The bottom line: the effect of written expert witness statements on juror verdicts and information processing

Mock jurors recruited from jury rolls were either not given written statements of expert witnesses' direct testimony or were provided with such statements before or after the presentation of that testimony. Presentation of the statements before the testimony and cross-examination provided jurors with a schema that allowed them to distinguish more effectively among the claims of four differentially worthy plaintiffs because they processed more probative evidence than other jurors. Jurors in receipt of written statements before the testimony found the evidence to be more comprehensible than other jurors. Jurors provided with written statements following testimony and cross-examination were able to differentiate between the most and least severely injured plaintiffs, whereas jurors not in receipt of any written statements were unable to differentiate among any of the differentially worthy claimants. The limitations of this case management technique and of the study are discussed.

Fatal Mycobacterium bovis BCG infection in TNF-LT-alpha-deficient mice

Neutralization of TNF or disruption of TNF-R1 leads to fatal Mycobacterium bovis BCG infection. Here we used TNF-LT-alpha-deficient mice to test whether a complete disruption of TNF and LT-alpha reduces further host resistance to BCG infection. The bacterial burden especially in the lungs of TNF-LT-alpha-deficient mice was significantly increased and the mice succumbed to infection between 8 and 10 weeks. In the absence of TNF-LT-alpha the granulomatous response was severely impaired and delayed. The cells in the granulomas of TNF-LT-alpha-deficient mice expressed low levels of MHC class II and ICAM-1. They contained a few T cells and F4/80-positive macrophages expressing little iNOS and acid phosphatase activity. By contrast, the lethal action of endotoxin was dramatically reduced in BCG-infected TNF-LT-alpha-deficient mice. In summary, in the absence of TNF-LT-alpha the recruitment and activation of mononuclear cells in response to BCG infection were significantly delayed and reduced resulting in immature granulomas allowing uncontrolled fatal infection.

Tumor necrosis factor receptor 2 plays a minor role for mycobacterial immunity

Tumor necrosis factor (TNF) signalling via the TNF receptor 1 (TNF-R1) is required for host resistance to mycobacterial infection. The role of TNF-R2 in anti-mycobacterial immunity is not known. Therefore, we compared TNF-R1 and TNF-R2 knockout (KO) mice infected with Mycobacterium bovis BCG (10(7) CFU, i.v.). While the bacterial burden of TNF-R1-deficient mice was significantly increased and the mice succumbed to infection between 4 and 5 weeks, TNF-R2 KO mice were less sensitive, and only 3 of 10 mice died within 12 weeks. Wild-type (WT) mice were resistant to BCG infection. The inability to clear the infection of TNF-R1 KO mice was associated with a reduced delayed-type hypersensitivity (DTH) response to purified protein derivative and severe impairment in forming granulomas with reduced macrophage recruitment and activation, and diminished expression of adhesion molecules. By contrast, TNF-R2 KO mice developed normal DTH response and mature mycobactericidal granulomas as the WT mice. Therefore, anti-mycobacterial immunity is largely dependent on TNF signalling via the TNF-R1, while activation of TNF-R2 plays a minor role.

Chest pain, enzymes and hypothyroidism

Hypothyroidism is a common disorder and when presenting with classical symptoms and signs is easy to recognise. However, hypothyroidism may present in a manner suggestive of an acute myocardial infarction with an elevated creatine kinase and electrocardiographic abnormalities. We report a case of severe hypothyroidism presenting as a cardiac event whose symptoms and signs dispersed following treatment with thyroxine.

