Management of vagus nerve simulation therapy in the peri-operative period: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists

Vagus nerve stimulation is a well-established treatment option for patients with drug-resistant epilepsy and has an expanding range of other clinical indications. Side effects of vagus nerve stimulation therapy include: cough; voice changes; vocal cord adduction; rarely, obstructive sleep apnoea; and arrhythmia. Patients with implanted vagus nerve stimulation devices may present for unrelated surgery and critical care to clinicians who are unfamiliar with their function and safe management. These guidelines have been formulated by multidisciplinary consensus based on case reports, case series and expert opinion to support clinicians in the management of patients with these devices. The aim is to provide specific guidance on the management of vagus nerve stimulation devices in the following scenarios: the peri-operative period; peripartum period; during critical illness; and in the MRI suite. Patients should be aware of the importance of carrying their personal vagus nerve stimulation device magnet with them at all times to facilitate urgent device deactivation if necessary. We advise that it is generally safer to formally deactivate vagus nerve stimulation devices before general and spinal anaesthesia. During periods of critical illness associated with haemodynamic instability, we also advise cessation of vagus nerve stimulation and early consultation with neurology services.

Improving endovascular access to the target vessel for thrombus aspiration -Use of the wedge device to overcome anatomic hurdles

BACKGROUND AND PURPOSE

Aspiration is a successful technique used in thrombectomy for acute stroke. It is contingent upon the appropriate position of the aspiration catheter, so that it is in contact with the thrombus. However, navigating the craniocervical vasculature is challenging is some patients. The wedge microcatheter (MicroVention®) is designed to reduce the gap between the microcatheter and the SofiaPlus 6F catheter for ease of advancement. The purpose of this study is to describe our initial experience with the wedge microcatheter.

MATERIALS AND METHODS

A retrospective review of 38 consecutive patients in whom the wedge microcatheter was used during thrombectomy was performed to determine whether the wedge microcatheter was successful in delivering the Sofia catheter to the desired location.

RESULTS

We have found this device to be successful in delivering the aspiration catheter to the correct position in 97% (N = 37) of cases. It was used predominantly to pass the origin of branching vessels and also to navigate the tortuous cavernous and petrous segments of the ICA.

CONCLUSION

The wedge microcatheter is a successful tool in delivering the aspiration catheter to the desired vessel for revascularisation.

Review of external referrals to a regional stroke centre: it is not just about thrombectomy

AIMS

To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO).

MATERIALS AND METHODS

Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not.

RESULTS

Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142).

CONCLUSION

These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

A Standardized Aspiration-First Approach for Thrombectomy to Increase Speed and Improve Recanalization Rates

BACKGROUND AND PURPOSE

Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates.

MATERIALS AND METHODS

We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever-first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b-3) and the number of passes were compared between the 2 groups.

RESULTS

In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b-3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005).

CONCLUSIONS

Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.

Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset

BACKGROUND AND OBJECTIVES

Benefit from endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) is well demonstrated. Furthermore, emerging evidence supports efficacy in appropriately selected patients treated beyond current recommendations of 6 h. We evaluated clinical outcomes in patients undergoing late EVT at our institution.

METHODS

Retrospective review of prospectively collected clinical database on 355 patients who underwent EVT for LVO AIS. Data collected consisted of patient demographics, radiological findings and outcome details. Outcomes, including 90-day functional status, recanalization, symptomatic intracranial haemorrhage (sICH) and 90-day mortality, for patients undergoing EVT <6 h, >6 h, and >7.3 h, were compared.

RESULTS

A total of 355 patients underwent EVT for LVO AIS at our institution during the review period, with 74 (21%) patients treated ≥6 h from symptom onset. Successful recanalization was achieved in 285 (80%) patients, with 228 (81%) achieving a mTICI ≥2b in the <6 h group, and 57 (77%) in the >6 h group (P = 0.429). Ninety-day functional independence (mRS 0-2) was achieved in 162 (46%) patients, with 130 (46%) achieving a mRS of 0-2 in the <6 h group, and 32 (43%) in the >6 h group (P = 0.643). No significant differences were found in rates of sICH or 90-day mortality. No significant differences in functional independence, recanalization rates, sICH or mortality were identified in patients treated with EVT >7.3 h compared to <7.3 h.

CONCLUSIONS

In appropriately selected patients, EVT >6 h was associated with comparable outcomes to those treated <6 h. These data support a physiological approach to patient selection.

