the chances of success were found to be greater the shorter the interval between vasectomy and vasovasostomy.

Diagnostic approaches to parotid swellings

Although the mainstay assessment of parotid swellings remains clinical examination, cytology, computed tomography and magnetic resonance imaging may give valuable preoperative information on both the likely histology and the location of the individual swelling. This is important for therapeutic and prognostic reasons.

Gastric telangiectasis: a rare cause of severe blood loss in CREST syndrome

A 46 year old woman presented with the CREST variety of systemic sclerosis and occult gastrointestinal bleeding due to vascular malformations of her stomach. Partial gastrectomy cured her anaemia. In systemic sclerosis, visceral angiography should be performed early when initial investigations have been negative.

Pleural effusion in breast cancer: a review of the Nottingham experience

A retrospective analysis of 40 patients with pleural effusions caused by breast cancer is presented. Evidence is presented which suggests that malignant pleural effusion in breast cancer is caused by lymphatic rather than blood spread. 70% of effusions are ipsilateral to the primary carcinoma and 22.5% of patients with pleural effusions have positive internal mammary node biopsies (compared to 10.4% in controls). 47.5% of effusions had positive cytology but this does not correlate with either survival or recurrence. In operable tumours, pleural effusion is correlated with the size of the primary tumour but effusions were uncommon with large, locally advanced Stage III tumours at presentation, which could be attributable either to the short survival of such patients or to the effect of adjuvant radiotherapy reducing the chance of an ipsilateral effusion. Although these patients overall had a short life expectancy (median 11 months) there was a wide range. Chest drainage and instillation of 100 mg mepacrine in 30 ml of bupivacaine to give rise to pleurodesis offers useful palliation and minimizes recurrence (29 treatments with only two symptomatic recurrences), compared with aspiration alone (19 treatments with 12 symptomatic recurrences) or instillation with tetracycline (10 treatments with five symptomatic recurrences). Pleural effusion secondary to breast cancer is a locoregional manifestation. Pleurodesis with mepacrine offers good local control.

MRI of an unusual case of peduncular hallucinosis (Lhermitte's syndrome)

We report a case of peduncular hallucinosis (Lhermitte's syndrome), unusual in that there were no associated neurological signs and the symptoms persisted over many years. Magnetic resonance imaging demonstrated the typical midbrain lesion.

Hypothesis--pouchitis represents a useful clinical model of ulcerative colitis

Various mechanisms have been proposed for the aetiology of inflammation in ileal pouches following restorative proctocolectomy. It is proposed that many of these processes may be involved in the pathogenesis of ulcerative colitis, and therefore pouchitis may be used to study pathogenesis and treatment of inflammatory bowel disease in general and, in particular, ulcerative colitis.

Can the elderly tolerate endoscopy without sedation?

The cardiopulmonary complications associated with gastroscopy could be reduced by giving little or no prior sedation. The ability to tolerate the procedure with and without sedation was compared in 62 elderly patients by recording responses to a questionnaire designed to evaluate the patient's own assessment of the examination. A similar percentage of sedated and unsedated patients described the procedure as mildly unpleasant (63% vs 57%; chi 2 = 0.500; p > 0.10). The majority (73%) of unsedated patients did not want to be sedated for future examinations because of the inconvenience of the recovery period. Elderly patients should therefore be given the choice of undergoing the procedure without sedation. Full counselling and explanation of the procedure are however even more important to allay anxiety and apprehension if the procedure is undertaken without sedation.

Choroid plexus tumours--an immunohistochemical analysis with review of literature

Immunohistochemical analysis of 9 choroid plexus papillomas (CPPs) and 3 choroid plexus carcinomas (CPCs) using a panel of antibodies against glial fibrillary acidic protein (GFAP), cytokeratin (CK), epithelial membrane antigen (EMA), S-100 protein, vimentin (vim), and neuron specific enolase (NSE) is presented. Focal positivity was observed for GFAP in 11, vimentin in 7, cytokeratin in 2 and EMA in 3 cases. Diffuse and intense immunoreactivity for S-100 protein was seen in all papillomas, however, unreactive areas were noted in carcinomas. All cases exhibited focal to diffuse NSE positivity. Location and type of the tumour and age of the patient did not influence the staining pattern except for predominant S-100 positivity in papillomas. The significance of these findings is discussed in relation to the differential diagnosis or immunoreactivity patterns of these tumours.