The spectrum of mutations in erythrokeratodermias--novel and de novo mutations in GJB3

Intercellular channels in skin are a complex and functionally diverse system formed by at least eight connexins (Cx). Our recent molecular studies implicating Cx defects in inherited skin disorders emphasize the critical role of this signaling pathway in epidermal differentiation. Erythrokeratodermia variabilis (EKV) is an autosomal dominant genodermatosis with a striking phenotype characterized by the independent occurrence of transient localized erythema and hyperkeratosis. The disease maps to 1p34-p35, and recently we identified the causative gene GJB3 encoding Cx31. We have now investigated GJB3 in two families and three sporadic cases with EKV, and report three new heterozygous mutations. In a sporadic case, we detected a mutation leading to substitution of a conserved phenylalanine (F137L) in the third transmembrane domain, which likely interferes with the proper assembly or gating properties of connexons. In another family, all three affected individuals carried two distinct mutations on the same GJB3 allele. However, only a de novo heterozygous missense mutation replacing arginine 42 with proline (R42P) co-segregated with the disease, while a 12 bp deletion predicted to eliminate four amino acid residues in the variable carboxy terminal domain of Cx31 was also found in clinically unaffected relatives but not in 90 unaffected controls. Including the previously published mutations, in toto, five different missense mutations have now been detected in 6 out of 17 families investigated by our laboratory, all of which presumably affect the cytoplasmic amino terminal and transmembrane domains of Cx31. In contrast, two mutations linked to progressive high-tone hearing impairment were located in the second extracellular domain, suggesting that the character and position of Cx mutations determine their phenotypic expression in different tissues. However, the phenotypic spectrum of GJB3 mutations seems not to include progressive symmetric erythrokeratodermia, another dominant genodermatosis with overlapping features, since no mutations were found in six unrelated families tested.

Mortality of patients admitted with a suspected acute myocardial infarction in whom the diagnosis is not confirmed

AIMS

To examine the survival of patients admitted with a suspected acute myocardial infarction in whom the diagnosis was not confirmed ('possible myocardial infarction').

METHODS AND RESULTS

A cohort study based on the Nottingham Heart Attack Register of 1716 sequential patients discharged alive from two acute teaching hospitals following admission in 1992. The main outcome was mortality following hospital discharge after 5 years of follow-up. Survival of the cohort of patients in whom myocardial infarction was suspected but not confirmed was 58% (95% C.I. 56 to 60%) after 5 years of follow-up, compared with an expected survival of 76% in an age/sex matched general population. Patients with ECG abnormalities that were not diagnostic of myocardial infarction had a 5-year survival of 56%, compared with 77% in those without such changes (P<0.00001). In the 703 patients who died in the first 5 years of follow-up, the cause of death was cardiovascular in at least 53% of cases. Survival following hospital discharge was worse than that in patients discharged alive in the same year following a confirmed myocardial infarction (63% vs 69% after 4 years of follow-up P=0.0016).

CONCLUSION

Patients in this study had a substantially increased risk of death in the 5 years after discharge from hospital, compared with an age- and sex-matched population, and worse than patients discharged following a confirmed myocardial infarction. Almost half of those with ECG changes at the time of their admission died over the next 5 years. As over half of all deaths in this cohort were due to cardiovascular causes, further work is needed to identify patients at high and low risk of subsequent mortality who may warrant investigation and treatment following hospital discharge.

Relationship of vascular maturation in breast cancer blood vessels to vascular density and metastasis, assessed by expression of a novel basement membrane component, LH39

Angiogenesis, the formation of new vessels, has been demonstrated to be an indicator of prognosis in breast cancer patients. The extent of differentiation of the tumour vessels may affect access of peripheral white cells and egress or invasion of tumour cells. This has not been assessed in relation to tumour microvessel density or other variables and may be a marker of vascular remodelling. LH39 is a monoclonal antibody recognizing an epitope located at the lamina lucida of mature small veins and capillaries but not in newly formed vessels. To study vascular differentiation in breast tumours, we examined the vascular maturation index (VMI) in 12 normal and 50 breast carcinomas and this was correlated with different clinicopathological variables including angiogenesis. Mature vessels were defined by staining with antibodies to both LH39 and to CD31, using double immunohistochemistry, whereas immature vessels stained only for CD31. VMI was defined as the % fraction of mature vessels (LH39-positive) / total number of vessels (CD31-positive). The VMI was significantly higher in normal (54-68.5%; median 66.5%) than in tumours (0-47%; median 8.8%) (P = 0.0005). There was a significant inverse correlation between the tumour VMI and nodal status (Fisher's exact test, P = 0.01) and between high VMI and low thymidine phosphorylase (TP) expression (Mann-Whitney U-test, P= 0.01). No significant association between VMI and tumour size, oestrogen receptor, epidermal growth factor receptor, grade, angiogenesis, patient age, or E-selectin was seen. There was a significant reduction in relapse-free survival (P = 0.01) with high angiogenesis. These findings show that the VMI gives new information on the mechanism of tumour angiogenesis independently from microvessel quantitation, there is a wide variation in the differentiation of tumour vasculature but the degree of capillary differentiation is not associated with quantitative angiogenesis. The VMI identifies a subset of patients who have a high chance of regional node involvement.

