General practice critical incident reviews of patient suicides: benefits, barriers, costs, and family participation

AIM

To explore the feasibility of holding critical incident reviews (CIRs) after patient suicides in general practice and their ability to change practice.

METHODS

Thirteen practices were invited to conduct a facilitated CIR on 18 current patient suicides. Next of kin views were sought. All staff attending a CIR were interviewed after the review.

RESULTS

Ten practices reviewed 12 deaths. Twenty six staff attended reviews; all were interviewed. Next of kin contributed to six reviews; only one criticised care. Changes following the reviews included steps to improve internal communication and bereavement support to set up internal CIRs and review prescribing policies. Communications between practices and other agencies were clarified.

CONCLUSION

Practices were willing to hold CIRs and appreciated the potential positive value but need reassurance that they will not be blamed for suicides, and that the cost in time and resources will be recognised.

Exotic meson decay to omegapi0pi-

A partial-wave analysis of the mesons from the reaction pi(-)p --> pi(+)pi(-)pi(-)pi(0)pi(0)p has been performed. The data show b(1)pi decay of the spin-exotic states pi(1)(1600) and pi(1)(2000). Three isovector 2(-+) states were seen in the omegarho(-) decay channel. In addition to the well known pi(2)(1670), signals were also observed for pi(2)(1880) and pi(2)(1970).

Molecular characterisation of chondrocytes in autologous chondrocyte implantation

Autologous chondrocyte implantation (ACI) relies on the use of cultured cells. However, the biosynthetic profile of cultured chondrocytes is shown to be altered during in vitro expansion. The purpose of this study therefore, was to examine the cellular phenotype of chondrocytes cultured for ACI and to determine the apoptotic index of cells implanted into patients. Using electron microscopy, immunohistochemistry, RT-PCR and flow cytometry analyses, we have investigated protein and gene expression of several chondrocyte-specific, or associated markers in cultured cells used for implantation in patients. They included S-100, type I and II collagen, aggrecan, transforming growth factor beta, glucocorticoid receptor alpha and beta and vitamin D3 receptor. We have also examined the apoptotic index of chondrocytes. Our results demonstrated that cultured cells for ACI display the characteristics of chondrocytes. These cells are round in shape, contain numerous small surface processes of cytoplasmic membrane and have an accumulation of glycogen within the cytoplasm. They express S-100, aggrecan TGF-beta, glucocorticoid receptor alpha and vitamin D3 receptor as evidenced by either immunohistochemistry or RT-PCR, however, there is variation in the expression of type I, type II collagen glucocorticoid receptor beta between cases. Chondrocyte used for implantation has relatively low level of apoptosis (<11%). In conclusion, although there was variation in the level of expression of these genetic markers, our data indicate that cultured cells used for ACI were of chondrocytic lineage cells and have low level of apoptotic cells.

Interferon-gamma and skin test responses of schoolchildren in southeast England to purified protein derivatives from Mycobacterium tuberculosis and other species of mycobacteria

The immune responses of schoolchildren in southeast England to Mycobacterium tuberculosis and other species of mycobacteria were studied prior to vaccination with bacille Calmette-Guérin (BCG). Data are presented for tuberculin (Heaf) skin test and interferon-gamma (IFN-gamma) responses to M. tuberculosis purified protein derivative (PPD), and IFN-gamma responses to PPDs from eight other environmental mycobacteria, measured in 424 schoolchildren (13-15 years of age). Responses to M. tuberculosis PPD were detected in 27% of schoolchildren by in vitro IFN-gamma response and in 20% by the Heaf test. IFN-gamma responses were more prevalent to PPDs from species of mycobacteria other than M. tuberculosis, predominantly those of the MAIS complex and M. marinum (45-60% responders). Heaf test and IFN-gamma responses were associated (P<0.001) for M. tuberculosis, MAIS and M. marinum. These findings have implications for appropriate implementation of vaccination against tuberculosis.

