Audit of eliminating biopsy for presumed fibroadenomas with benign ultrasound greyscale and shear-wave elastography findings in women aged 25-39 years

AIM

To assess the safety of a policy of not biopsying presumed fibroadenomas with benign ultrasound and shear-wave elastography findings in women aged 25-39 years.

MATERIALS AND METHODS

Patients aged 25-39 years were included after attending a one-stop clinic before 01/05/2019 where clinical and ultrasound greyscale findings suggested a benign mass and shear-wave elastography showed a mean stiffness of <50 kPa. Such patients were reassured and discharged without biopsy or follow-up. The archived ultrasound images were reviewed subsequently by a second radiologist who could recall patients for biopsy if he deemed the imaging findings to be not definitively benign. Local and national electronic records were reviewed to identify whether these patients later re-presented with breast problems.

RESULTS

Seventy-six women with a mean age of 33 years were included. The minimum follow-up was 12 months and the mean follow-up was 2 years. Three (4%) of patients were recalled after review of the ultrasound images by a second radiologist. Five (7%) patients re-presented with the same lump. Three (4%) patients re-presented with a different benign problem. Two patients presented with breast cancer in the ipsilateral breast but at a different location from the assessed benign lesion.

CONCLUSION

Early audit results of a policy of not biopsying or following up clinically benign masses with benign ultrasound greyscale appearances and shear wave stiffness <50 kPa in women aged 25-39 years suggest that this approach may be safe and acceptable.

Aflatoxin and ochratoxin A residues in supplementary foods used for wild birds

Provision of supplementary food for garden birds is practiced on a large scale in multiple countries. While this resource has benefits for wild bird populations, concern has been expressed regarding the potential for contamination of foodstuffs by mycotoxins, and the implications this might have for wildlife health. We investigated whether aflatoxin (AF) and ochratoxin A (OA) residues are present in foodstuffs sold for wild bird consumption at point of sale in Great Britain using high pressure liquid chromatography analyses. The hypothesis that production of these mycotoxins occurs in British climatic conditions, or under storage conditions after the point of sale, was tested under experimental conditions but was not proved by our study. While the majority of peanut samples were negative for AF residues, 10% (10/98) of samples at point of sale and 11% (13/119) of those across the storage and climate exposure treatment replicates contained AFB₁ that exceeded the maximum permitted limit of 20 μg/kg. No significant difference was found in the detection of either mycotoxin between branded and non-branded products. The clinical significance, if any, of exposure of wild birds to mycotoxins requires further investigation. Nevertheless, the precautionary principle should be adopted and best practice steps to reduce the likelihood of wild bird exposure to mycotoxins are recommended.

Development of comparable algorithms to measure primary care indicators using administrative health data across three Canadian provinces

INTRODUCTION

Performance measurement has been recognized as key to transforming primary care (PC). Yet, performance reporting in PC lags behind even though high-performing PC is foundational to an effective and efficient health care system.

OBJECTIVES

We used administrative data from three Canadian provinces, British Columbia, Ontario and Nova Scotia, to: 1) identify and develop a core set of PC performance indicators using administrative data and 2) examine their ability to capture PC performance.

METHODS

Administrative data used included Physician Billings, Discharge Abstract Database, the National Ambulatory Care and Reporting System database, Census and Vital Statistics. Indicators were compiled based on a literature review of PC indicators previously developed with administrative data available in Canada (n=158). We engaged in iterative discussions to assess data conformity, completeness, and plausibility of results in all jurisdictions. Challenges to creating comparable algorithms were examined through content analysis and research team discussions, which included clinicians, analysts, and health services researchers familiar with PC.

RESULTS

Our final list included 21 PC performance indicators pertaining to 1) technical care (n=4), 2) continuity of care (n=6), and 3) health services utilization (n=11). Establishing comparable algorithms across provinces was possible though time intensive. A major challenge was inconsistent data elements. Ease of data access, and a deep understanding of the data and practice context, was essential for selecting the most appropriate data elements.