Suppression of atrial myosin gene expression occurs independently in the left and right ventricles of the developing mouse heart

Many cardiac genes are broadly expressed in the early heart and become restricted to the atria or ventricles as development proceeds. Additional transcriptional differences between left and right compartments of the embryonic heart have been described recently, in particular for a number of transgenes containing cardiac regulatory elements. We now demonstrate that three myosin genes which become transcriptionally restricted to the atria between embryonic day (E) 12.5 and birth, alpha-myosin heavy chain (MHC), myosin light chain (MLC) 1A and MLC2A, are coordinately downregulated in the compact myocardium of the left ventricle before that of the right ventricle. alpha-MHC protein also accumulates in the right, but not left, compact ventricular myocardium during this period, suggesting that this transient regionalization contributes to fktal heart function. dHAND and eHAND, basic helix-loop-helix transcription factors known to be expressed in the right and left ventricles respectively at E10. 5, remain regionalized between E12.5 and E14.5. Downregulation of alpha-MHC, MLC1A, and MLC2A in iv/iv embryos, which have defective left/right patterning, initiates in the morphological left (systemic) ventricle regardless of its anatomical position on the right or left hand side of the heart. This points to the importance of left/right ventricular differences in sarcomeric gene expression patterns during fktal cardiogenesis and indicates that these differences originate in the embryo in response to anterior-posterior patterning of the heart tube rather than as a result of cardiac looping. Dev Dyn 2000;217:75-85.

Mental health service user involvement in nurse education: exploring the issues

This paper reports on findings and issues arising from a study designed to promote mental health service users' involvement in a preregistration nursing curriculum. Users' views about the knowledge, skills and attributes required by mental health nurses were explored to inform the curriculum design. Strategies that would facilitate long term, active user involvement in the design and delivery of the curriculum were also explored. Findings are presented with concurrent discussion of issues arising from the research process in relation to user involvement in education. The issue of 'conflict' explores findings relating to users' views of a 'good' mental health nurse and inherent conflicts between user and professional views are highlighted. The representativeness of the research participants is explored and debated in relation to service user involvement in nurse education. Finally, the concepts of 'involvement' and 'tokenism' are discussed and recommendations made about how active user involvement in nurse education can be achieved.

Growth and survivorship of dipterocarp seedlings: differences in shade persistence create a special case of dispersal limitation

A series of growth experiments and observations on natural populations have been carried out on dipterocarp species of contrasting ecology growing in artificial gaps and the forest understorey. These studies have demonstrated that although differences exist between species in photosynthetic and growth responses to the high-light environment, competition for light in canopy gaps is highly asymmetrical and tends to reinforce any pre-existing dominance hierarchy. We propose that differences in seedling persistence in forest canopy shade are highly influenced by species-specific biotic and abiotic interactions. Our experiments suggest that as seedlings, dipterocarp species trade off traits which enhance persistence and growth in shade against those that enhance their ability to exploit gaps. Less competitive species survive for progressively longer periods of time after a gregarious fruiting event. This leads to significant shifts with time in the number of species present in the seedling bank and hence in the importance of interspecific competition in determining which species dominates regrowth in gaps. We propose that this special case of dispersal limitation is more likely to account for coexistence of dipterocarp species than differences in growth responses to gaps of different size, with stochastic and environmental variables interacting to determine species distribution and abundance.