Double Stent-Retriever Technique in Endovascular Treatment of Middle Cerebral Artery Saddle Embolus

Ischemic stroke is a major public health problem worldwide, considered as the third most costly health condition in developed countries, with urgent reperfusion remaining the paramount goal for its treatment. In line with the results of recent randomized control trials, the introduction of stent retrievers was a major advancement in the treatment of stroke; however, interventionalists sometimes encounter thrombi not-retrievable by applying conventional techniques. In this article, we present a case treated by an innovative double-stent retrieval in Y-configuration that may potentially help other clinicians in similar situations.

Estimating epidemiological parameters for bovine tuberculosis in British cattle using a Bayesian partial-likelihood approach

Fitting models with Bayesian likelihood-based parameter inference is becoming increasingly important in infectious disease epidemiology. Detailed datasets present the opportunity to identify subsets of these data that capture important characteristics of the underlying epidemiology. One such dataset describes the epidemic of bovine tuberculosis (bTB) in British cattle, which is also an important exemplar of a disease with a wildlife reservoir (the Eurasian badger). Here, we evaluate a set of nested dynamic models of bTB transmission, including individual- and herd-level transmission heterogeneity and assuming minimal prior knowledge of the transmission and diagnostic test parameters. We performed a likelihood-based bootstrapping operation on the model to infer parameters based only on the recorded numbers of cattle testing positive for bTB at the start of each herd outbreak considering high- and low-risk areas separately. Models without herd heterogeneity are preferred in both areas though there is some evidence for super-spreading cattle. Similar to previous studies, we found low test sensitivities and high within-herd basic reproduction numbers (R₀), suggesting that there may be many unobserved infections in cattle, even though the current testing regime is sufficient to control within-herd epidemics in most cases. Compared with other, more data-heavy approaches, the summary data used in our approach are easily collected, making our approach attractive for other systems.

Genome-wide association analyses of child genotype effects and parent-of-origin effects in specific language impairment

Specific language impairment (SLI) is a neurodevelopmental disorder that affects linguistic abilities when development is otherwise normal. We report the results of a genome-wide association study of SLI which included parent-of-origin effects and child genotype effects and used 278 families of language-impaired children. The child genotype effects analysis did not identify significant associations. We found genome-wide significant paternal parent-of-origin effects on chromosome 14q12 (P = 3.74 × 10⁻⁸) and suggestive maternal parent-of-origin effects on chromosome 5p13 (P = 1.16 × 10⁻⁷). A subsequent targeted association of six single-nucleotide-polymorphisms (SNPs) on chromosome 5 in 313 language-impaired individuals and their mothers from the ALSPAC cohort replicated the maternal effects, albeit in the opposite direction (P = 0.001); as fathers’ genotypes were not available in the ALSPAC study, the replication analysis did not include paternal parent-of-origin effects. The paternally-associated SNP on chromosome 14 yields a non-synonymous coding change within the NOP9 gene. This gene encodes an RNA-binding protein that has been reported to be significantly dysregulated in individuals with schizophrenia. The region of maternal association on chromosome 5 falls between the PTGER4 and DAB2 genes, in a region previously implicated in autism and ADHD. The top SNP in this association locus is a potential expression QTL of ARHGEF19 (also called WGEF) on chromosome 1. Members of this protein family have been implicated in intellectual disability. In summary, this study implicates parent-of-origin effects in language impairment, and adds an interesting new dimension to the emerging picture of shared genetic etiology across various neurodevelopmental disorders.

Management of drooling in children: a survey of UK paediatricians' clinical practice

BACKGROUND

Drooling is common in children with disordered oral-motor control. There is little evidence about the comparative effectiveness of different interventions used to reduce the impact of drooling. Anecdotal reports suggest clinicians' management of drooling varies widely. The aims of this survey were to establish which drooling interventions are currently used, how their effectiveness is monitored and how frequently adverse effects are reported.

METHODS

151 UK paediatricians completed a questionnaire about their management of drooling.

RESULTS

Paediatricians saw one new child with problematic drooling and three follow-up children per month. The most common prescribing pattern was hyoscine first line (84.7%) followed by glycopyrronium bromide second line. The reported rate of adverse effects of medications was lower than expected (median 10% for hyoscine). Very few paediatricians used standardized methods of measuring the medication's effectiveness or adverse effects.

CONCLUSION

Paediatricians regularly see small numbers of children with problematic drooling. Their clinical management of drooling varies; this is most likely because of a lack of evidence about the most effective approach. Comparative trials of interventions and the development of evidence-based clinical guidelines would improve the management of children's drooling.

A stable "flat" form of two-dimensional crystals: could graphene, silicene, germanene be minigap semiconductors?