CONCLUSIONS

This project is unique in creating algorithms to measure PC performance across provinces. It was essential to balance internal validity of the indicators within a province and external validity across provinces. The intuitive desire of having the exact same coding across provinces was infeasible due to lack of standardized PC data. Rather, a context-tailored definition was developed for each jurisdiction. This work serves as an example for developing comparable PC performance indicators across different provincial/territorial jurisdictions.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Quantum oscillations of electrical resistivity in an insulator

In metals, orbital motions of conduction electrons on the Fermi surface are quantized in magnetic fields, which is manifested by quantum oscillations in electrical resistivity. This Landau quantization is generally absent in insulators. Here, we report a notable exception in an insulator-ytterbium dodecaboride (YbB₁₂). The resistivity of YbB₁₂, which is of a much larger magnitude than the resistivity in metals, exhibits distinct quantum oscillations. These unconventional oscillations arise from the insulating bulk, even though the temperature dependence of the oscillation amplitude follows the conventional Fermi liquid theory of metals with a large effective mass. Quantum oscillations in the magnetic torque are also observed, albeit with a lighter effective mass.

Herpesvirus skin disease in free-living common frogs Rana temporaria in Great Britain

Infectious disease is a significant driver of global amphibian declines, yet despite this, relatively little is known about the range of pathogens that affect free-living amphibians. Recent detection of the tentatively named Ranid herpesvirus 3 (RHV3), associated with skin disease in free-living common frogs Rana temporaria in Switzerland, helps to address this paucity in knowledge, but the geographic distribution and epidemiology of the pathogen remains unclear. Syndromic surveillance for ranid herpesvirus skin disease was undertaken throughout Great Britain (GB), January 2014 to December 2016. Reports of common frogs with macroscopic skin lesions with a characteristic grey appearance were solicited from members of the public. Post-mortem examination was conducted on one affected frog found dead in 2015 at a site in England. In addition, archived samples from an incident involving common frogs in England in 1997 with similar macroscopic lesions were further investigated. Transmission electron microscopy identified herpes-like virions in skin lesions from both the 1997 and 2015 incidents. RHV3, or RHV3-like virus, was detected in skin lesions from the 2015 case by PCR and sequencing. Our findings indicate that herpesvirus skin disease is endemic in common frogs in GB, with widespread distribution at apparently low prevalence. Further research into the role of host immunity, virus latency and the significance of infection to host survival is required to better understand the epidemiology and impact of cutaneous herpesvirus infections in amphibian populations.

Temporal association between home nursing and hospital costs at end of life in three provinces

BACKGROUND

Research has demonstrated that increases in palliative homecare nursing are associated with a reduction in the rate of subsequent hospitalizations. However, little evidence is available about the cost-savings potential of palliative nursing when accounting for both increased nursing costs and potentially reduced hospital costs.

METHODS

Our retrospective cohort study included cancer decedents from British Columbia, Ontario, and Nova Scotia who received any palliative nursing in the last 6 months of life. A Poisson regression analysis was used to determine the association of increased nursing costs (in 2-week blocks) on the relative average hospital costs in the subsequent 2-week block and on the overall total cost (hospital costs plus nursing costs in the preceding 2-week block).

RESULTS

The cohort included 58,022 cancer decedents. Results of the analysis for the last month of life showed an association between increased nursing costs and decreased relative hospital costs in comparisons with a reference group (>0 to 1 hour nursing in the block): the maximum decrease was 55% for Ontario, 31% for British Columbia, and 38% for Nova Scotia. Also, increased nursing costs in the last month were almost always associated with lower total costs in comparison with the reference. For example, cost savings per person-block ranged from $376 (>10 nursing hours) to $1,124 (>4 to 6 nursing hours) in British Columbia.

CONCLUSIONS

In the last month of life, increased palliative nursing costs (compared with costs for >0 to 1 hour of nursing in the block) were associated with lower relative hospital costs and a lower total cost in a subsequent block. Our research suggests a cost-savings potential associated with increased community-based palliative nursing.