Multicentric gliomas: report of 2 cases

Two cases of multicentric gliomas with long survival are reported. One patient underwent multiple surgical procedures while another had two separate surgical procedures at the same time. Presence of calcification of CT scan in one case raised suspicion for a preoperative diagnosis of oligodendroglioma. Lack of direct continuity or subarachnoid enhancement on CT scan and low histological grade of the tumours suggested their primary multicentric origin. The incidence of multicentric gliomas in our experience is 0.4% amongst 500 glial tumours over a period of eight years.

Subcutaneous alveolar soft-part sarcoma mimicking metastatic hypernephroma

Alveolar soft-part sarcoma represents a rare tumor of the subcutaneous and soft tissues that may present to the dermatologist. It may mimic both other primary tumours and other metastatic tumours. This mimicry has not been emphasised in the previous literature.

Mapping of interacting domains between the nucleocapsid protein and the phosphoprotein of vesicular stomatitis virus by using a two-hybrid system

Specific interaction between the nucleocapsid protein (N) and the phosphoprotein (P) of vesicular stomatitis virus (VSV), an important step in the life-cycle of the virus, was studied by using a two-hybrid system. Plasmids encoding P fused with the yeast GAL4 DNA-binding domain (pGALP) and N fused with the herpes simplex virus VP16 transactivating region (pVPN) were transfected into CHO cells along with a reporter plasmid encoding chloramphenicol acetyltransferase (CAT). The ability of N and P to associate in vivo was measured by activation of the CAT gene by the VP16 transactivating region. Transfection of plasmids pGALP and pVPN resulted in a high level of CAT activity, indicating that the N and P portions of the fusion proteins associated very strongly with each other. Progressive C-terminal deletions of the P protein revealed two regions that are important for association with the N protein: the N-terminal acidic domain and the C-terminal basic domain. Phosphorylation of P protein was not required for N-P association. Various deletions and mutations of the N protein revealed the C-terminal 5 amino acids (Val-Glu-Phe-Asp-Lys), in particular the amino acids Val-Glu-Phe, to be critical for N association with P. This two-hybrid system can be used in other viral systems to study the interaction between proteins involved in transcription and replication.

Carcinosarcoma of parotid gland having osteosarcoma as sarcomatous component: a case report

We report a rare case of carcinosarcoma of parotid gland in a pleomorphic adenoma. The tumor showed two distinct heterologous components, a ductal carcinoma and an osteosarcoma. The latter has not been described so far in such tumors arising in pleomorphic adenoma of parotid gland.

Rescue of synthetic analogs of genome RNA of human parainfluenza virus type 3

A simple system that allows expression and packaging of a foreign gene by human parainfluenza virus type 3 (HPIV-3) has been described. First, a cDNA was constructed to encode an internally deleted version of HPIV-3 genome RNA. The viral genes were replaced with a negative sense copy of the bacterial chloramphenicol acetyl transferase (CAT) reporter gene. In vitro run-off transcription with T7 RNA polymerase synthesized an 870 nucleotide RNA that contained the antisense coding region of the CAT gene flanked by the transcription regulatory sequences and the 3' and 5' end extracistronic sequences of the HPIV-3 genome. When introduced into cells that are infected with HPIV-3, this RNA was amplified and the reporter gene was expressed, as measured by the CAT activity in the cell extract. Furthermore, the synthetic RNA was packaged into infectious virions. The addition of two extra nucleotides at the 5' end of the parental trailer region decreased the CAT activity by more than 90%, suggesting a requirement for the intact 5'-regulatory domain in the viral replicative cycle. Interestingly, the addition of one extra nucleotide to the 3' end totally abolished the CAT activity indicating that an exact 3' terminus is critical in this process.

Characterization of the in vitro system for the synthesis of mRNA from human respiratory syncytial virus

An in vitro transcription system for human respiratory syncytial virus (RSV) is described. Purified viral nucleocapsid (RNP) isolated from virus-infected cells was shown to support transcription of all 10 genes encoded by the virus as determined by Northern blot hybridization. The mRNAs synthesized were polyadenylated and comigrated with the corresponding mRNAs synthesized in virus-infected cells when analyzed in agarose-urea gel electrophoresis. The in vitro-synthesized mRNAs are functional as determined by their capacity to synthesize protein in vitro. The transcriptional reaction was significantly stimulated by the uninfected host cell lysate, indicating a requirement of host factor(s) in mRNA synthesis. Preliminary results suggest that cellular actin is involved in this process.

