Use of narrative analysis for comparisons of the causes of fatal accidents in three countries: New Zealand, Australia, and the United States

OBJECTIVES

To investigate the utility of narrative analysis of text information for describing the mechanism of injury and to compare the patterns of the mechanism of injury for work related fatalities in three countries.

METHODS

Three national collections of data on work related fatalities were used in this study including those for New Zealand, 1985-94 (n=723), for Australia, 1989-92 (n=1,220), and for the United States, 1989-92 (16,383). The New Zealand and Australian collections used the type of occurrence standard code for the mechanism of injury, however the United States collection did not. All three databases included a text description of the circumstances of the fatality so a text based analysis was developed to enable a comparison of the mechanisms of injury in each of the three countries. A test set of 200 cases from each country dataset was used to develop the narrative analysis and to allow comparison of the narrative and standard approaches to mechanism coding.

RESULTS

The narrative coding was more useful for some types of injury than others. Differences in coding the narrative codes compared with the standard code were mainly due to lack of sensitivity in detecting cases for all three datasets, although specificity was always high. The pattern of causes was very similar between the two coding methods and between the countries. Hit by moving objects, falls, and rollovers were among the five most common mechanisms of workplace fatalities for all countries. More common mechanisms that distinguished the three countries were electrocutions for Australia, drowning for New Zealand, and gunshot for the United States.

CONCLUSION

Narrative analysis shows some promise as an alternative approach for investigating the causes of fatalities.

Cryptic epitopes in N-terminally truncated prion protein are exposed in the full-length molecule: dependence of conformation on pH

Prion diseases are diseases of protein conformation. Structure-dependent antibodies have been sought to probe conformations of the prion protein (PrP) resulting from environmental changes, such as differences in pH. Despite the absence of such antibodies for full-length PrP, a recombinant Fab (D13) and a Fab derived from mAb 3F4 showed pH-dependent reactivity toward epitopes within the N-terminus of N-terminally truncated PrP(90-231). Refolding and maintaining this protein at pH > or =5.2 before immobilization on an ELISA plate inhibited reactivity relative to protein exposed to pH < or =4.7. The reactivity was not affected by pH changes after immobilization, showing retention of conformation after binding to the plate surface, although guanidine hydrochloride at 1.5-2 M was able to expose the cryptic epitopes after immobilization at pH > or =5.2. The alpha-helical CD spectrum of PrP(90-231) refolded at pH 5.5 was reduced somewhat by these pH changes, with a minor shift toward beta-sheet at pH 4 and then toward coil at pH 2. No covalent changes were caused by the pH differences. This pH dependence suggests titration of an acidic region that might inhibit the N-terminal epitopes. A similar pH dependence for a monoclonal antibody reactive to the central region identified an acidic region incorporating Glu152 as a significant participant.

Age and sex differences in the cerebellum and the ventral pons: a prospective MR study of healthy adults

BACKGROUND AND PURPOSE

The human brain exhibits a complex pattern of differential aging. The purpose of this study was to examine whether age differences in the volume of cerebellar regions and the ventral pons are differential or generalized, whether the age-related shrinkage is linear or exponential, and whether there are sex differences in the size of the cerebellum and pons.

METHODS

The volumes of the cerebellar hemispheres (excluding the vermis and the peduncles), the vermis, and the ventral pons were estimated from the prospectively acquired MR scans of 190 healthy volunteers (aged 18-81 years). The relation between regional volumes, age, and sex was assessed while taking into account differences in body size (height).

RESULTS

We found a moderate age-related reduction in the volume of the cerebellar hemispheres and the cerebellar vermis. In contrast to previous findings that suggested differential vulnerability of the posterior vermis, the age-related shrinkage of the vermian lobules was uniform-about 2% per decade. In accord with all reports in the literature, the size of the ventral pons was unrelated to age. The volume of the cerebellar hemispheres, the vermis, and the ventral pons were larger in men, even after adjustment for height. The magnitude of the sex difference was the largest in the hemispheres and the anterior vermis, and the smallest in the lobules VI-VII (declive-folium-tuber).

