Association of ethnic concordance between patients and psychiatrists with the management of suicide attempts in the emergency department

BACKGROUND

Suicide attempt is a psychiatric emergency that can be treated with different approaches. Understanding of patient- and physician-related determinants of psychiatric interventions may help to identify sources of bias and improve clinical care.

OBJECTIVE

To evaluate the demographic predictors of psychiatric intervention in the emergency department (ED) following a suicide attempt.

METHODS

We analyzed all ED visits in Rambam Health Care Campus following suicide attempts carried out by adults between 2017-2022. Two logistic regression models were built to examine whether patient and psychiatrist's demographic variables can predict 1) the clinical decision to provide a continued psychiatric intervention and 2) the setting for the psychiatric intervention (inpatient or outpatient).

RESULTS

In total, 1,325 ED visits were evaluated, corresponding to 1,227 unique patients (mean age; 40.47±18.14 years, 550 men [41.51%]; 997 Jewish [75.25%] and 328 Arabs [24.75%]]), and 30 psychiatrists (9 men [30%]; 21 Jewish [70%] and 9 Arabs [30%]). Demographic variables had a limited predictive power for the decision to intervene (R²=0.0245). Yet, a significant effect of age was observed as intervention rates increased with age. In contrast, the type of intervention was strongly associated with demography (R²=0.289), with a significant interaction between patient and psychiatrist's ethnic identities. Further analysis revealed that Arab psychiatrists preferentially referred Arab patients to outpatient over inpatient treatment.

CONCLUSIONS

The results indicate that while demographic variables, and specifically patient and psychiatrist's ethnicity, do not affect clinical judgement for psychiatric intervention following a suicide attempt, they do play a major role in selecting treatment setting. Further studies are required to better understand the causes underlying this observation and its association with long-term outcomes. Yet, acknowledging the existence of such bias is a first step towards better culturally mindful psychiatric interventions.

POS0954 WHAT DOES IT MEAN – A GOOD RESPONSE TO NSAIDs? A SYSTEMATIC COMPARISON OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS AND CONTROLS WITH CHRONIC BACK PAIN

Background

A fast response to non-steroidal anti-inflammatory drugs (NSAIDs) is an important finding in the evaluation of clinical findings within the items comprising the ASAS classification criteria but also for the treatment decision for escalation to a bDMARD in patients with axial spondyloarthritis (axSpA). However, the differentiation of NSAID responses between patients with axSpA and degenerative or unspecific back pain is still unclear.

Objectives

To study the differences in the velocity and magnitude of NSAID response velocity in patients with established bDMARD naïve axSpA vs. patients with other, non-inflammatory reasons of back pain.

Methods

Patients with axSpA without degenerative reasons for back pain or patients with degenerative or unspecific back pain presenting due to high levels of back pain (NRS≥4/10) were consecutively recruited. Assessments included clinical examination, laboratory tests and MRI of the lumbar spine.

Previous NSAID intake was allowed only if it was taken in low doses without showing a clinical response, otherwise patients were NSAID naïve. Upon study inclusion, patients were treated with the maximum possible dose of an NSAID that they have reported to tolerate in lower doses in the past, independent of whether this was a Cox-2 inhibitor or a non-coxib. Assessment of response was performed using a standardized questionnaire after 2, 6, 12, 24, 36, 48 hours and after 1, 2 and 4 weeks. Any NSAID response was defined as improvement of pain >2/10 points and a good response to NSAIDs as an improvement >50% from the initial status.

Results

A total of 68 patients with axSpA, 107 patients with degenerative back pain and 58 patients with unspecific back pain were included.

The mean age was 42.7±10.7, 51.2±11.3, and 45.8±10.0 years, the main symptom duration 15.1±11.1, 16.1±12.6, and 11.9 ±10.1 years and the proportion of males was 57.4%, 19.6%, and 19.0% respectively. Inflammatory back pain was reported by 42 (75%), 48 (57.8%), and 29 (60.4%) patients, respectively and the mean pain score was 6.2±2.3,6.7±1.8, and 6.2±1.8, respectively.

In axSpA, the mean BASDAI and BASFI scores were 5.5±1.8 and 4.5±2.5, respectively.