Role of cellular actin in human parainfluenza virus type 3 genome transcription

The transcribing ribonucleoprotein (RNP) complex of human parainfluenza virus type 3 (HPIV-3) requires cellular actin for transcription of viral genome in vitro (De, B. P., Lesoon, A., and Banerjee, A. K. (1991) J. Virol. 65, 3268-3275). In this communication, we have studied the interactions between different molecular forms of actin and the RNP of HPIV-3 to understand the role of actin in mRNA synthesis. We demonstrate that both polymeric and monomeric forms of actin (obtained by DNase I treatment) bind strongly to the RNP at 100 mM KCl concentration (polymerizing buffer). The binding was virtually abolished at zero KCl concentration (depolymerizing buffer). Isolation of the RNP-actin complex and subsequent use in a transcription reaction showed that the bound actin alone was sufficient for mRNA synthesis in vitro. Interestingly, the DNase I-arrested monomeric form of actin failed to activate mRNA synthesis, indicating a requirement of polymerization of the bound actin during HPIV-3 transcription. Electron microscopic analyses revealed that a drastic structural modification of the RNP occurred because of the polymerization of actin from a loosely coiled and irregular structure to a condensed and flexible structure. Activation of transcription was observed also with poly-L-glutamic acid, a highly acidic polypeptide. However, unlike cellular actin, poly-L glutamic acid was able to activate only 10% of the input RNP. These results suggest that cellular actin activates HPIV-3 transcription by polymerizing specifically on the RNP complex. This event results in an alteration of the RNP structure that enhances its suitability for efficient transcription. The acidic domain of actin may play an important role in this process.

Functional significance of coronary collateral vessels in patients with previous 'Q' wave infarction: relation to aneurysm, left ventricular end diastolic pressure and ejection fraction

The importance of coronary collateral circulation in relation to the left ventricular function, aneurysm formation and size was investigated in 100 patients with previous 'Q' wave myocardial infarction who underwent coronary angiography. Aneurysms were present in 20% of patients. The majority of these (80%) patients had severe or total occlusion of the left anterior descending artery. Thirty four percent of patients without aneurysm had significant collaterals whereas 25% of patients with aneurysms had collaterals (P > 0.05). However, the size of the aneurysm was smaller when adequate collateral circulation was present (Collateral Index 2 or above). The incidence of hypertension and diabetes was similar in both groups. Collateral circulation was more frequently seen in the anterior (60%) as compared to inferior myocardial infarction (40%), but Collateral Index was higher in right coronary artery disease. The number of patients with an elevated left ventricular end-diastolic pressure (> 12) or poor ejection fraction was similar in the two groups with and without collaterals. Thus, there was no beneficial effect of collateral circulation on left ventricular function. The incidence of aneurysm was not significantly lower, although the size of the aneurysm was significantly smaller in the presence of collateral circulation.

Transcriptional activity and mutational analysis of recombinant vesicular stomatitis virus RNA polymerase

The 241-kDa large (L) protein of vesicular stomatitis virus (VSV) is the multifunctional catalytic component of the viral RNA polymerase. A protocol has been developed for the synthesis of recombinant L protein that will support viral mRNA synthesis in vitro. COS cells were transfected with a transient expression vector (pSV-VSL1 [M. Schubert, G. G. Harmison, C. D. Richardson, and E. Meier, Proc. Natl. Acad. Sci. USA 82:7984-7988, 1985]) which contains the simian virus 40 late promoter for the transcription of a cDNA copy of the L protein of the Indiana serotype of VSV. Cytoplasmic extracts of these cells efficiently transcribed VSV mRNAs in vitro in conjunction with N protein-RNA template purified from virus and recombinant phosphoprotein synthesized in Escherichia coli. mRNA synthesis was completely dependent upon addition of both bacterial phosphoprotein and extracts from cells transfected with the L gene. Extracts from mock-transfected cells or from cells transfected with the expression vector alone did not support VSV RNA synthesis. RNA synthesis was proportional to the concentration of cell extract used, with an optimum of 0.2 mg/ml. Rhabdoviruses and paramyxoviruses contain a highly conserved GDNQ motif which was mutated in the transfected L gene. All constructs with mutations within the core GDN abrogated transcriptional activity except for the mutant containing GDD, which retained 25% activity. Conserved amino acid changes outside of the core GDN and changes corresponding to other paromyxovirus and rhabdovirus L proteins retained variable transcriptional activity. These findings provide experimental evidence that the GDN of negative-strand, nonsegmented RNA viruses is a variant of the GDD motif of plus-strand RNA viruses and of the XDD motif of DNA viruses and reverse transcriptases.