Quality of end-of-life cancer care in Canada: a retrospective four-province study using administrative health care data

BACKGROUND

The quality of data comparing care at the end of life (eol) in cancer patients across Canada is poor. This project used identical cohorts and definitions to evaluate quality indicators for eol care in British Columbia, Alberta, Ontario, and Nova Scotia.

METHODS

This retrospective cohort study of cancer decedents during fiscal years 2004-2009 used administrative health care data to examine health service quality indicators commonly used and previously identified as important to quality eol care: emergency department use, hospitalizations, intensive care unit admissions, chemotherapy, physician house calls, and home care visits near the eol, as well as death in hospital. Crude and standardized rates were calculated. In each province, two separate multivariable logistic regression models examined factors associated with receiving aggressive or supportive care.

RESULTS

Overall, among the identified 200,285 cancer patients who died of their disease, 54% died in a hospital, with British Columbia having the lowest standardized rate of such deaths (50.2%). Emergency department use at eol ranged from 30.7% in Nova Scotia to 47.9% in Ontario. Of all patients, 8.7% received aggressive care (similar across all provinces), and 46.3% received supportive care (range: 41.2% in Nova Scotia to 61.8% in British Columbia). Lower neighbourhood income was consistently associated with a decreased likelihood of supportive care receipt.

INTERPRETATION

We successfully used administrative health care data from four Canadian provinces to create identical cohorts with commonly defined indicators. This work is an important step toward maturing the field of eol care in Canada. Future work in this arena would be facilitated by national-level data-sharing arrangements.

Two-dimensional Fermi surfaces in Kondo insulator SmB6

In the Kondo insulator samarium hexaboride (SmB6), strong correlation and band hybridization lead to an insulating gap and a diverging resistance at low temperature. The resistance divergence ends at about 3 kelvin, a behavior that may arise from surface conductance. We used torque magnetometry to resolve the Fermi surface topology in this material. The observed oscillation patterns reveal two Fermi surfaces on the (100) surface plane and one Fermi surface on the (101) surface plane. The measured Fermi surface cross sections scale as the inverse cosine function of the magnetic field tilt angles, which demonstrates the two-dimensional nature of the conducting electronic states of SmB6.

Chlamydiosis in British Garden Birds (2005-2011): retrospective diagnosis and Chlamydia psittaci genotype determination

The significance of chlamydiosis as a cause of mortality in wild passerines (Order Passeriformes), and the role of these birds as a potential source of zoonotic Chlamydia psittaci infection, is unknown. We reviewed wild bird mortality incidents (2005-2011). Where species composition or post-mortem findings were indicative of chlamydiosis, we examined archived tissues for C. psittaci infection using PCR and ArrayTube Microarray assays. Twenty-one of 40 birds tested positive: 8 dunnocks (Prunella modularis), 7 great tits (Parus major), 3 blue tits (Cyanistes caeruleus), 2 collared doves (Streptopelia decaocto, Order Columbiformes), and 1 robin (Erithacus rubecula). Chlamydia psittaci genotype A was identified in all positive passerines and in a further three dunnocks and three robins diagnosed with chlamydiosis from a previous study. Two collared doves had genotype E. Ten of the 21 C. psittaci-positive birds identified in the current study had histological lesions consistent with chlamydiosis and co-localizing Chlamydia spp. antigens on immunohistochemistry. Our results indicate that chlamydiosis may be a more common disease of British passerines than was previously recognized. Wild passerines may be a source of C. psittaci zoonotic infection, and people should be advised to take appropriate hygiene precautions when handling bird feeders or wild birds.