CONCLUSION

Moderate age-related shrinkage of the cerebellum and lack of age-related differences in the ventral pons are robust phenomena. However, in all likelihood, the effects of age on the cerebellum are not differential but uniform. The cerebellum and the pons are larger in men than in women and the difference is especially pronounced in the cerebellar hemispheres and the anterior vermis.

GABA uptake and heterotransport are impaired in the dentate gyrus of epileptic rats and humans with temporal lobe sclerosis

In vivo dialysis and in vitro electrophysiological studies suggest that GABA uptake is altered in the dentate gyrus of human temporal lobe epileptics characterized with mesial temporal sclerosis (MTLE). Concordantly, anatomical studies have shown that the pattern of GABA-transporter immunoreactivity is also altered in this region. This decrease in GABA uptake, presumably due to a change in the GABA transporter system, may help preserve inhibitory tone interictally. However, transporter reversal can also occur under several conditions, including elevations in [K(+)]o, which occurs during seizures. Thus GABA transporters could contribute to seizure termination and propagation through heterotransport. To test whether GABA transport is compromised in both the forward (uptake) and reverse (heterotransport) direction in the sclerotic epileptic dentate gyrus, the physiological effects of microapplied GABA and nipecotic acid (NPA; a compound that induces heterotransport) were examined in granule cells in hippocampal slices from kainate (KA)-induced epileptic rats and patients with temporal lobe epilepsy (TLE). GABA- and NPA-induced responses were prolonged in granule cells from epileptic rats versus controls (51.3 and 31.3% increase, respectively) while the conductance change evoked with NPA microapplication was reduced by 40%. Furthermore the ratio of GABA/NPA conductance, but not duration, was significantly >1 in epileptic rats but not controls, suggesting a compromise in transporter function in both directions. Similar changes were observed in tissue resected from epileptic patients with medial temporal sclerosis but not in those without the anatomical changes associated with MTLE. These data suggest that the GABA transporter system is functionally compromised in both the forward and reverse directions in the dentate gyrus of chronically epileptic tissue characterized by mesial temporal sclerosis. This alteration may enhance inhibitory tone interically yet be permissive for seizure propagation due to a decreased probability for GABA heterotransport during seizures.

Neuroanatomical and cognitive correlates of adult age differences in acquisition of a perceptual-motor skill

The objective of this study was to examine age differences in procedural learning and performance in conjunction with differential aging of central nervous system (CNS) structures. Sixty-eight healthy volunteers (age 22-80) performed a pursuit rotor task (four blocks of 20 15-second trials each). Volumes of the cerebellar hemispheres, neostriatum, prefrontal cortex, and hippocampus were measured from Magnetic Resonance (MR) images. Improvement in pursuit rotor performance was indexed by increase in time on target (TOT). A general improvement trend was evident across the blocks of trials. Overall, younger participants showed significantly longer TOT. The rate of improvement was age-invariant during the initial stages of skill acquisition but became greater in middle-aged participants as the practice progressed. When the influences of regional brain volumes were taken into account, the direct age effect on mean TOT measured during the first day of practice disappeared. Instead, reduced volumes of the cerebellar hemispheres and the putamen and poorer performance on nonverbal working memory tasks predicted shorter TOT. In contrast, neither the volume of the caudate and the hippocampus, nor verbal working memory showed association with motor performance. Pursuit rotor performance at the later stages of practice was unrelated to the reduction in putamen volume and was affected directly by age, cerebellar volume, and nonverbal working memory proficiency. We conclude that in a healthy population showing no clinical signs of extrapyramidal disease, age-related declines in procedural learning are associated with reduced volume of the cerebellar hemispheres and lower nonverbal working memory scores. During initial stages of skill acquisition, reduced volume of the putamen is also predictive of poorer performance.

Overexpression of GluR6 in rat hippocampus produces seizures and spontaneous nonsynaptic bursting in vitro

We hypothesized that overexpression of specific glutamate receptors within the hippocampus would induce seizures and the associated cellular changes seen in temporal lobe epilepsy (TLE). The GluR6 kainate receptor was overexpressed by injecting rat hippocampi with HSVGluR6, a viral vector transducing fully edited GluR6. These animals experienced limbic seizures approximately 4 h following the injection. Control animals injected with HSVlac, a vector expressing beta-galactosidase, did not have seizures. Recordings from hippocampal CA1 pyramidal cells were performed 12 to 48 h and 1 week to 1 month postinjection. We observed nonsynaptic Na(+)-mediated bursting in 77.5% of cells 12 to 48 h following injection of HSVGluR6 but not HSVlac. The synaptic responses were normal in both groups. However, the physiological properties of cells from HSVGluR6-injected hippocampi changed over time. Two weeks following HSVGluR6 injection, synaptic bursts could be evoked, but intrinsic bursting became rare. These changes persisted for at least 1 month. We postulate that this transition from intrinsic to synaptic hyperexcitability may be important in the development of TLE.