Expression of the vesicular stomatitis virus nucleocapsid protein gene in Escherichia coli: analysis of its biological activity in vitro

The nucleocapsid (N) protein genes of vesicular stomatitis virus, serotypes New Jersey and Indiana, were expressed in Escherichia coli BL21(DE3) transformed by the recombinant expression vector pET-3a containing N genes under the control of the T7 RNA polymerase promoter. Following induction with isopropylthiogalactopyranoside, the N protein was synthesized, representing 10 to 20% of total cellular protein. The N protein remained in a nonaggregated form in 1 M NaCl solution. The purified N protein was found to be biologically active as demonstrated by its encapsidation of preformed leader RNA as well as its synthesis of genome length RNA in an in vitro transcription-replication reaction. The availability of recombinant N protein in a sufficient amount would facilitate structure and function studies of this important viral protein.

Autopsy findings and clinical diagnoses: a review of 1,000 cases

The protocols of 1,000 consecutive adult patients autopsied during the period June 1983 to December 1988 were retrospectively analyzed and the findings were compared with clinical diagnoses. The autopsy rates during this period ranged between 23% and 27% of hospital deaths. Eighty-seven percent of the autopsied patients were between 15 and 59 years of age. Major discrepancies between the autopsy reports and the clinical diagnoses were present in 31.7% of all autopsy reports reviewed. Infectious diseases were the most common cause of death (46.8%), followed by cardiovascular diseases (17.1%) and neoplastic diseases (14.3%). Infections were clinically recognized in 66.7% of cases and were missed or found to be incorrect in 33.3% of cases. Tuberculosis comprised 33.8% of the major bacterial infections and was clinically diagnosed in 82% of cases. Eighty-nine percent of the major fungal infections were not suspected clinically. Rheumatic heart disease (43.8%) was the most common cardiovascular disorder and was clinically diagnosed in 93.3% of cases. Pulmonary vascular episodes were the least common cause of death and were not suspected clinically in 62.9% of cases. Malignancies were incorrectly diagnosed in 25.8% of cases. We conclude from this study that routine autopsies revealed major unexpected findings that are of clinical importance, and that a continued emphasis on autopsy evaluation is necessary for the improvement of the quality of patient care.

Mortality profile in trauma victims

To assess the mortality incidence among trauma victims, one year prospective study comprising all patients admitted in Rajendra Hospital, Patiala, Punjab with physical trauma was undertaken. Road traffic accidents were the commonest cause of trauma-death followed closely by thermal injury. Mortality was highest among victims of multiple injuries. The mortality rate increased in direct proportion to increase in transportation time and Injury Severity Score (ISS). We advocate some simple preventive and regulatory steps to lower the mortality incidence in trauma cases.

Immunological characterization of the VSV nucleocapsid (N) protein expressed by recombinant baculovirus in Spodoptera exigua larva: use in differential diagnosis between vaccinated and infected animals

Vesicular stomatitis is a viral disease of cattle, pigs, and horses. The disease is characterized by vesicular lesions on the epithelium of the mouth, feet, and teats. The pathological lesions are virtually indistinguishable from that of foot-and-mouth disease. We have developed a recombinant baculovirus that expresses the nucleocapsid (N) protein of the New Jersey serotype of vesicular stomatitis virus (VSVNJ) in insect cells (Sf9) and larvae (Spodoptera exigua). The gene was expressed under control of the polyhedrin promoter as a fusion or nonfusion protein. The recombinant N protein expressed in insect cells could not be distinguished from N protein produced in VSVNJ-infected CHO cells by immunological and biochemical analyses. The level of expression of N as a percentage of the total protein in Sf9 cells was 41% for the fusion and 60% for the nonfusion protein. Higher level (68%) of expression of the nonfusion N protein was obtained in larvae. Recombinant N protein was used in an ELISA to distinguish animals vaccinated with a recombinant VSV glycoprotein from those exposed to the whole virus by infection or classical vaccine. Lysate of a single infected larva (0.2-0.3 g) was adequate for coating ELISA plates to perform 10,000 serum assays in duplicate.