Lipopolysaccharide and hypoxia significantly alters interleukin-8 and macrophage chemoattractant protein-1 production by human fibroblasts but not fibrosis related factors

Besides extracellular matrix production, fibroblasts are able to produce various cytokines. Their ubiquitous position makes fibroblasts appropriate cells for sensing various noxious stimuli and for attracting immune cells in the affected area. In the present study the effect of lipopolysaccharide (LPS) and cobalt chloride (CoCl(2)) on the above fibroblasts functions were evaluated in primary human skin fibroblasts cultures. Collagen, matrix metalloproteinase-1, tissue inhibitor of metalloproteinases-1, transforming growth factor-β1, interleukin-8 (IL-8) and macrophage chemoattractant protein-1 (MCP-1) were measured in fibroblasts culture supernatants. Fibroblasts proliferation and viability were assessed as well. Hypoxia inducible factor-1α and the phosphorylated p65 portion of NF-κB were assessed in fibroblasts protein extracts. LPS and CoCl(2) had a minor effect on fibrosis related factors in human primary fibroblasts, possibly due to the absence of interplay with other cell types in the used experimental system. On the contrary both LPS and CoCl(2) increased significantly IL-8. LPS also increased considerably MCP-1, but CoCl(2) decreased it. Thus LPS and CoCl(2) induce a sentinel, nevertheless not identical, phenotype in primary human fibroblasts. The last disparity could result in different body response to infectious or hypoxic noxious stimuli.

Renal calculi in wild Eurasian otters (Lutra lutra) in England

Macroscopic renal calculi were seen in 50 of 492 (10.2 per cent) wild Eurasian otters found dead in England from 1988 to 2007. Forty-eight adults and two subadults were affected. Calculi were present in 15.7 per cent (31 of 197) of adult males and 12.7 per cent (17 of 134) of adult females. There was an increase in prevalence in the study population over time; no calculi were found in 73 otters examined between 1988 and 1996, but in most subsequent years they were observed with increased frequency. Calculi occurred in both kidneys but were more common in the right kidney. They varied greatly in shape and size; larger calculi were mostly seen in the calyces while the smallest ones were commonly found in the renal medulla. Calculi from 45 cases were examined by x-ray diffraction analysis; in 43 (96 per cent), they were composed solely of ammonium acid urate. Affected otters had heavier adrenal glands relative to their body size than unaffected otters (P<0.001). There was no significant association between body condition index and the presence of calculi (P>0.05). Many otters had fresh bite wounds consistent with intraspecific aggression. The proportion bitten increased over time and this coincided with the increased prevalence of renal calculi.

Epidemiology of salmonellosis in garden birds in England and Wales, 1993 to 2003

Salmonellosis has been reported as an important cause of mortality of garden birds in several countries, including Norway and Scotland. We investigated the frequency of the disease in garden birds submitted for postmortem examination by members of the public in England and Wales between 1993 and 2003, inclusive. We found salmonellosis to be the most frequent cause of death due to infectious disease in the garden birds submitted. This disease was confirmed in 7 of the 45 bird species that were examined postmortem, with the greenfinch (Carduelis chloris) and the house sparrow (Passer domesticus) most frequently affected. Salmonella Typhimurium definitive phage type (DT) 40, DT56 variant(v), and DT160 accounted for the majority of isolates. Salmonellosis incidents chiefly occurred in the English Midlands, the English/Welsh border region, and southern England. Variation in the temporal and spatial distribution of the phage types occurred over the study period. While birds were examined throughout the year, there was a marked winter seasonality in salmonellosis. A significant sex bias was observed in affected greenfinches, with males more frequently diagnosed with salmonellosis than females. No sex bias was observed for other affected species. Further research is required to determine if salmonellosis is an important constraint to the populations of affected species and if disease outbreaks are driven by human factors, such as provisioning.

[Lower extremity venous thrombosis in Togo]

The purpose of this report was to describe epidemiologic, clinical, and paraclinical aspects and to identify etiologic factors associated with lower extremity venous thrombosis in Lome, Togo.