There was no difference in the cumulative response to NSAIDs between all three diagnoses, with an overall proportion of 27%-30% of patients showing improvement. However, better but not faster responses were found for the subgroups of patients with nr-axSpA (Figure 1) and for the male patients in the entire axSpA group, while axSpA patients with systemic inflammatory activity defined by increased CRP showed lower rates of response as compared to non-inflammatory reasons of back pain diagnoses. All other subanalyses did not reveal any differences between axSpA patients and other non-inflammatory reasons of back pain.

Figure 1.

Conclusion

In this prospective evaluation, the generally proposed better response of axSpA patients to treatment with high doses of NSAIDs as compared with non-inflammatory back pain was not confirmed, although the overall rate of responders was similar to previously reported rates. On the other hand, better responses were found in patients treated in the early (nr-axSpA) stage and in male patients. axSpA patients with increased CRP values showed lower rates of response.

Disclosure of Interests

None declared

Structural and functional brain-wide alterations in A350V Iqsec2 mutant mice displaying autistic-like behavior

IQSEC2 is an X-linked gene that is associated with autism spectrum disorder (ASD), intellectual disability, and epilepsy. IQSEC2 is a postsynaptic density protein, localized on excitatory synapses as part of the NMDA receptor complex and is suggested to play a role in AMPA receptor trafficking and mediation of long-term depression. Here, we present brain-wide structural volumetric and functional connectivity characterization in a novel mouse model with a missense mutation in the IQ domain of IQSEC2 (A350V). Using high-resolution structural and functional MRI, we show that animals with the A350V mutation display increased whole-brain volume which was further found to be specific to the cerebral cortex and hippocampus. Moreover, using a data-driven approach we identify putative alterations in structure-function relations of the frontal, auditory, and visual networks in A350V mice. Examination of these alterations revealed an increase in functional connectivity between the anterior cingulate cortex and the dorsomedial striatum. We also show that corticostriatal functional connectivity is correlated with individual variability in social behavior only in A350V mice, as assessed using the three-chamber social preference test. Our results at the systems-level bridge the impact of previously reported changes in AMPA receptor trafficking to network-level disruption and impaired social behavior. Further, the A350V mouse model recapitulates similarly reported brain-wide changes in other ASD mouse models, with substantially different cellular-level pathologies that nonetheless result in similar brain-wide alterations, suggesting that novel therapeutic approaches in ASD that result in systems-level rescue will be relevant to IQSEC2 mutations.

Individual variability in functional connectivity architecture of the mouse brain

In recent years precision fMRI has emerged in human brain research, demonstrating characterization of individual differences in brain organization. However, mechanistic investigations to the sources of individual variability are limited in humans and thus require animal models. Here, we used resting-state fMRI in awake mice to quantify the contribution of individual variation to the functional architecture of the mouse cortex. We found that the mouse connectome is also characterized by stable individual features that support connectivity-based identification. Unlike in humans, we found that individual variation is homogeneously distributed in sensory and association networks. Finally, connectome-based predictive modeling of motor behavior in the rotarod task revealed that individual variation in functional connectivity explained behavioral variability. Collectively, these results establish the feasibility of precision fMRI in mice and lay the foundation for future mechanistic investigations of individual brain organization and pre-clinical studies of brain disorders in the context of personalized medicine.

Autism-associated Nf1 deficiency disrupts corticocortical and corticostriatal functional connectivity in human and mouse