The discovery of a flat two-dimensional crystal known as graphene has contradicted Landau-Peierls-Mermin-Wagner arguments that there is no stable flat form of such crystals. Here, we show that the "flat" shape of graphene arises due to a microscopic buckling at the smallest possible interatomic scale. We show that the graphene, silicene, and other two-dimensional crystals are stable due to transverse short-range displacements of appropriate atoms. The distortions are small and form various patterns, which we describe in a framework of Ising model with competing interactions. We show that when temperature decreases, two transitions, disorder into order and order into disorder, arise. The ordered state has a form of stripes where carbon atoms are shifted regularly with respect to the plane. The flat graphene, silicene, or germanene planes look like a microscopic "washboard" with the wavelength of about couple of interatomic spacing of appropriate sublattices, which for graphene is about 1.8-3.6 Å. At lower temperatures, the ordered state transforms into a glass. Because of up-down asymmetry in buckled graphene, silicene and other two-dimensional crystals deposited on substrate, a minibandgap may arise. We derive a criterion for the minigap formation and show how it is related to the buckling and to the graphene-substrate interaction. Because of the bandgap, there may arise new phenomena and in particular a rectification of ac current induced by microwave or infrared radiation. We show that the amplitude of direct current arising at wave mixing of two harmonics of microwave electromagnetic radiation is huge. Moreover, we predict the existence of miniexcitons and a new type of fermionic minipolaritons whose behavior can be controlled by the microwave and terahertz radiation.

Coil Migration through a Neuroform 3 Stent during Endovascular Coiling. A Case Report

SUMMARY

A 43-year-old woman attended for stent assisted coiling. A Neuroform 30 x 4.5 mm stent had been successfully placed over the left periophthalmic aneurysm. During the coiling the first coil migrated through the crowns in the stent, lodging at the MCA bifurcation. We believe that the coil herniated through the overlying stent due to the carotid siphon curvature and the open cell design. Furthermore the distal markers of the stent impeded coil extraction with a MERCI device.

Retrieval of a Migrated Coil Using an X6 MERCI Device

SUMMARY

Coil migration is a recognised but rare complication of endovascular coiling. Many techniques are available commercially for coil retrieval. We report the case of an acute subarachnoid hemorrhage in a 54-year-old woman in which a migrated coil was successfully retrieved using an X6 MERCI device.

Novel use of the "buddy"wire

SUMMARY

During interventional procedures the tortuosity of the vasculature hampers catheter stability. The buddy wire may be used to aid and maintain vascular access.We describe a case of acute subarachnoid haemorrhage secondary to dissecting aneurysm of the vertebral artery.We discuss the value of the buddy wire during balloon occlusion of the vertebral artery not as it is typically used, but to actually prevent the balloon repeatedly entering the posterior inferior cerebellar artery during the procedure.

Characterisation of an optical clock recovery method based on a mode-locked laser diode using spectrographic pulse measurement

As channels rates in optical networks are expected to exceed 100 Gb/s in the near future, new optical techniques for clock recovery will have to be developed for optical regeneration. This paper describes an optical clock recovery method based on a mode-locked laser diode. Experimental results show that a 42 GHz high quality optical clock can be retrieved from a 170 Gb/s OTDM data signal. Chirp transfer between the incident signal and the recovered clock signal is investigated using the SHG-FROG method. Results demonstrate that this clock recovery technique is invariant to input dispersion varying between +/-75 ps/nm, making it ideal for use in 3R regenerators.

Associated features of Asperger Syndrome and their relationship to parenting stress

BACKGROUND

Studies have shown an increased level of stress in parents of autistic children relative to parents of non-autistic children. Few studies have examined parenting stress specifically within the Asperger Syndrome (AS) population. Children with AS often have associated difficulties such as sensory sensitivities and problems with executive functioning (i.e. planning, inhibiting, shifting set). This study was designed to study parenting stress as well as to consider the relationship between parenting stress and some of the associated difficulties of AS. More specifically, the aims of this study were to demonstrate the following: that, as a group, parents of children with AS would report elevated levels of parenting stress, a finding which may be more significant for mothers than fathers; that children with AS show impairment in executive functioning as well as heightened sensory sensitivity according to parent report; that parent report of their child's demanding characteristics would be positively associated with their self-reported levels of parenting stress.

METHODS

Participants in this study were the parents of 39 children between the ages of 5 and 12 years, reflecting a 71% response rate, in the Lothian region of Scotland who completed The Parenting Stress Index, the Behavioural Rating Inventory of Executive Function and the Short Sensory Profile.

RESULTS

The study revealed that both mothers and fathers of AS children reported elevated levels of parenting stress. There was a significant positive correlation between mother's parenting stress and the child's level of impairment, both with respect to executive dysfunction as well as sensory difficulties.

CONCLUSION

The challenges of parenting a child with AS should not be underestimated. Further study is needed to explore the causative role that child impairments play in parenting stress and what types of interventions may prove most helpful to these families.