[Cardiovascular emergencies and their morbimortality at the hospital. Report of 733 cases at the CHU campus in Lome (national reference hospital in Togo)]

Due to the recent establishment of the emergencies Units in Black Africa, their epidemiological aspects are not well known. Our aims was to describe the epidemiology of this desease in Togo. Through a retrospective analysis we study over a period of 42 mouths. From January first, 2001 to June 30th, 2004. It was carried out exclusively at CHU-Campus, the hospital of Lomé Campus, the second national medical center of reference. Included were all the patients with cardio-vascular emergency cases. We have studied the epidemilogical aspects according to the age, sex, profession, morbidity, and mortality. The treatment of results have been done by Computer. The registered emergency cases were 733 il all with is a frequency of the patients admitted at CHU-CAMPUS. The average age is 56 +/- 13 years with extreme ages from 20 to 97 years. The age group most affected is between 30 and 69 years--The ratio according to the sex is 1.09 in favour of men. Housewives are the professional category most affected (42.3%). Constitute the essential of the cardiovascular emergency cases with a ratio of the 78.3%. The mortality is 17.1% which in most registered between 30 and 69 years. The morbidity ratio is 64.1% We have to keep in mind that cardio-vascular emergency cases are very frequent in Togo. A very active population of young people is concerned. The poor are the most threatened. Henceforth the establishment and equipment of cardiological units are absolutely necessary, for they constitute the only solution by which the level of morbi-mortality can be reduced.

[Double thrombosis of left cardiac cavities: report of a case seen at the CHU Campus in Lome]

We report an observation of a double left thrombosis intraventriculaire and atrium at a subject 45 years. The diagnosis was made by the transthoracic two-dimensional echocardiography which showed a dilated cardiomyopathy and two bulky thrombi in the left ventricle and atrium. As the chirurgical treatment is not accessible, we use the medical treatment: anticoagulant treatment associated on the low salt diet, with diuretic and the inhibitors of the enzyme of conversion, the evolution was favourable without embolic accident.

Administration of fludarabine-loaded autologous red blood cells in simian immunodeficiency virus-infected sooty mangabeys depletes pSTAT-1-expressing macrophages and delays the rebound of viremia after suspension of antiretroviral therapy

A major limitation of highly active antiretroviral therapy is that it fails to eradicate human immunodeficiency virus (HIV) infection due to its limited effects on viral reservoirs carrying replication-competent HIV, including monocytes/macrophages (M/M). Therefore, therapeutic approaches aimed at targeting HIV-infected M/M may prove useful in the clinical management of HIV-infected patients. In previous studies, we have shown that administration of fludarabine-loaded red blood cells (RBC) in vitro selectively induces cell death in HIV-infected M/M via a pSTAT1-dependent pathway. To determine the in vivo efficacy of this novel therapeutic strategy, we treated six naturally simian immunodeficiency virus (SIV)-infected sooty mangabeys (SMs) with either 9-[2-(R)-(phosphonomethoxy)propyl]adenine (PMPA) only, fludarabine-loaded RBC only, or PMPA in association with fludarabine-loaded RBC. The rationale of this treatment was to target infected M/M with fludarabine-loaded RBC at a time when PMPA is suppressing viral replication taking place in activated CD4+ T cells. In vivo administration of fludarabine-loaded RBC was well tolerated and did not induce any discernible side effect. Importantly, addition of fludarabine-loaded RBC to PMPA delayed the rebound of viral replication after suspension of therapy, thus suggesting a reduction in the size of SIV reservoirs. While administrations of fludarabine-loaded RBC did not induce any change in the CD4+ or CD8+ T-cell compartments, we observed, in chronically SIV-infected SMs, a selective depletion of M/M expressing pSTAT1. This study suggests that therapeutic strategies based on the administration of fludarabine-loaded RBC may be further explored as interventions aimed at reducing the size of the M/M reservoirs during chronic HIV infection.