Children with the autosomal dominant single gene disorder, neurofibromatosis type 1 (NF1), display multiple structural and functional changes in the central nervous system, resulting in neuropsychological cognitive abnormalities. Here we assessed the pathological functional organization that may underlie the behavioral impairments in NF1 using resting-state functional connectivity MRI. Coherent spontaneous fluctuations in the fMRI signal across the entire brain were used to interrogate the pattern of functional organization of corticocortical and corticostriatal networks in both NF1 pediatric patients and mice with a heterozygous mutation in the Nf1 gene (Nf1^+/-). Children with NF1 demonstrated abnormal organization of cortical association networks and altered posterior-anterior functional connectivity in the default network. Examining the contribution of the striatum revealed that corticostriatal functional connectivity was altered. NF1 children demonstrated reduced functional connectivity between striatum and the frontoparietal network and increased striatal functional connectivity with the limbic network. Awake passive mouse functional connectivity MRI in Nf1^+/- mice similarly revealed reduced posterior-anterior connectivity along the cingulate cortex as well as disrupted corticostriatal connectivity. The striatum of Nf1^+/- mice showed increased functional connectivity to somatomotor and frontal cortices and decreased functional connectivity to the auditory cortex. Collectively, these results demonstrate similar alterations across species, suggesting that NF1 pathogenesis is linked to striatal dysfunction and disrupted corticocortical connectivity in the default network.

The Organization of Mouse and Human Cortico-Hippocampal Networks Estimated by Intrinsic Functional Connectivity

While the hippocampal memory system has been relatively conserved across mammals, the cerebral cortex has undergone massive expansion. A central question in brain evolution is how cortical development affected the nature of cortical inputs to the hippocampus. To address this question, we compared cortico-hippocampal connectivity using intrinsic functional connectivity MRI (fcMRI) in awake mice and humans. We found that fcMRI recapitulates anatomical connectivity, demonstrating sensory mapping within the mouse parahippocampal region. Moreover, we identified a similar topographical modality-specific organization along the longitudinal axis of the mouse hippocampus, indicating that sensory information arriving at the hippocampus is only partly integrated. Finally, comparing cortico-hippocampal connectivity across species, we discovered preferential hippocampal connectivity of sensory cortical networks in mice compared with preferential connectivity of association cortical networks in humans. Supporting this observation in humans but not in mice, sensory and association cortical networks are connected to spatially distinct subregions within the parahippocampal region. Collectively, these findings indicate that sensory cortical networks are coupled to the mouse but not the human hippocampal memory system, suggesting that the emergence of expanded and new association areas in humans resulted in the rerouting of cortical information flow and dissociation of primary sensory cortices from the hippocampus.

[Atypical metastatic site of lung adenocarcinoma]

The case concerns a 40 years old smoker male, treated for an adenocarcinoma of the left upper lobe, metastatic in muscle extended to the right femur cortex. The patient had first a surgical excision of the mass of the thigh, an intramedullary femoral nailing, and six courses of chemotherapy (cisplatin-vinorelbine) with concurrent thoracic radiotherapy. This treatment led to disease stability. One year later, hematuria revealed a bladder tumor. Cystoscopy with biopsy concluded to an adenocarcinoma pulmonary origin. The PET-scanner showed an uptake of the bladder mass, a hypermetabolic right adrenal gland and subcutaneous left shoulder nodule. The patient had a partial cystectomy associated with enterocystoplasty and left ureteral reimplantation, plus excision of the subcutaneous nodule located in the left shoulder and a right adrenalectomy during the same time. All of the sites were metastasis from adenocarcinoma of pulmonary origin. A salvage chemotherapy was initiated. In the vast majority of cases, bladder metastasis as primary bladder tumours is revealed by hematuria, cystitis or sometimes vague pelvic pain. Our case is a very unusual bladder metastatic site from lung cancer. We will discuss the different procedures and the therapeutic strategies on the basis of the published data.

[Use of medical services. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]

The use of operations, visits to doctors and early diagnostic tests for children are examples of different services selected from the whole spectrum of preventative and therapeutic health service provisions in childhood and adolescence. In the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), which is representative for Germany, 17,641 children and adolescents aged 0-17 or their parents were questioned on subjects such as their use of medical services. The use made of individual early diagnostic tests for children remains above the 90 % limit until the U7 test and drops to 89.0 % at U8, falling to 86.4 % at U9. 81 % of children took part in all the early diagnostic tests provided until age 6 (U3 to U9). Another 16 % only took advantage of some parts of this service and 3 % of the children never went to one of these check-ups. As was to be expected, the annual rate of visits to paediatricians drops as children get older from 95.1 % for 0-2-year-olds to 25.4 % of the 14-17-year-olds, while the rate of visits to general practitioners rises from 11.8 % to 53.1 %. If one tracks the rate of visits to specialist doctors all the way across childhood and adolescence, different paths emerge: while children aged 3-6 most often visit the ear, nose and throat doctor, at primary school age they mainly see opticians, and 14-17-year-olds most often visit doctors of internal medicine, dermatologists and surgeons. 37.1 % of the 0-17-year-old children and adolescents had undergone an operation. In order of declining frequency, the operations named were adenoidectomy (15.2 %), tonsillectomy (5.9 %), herniotomy (3.6 %) and appendectomy (2.4 %). Circumcisions had been carried out on 10.9 % of the boys. The different way medical services are used in different subgroups may not only depend on medical factors but also on social factors, medical attitudes and the availability of services provided.