A randomised controlled trial and economic evaluation of direct versus indirect and individual versus group modes of speech and language therapy for children with primary language impairment

OBJECTIVES

To compare language outcomes following direct individual therapy [speech and language therapist (SLT) working individually with a child], indirect individual therapy [speech and language therapy assistant (SLTA) working individually with a child], direct group therapy (SLT working with a small group of children) and indirect group therapy (SLTA working with a small group of children) for primary school-age children with persistent primary receptive and/or expressive language impairment relative to a comparison group receiving current models and levels of SLT service.

DESIGN

The trial had a 2 x 2 factorial design (direct/indirect versus individual/group therapy) together with a control group that received existing levels of community-based speech and language therapy and served as a comparator for the economic analysis. All postintervention language outcome measures were blind assessed. A short-run economic evaluation across the four different modes of therapy was carried out using the primary outcome measure. A comparable method was used for estimating the costs of providing services in the community for children allocated to the control group.

SETTING

Research intervention took place in school settings in Scotland, with some of the children randomised to group therapies transported to join a group in a different school.

PARTICIPANTS

Children aged between 6 and 11 years, attending a mainstream school, with standard scores on the Clinical Evaluation of Language Fundamentals (CELF-3UK) of less than -1.25 SD (receptive and/or expressive) and non-verbal IQ on the Wechsler Abbreviated Scale of Intelligence (WASI) above 75, and no reported hearing loss, no moderate/severe articulation/phonology/dysfluency problems or otherwise requiring individual SLT work. Informed, written parental consent was required.

INTERVENTIONS

A therapy manual was constructed that provided a range of procedures and activities for intervention in areas identified by a search of the research and professional literature for examples of language therapies of proven effectiveness. SLTs planned activities for children seen by therapists and SLTAs, using the manual.

MAIN OUTCOME MEASURES

Primary outcome measures were standardised scores on tests of expressive and receptive language. Secondary outcome measures were scores on a test of receptive vocabulary, together with questionnaire, rating scale and focus group data from parents, teachers, project SLTs and SLTAs, and an audit of therapy sessions.

RESULTS

There was no evidence that the five modes involved in the project were different at the onset in terms of primary outcome measures, although there were significant gender differences. The results from both the intention-to-treat analyses of the outcomes from the 161 children randomised who met the eligibility criteria and the protocol analyses of the outcomes from the 152 children for whom postbaseline data were available revealed that there were no significant postintervention differences between direct and indirect modes of therapy on the one hand, or between individual and group modes on the other on any of the primary language outcome measures. However, there was evidence of some benefits from direct therapy from an SLT in secondary outcome measures. Intervention delivered three times a week for 30-40 minutes over a 15-week period also yielded significant improvements in age-corrected standardised scores for expressive language, although not for receptive language, relative to those receiving community-based SLT services. Children with specific expressive language delay were more likely to show improvement than those with mixed receptive-expressive difficulties, and non-verbal IQ was not a significant moderating variable. The within-trial economic evaluation identified indirect therapy, particularly indirect group therapy, as the least costly of the modes investigated in the study, with direct individual therapy as the most costly option.

CONCLUSIONS

SLTAs can act as effective surrogates for SLTs in the delivery of services within primary schools to children with primary language impairment who do not to require the specialist skills of an SLT. Generalising the central estimates of the relative cost of different therapy modes to other educational/health systems is possible, but the precise differences reported in resource use need to be qualified by the level of programme intensity and other characteristic features of education and therapy services that may differ from those observed in this trial. Further research is needed into effective interventions for receptive language problems and also investigations of the efficacy of the relationship between dose and treatment effect in both expressive and receptive language. Research is also needed into models of integrative service delivery, cluster models of delivery via integrated community schools, and the involvement of class teachers, classroom assistants and parents/carers. There is also a need for studies to identify the characteristics of children who are most likely to succeed with indirect intervention approaches, and also to evaluate alternative methods of working with those who may benefit from different modes. Finally, research to refine the therapy manual would also be helpful.

Absence of detectable measles virus genome sequence in blood of autistic children who have had their MMR vaccination during the routine childhood immunization schedule of UK

Leukocyte preparations from children with documented evidence of MMR vaccination and confirmed diagnosis of autism were examined by several assays designed to target multiple regions of the measles virus genome sequence. No sample was found positive by any method. The assays applied were highly sensitive, specific and robust in nature, and were based on the amplification of measles virus RNA transcripts by real-time quantitative RT-PCR (QRT-PCR) as well as by conventional RT-PCR-nested PCR. The assays applied were potentially able to detect measles virus RNA down to single figure copy numbers per reaction. The amount of total nucleic acid extract of leukocytes subjected to various measles virus-specific investigations was several fold higher than minimally required of a sample where measles virus persistence is well documented. This study failed to substantiate reports of the persistence of measles virus in autistic children with development regression.