Quality indicators for end-of-life breast cancer care: Testing the use of administrative databases

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Background: Defining, measuring and monitoring quality of care is a facet of health services research that is growing in importance. Breast cancer offers a disease model to examine quality end-of-life (EOL) care provided to women. Administrative data have the unique potential to provide population-based measures of quality of care. The objective of this study was to assess the feasibility of using routinely-collected administrative data to measure quality EOL care for breast cancer patients. Methods: A cohort of all women in Nova Scotia who died of breast cancer between 01/01/1998 and 31/12/2002 was assembled from the Cancer Registry and Vital Statistics data. The EOL study period was defined as the last 6 months of life. A total of 864 women met the eligibility criteria. After a literature review, an expert panel identified 19 indicators that were potentially measurable through administrative data. Physician billings, hospital discharge abstracts and seniors pharmacare data, supplemented by clinical datasets, were utilized to calculate the statistics with which to represent the indicators. Results: Benchmark measures of care across the cohort show 63.4% died in a hospital, a mean continuity of care index of 0.786, and the mean number of inpatient days in the last 30 was 9.9. Indicators of aggressive care include 9.3% had chemotherapy in the last 14 days, 5.6% had more than 1 emergency room visit in the last 30 days, and 29.1% had more than 14 inpatient days in the last 30 days. Conclusions: Weaknesses of using these data include: 1) fixed variables with an administrative rather than a clinical objective; 2) lack of comprehensiveness of various datasets; and 3) the use of billings data where increasingly physicians are paid through methods other than fee-for-service. Strengths of this approach are: 1) population-based cohort; 2) comprehensiveness of cohort selection through the provincial Vital Statistics file; and 3) accessibility of data.

No significant financial relationships to disclose.

Exposure of garden birds to aflatoxins in Britain

Aflatoxins are potent biological toxins that have been shown to exert a range of acute and chronic pathological effects. Multiple mortality events of waterfowl caused by acute aflatoxicosis have been documented in the USA. However, international concern has recently been expressed regarding the potential effects of chronic exposure of wildlife species to low levels of dietary aflatoxin. This study documents for the first time the presence of hepatic aflatoxin residues in British wild birds: two passerine species, the house sparrow (Passer domesticus) and greenfinch (Carduelis chloris). Further research is required to investigate the source of the dietary aflatoxins and their pathological significance, if any, for wild birds in Britain.

Childhood medulloblastoma in northwest England 1954 to 1997: incidence and survival

The incidence, survival patterns, and presenting symptoms of children with medulloblastoma were studied. Data were ascertained from the Manchester Tumour Registry which is population-based and has collected data on all childhood malignancies in northwest England since 1954. Incidence rates standardized to the European standard population were calculated and Poisson regression models were used to examine temporal changes in the incidence rates during the period 1954 to 1997. Kaplan-Meier survival curves were derived and used to study changes in survival patterns. World-standardized incidence rates were 5.5 per million child years in males and 3.4 per million child years in females. Incidence rates increased from the 1950s to the 1980s but have declined recently. The 5-year survival rate has improved from 29 to 58% with similar rates for males and females. The 1-year survival rate has also improved, but females had worse survival at this point (58%) than males (75%). The type of symptom or sign at presentation is strongly affected by age, with 10 of the 22 recorded symptoms or signs showing significant age differences. The older the child is, the more likely is the presentation to show pressure features of headache, vomiting, and ophthalmic signs. Younger children present with non-specific features such as lethargy, behavioural disturbance, or increasing head size. Ataxia is seen in about 75% of children across the age range.

[Central pontine myelinolysis and hyponatremia. Clinical case]

There is a controversy whether central pontine myelinolysis can complicate either hyponatremia or its rapid correction. We report a 69 years old woman with a history of one month of vertigo, nausea, vomiting and diarrhea. She was admitted dehydrated ad stuporous, and initial laboratory values showed a serum sodium of 96 mEq/L. She was treated with dextrose 5% and 3% NaCl. Serum sodium raised to 120 mEq/L at the next day and the level of consciousness improved. At the 4th day of admission, the patient was again stuporous and with spastic quadriplegia. A magnetic resonance imaging showed a central and symmetrical pontine lesion on T1 and T2 weighed images. Thereafter, the patient experienced a progressive improvement of her neurological condition and was discharged three months later, moving her lower limbs. Nine month later she was able to walk.