[Public health care utilisation. Initial results of the Telephone Health Survey 2003]

More than 90% of adults have a family doctor. The more chronic diseases and the more subjective health problems the interviewees had, the more often they had been to see their family doctor. Senior citizens and people with lower social status or a higher BMI go to see their family doctors more frequently. People who say they consume a lot of alcohol consult a doctor less often than others. Privately insured people also go to see their family doctors less frequently. Almost two-thirds of the adult population in Germany have seen a doctor in the last 3 months, and 44% of people over 60 had an influenza vaccination this year. People are much more willing to have an influenza injection in eastern Germany than in the west. More than half of the people questioned over the age of 35 has had a general health check-up at least once in their lives. Men have health check-ups slightly more often than women do. Of the women, 80% have participated at least once in a cancer screening programme, and as many as 60% of women had a cancer scan during the last year. Men take up cancer screening offers less often than women do. Inpatients stay for an average of 2 weeks in hospital per year. Just under 30% of those questioned have had medical rehabilitation treatment.

Übergewicht und Adipositas in Deutschland 1984–2003

The magnitude and the development of the prevalence of overweight and obesity in Germany during the past 20 years are analysed in this contribution. Using body mass index (BMI) data of the National Examination Surveys (1984-1992), the German National Health Interview and Examination Survey 1998 as well as the Telephone Health Survey 2003, all representative of the adult non-institutionalised population, the occurrence of overweight and obesity is studied. To improve the comparability with measurement values, the Telephone Health Survey data which were based on self-reporting were adjusted. All data were weighted to improve the representativeness for the time of assessment. Although the proportion of persons with a BMI between 25 and 30 did not change essentially during the last 20 years, the proportion of obese individuals (BMI>or=30) increased considerably. At present, about 70% of men and 50% of women in Germany are overweight or obese. In conclusion, the prevalence of overweight and obesity in Germany continues to increase.

Einflussfaktoren auf die ambulante Inanspruchnahme in Deutschland

An analysis of the possible influences on primary health care utilization is made. The theoretical framework is the health behavioural model of R. M. Andersen, dividing the influencing variables into the components predisposing characteristics, enabling resources, and need factors. The study was based on data from the German National Health Examination and Interview Survey of the adult population in 1998. The data were linked to regional structural data and aggregated account data. The total number of contacts, the number of contacts with general practitioners and internists, and the number of different specialists contacted in the last 12 months, as calculated from interview data, were used to indicate primary health care utilization. In addition to the expected strong influence of need factors such as morbidity and health-related quality of life, the predisposing characteristics such as region, urban/rural, age, and gender have a significant influence on the primary care utilization. With regard to the enabling factors, persons with a family doctor had more contacts overall, which contrasts with the family doctor's assumed gate-keeper function. From the results of the study, recommendations on possible regulatory measures are given, but also some restrictions for influencing the number of contacts are pointed out.

[The Child and Adolescent Health Survey as a source of data for assessment of the essential aspects of health care in childhood and adolescence]

The German National Health Survey for Children and Adolescents aims at collecting representative data on the health status of the population in the 0 to 18 years age bracket. Examination of about 18.000 participants is planned. In this cross-sectional study relevant data concerning health services will be gathered. These include parameters of health care demands, health insurance, vaccination status and drug utilisation. The data collection will start in the first quarter of 2003 and will probably be terminated in the last quarter of 2005. The study design has been tested in a pilot study for one year and was adapted to the demands of this specific health survey. The instruments used for data collection are a self-administered questionnaire as well as a standardised, computer-based medical interview.