Human eosinophils release matrix metalloproteinase-9 on stimulation with TNF-alpha

BACKGROUND

The eosinophil is a prominent cell in allergic lung inflammation and is exposed to a range of cytokines, including TNF-alpha, at the site of allergen challenge. Matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) produced by inflammatory cells are thought to play a crucial role in interstitial matrix turnover and tissue remodeling in acute and chronic lung diseases. In addition, protein kinase C is known to be important in MMP-9 expression and secretion.

OBJECTIVE

We investigated the regulation of eosinophil-derived MMP-9 and TIMP proteins by TNF-alpha.

METHODS

Using RT-PCR and gelatin zymography, we investigated the ability of human eosinophils to produce and secrete active MMP-9 on stimulation with TNF-alpha. We also studied the production of TIMP-1 and TIMP-2 in eosinophils by using Western blotting.

RESULTS

The gelatinolytic activity of MMP-9 in unstimulated eosinophils was low, but it increased by 95% after TNF-alpha stimulation. This increase was regulated at both the transcriptional and translational levels. The transcription inhibitor actinomycin D, the nuclear factor kappaB (NFkappaB) inhibitor N-CBZ-Leu-Leu-Leu-AL, the protein synthesis inhibitor cycloheximide, and the protein kinase C inhibitor H7 significantly decreased MMP-9 activity in TNF-alpha-treated cells. TIMP-1 and TIMP-2 gene expression and protein production varied significantly among different cell donors.

CONCLUSION

Eosinophils, on stimulation with TNF-alpha, may play a major role in asthmatic airway remodeling through increased MMP-9 production at the inflammatory site.

Low intensity laser therapy for chronic venous leg ulcers

Ulceration of the lower extremities is one of the most important medicosocial problems (Skobelkin et al 1990). In this article, two case studies show that it is the length of time that laser therapy is used that can have a significant impact on ulcer size.

An antibiotic policy associated with reduced risk of Clostridium difficile-associated diarrhoea

BACKGROUND

antibiotic-associated diarrhoea caused by Clostridium difficile is increasing in hospitals, and older people are at particular risk.

OBJECTIVE

to establish whether reducing patient exposure to injectable third-generation cephalosporins by substituting alternative antibiotics can produce a cost-effective reduction in the incidence of antibiotic-associated diarrhoea.

DESIGN

we prospectively investigated 2157 patients admitted to the department of elderly medicine in the year before introduction of antibiotic restrictions and 2037 patients admitted in the following year. Patients admitted to other wards, where antibiotic prescribing was unchanged, acted as controls.

SETTING

a 900-bed teaching hospital in Cambridge, UK.

MEASUREMENTS

use and cost of injectable antibiotics prescribed in the department of elderly medicine and the other wards studied; occurrence of C. difficile-associated diarrhoea.

RESULTS

in the wards for older people, consumption of injectable cephalosporins fell by 92% (compared with 8% on other wards) and cases of C. difficile-associated diarrhoea fell from 98 to 45 (cases in other wards rose from 213 to 253; P < 0.001). The Pound Sterling 8062 increase in injectable antibiotic costs on the elderly wards were offset by the release of 1087 wasted bed-days attributable to the 53 fewer cases, with potential savings of Pound Sterling 212,000.

CONCLUSIONS

restricting the consumption of injectable third-generation cephalosporins is a cost-effective method of reducing the incidence of C. difficile-associated diarrhoea.

Extended lamivudine retreatment for chronic hepatitis B: maintenance of viral suppression after discontinuation of therapy