Association of the androgen receptor CAG repeat polymorphism with Alzheimer's disease in men

We examined the CAG repeat polymorphism in exon 1 of the androgen receptor (AR) in an Oxford cohort of 150 cases (101 men) of definite or probable Alzheimer's disease (AD) and 190 elderly controls (140 men). We found that short alleles (< or = 20 CAG repeats) were associated with AD (adjusted odds ratio = 2.5, 95% confidence intervals: 1.2-5.0) in men, but not in women. This association appeared stronger in early-onset AD (< 65 years). We conclude that this AR polymorphism is of potential relevance to the risk of AD in men.

Quantification of the non-planarity of the human carotid bifurcation

The carotid bifurcation has been a region of particular interest due to its predilection for clinically significant atherosclerosis. It has been shown that the vessel geometry is a major determinant of the local haemodynamic properties which are believed to be associated with the location of atherosclerotic lesions. Current knowledge of the geometry of the carotid bifurcation is insufficient and restricted to basic geometric parameters. To provide some means of quantifying the degree of complexity of the 3D shape of the bifurcation, we made an initial attempt by evaluating the non-planarity of an arterial bifurcation based upon the singular value decomposition theorem. In this paper we present our results obtained on the right carotid bifurcations of six normal subjects, each of whom was scanned twice using the 2D time-of-flight MR sequence. The acquired 2D cross sectional images were processed by using our in-house software which comprises 2D segmentation, 3D reconstruction and smoothing. The centroids of each transverse slices were determined and used as input data for the non-planarity analysis. Our results using the singular value decomposition method have demonstrated discernible differences in non-planarity among individuals. Comparisons with the planarity definition proposed by other investigators suggest that the singular value decomposition method offers more information about the linearity and planarity of the bifurcation. However, it is also realised that a single measure of non-planarity can never fully characterise a bifurcation owing to the great variety of geometries.

Metastatic meningioma to the lung with multiple pleural metastases

Meningiomas with both malignant clinical behavior and cytology are rare. Meningiomas comprise approximately 15% of the primary brain tumors. The majority are benign; less than 1% metastasize, most commonly to the lung (61%) followed by liver, lymph node, and bone. Approximately 130 cases of extracranial metastatic meningiomas have been described. Only 13% had more than three metastases, with few cases reported with extensive pleural involvement. We report an interesting case of a malignant meningioma that invaded through the skull in the frontal sinus that later metastasized to the left lung with multiple pulmonary and pleural nodules.

The -590C/T and -34C/T interleukin-4 promoter polymorphisms are not associated with atopic eczema in childhood

Susceptibility to the development of asthma and other atopic diseases is known to have a genetic component. To date, several studies have linked chromosome 5q31 to asthma and atopy in human beings. This region harbors a cluster of cytokine and growth factor genes, IL-4 presenting as a prime atopy candidate gene, inasmuch as it plays a pivotal role in the atopy pathway. Our approach was to identify polymorphisms within the promoter regions of IL-4 and test their association with atopic eczema. Polymorphisms were typed in a cohort of 76 small nuclear families and 25 triads with childhood atopic eczema. The genotypes were used to test for linkage in the presence of association with atopic eczema. A new polymorphism, -34C/T, was identified and studied with a known polymorphism, -590C/T. On its own, each polymorphism showed no association with atopic eczema. The 2 polymorphisms were used to generate haplotypes, and a significant result was found for the -590C/-34C haplotype. However, after Bonferroni correction for multiple testing, the association became nonsignificant. Neither polymorphism predisposes to early-onset atopic eczema by itself, but suggestive linkage was found for the -590C/-34C haplotype in this study.