TFIIH functions are altered by the P210BCR-ABL oncoprotein produced on the Philadelphia chromosome

P210BCR-ABL counteracted against the complementary effect of XPB on DNA repair when ultraviolet (UV)-sensitive 27-1 cells were treated with UV or cisplatin but not with hydrogen peroxide. Wortmannin, an inhibitor of PI3 kinase did not affect its anti-repair effect. Enhanced recruitment of p44 with TFIIH after cisplatin treatment is inhibited by the expression of P210BCR-ABL in a kinase activity-dependent manner. Although purified TFIIH from P210BCR-ABL expressor and non-expressor showed almost no difference in molar ratio of each component, the in vitro activity of TFIIH was decreased by 5-10% in repair assay but was increased by more than two-fold in transcription assay.

Expression of P27(KIP1) is prognostic and independent of MYCN amplification in human neuroblastoma

Amplification of the MYCN gene is significantly associated with an unfavorable prognosis and rapid progression in human neuroblastoma tumors. One potential mechanism by which MYCN may cause these effects is by deregulating cell proliferation. Tissue culture experiments support a model in which MYC genes stimulate cell cycle progression by antagonizing the function of the cell cycle inhibitor p27(kip1). In culture, activation of MYC induces both sequestration of p27(kip1) by cyclin D complexes and its subsequent proteolytic degradation. We have tested whether this model applies to human neuroblastoma in a retrospective study of 100 primary tumor biopsy samples from neuroblastoma patients with a documented follow-up. Consistent with this hypothesis, MYCN-amplified tumors express high levels of both cyclin A and proliferating cell nuclear antigen, 2 marker proteins of cell proliferation. Further, expression levels of p27(kip1) are of prognostic significance in human neuroblastoma patients. Similar to tissue culture systems, p27(kip1) is sequestered by cyclin D complexes in a subset of human neuroblastoma samples. Surprisingly, however, expression levels of p27(kip1) are prognostic independent of MYCN amplification, and tumors that have an amplified MYCN gene do not express elevated levels of D-type cyclins or contain significantly lower levels of p27(kip1). Our data do not support a model in which regulation of p27(kip1) function is an important mechanism by which amplified MYCN deregulates cell proliferation in neuroblastoma.

Trichothiodystrophy, a transcription syndrome

Trichothiodystrophy (TTD) is a rare genetic disorder characterized by a hair dysplasia and associated with numerous symptoms affecting mainly organs derived from the neuroectoderm. About half of TTD patients exhibit photosensitivity because their nucleotide-excision repair pathway (NER) does not remove UV-induced DNA lesions efficiently. However, they do not present the skin cancer susceptibility expected from such an NER disorder. Their deficiencies result from phenotype-specific mutations in either XPB or XPD. These genes encode the helicase subunits of TFIIH, a DNA repair factor that is also required for transcription of class II genes. Thus, time- and tissue-specific impairments of transcription might explain the developmental and neurological symptoms of TTD. In a third group of photosensitive patients, TTD-A, no mutation has been identified, although TFIIH amount is reduced.

Sublimiting concentration of TFIIH transcription/DNA repair factor causes TTD-A trichothiodystrophy disorder

The repair-deficient form of trichothiodystrophy (TTD) most often results from mutations in the genes XPB or XPD, encoding helicases of the transcription/repair factor TFIIH. The genetic defect in a third group, TTD-A, is unknown, but is also caused by dysfunctioning TFIIH. None of the TFIIH subunits carry a mutation and TFIIH from TTD-A cells is active in both transcription and repair. Instead, immunoblot and immunofluorescence analyses reveal a strong reduction in the TFIIH concentration. Thus, the phenotype of TTD-A appears to result from sublimiting amounts of TFIIH, probably due to a mutation in a gene determining the complex stability. The reduction of TFIIH mainly affects its repair function and hardly influences transcription.

p44/SSL1, the regulatory subunit of the XPD/RAD3 helicase, plays a crucial role in the transcriptional activity of TFIIH