Hospital design. Room for improvement

Psychiatric and orthopaedic patients treated in new or upgraded units rated their experience and treatment significantly higher than those on old wards. Length of stay on the new psychiatric unit was lower than in the old unit. Orthopaedic patients treated on a refurbished ward required fewer analgesics than those on the older ward. Patients treated in single rooms were more satisfied with their care than those treated in multiple-bed wards.

[Behavior disorder of the REM sleep in 2 documented cases with polysomnography]

We report a 69 years old male with a parkinsonian syndrome and a 50 years old female without neurological problems who showed violent behavior during REM sleep. Polysomnography showed that both bad tonic or phasic muscular activity during REM sleep and a REM sleep behavior disorder was diagnosed. Clonazepam was used in both, with good clinical response. This condition is frequently unrecognized and confused with nightmares, nocturnal delirium or other parasomnias.

Geldanamycin, an hsp90/GRP94-binding drug, induces increased transcription of endoplasmic reticulum (ER) chaperones via the ER stress pathway

Geldanamycin, a benzoquinone ansamycin, binds specifically to hsp90 and GRP94 in vitro and in vivo. Treatment of cells with geldanamycin alters the molecular chaperone function of hsp90, and as a result, blocks certain cytosolic proteins from reaching their mature form, inhibits their activity, and/or affects their stability. In contrast, little is known about either the effects of geldanamycin on GRP94, the endoplasmic reticulum (ER) homologue of hsp90, or the role of GRP94 in protein folding. In this study, we demonstrate in a variety of cell lines that geldanamycin is a potent inducer of the cellular response to stress in the ER, resulting in the transcriptional up-regulation of ER chaperones and expression of the gadd153/CHOP transcription factor. Their induction occurs through the unfolded protein response pathway originating in the ER and is not due to effects of the drug on hsp90. Geldanamycin increases the association of nascent proteins with BiP, which indicates that their folding and/or assembly has been altered. These data suggest that GRP94 may play an essential role in the maturation of a number of secretory pathway proteins.

Aftereffects and sense of presence in virtual environments: formulation of a research and development agenda

This report represents a committee summary of the current state of knowledge regarding aftereffects and sense of presence in virtual environments (VEs). The work presented in this article, and the proposed research agenda, are the result of a special session that was set up in the framework of the Seventh International Conference on Human Computer Interaction. Recommendations were made by the committee regarding research needs in aftereffects and sense of presence, and, where possible, priorities were suggested. The research needs were structured in terms of the short, medium, and long term and, if followed, should lead toward the effective use of VE technology. The 2 most critical research issues identified were (a) standardization and use of measurement approaches for aftereffects and (b) identification and prioritization of sensorimotor discordances that drive aftereffects. Identification of aftereffects countermeasures (i.e., techniques to assist users in readily transitioning between the real and virtual worlds), reduction of system response latencies, and improvements in tracking technology were also thought to be of critical importance.

Signals from the stressed endoplasmic reticulum induce C/EBP-homologous protein (CHOP/GADD153)

The gene encoding C/EBP-homologous protein (CHOP), also known as growth arrest and DNA-damage-inducible gene 153 (GADD153), is activated by agents that adversely affect the function of the endoplasmic reticulum (ER). Because of the pleiotropic effects of such agents on other cellular processes, the role of ER stress in inducing CHOP gene expression has remained unclear. We find that cells with conditional (temperature-sensitive) defects in protein glycosylation (CHO K12 and BHK tsBN7) induce CHOP when cultured at the nonpermissive temperature. In addition, cells that are defective in initiating the ER stress response, because of overexpression of an exogenous ER chaperone, BiP/GRP78, exhibit attenuated inducibility of CHOP. Surprisingly, attenuated induction of CHOP was also noted in BiP-overexpressing cells treated with methyl methanesulfonate, an agent thought to activate CHOP by causing DNA damage. The roles of DNA damage and growth arrest in the induction of CHOP were therefore reexamined. Induction of growth arrest by culture to confluence or treatment with the enzymatic inhibitor N-(phosphonacetyl)-L-aspartate did not induce CHOP. Furthermore, both a DNA-damage-causing nucleoside analog (5-hydroxymethyl-2'-deoxyuridine) and UV light alone did not induce CHOP. These results suggest that CHOP is more responsive to ER stress than to growth arrest or DNA damage and indicate a potential role for CHOP in linking stress in the ER to alterations in gene expression.