Audit of an inpatient neurology consultation service in a tertiary referral centre: value of the consulting neurologist

The Mater Misericordiae Hospital is a 575-bed tertiary referral centre with busy medical and surgical subspecialty services (including the national cardiac, cardiothoracic, spinal cord injury and pulmonary hypertension units). An audit of in-patient referrals to a neurology service was carried out over the twelve-month period of January to December 2002 inclusively. Five hundred and seventy seven inpatients were evaluated and managed in conjunction with the referring services. Consultation by the neurological service led to a significant contribution in the management of clinical cases in one of three ways: establishing a de novo diagnosis in patients admitted with active neurological symptoms where no working diagnosis exists (40.7% of referrals), significant alteration in diagnosis where the referring service have already established a specific working diagnosis (11.1% of referrals), or offering advice in the ongoing management of active neurological symptoms when the diagnosis is historically established and secure (48.2% of referrals). In order of frequency the most common reason for referral was stroke (131 cases (22.7%)), seizures unrelated to alcohol (59 cases (10.2%)), alcohol-related neurological problems (55 cases (9.5%)), movement disorders (41 cases (7.1%)), neuromuscular (40 cases (6.9%)), coma (35 cases (6%)), disorders of cognition (31 cases (5.3%)), acute headache (28 case (4.8%)) and functional neurological syndromes (26 cases (4.5%)). This audit highlights the value of a consulting neurology service in a multidisciplinary tertiary referral setting.

Risk of Pulmonary Embolism After Negative MDCT Pulmonary Angiography Findings

OBJECTIVE

The purpose of our study was to determine the risk of pulmonary embolism in patients who have negative MDCT pulmonary angiography findings.

SUBJECTS AND METHODS

In this prospective study, one hundred two consecutive patients with suspected pulmonary embolism underwent MDCT pulmonary angiography. Scans were reviewed jointly by two observers and findings recorded by consensus. Observers noted whether pulmonary embolism or other disease was present. No pulmonary embolism was seen in 85 patients (52 men and 33 women; age range, 20-94 years; mean age, 60 years) who were followed up for a mean of 9 months (range, 4-13 months) for evidence of subsequent pulmonary embolism.

RESULTS

One patient had a diagnosis of pulmonary embolism made within 3 weeks of undergoing CT pulmonary angiography. MDCT pulmonary angiography showed additional potentially significant findings in 76% of patients; 47% of these findings were not suspected on chest radiography.

CONCLUSION

The risk of pulmonary embolism at a mean of 9 months after negative MDCT pulmonary angiography findings is 1%. In our study of patients without pulmonary embolism, MDCT pulmonary angiography revealed other causes for individual patients' signs or symptoms in most cases.

Opioid peptides and dipeptidyl peptidase in autism

It has been hypothesized that autism results from an 'opioid peptide excess'. The aims of this study were to (1) confirm the presence of opioid peptides in the urine of children with autism and (2) determine whether dipeptidyl peptidase IV (DPPIV/CD26) is defective in children with autism. Opioid peptides were not detected in either the urine of children with autism (10 children; nine males, one female; age range 2 years 6 months to 10 years 1 month) or their siblings (10 children; seven males, three females; age range 2 years 3 months to 12 years 7 months) using liquid chromatography-ultraviolet-mass spectrometric analysis (LC-UV-MS). Plasma from 11 normally developing adults (25 years 5 months to 55 years 5 months) was also tested. The amount and activity of DPPIV in the plasma were quantified by an ELISA and DPPIV enzyme assay respectively; DPPIV was not found to be defective. The percentage of mononuclear cells expressing DPPIV (as CD26) was determined by flow cytometry. Children with autism had a significantly lower percentage of cells expressing CD3 and CD26, suggesting that they had lower T-cell numbers than their siblings. In conclusion, this study failed to replicate the findings of others and questions the validity of the opioid peptide excess theory for the cause of autism.

Development of an instrument to measure manual praxis

The purpose of this study was to develop an instrument to measure manual praxis by assessing areas of function considered important in learning and planning movement; use of tools, imitation of gesture, and motor sequencing. Participants included 362 healthy children aged between 3 and 12 years. Their parents completed a questionnaire on hand skills. Performance on all tasks improved with age. However, transitive gestures reached an early ceiling effect at around 5 years of age. Assessment of manual praxis from the parental questionnaire correlated with the child's directly measured competency during a test of object use (P<0.01) but not with the ability to imitate transitive gestures or enact a motor sequence with a 'novel' task. Children from schools where a higher number were eligible for free school meals because of low family income had more difficulty with imitation of gesture and motor sequencing to verbal and picture commands (P<0.001, P<0.05, P<0.05). They were neither disadvantaged in tool use nor in appreciation of extracorporeal space. The pattern of errors made in tool use and motor sequencing differed from those described in adults with acquired dyspraxia. These results suggest that assessment of manual praxis in clinical populations should include tool use, imitation of gesture, and motor sequencing and that they should not necessarily be regarded as measuring a unitary function.