Transcriptional repression of the 5-HT1A receptor promoter by corticosterone via mineralocorticoid receptors depends on the cellular context

The diverse effects of the corticosteroid hormones are mediated in large measure by the mineralocorticoid and glucocorticoid receptors, two closely related members of the nuclear receptor superfamily. In the brain, corticosteroids regulate neuronal excitability and responses to neurotransmitters in a cell type-specific manner. The 5-HT1A receptor, for example, is highly expressed in the hippocampus and raphe but transcription is repressed by corticosterone (the principal glucocorticoid in rodents) only in hippocampus. We have used transient transfection of cultured cells to study the transcriptional regulation of the 5-HT1A receptor promoter by activators and repression by glucocorticoids. We find that transcription factors Sp1 and NF-kB subunit p65, both of which are coexpressed in hippocampus with the 5-HT1A receptor in vivo, synergistically activate a reporter driven by receptor 5'-flanking region. Primer extension data suggest that the multiple transcription initiation sites used in reporter gene transcription correlate with those used in transcription of the endogenous gene which has a TATA-less promoter. Repression of transcription by corticosteroids was found to be mediated by both mineralocorticoid and glucocorticoid receptors, but not identically. While glucocorticoid receptors potently inhibited both p65- and p65/Sp1-stimulated transcription, repression via mineralocorticoid receptors (MR) depended on the transcriptional activators that were present: p65-stimulated reporter activity was not repressed via MR, whereas a similar level of transcription resulting from synergistic activation by p65/Sp1-stimulation was repressed via MR. The context-dependence of these MR-mediated effects provides a model for the cell-type and state-dependent actions of corticosterone in the brain.

Metastatic neuroblastoma with ganglioneuromatous differentiation and mandibular involvement

Neuroblastic tumors comprise neuroblastoma (NB), ganglioneuroblastoma, and ganglioneuroma (GN). NBs have shown remarkable differentiation capabilities, which include spontaneous regression. In the last 3 decades, the prognosis for metastatic NB has improved significantly. The ability to distinguish prognostic subtypes based on clinical and biologic features allows for understanding of this disease process and development of management procedures. NBs are often asymptomatic and remain undetected until a large abdominal mass or metastasis is found. GN, the most differentiated variant, is a benign neoplasm with significant growth potential and ability to cause clinical complications. GN of the mandible has seldom been reported in the literature in English. We present a case of NB metastatic to the mandible exhibiting ganglioneuromatous differentiation. We discuss the current understanding of the biology, grading, classification, and prognostic implications of NB.

NPY inhibits glutamatergic excitation in the epileptic human dentate gyrus

Neuropeptide Y (NPY) has been shown to depress hyperexcitable activity that has been acutely induced in the normal rat brain. To test the hypothesis that NPY can also reduce excitability in the chronically epileptic human brain, we recorded intracellularly from dentate granule cells in hippocampal slices from patients with hippocampal seizure onset. NPY had a potent and long-lasting inhibitory action on perforant path-evoked excitatory responses. In comparison, the group 3 metabotropic glutamate receptor agonist L-2-amino-4-phosphonobutyric acid (L-AP4) evoked a mild and transient decrease. NPY-containing axons were found throughout the hippocampus, and in many epileptic patients were reorganized, particularly in the dentate molecular layer. NPY may therefore play a beneficial role in reducing granule cell excitability in chronically epileptic human tissue, and subsequently limit seizure severity.

Lack of correlation between neuronal hyperexcitability and electrocorticographic responsiveness in epileptogenic human neocortex

OBJECT

The purpose of this study was to determine whether intrinsic neuronal properties and synaptic responses differed between interictally active and inactive tissue removed in neocortical resections from patients undergoing surgical treatment for epilepsy.