The antidiuretic effect of pneumadin requires a functional arginine vasopressin system

Pneumadin is an antidiuretic decapeptide, recently isolated from rat and human lung. Bolus intravenous injection of 5 nmol of pneumadin into water-loaded rats caused a rapid and significant antidiuresis and a reduction in Na+ and Cl- excretion. Pneumadin administration did not alter mean arterial pressure, right atrial pressure, heart rate or haematocrit. Bolus intravenous injection of 20 nmol of pneumadin into non-water-loaded rats caused a significant increase in arginine vasopressin (AVP) within 10 min. Pneumadin administration also increased circulating atrial natriuretic peptide (ANP) but did not alter aldosterone or plasma renin activity levels. Injection of pneumadin into water-loaded Brattleboro rats, which genetically lack circulating AVP, did not change urine flow, confirming that the pneumadin induced antidiuresis is AVP dependent. Radioactive pneumadin was cleared from the circulation with a t1/2 beta of 480.3 s. Radioactive pneumadin, isolated from plasma, eluted at an altered position on reverse phase HPLC, which indicated that the peptide was modified in vivo. This modification was also observed when synthetic pneumadin was incubated in rat plasma in vitro. Purification and sequencing of the modified synthetic peptide indicated that the modification is not a proteolytic cleavage. These results indicate that pneumadin injected into the rat caused an antidiuresis by altering circulating AVP levels.

In vivo expression of mammalian BiP ATPase mutants causes disruption of the endoplasmic reticulum

BiP possesses ATP binding/hydrolysis activities that are thought to be essential for its ability to chaperone protein folding and assembly in the endoplasmic reticulum (ER). We have produced a series of point mutations in a hamster BiP clone that inhibit ATPase activity and have generated a species-specific anti-BiP antibody to monitor the effects of mutant hamster BiP expression in COS monkey cells. The enzymatic inactivation of BiP did not interfere with its ability to bind to Ig heavy chains in vivo but did inhibit ATP-mediated release of heavy chains in vitro. Immunofluorescence staining and electron microscopy revealed vesiculation of the ER membranes in COS cells expressing BiP ATPase mutants. ER disruption was not observed when a "44K" fragment of BiP that did not include the protein binding domain was similarly mutated but was observed when the protein binding region of BiP was expressed without an ATP binding domain. This suggests that BiP binding to target proteins as an inactive chaperone is responsible for the ER disruption. This is the first report on the in vivo expression of mammalian BiP mutants and is demonstration that in vitro-identified ATPase mutants behave as dominant negative mutants when expressed in vivo.

Brain oxidative phosphorylation following alteration in head position in preterm and term neonates

An alteration in head position, which effects cerebral blood flow, may increase the risk for intraventricular hemorrhage in the critically ill infant. The purpose of this study was to evaluate in vivo cerebral oxidative metabolism as an index of tissue oxygen delivery reflecting brain blood flow, in healthy preterm and term infants following a change in head position. Cerebral phosphoenergetics using 31 phosphorus nuclear magnetic resonance spectroscopy were measured in 10 preterm and eight term infants following three different head positions: neutral, prone, and supine. All infants were clinically stable at the time of study. The phosphocreatine to inorganic phosphate ratio, an indicator of bioenergetic reserve, was determined. The mean +/- SD for phosphocreatine to inorganic phosphate ratio in the neutral position in preterm and term infants was 1.08 +/- 0.15 and 1.12 +/- 0.21, respectively, and did not change significantly following head turning. These data suggest that any alteration in cerebral blood flow as a result of a change in head position in the healthy neonate may be compensated by physiological and biochemical regulations so that no changes in brain oxidative phosphorylation are measurable.