A genome scan localizes five non-MHC loci controlling collagen-induced arthritis in rats

Identification of specific genetic loci that contribute to susceptibility to rheumatoid arthritis (RA) in humans has been hampered by several factors, including: i) multiple interacting genetic loci contributing to susceptibility; ii) complex interactions of environmental and genetic factors; iii) genetic heterogeneity; and iv) low penetrance. We have, therefore, mapped quantitative trait loci (QTLs) that control inflammatory arthritis susceptibility and/or severity in progeny of two inbred rat strains with significantly different susceptibilities to collagen-induced arthritis (CIA), an animal model for RA. Not surprisingly, we identified a major susceptibility factor, Cia1, on chromosome 20 in the vicinity of the rat major histocompatibility complex (MHC). However, by limiting the analysis to animals with arthritis-susceptible MHC genotypes and using genome-wide QTL analytic techniques, we also found four non-MHC QTLs-Cia2, 3, 4 and 5-on chromosomes 1, 4, 7 and 10, that contributed to disease severity. In addition, a QTL on chromosome 8 was suggestive for linkage. Characterization of the genes underlying these QTLs will facilitate the identification of key biochemical pathways regulating experimental autoimmune arthritis in rats and may provide insights into RA and other human autoimmune diseases. These genes may also represent novel targets for therapy.

The Roscommon Family Study. IV. Affective illness, anxiety disorders, and alcoholism in relatives

OBJECTIVES

This report seeks to evaluate the specificity of the familial liability to schizophrenia by examining in the relatives of the various proband groups the risk for affective illness (AI), anxiety disorders, and alcoholism.

DESIGN

A case-controlled epidemiologic family study using DSM-III-R criteria.

PARTICIPANTS

Three hundred eighty-four index probands from a psychiatric case register, 150 unselected control probands from an electoral register and 2043 of their living and traceable relatives, of whom 1753 were personally interviewed.

RESULTS

In personally interviewed relatives of schizophrenic probands, the lifetime risk for all AI (24.9% +/- 3.8%) or just bipolar AI (1.2% +/- 0.7%) was very similar to that found in interviewed relatives of controls (22.8% +/- 4.0% and 1.4% +/- 0.7%, respectively). However, the risk for all AI (49.7% +/- 12.9%) or bipolar AI (4.8% +/- 3.2%) was substantially increased in relatives of schizoaffective probands. A substantially higher proportion of relatives of schizophrenic vs control probands who had AI demonstrated psychotic--and specially mood-incongruent psychotic--symptoms when affectively ill. Neither the risk for anxiety disorders nor that for alcoholism was increased in relatives of schizophrenic vs control probands.

CONCLUSIONS

The familial liability to schizophrenia possesses some specificity and does not substantially increase the risk to AI, anxiety disorders, or alcoholism. Even when narrowly defined, schizoaffective disorder has a substantial familial link to classic AI. The familial liability to schizophrenia predisposes to psychosis, and especially mood-incongruent psychosis, when affectively ill. Finally, these results do not support the hypothesis that, from a familial perspective, schizophrenia and AI are on a single etiologic continuum.

The Roscommon Family Study. III. Schizophrenia-related personality disorders in relatives

OBJECTIVES

We sought to clarify the familial relationship between five putative schizophrenia-related personality disorders (schizotypal [SPD], paranoid, schizoid, avoidant, and borderline) and schizophrenia, other nonaffective psychoses, and affective illness.

DESIGN

A case-controlled epidemiologic family study using DSM-III-R criteria.

PARTICIPANTS

Five hundred thirty-four probands selected from a psychiatric case register or electoral register, of whom 415 were personally interviewed, and 2043 living and traceable relatives, of whom 1753 were personally interviewed.

RESULTS

Compared with relatives of unscreened controls, relatives of probands with schizophrenia had a highly significantly increased prevalence of SPD, and modest, but significant, increased prevalences of paranoid, schizoid, and avoidant personality disorders. Borderline personality disorder was rare, with a modest clustering of cases in relatives of affective disorder probands. The prevalence of SPD was also significantly elevated in relatives of probands with SPD and with other nonaffective psychoses but not in relatives of probands with psychotic or nonpsychotic affective illness. In contrast to the pattern seen for schizophrenia, the prevalence rate of SPD was substantially greater in parents than in siblings of schizophrenic probands.