Constructional apraxia in Alzheimer's disease: association with occipital lobe pathology and accelerated cognitive decline

The functional impact and progression of occipital lobe pathology in sporadic late onset Alzheimer's disease (AD) is barely explored. It is accepted that the primary and association visual areas are affected relatively late, in the neocortical stages of AD. We analysed 60 prospectively assessed AD patients in whom global cognitive deterioration and constructional apraxia were evaluated longitudinally using the CAMDEX. Radioactive immunohistochemistry was used to assess the amount of AD-related pathology in Brodmann areas 18 and 17. Braak staging of each case was also carried out. This study showed that in AD patients constructional apraxia is associated with higher expression of hyperphosphorylated tau. Additionally our findings indicate that early constructional apraxia is a predictor of accelerated cognitive decline in AD.

Anosmia in dementia is associated with Lewy bodies rather than Alzheimer's pathology

OBJECTIVES

To assess olfactory function of patients with dementia. Odour detection ability is impaired in clinical Parkinson's disease. Evidence of impaired detection in patients with clinically diagnosed Alzheimer's disease is inconsistent. No studies of olfaction have been neuropathologically validated.

METHODS

The olfactory function of 92 patients with dementia and 94 controls was assessed using a simple bedside test as part of the Oxford Project To Investigate Memory and Ageing (OPTIMA). Neuropathological assessment was made of cortical Lewy bodies and substantia nigra (SN) cell counts and of Alzheimer's disease in all 92 patients, 22 of whom had SN Lewy bodies and 43 of whom had only Alzheimer's disease.

RESULTS

Patients with Lewy bodies were more likely to be anosmic than those with Alzheimer's disease or controls. Patients with Alzheimer's disease were not more likely to be anosmic than controls. Nor was anosmia associated with degree of neurofibrillary tangles, as assessed by Braak stage. Among subjects with Lewy bodies, overall cortical Lewy body scores and Lewy body density in the cingulate were higher in those who were anosmic. Consensus clinical criteria for dementia with Lewy bodies had a sensitivity of 64% and specificity of 89%. In the absence of definite Alzheimer's disease, the criteria had sensitivity of 100%. In patients with definite Alzheimer's disease, anosmia was slightly more sensitive (55%) than the consensus criteria (33%). However, the addition of anosmia to the consensus criteria did not improve their overall performance.

CONCLUSION

Dementia with Lewy bodies is associated with impaired odour detection. Misdiagnosis may have accounted for some previous reports of impaired odour detection in Alzheimer's disease. Simple but more sensitive tests of anosmia are required if they are to be clinically useful in identifying patients with dementia with Lewy bodies.

Observation of exotic meson production in the reaction pi- p --> eta'pi- p at 18 GeV/c

An amplitude analysis of an exclusive sample of 5765 events from the reaction pi- p-->eta'pi- p at 18 GeV/c is described. The eta'pi- production is dominated by natural parity exchange and by three partial waves: those with J(PC) = 1(-+), 2(++), and 4(++). A mass-dependent analysis of the partial-wave amplitudes indicates the production of the a2(1320) meson as well as the a4(2040) meson, observed for the first time decaying to eta'pi-. The dominant, exotic (non- qq) 1(-+) partial wave is shown to be resonant with a mass of 1.597+/-0.010(+0.045)(-0.010) GeV/c2 and a width of 0.340+/-0.040+/-0.050 GeV/c2. This exotic state, the pi1(1600), is produced with a t dependence which is different from that of the a2(1320) meson, indicating differences between the production mechanisms for the two states.

Interleukin-4 acts at the locus of the antigen-presenting dendritic cell to counter-regulate cytotoxic CD8+ T-cell responses

The mechanism underlying suppression of immune responses by interleukin-4 (IL-4) has remained unexplained. Here we show that the antigen-presenting dendritic cell is central to counter-regulation of autoimmune disease by IL-4. IL-4 acts at the locus of the dendritic cell to decrease the cytolytic T-cell response, preventing autoimmunity. Stimulation of cytotoxic precursors by antigen pulsed dendritic cells induces their differentiation but the process is blocked by IL-4. IL-4-influenced DC produce distinct effects on CD8+ T cells depending on their state of activation. The molecular basis for this regulation is the alteration of the expression ratio of the costimulatory ligands B7.1/B7.2 on dendritic cells. Our findings demonstrate that B7.2 induces expansion of CD8+ T cells and B7.1 governs their acquisition of cytolytic activity. IL-4 influences the dendritic cell to elicit qualitative differences in T-cell responses, providing the basis for counter-regulation mediated by IL-4.