In patients with chronic hepatitis B, brief lamivudine therapy suppresses hepatitis B virus (HBV) DNA but results infrequently in sustained losses of virus replication posttreatment. We evaluated treatment response and its posttreatment durability during up to 18 months of lamivudine therapy (100 mg/d) in 24 patients who had hepatitis B e antigen (HBeAg) despite 1 to 3 months of prior therapy. Therapy was to be stopped after HBeAg loss or seroconversion (acquisition of antibody to HBeAg); posttreatment monitoring continued for 6 months. During therapy, which was well tolerated, HBV DNA became undetectable in all evaluable patients, accompanied by reduced alanine transaminase (ALT) activity. The cumulative 18-month confirmed loss of HBeAg during therapy was 9 of 24 (38%) and seroconversion was 5 of 24 (21%). Therapy was discontinued after HBeAg loss/seroconversion in 7 patients, and HBeAg status was maintained in all. Four of the patients with HBeAg responses lost HBsAg at least once. In 10 (43%) of 23 patients tested, we identified HBV polymerase YMDD mutations, 3 with detectable HBV DNA (2 with ALT elevations) and 7 without virological/biochemical breakthrough. In conclusion, up to 18 months of lamivudine therapy was well tolerated, suppressed HBV replication consistently, and tripled the frequency of HBeAg losses observed during brief-duration therapy; HBeAg loss/seroconversion remained durable posttreatment. The emergence of YMDD-variant HBV was relatively common but occurred typically without reappearance of detectable HBV DNA or ALT elevation. Our observations suggest that lamivudine can be stopped after confirmed HBeAg loss or seroconversion.

5-Aminolevulinic acid photosensitization of dysplastic Barrett's esophagus: a pharmacokinetic study

Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) may have a role in the treatment of dysplastic Barrett's esophagus. Before ALA-induced PDT can be used clinically, optimum treatment parameters must be established. In this study of 35 patients, the issues of drug dosage, time interval between drug and light delivery and side effects of oral ALA administration are addressed. Spectrofluorometric analysis of tissue samples demonstrates that oral ALA administration induces porphyrin accumulation in esophageal tissues, with maximum levels at 4-6 h. High-performance liquid chromatography confirms the identity of this porphyrin as PpIX, and fluorescence microscopy analysis demonstrates that it preferentially accumulates in the esophageal mucosa, rather than in the underlying stroma. Side effects of ALA administration included malaise, headache, photosensitivity, alopecia, transient derangement of liver function, nausea and vomiting. Fewer side effects and less hepatic toxicity was seen with 30 mg/kg than 50 mg/kg ALA. In conclusion, oral ALA administration induces preferential PpIX accumulation in the esophageal mucosa, with peak PpIX fluorescence noted at 4 h and minimal systemic toxicity at a dose of 30 mg/kg.

Age-related changes in the cerebellum: parallel fibers

Between the ages of 3 and 23 months, the cerebella of NIH Fischer 344 rats lose 30% of the thickness of the molecular layer, 60% of the length of parallel fibers, and 80% of the synaptic varicosities along parallel fibers. Nearly 60% of these synaptic varicosities disappear between 3 and 9 months. Thus, the loss of cerebellar synapses is unusual, may have begun early in life, and continue into old age, causing profound synaptic losses in older rats. In addition to serious implications to functional losses, we speculate that these synaptic losses may trigger other age-related cellular losses in the cerebellum.

Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited

OBJECTIVE

To identify factors associated with the uptake of cardiac rehabilitation following acute myocardial infarction.

DESIGN

Retrospective analysis using multivariate logistic regression modelling.

SETTING

Two large teaching hospitals in Nottingham.

PATIENTS

Cohorts of patients admitted with acute myocardial infarction in 1992 and 1996.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Factors in multivariate analysis found to be associated with attendance at cardiac rehabilitation. Use of secondary prevention in those who were and were not invited and those who did and did not attend cardiac rehabilitation.

RESULTS

58% of all patients were offered cardiac rehabilitation. Attendance rates were 60% in 1992 and 74% in 1996. Invitations were more likely to be offered to younger patients, those who had received thrombolysis, and to patients admitted to one of the two Nottingham hospitals. Use of secondary prevention was only 48% in 1992 but this increased to 80% in 1996. Patients not receiving secondary prevention were less likely to be invited to cardiac rehabilitation. Social deprivation was the only factor significantly associated with poor uptake of cardiac rehabilitation in both years. There was no difference in the use of secondary prevention between those who did and did not attend cardiac rehabilitation.