CONCLUSIONS

Schizotypal personality disorder has a strong familial relationship with schizophrenia. Paranoid, schizoid, and avoidant, but not borderline, personality disorders may have a significant familial relationship with schizophrenia. Schizotypal personality disorder also reflects the familial liability to other psychotic disorders but probably not to affective illness. Fitness effects may substantially influence the pattern of schizophrenia-related personality disorders in relatives.

The Roscommon Family Study. II. The risk of nonschizophrenic nonaffective psychoses in relatives

OBJECTIVE

We sought to clarify the familial relationship between the nonschizophrenic, nonaffective psychoses (schizoaffective disorder [SAD], schizophreniform disorder, delusional disorder, and atypical psychosis) and schizophrenia and affective illness (AI).

DESIGN

A case-controlled epidemiologic family study using DSM-III-R criteria.

RESULTS

Compared with relatives of unscreened controls, the risk of nonschizophrenic, nonaffective psychoses was significantly elevated in relatives of probands with schizophrenia, SAD, schizotypal personality disorder, and psychotic AI. No significant elevation in risk to these disorders was seen in relatives of probands with nonpsychotic AI. The risk for SAD alone was significantly increased in relatives of probands with psychotic or bipolar AI.

CONCLUSIONS

The nonschizophrenic, nonaffective psychoses have a significant familial relationship with both schizophrenia and schizotypical personality disorder. Schizoaffective disorder, as defined by DSM-III-R, shares familial etiologic factors with at least some forms of AI.

The Roscommon Family Study. I. Methods, diagnosis of probands, and risk of schizophrenia in relatives

OBJECTIVES

We sought to examine, in a rural county in the West of Ireland, the degree of familial relationship between schizophrenia and other nonaffective psychoses and affective illness (AI).

DESIGN

A case-controlled epidemiologic family study using DSM-III-R criteria.

PARTICIPANTS

This study included three proband groups: (1) all cases with a clinical diagnosis of schizophrenia from the Roscommon County Case Register born from 1930 onward (n = 285); (2) a random sample of cases from the register with a clinical diagnosis of severe AI (n = 99); and (3) a matched, random sample of Roscommon residents ascertained from the electoral register (n = 150). Face-to-face structured interviews were conducted with 86% of traceable, living relatives (n = 1, 753) and 88% of traceable, living probands (n = 415).

RESULTS

In interviewed relatives, the lifetime risks (+/- SE) for schizophrenia, as a function of the "blind" proband diagnosis, were as follows: schizophrenia, 6.5% +/- 1.6%; schizoaffective disorder, 6.8% +/- 2.5%; schizotypal personality disorder, 6.9% +/- 3.9%; other nonaffective psychoses, 5.1% +/- 2.4%; psychotic AI, 2.8% +/- 1.2%; nonpsychotic AI, 0.6% +/- 0.6%; and control, 0.5% +/- 0.3%. Individuals with schizophrenia reproduced at a rate about one quarter that of controls and the risk for schizophrenia in parents of probands was much less than that found in siblings.

CONCLUSIONS

These results support the following hypotheses: (1) in the West of Ireland, as in other populations, schizophrenia is a strongly familial disorder; (2) schizophrenia shares a familial predisposition with a spectrum of clinical syndromes that includes schizoaffective disorder, other nonaffective psychoses, schizotypal personality disorder, and probably psychotic AI, but not nonpsychotic AI; and (3) the diminished reproductive rates associated with schizophrenia have a large impact on the pattern of risk of illness in relatives.

The prevalence of schizophrenia in three counties in Ireland

This article reports a study of the prevalence of schizophrenia in 3 counties in Ireland based on case-register data and using a standardized diagnostic instrument--the Present State Examination. The estimate of prevalence varies depending on the criteria of schizophrenia employed. A middle-range estimate of 3.9 per 1000 population does not differ substantially from previous estimates of prevalence obtained elsewhere. Over 60% of all schizophrenic prevalence patients and over half of schizophrenic inpatients did not score as cases, suggesting that the continued hospitalization of symptomatically recovered cases has given rise to the mistaken impression that the prevalence of schizophrenia is unduly high in Ireland. The work reported here indicates substantial differences between the results of case ascertainment by hospital admission data compared with those arrived at by standardized interview diagnostic techniques.

Incidence of schizophrenia in Ireland

This paper reports an investigation of the incidence of schizophrenia in Ireland by means of standardized case-finding procedures. Our findings do not support the popular belief, based on first admissions figures, of a raised incidence in Ireland. We show this to have been considerably overestimated.