Spending on mental health and substance abuse treatment, 1987-1997

This paper is the result of an ongoing effort to track spending on mental health and substance abuse (MH/SA) treatment nationwide. Spending for MH/SA treatment was $85.3 billion in 1997: $73.4 billion for mental illness and $11.9 billion for substance abuse. MH/SA spending growth averaged 6.8 percent a year between 1987 and 1997, while national health expenditures grew by 8.2 percent.

Binding of nascent collagen by amyloidogenic light chains and amyloid fibrillogenesis in monolayers of human fibrocytes

Light (L) chain dimers expressed by multiple myeloma cells and collected as Bence-Jones proteins from the urine of human subjects were tested for their ability to form deposits in fibroblast monolayer cell cultures. Bence-Jones proteins from subjects with primary amyloidosis associated with L chains were shown to form fibrillar deposits by the in vitro assay introduced in this report. Filaments interspersed with nascent collagen could be detected after only 48 h. Deposition of L chains continued over a period of 72 h culminating in the appearance of dense fibrils with widths of 80-100 A and a variety of lengths. Formation of amyloid-like fibrils was accompanied by interference with the maturation of the collagen produced by the fibroblast cells. Fibrils composed of the Mcg lambda-type L chain were deposited between collagen fibers, thus expanding them laterally and leading to their partial disintegration. Mature collagen was completely missing from fibroblast monolayers exposed to the Sea lambda chain and the Jen kappa chain. Collagen with the characteristic striped pattern matured normally in control samples, such as those not dosed with amyloid precursors or those treated with a non-amyloidogenic Bence-Jones protein (e.g., the Hud lambda chain dimer). By immunochemical techniques using fluorescein- and gold-labeled anti-L chain antibodies, amyloidogenic L chains were shown to decorate the strands of nascent collagen. This observation suggests that amyloidogenic L chains are concentrated in the extracellular matrix by monovalent antigen-antibody type reactions. The capacity of the Mcg L chain dimer to bind collagen-derived sequences was tested by soaking crystals with a collagenase substrate, PZ-Pro-Leu-Gly-Pro-D-Arg. Difference Fourier analysis at 2.7 A resolution indicated that the PZ-peptide is a site-filling ligand. It could not be removed from the active site by perfusion of the crystal with ammonium sulfate crystallizing media. Similar experiments with the collagen-derived peptide (Pro-Pro-Gly)(5) showed substantial hysteresis effects extending from one end of the Mcg dimer to the other. After the ligand was withdrawn, the active site of the Mcg dimer could no longer bind the PZ-peptide. However, if the active site was first blocked by the PZ-peptide and subsequently exposed to the (Pro-Pro-Gly)(5) peptide, the difference Fourier map was indistinguishable from that obtained with the PZ-peptide alone. We concluded that amyloidogenic L chains such as the Mcg dimer could be concentrated in the perivascular space by binding to normal tissue constituents. These components include nascent collagen, which can be deterred from maturing as a result of this binding. Participation in such pathological activity is also self-destructive to the amyloidogenic L chains, which lose their binding capabilities for collagen-derived peptides and also become susceptible to irreversible conversion to amyloid fibrils. All of these events may be prevented by prior treatment of the amyloidogenic L chains with site-filling ligands. (c) 2000 John Wiley & Sons, Ltd.