Oxygen desaturation during endoscopy in the elderly

Arterial oxygen desaturation during oesophago-gastro duodenoscopy (OGD) is well recognised. It has been suggested that severe desaturation (greater than 7%) may predispose patients with cardiopulmonary disease and the elderly to cardiac arrhythmias. During OGD, of 106 elderly patients 26 developed ventricular and/or supraventricular ectopics, but these were not related to the degree of oxygen desaturation induced in this study. Apart from one episode of vasovagal syncope, which responded to intravenous atropine, no serious arrhythmias were recorded. Arterial oxygen desaturation during OGD was easily preventable with oxygen administration via nasal cannulae and was not associated with any adverse haemodynamic effects. Continuous cardiac and oxygen saturation monitoring should be routine practice in order to identify such problems.

Mortality profile in trauma victims

To assess the mortality incidence among trauma victims a one year prospective study was conducted on all patients admitted with physical trauma. The causes of death amongst trauma victims comprised road traffic accident (44.71%), thermal injuries (19.71%), domestic causes (11.54%), agriculture related injury and criminal violence (9.61% each), fall of construction workers (2.4%), collapse of buildings and train accidents (0.96% each) and industrial injury (0.48%). Mortality was highest among victims with multiple injuries (41.35%). The mortality rate increased in direct proportion to increase in transportation time and injury severity score.

Restricted replication of vesicular stomatitis virus in T lymphocytes is coincident with a deficiency in a cellular protein kinase required for viral transcription

Vesicular stomatitis virus (VSV) fails to replicate in mouse T lymphocytes unless the cells have been mitogenically stimulated with concanavalin A (Con A). We have examined the possibility that the failure of VSV to replicate in unstimulated T lymphocytes can be attributed to a deficiency in a host protein kinase which activates the viral P protein by phosphorylation, thus rendering it transcriptionally competent. Soluble extracts were prepared from purified mouse T lymphocytes, with or without prior treatment with Con A. The ability of these extracts to phosphorylate bacterially synthesized P protein of two VSV serotypes was measured in vitro. Activity of the protein kinase on the P proteins of the Indiana or New Jersey serotypes of VSV increased, on average 2.4- and 2.1-fold respectively, after treatment of the cells with 3 micrograms/ml Con A. Higher concentrations of Con A induced proportional increases (up to 10-fold) in the activity of the host protein kinase. Activities of the kinase phosphorylating the P protein in separate populations of CD4- and CD8-containing murine T lymphocytes increased similarly on mitogenic activation. No biochemical or immunological differences were observed between the T cell protein kinase and the previously characterized protein kinase (casein kinase II) from BHK-21 cells. The activity of the kinase that phosphorylates the P protein did not vary in CV-1 cells on treatment with alpha- or gamma-interferon, both of which inhibited VSV replication. Similarly, casein kinase II activities in Raji and SIRC cells, which do not normally support VSV growth, were the same as in BHK-21 cells. Thus restriction of VSV replication in these cells, in contrast to T lymphocytes, was not associated with a deficiency in the host casein kinase II activity.

Unilateral subungual hyperkeratosis following a cerebrovascular incident in a patient with psoriasis

The prevalence of nail abnormalities in psoriasis is reported to be between 50 and 90% of affected adults. These include pitting, nail discoloration, onycholysis and subungual hyperkeratosis. Although nail changes may be associated with neurological disease, there are no previous reports of psoriatic nail changes following cerebrovascular events. We report the first case to our knowledge of unilateral subungual hyperkeratosis in a psoriatic patient which developed following a cerebrovascular event.

Phosphorylation of specific serine residues within the acidic domain of the phosphoprotein of vesicular stomatitis virus regulates transcription in vitro

The phosphorylated state of the vesicular stomatitis virus phosphoprotein (P), an essential component of the virion-associated RNA polymerase complex, has been shown to be important for the transcriptional activity of the complex. Recent studies indicate that phosphorylation within the acidic domain of the P protein by cellular casein kinase II is necessary for its activity. In an attempt to identify the exact location of the cell kinase-mediated phosphorylation, we altered specific serine and threonine residues within the acidic domain of the New Jersey serotype of P protein by site-directed mutagenesis. The altered P proteins were then tested to determine what effect these mutations had on the phosphorylated state of the protein in vivo as well as its transcriptional activity in vitro. We report that serine residues 59 and 61 within the acidic domain of the P protein must be phosphorylated for it to be functionally active in a reconstituted transcription assay. These results demonstrate the importance of site-specific phosphorylation in the transcriptional activity of a negative-strand RNA viral phosphoprotein and the crucial role played by a cell protein kinase in this process.