Endemic psychosis in western Ireland

For over 200 years parts of Ireland have been thought to have a high prevalence of psychosis, and recent hospital and community studies have confirmed this impression. In an intensive study of a rural area, the authors found that 4% of the population over age 40 was actively psychotic, with diagnoses of schizophrenia, schizoaffective disorder, and bipolar disorder. Psychosis seems to be endemic in some rural, lower socioeconomic areas in Ireland. Possible etiological explanations are discussed.

The treated prevalence of mental illness in the Republic of Ireland--the three county case register study

In-patient data show high rates for mental illness in the Republic of Ireland, particularly for schizophrenia. 'One-day prevalence' figures from the Three County psychiatric case register have been compared with similar data from the Camberwell register. The results confirm much higher contact rates in Ireland.

Seasonality of schizophrenic births in Ireland

The seasonality of births was examined for 4,855 schizophrenic patients born in Ireland between 1921 and 1955. All general births for the same years were used as controls. Schizophrenic births were found to be significantly elevated in the second quarter of the year (P less than .001). The excess was 11 per cent higher than for any European country examined to date.

Uterine chromatin template activity during the early stages of pregnancy in the rat

1. The template activity of chromatin prepared from rat uterine nuclei during dioestrus, oestrus and the first 7 days of pregnancy has been examined. 2. The DNA, RNA, histone and non-histone protein contents of uterine chromatin remained constant during early pregnancy. 3. The rate of RNA synthesis on Day 1 uterine chromatin was 8.61 +/- 0.59 (mean +/- S.E.) pmol of UMP incorporated/mg DNA per 10 min. When compared with DNA prepared from rat liver nuclei, 13.20 +/- 0.27% (mean +/- S.E.) of the Day 1 chromatin DNA was available for transcription by Escherichia coli RNA polymerase. 4. Uterine chromatin from rats in early dioestrus had significantly less template activity than during oestrus. 5. Chromatin prepared from whole uterus on Day 5 and from implantation sites on Days 6 and 7 of pregnancy had a significantly higher template activity than chromatin obtained from uteri on Day 1. Chromatin from interimplantation tissue on Day 6 had a lower template activity than that from uteri on Day 1. 6. RNA - DNA hybridisation of RNA transcribed from chromatin obtained on Days 2, 5 and 7 of pregnancy showed that RNA transcribed from Day 5 chromatin obtained species not present (or present in very small amounts) in RNA transcribed by chromatin from uteri on Day 2 and from implantation tissue on Day 7 of pregnancy. 7. The results are discussed in relation to the cellular changes occurring in the stroma immediately before implantation and it is postulated that the appearance of a new species of RNA on Day 5 is related to the preparation of the stromal cells for decidualisation.

Nucleic acid metabolism of cells of the luminal epithelium and stroma of the rat uterus during early pregnancy

The uptake of [5-3H]uridine into RNA and DNA of the cells of the uterine luminal epithelium, stroma and myometrium of the rat has been studied in early pregnancy using a technique for separation of the cell fractions before quantitative analysis. Comparisons of the metabolism between the pregnant and pseudopregnant horn of the unilaterally ovariectomized rat has shown that RNA and DNA synthesis are markedly increased by 04.00 hours on the morning of Day 5 in the pregnant horn. This increased metabolism occurs in all cell fractions and before the zona pellucida is shed. The results are discussed in relation to the onset of the decidual response.

Incorporation of [3H] uridine into the ribonucleic acid of rat uterus during pseudopregnancy and in the presence of I.C.I. 46474 [trans-1-(p-beta-dimethylaminoethoxyphenyl)-1,2-diphenylbut-1-ene]

1. The incorporation of [(3)H]uridine into RNA of rat uterine tissue has been measured during pseudopregnancy and in rats receiving different doses of an anti-implantation compound [trans-1-(p-beta-dimethylaminoethoxyphenyl)-1,2-diphenylbut- 1-ene, I.C.I. 46474]. 2. In the uterus of the pseudopregnant rat uridine incorporation into RNA increased markedly on day 3 of pseudopregnancy, remained high until day 5 and decreased sharply by day 6, rising again by day 9. 3. This pattern of change was similar to, but not identical with, that previously found in the pregnant rat. 4. Rats receiving I.C.I. 46474 at a dose concentration below that preventing implantation showed a pattern of RNA synthesis similar to that found in untreated control rats. 5. Rats treated with doses of I.C.I. 46474 sufficient to inhibit implantation revealed a totally different pattern of incorporation of [(3)H]uridine into uterine RNA. 6. The results are discussed in terms of previous findings with the normally pregnant rat. It is concluded that the increasing uterine RNA synthesis found on day 3 in the pregnant rat is an important requirement for the occurrence of the subsequent implantation.