Population-based estimates of surfactant protein B deficiency

OBJECTIVE

Surfactant protein B deficiency is a lethal cause of respiratory distress in infancy that results most commonly from a homozygous frameshift mutation (121ins2). Using independent clinical ascertainment and molecular methods in different populations, we sought to determine allele frequency.

STUDY DESIGN

Using clinical characteristics of the phenotype of affected infants, we screened the Missouri linked birth-death database (n = 1 052 544) to ascertain potentially affected infants. We used molecular amplification and restriction enzyme digestion of DNA samples from a metropolitan New York birth cohort (n = 6599) to estimate allele frequency.

RESULTS

The point estimate and 95% confidence interval of the 121ins2 allele frequency in the Missouri cohort are 1/1000 individuals (.03-5.6/1000) and in the New York cohort are.15/1000 (. 08-.25/1000). These estimates are not statistically different.

CONCLUSIONS

The close approximation of these independent estimates suggests accurate gene frequency (approximately one 121ins2 mutation per 1000-3000 individuals) despite its rare occurrence and that this mutation does not account for the majority of full-term infants with lethal respiratory distress.

Rhabdomyosarcoma in a child with massive pleural effusion: cytological diagnosis from pleural fluid

We report on a case of embryonal rhabdomyosarcoma in an 11-yr-old boy investigated for mild chest pain after trauma. Chest radiography showed a massive right pleural effusion. Cytological analysis of the pleural fluid demonstrated the presence of malignant small undifferentiated cells. The rhabdomyoblastic nature of the cells was confirmed by positive immunostains of HHf35 actin, desmin, and skeletal muscle myosin; histological examination of a core biopsy confirmed the diagnosis of rhabdomyosarcoma. Computed tomography and gallium scan revealed the presence of an extensive anterior and lower chest wall mass involving the mediastinum, as well as retroperitoneal lymphadenopathy. Massive pleural effusion is a frequent presentation in malignant disease, but is rare in rhabdomyosarcoma. The immunochemical stain studies performed on cytological smears in this case proved to be very useful for making the definitive and accurate diagnosis. Diagn. Cytopathol. 1999;21:125-128.

Localization and regulation of ryanodine receptor in bovine oocytes

We have previously reported that injection of ryanodine receptor agonists into mature bovine oocytes induces intracellular calcium release, indicative of the existence of ryanodine receptors. In this experiment, further evidence of the ryanodine receptor localization, and developmental regulation in bovine oocytes is presented. The possible physiological significance is also suggested. Using a rabbit antibody against the rabbit cardiac muscle ryanodine receptor, the ryanodine receptor was observed uniformly localized in the periphery of mature bovine oocytes, while a weak and discontinuous signal was observed in the germinal vesicle intact stage of bovine oocytes. As oocytes progress to the metaphase I stage, the ryanodine receptor localization became more intense and continuous, yet not comparable to that observed in the metaphase II oocytes. These modifications correlate with the intracellular calcium responsiveness to ryanodine. A 200-microM injection of ryanodine induces a low intracellular calcium transient in germinal vesicle-stage bovine oocytes, while peaked intracellular calcium transients are subsequently observed in the metaphase II-stage oocytes. However, no significant changes in the amplitude of intracellular calcium transients induced by 250 nM inositol 1,4,5-trisphosphate and 10 microM ionomycin were observed in oocytes at a comparable stage. Fertilization induced a significant decrease in ryanodine receptor signal; similar changes were also observed in oocytes injected with 200 microM ryanodine or incubated with 10 microM ionomycin. However, no changes in ryanodine signal were observed in oocytes injected with vehicle medium. Furthermore, injection of either ryanodine or inositol 1,4,5-trisphosphate induced subsequent pronuclear formation and cleavage. These data indicate that the ryanodine receptor is closely regulated and associated with early cellular changes following fertilization; stimulation of this receptor results in the activation of bovine oocytes, and it is likely that this receptor may play a role at fertilization.