METHODS

Whole-cell patch recordings were performed in layer 2 or 3 and layer 5 pyramidal cells in neocortical slices obtained from tissue surgically removed from patients for the treatment of medically intractable seizures. Synaptic responses to stimulation at the layer 6-white matter border were used to classify cells as nonbursting if they responded with only a single action potential for all above-threshold stimuli (80%). These responses were usually followed by biphasic inhibitory postsynaptic potentials (IPSPs). Cells were classified as bursting if they fired at least three action potentials in response to synaptic stimulation (20%). These cells typically showed no IPSPs and responded in either an all-or-nothing or graded fashion. Approximately twice as many cells at layer 2 or 3 (29%) than cells at layer 5 (14%) fired synaptic bursts. Synaptic bursting was not associated with an alteration in a cell's response properties to gamma-aminobutyric acid. It was notable that, in tissue samples determined by electrocorticography (ECoG) to be either interictally active or not active, the proportion of cells that burst was exactly the same in both groups (24%). We found no cells with intrinsic burst firing.

CONCLUSIONS

We conclude that synaptic bursting was characteristic of a small proportion of cells from epileptic tissue; however, this did not correlate with interictal spikes on ECoG.

Establishing community pharmacy-based anticoagulation education and monitoring programs

OBJECTIVE

To determine the process for establishing community pharmacy-based anticoagulation education and monitoring programs using fingerstick capillary whole blood testing.

DESIGN

Pilot community-based intervention study using convenience sample of patients.

SETTING

Three community pharmacies with pre-established health education centers and laboratories certified for moderate complexity.

PARTICIPANTS

26 patients were referred to the clinics by 2 primary care physicians for each pharmacy, most with a diagnosis of atrial fibrillation.

INTERVENTION

Patient assessment, including adherence to prescribed regimens; changes in medication use, including prescription and nonprescription medications, vitamins, health foods, and nutrition supplements; changes in diet and ethanol consumption; assessment of adverse experiences; and needed changes in warfarin dosage.

MAIN OUTCOME MEASURES

Percentage of international normalized ratio (INR) values within therapeutic range, major bleeding events, and thrombotic events.

RESULTS

A total of 21 patient charts were available for analysis. More than 80% of patients had INR values within their targeted range (+/- 0.2) 60% or more of the time, comparable with values reported for anticoagulation clinics. Of the 235 INR values obtained during the study, 75% were within the individualized targeted therapeutic range (e.g., 2 to 3 +/- 0.2). One patient experienced a major bleeding event related to an underlying cancer. None of the patients experienced a thrombotic event.

CONCLUSION

Community pharmacies can effectively implement an anticoagulation education and monitoring program.

Decrease in inhibition in dentate granule cells from patients with medial temporal lobe epilepsy

Alterations in synaptic inhibition are associated with epileptiform activity in several acute animal models; however, it is not clear if there are changes in inhibition in chronically epileptic tissue. We have used intracellular recordings from granule cells of patients with temporal lobe epilepsy to determine whether synaptic inhibition is compromised. Two groups of patients with medial temporal lobe epilepsy were used, those with medial temporal lobe sclerosis (MTLE), and those with extrahippocampal masses (MaTLE) where the cell loss and synaptic reorganization that characterize MTLE are not seen. Although the level of tonic inhibition at the somata was not significantly different in the two patient groups, there was a reduction in the conductance of polysynaptic perforant path-evoked fast and slow inhibitory postsynaptic potentials (IPSPs) (53% and 66%, respectively). We found that there was a comparable decrease in the monosynaptic IPSP conductances examined in the presence of glutamatergic antagonists as that seen for the polysynaptically evoked IPSPs. These data suggest that the decrease in inhibition seen in normal artificial cerebrospinal fluid in MTLE granule cells cannot be solely explained by a decrease in excitatory input onto inhibitory interneurons and may reflect changes at the interneuron-granule cells synapse or in the number of specific inhibitory interneurons.