CONCLUSION

Those invited to attend a cardiac rehabilitation programme are likely to be in a good prognosis group, comprising those who are young and have received thrombolysis. Those at greatest risk, particularly patients from socially deprived areas, seem to be missing out on the potential benefits of cardiac rehabilitation. High risk patients should be specifically targeted to ensure that they are invited to, and encouraged to, attend a programme of cardiac rehabilitation.

theta, a novel gamma-aminobutyric acid type A receptor subunit

gamma-Aminobutyric acid type A (GABA-A) receptors are a major mediator of inhibitory neurotransmission in the mammalian central nervous system, and the site of action of a number of clinically important drugs. These receptors exist as a family of subtypes with distinct temporal and spatial patterns of expression and distinct properties that presumably underlie a precise role for each subtype. The newest member of this gene family is the theta subunit. The deduced polypeptide sequence is 627 amino acids long and has highest sequence identity (50.5%) with the beta1 subunit. Within the rat striatum, this subunit coassembles with alpha2, beta1, and gamma1, suggesting that gamma-aminobutyric acid type A receptors consisting of arrangements other than alpha beta + gamma, delta, or epsilon do exist. Expression of alpha2beta1gamma1theta in transfected mammalian cells leads to the formation of receptors with a 4-fold decrease in the affinity for gamma-aminobutyric acid compared with alpha2beta1gamma1. This subunit has a unique distribution, with studies so far suggesting significant expression within monoaminergic neurons of both human and monkey brain.

Comparison of antiplatelet activity of microencapsulated aspirin 162.5 Mg (Caspac XL), with enteric coated aspirin 75 mg and 150 mg in patients with atherosclerosis

AIMS

A new formulation, low dose microencapsulated aspirin, permits slow absorption of aspirin and presystemic acetylation of platelet cyclo-oxygenase within the portal circulation, potentially avoiding deleterious effects on gastric and systemic prostaglandin synthesis. The objective of this study was to determine whether the administration of microencapsulated aspirin was as effective as enteric coated (EC) aspirin as an inhibitor of platelet function in patients with atherosclerosis.

METHODS

One hundred and four patients were enrolled and randomised after a run in period of at least 14 days on aspirin EC 75 mg (day 0), to receive either microencapsulated aspirin 162.5 mg (n=34), aspirin EC 150 mg (n=36) or continue on aspirin EC 75 mg (n=34) for 28 days. Serum thromboxane B2 and collagen-induced platelet aggregation and release of 5-hydroxytryptamine (EC50 values) were measured on days 0 and 28. Aggregation/release EC50s were then repeated in the presence of a large dose of aspirin added in vitro to determine the EC50 at the maximum level of platelet inhibition.

RESULTS

Median thromboxane B2 levels were low after 14 days run-in therapy with aspirin EC 75 mg, but significant further reductions were seen on day 28 in patients randomised to microencapsulated aspirin 162.5 mg (P=0.0368) and aspirin EC 150 mg (P=0.0004) compared with those remaining on aspirin EC 75 mg. Median EC50 s on day 28 showed small but significant increases from baseline (day 0) in aggregation in patients randomised to microencapsulated aspirin 162.5 mg (0.62-0.85, P=0.0482) and in both aggregation and release in patients randomised to aspirin EC 150 mg (0.95-1.20, P=0.0002, 8.4-11.7, P<0. 0001, respectively) signifying enhanced antiplatelet activity. No changes were seen in patients continuing on aspirin EC 75 mg. Results following addition of high dose aspirin in vitro suggest that mechanisms other than thromboxane synthesis may be operative in the long term effects of microencapsulated aspirin 162.5 mg and aspirin EC 150 mg over aspirin EC 75 mg.

CONCLUSIONS

The results show good inhibition of thromboxane B2 synthesis and subsequent platelet activity by all preparations of aspirin, although both microencapsulated aspirin 162.5 mg and aspirin EC 150 mg are slightly more effective than aspirin EC 75 mg. A randomised trial is now required to determine whether microencapsulated aspirin is associated with fewer gastric side-effects.