Maximizing the cost-effectiveness of lipid-lowering therapy

Cardiovascular disease, including coronary heart disease, is the leading cause of death both in men and in women in the United States. The purpose of this review is to describe the effectiveness of lipid-lowering therapy in reducing cardiovascular morbidity and mortality, which has recently been extended to patients with mild to moderate hypercholesterolemia, and the cost of providing therapy, which would be prohibitive if all persons with hypercholesterolemia received treatment. Cost-effectiveness analysis provides a rational means of allocating limited health care resources by allowing the comparison of the costs of lipid-lowering therapy, in particular, therapy with beta-hydroxy-beta-methylglutaryl-CoA (coenzyme A) reductase inhibitors (statins), with the costs of atherosclerosis that could be prevented by lowering cholesterol. To extend the benefits of treatment to the large number of persons not receiving therapy, we need to implement more cost-effective treatment by improving risk assessment, increasing treatment effectiveness, and reducing the cost of therapy.

The reported training and experience of editors in chief of specialist clinical medical journals

CONTEXT

The majority of the peer-reviewed clinical literature is edited by editors whose training in editorial matters may be limited or nonexistent. We suspect that editors are selected for their clinical or academic rather than editorial ability.

OBJECTIVE

To test the hypothesis that editors of medical specialist clinical journals were recruited from active clinicians rather than those with evident ability or training as editors.

DESIGN, SETTING, AND SUBJECTS

Anonymous mail survey to editors of the 262 peer-reviewed clinical journals that had received at least 1000 citations in the 1994 Science Citation Index.

MAIN OUTCOME MEASURES

Training and editorial practices of editors.

RESULTS

Replies were received from 191 editors (73%): in 1994 the journals they edited had 6060 (27300/1000 [maximum/minimum]) citations, 234 (740/31) source items, and an impact factor of 2.10 (18.3/0.2); nonresponders' journals had similar characteristics. Of the responding editors, 181 (95%) were part-time, 132 (69%) treated patients, and 164 (86%) were recruited by one of the following methods: election by a scientific society (49 [30%]), nomination by the previous editor (41 [25%]), or response to an advertisement (29 [18%]). There was no strong association between method of recruitment or formal editorial training and the status of the journal. Only 9% of editors in the United States send at least half of the papers to reviewers outside their own country, compared with 41% of editors in the United Kingdom and 73% in other countries, and 69% do not feel bound to follow the advice they receive concerning acceptance of papers.

CONCLUSIONS

Clinical journals are usually edited by practicing clinicians who are self-taught part-time editors, but willing to accept further training. They usually consult 2 reviewers, but exercise independent judgment on the acceptability of papers.

Dynorphin and the kappa 1 ligand [3H]U69,593 binding in the human epileptogenic hippocampus

The distribution of dynorphin (DYN), one of its binding sites (kappa 1 receptor) and their relationship to neuronal loss and granule cell hyperexcitability was examined in hippocampi from patients with temporal lobe epilepsy (TLE). In hippocampi that were not the seizure focus (mass associated temporal lobe epilepsy, MaTLE; and paradoxical temporal lobe epilepsy, PTLE) DYN-like immunoreactivity was localized in the dentate granule cells and their mossy fiber terminals within the hilus and area CA3. In hippocampi that were the seizure focus (MTLE), 89% showed an additional band of immunoreactivity confined to the inner molecular layer (IML) of the dentate gyrus, representing recurrent mossy fiber collaterals. In 11% of MTLE patients no staining was found in the IML (MTLE/DYN-). The MTLE/DYN- hippocampi were also characterized by a significantly lower degree of cell loss than in MTLE hippocampi in the dentate granule cell layer, the hilus and CA3. Both MTLE and MTLE/DYN- hippocampi showed evoked epileptiform bursting in granule cells while MTLE showed greater polysynaptic EPSPs and spontaneous excitatory activity. Thus granule cell recurrent collateral sprouting may account for only some aspects of hyperexcitability. In 30% of the MTLE group, hilar neurons of a variety of morphological types expressed DYN immunoreactivity in their somata and dendrites. The density of [3H]U69,593 binding sites in MaTLE and PTLE patients was highest in areas CA1 and the subiculum-regions having little or no DYN-staining. In the dentate molecular layer, hilus and CA3--regions with the most DYN immunoreactivity--there was a low density of ligand binding. The significance of this transmitter/receptor mismatch is yet unknown.