In order to unravel the mechanism that regulates transcription of protein-coding genes, we investigated the function of the p44 subunit of TFIIH, a basal transcription factor that is also involved in DNA repair. We have shown previously that mutations in the C terminus of the XPD helicase, another subunit of TFIIH, prevent its regulation by p44 (Coin, F., Bergmann, E., Tremeau-Bravard, A., and Egly, J. M. (1999) EMBO 18, 1357-1366). By using a site-directed mutagenesis approach within the p44 region from amino acids 66 to 200, we indicate how a decrease in the interaction between p44 and XPD results in a decrease of the XPD helicase activity and leads to a defect in the first steps of the transcription reaction, namely the first phosphodiester bond formation and promoter clearance. We thus provide some explanation for the transcriptional defect found in SSL1 mutated yeast (Wang, Z., Buratowski, S., Svejstrup, J. Q., Feaver, W. J., Wu, X., Kornberg, R. D., Donahue, T. F., and Friedberg, E. C. (1995) Mol. Cell. Biol. 15, 2288-2293). Moreover, this study shows how the activity of the the cyclin-dependent kinase-activating kinase associated with TFIIH complex in stimulating transcription is mediated in part by p44/XPD interaction.

[Utilization of medical services]

About 90% of all Germans are seeing their doctor at least once a year. Half of the population has consulted a doctor during the past four weeks. More than 95% of the patients have been satisfied with these consultations. On average, a medical practitioner was consulted 11 times a year. Half of the consultations were caused by 20% of population. In most cases, dentists and general practitioners are contacted. More than 90% of the members of the german official health insurance system (Gesetzliche Krankenversicherung) have a family doctor already today. Annually, 12 working days are lost for illness. The average duration of a stay in hospital is rising with age, from 6 days for the youngest to 28 days for the oldest. For 2/3 of cures, the duration was 4 weeks.

Ozone threshold doses and exposure-response relationships for the development of ozone injury symptoms in wild plant species

The relative ozone sensitivities of 25 German native herbaceous plant species, representative of arable field margins or disturbed habitats, were examined over three consecutive growing seasons. Plants were grown from seed, potted into natural soils and exposed in open-top chambers for the entire season to different ozone-exposure regimes covering a range of concentrations from <5 to 48 ppb (seasonal 8 h daily mean). The assessment of ozone effects was carried out by recording the first day of visible symptom appearance and the percentage of injured leaves at the end of vegetative growth. Species exhibited contrasting patterns of symptom expression under ozone stress, with either ozone-specific symptoms or ozone-enhanced foliar pigmentation and senescence. Classifications of species according to their ozone susceptibility varied depending on whether measurement was of the total extent of visible injury, ozone threshold doses for the incidence of symptoms, or modelled exposure-response relationships. The most sensitive species exhibiting ozone-specific symptoms were Cirsium arvense and Sonchus asper, which responded to accumulated ozone exposures <1500 ppb.h (AOT40). For these and three other species, an AOT40 peak of a single day was found to be responsible for the incidence of ozone-specific symptoms, i.e. injury occurred rapidly within a few days of the day with the highest AOT40, while other species responded only to longer-term ozone exposures. The relative ozone sensitivity of the species was calculated by combining the different sensitivity criteria, and possible systematic trends (taxonomic or evolutionary features) are pointed out. The results suggest it may be possible to use a particular group of native herbaceous plant species with contrasting patterns of ozone sensitivity as a biomonitoring system in the field. This allows plant responses to be related either to peak values or to prolonged ozone exposure, making it possible to distinguish between short- and long-term effects of ozone.

The structures of picornaviral proteinases

Picornaviruses are a family of positive-strand RNA viruses the members of which include poliovirus, hepatitis A virus, rhinovirus, foot-and-mouth disease virus and encephalomyocarditis virus. The genetic information contained in the single-stranded, positive sense RNA genome is expressed as a single protein of around 2000 amino acids. This primary product of protein synthesis, designated the polyprotein, is subsequently cleaved into the mature viral proteins by proteinases present within it. The properties of the three defined proteolytic activities present in the picornaviruses are reviewed and the three-dimensional structures of the hepatitis A 3C proteinase and the leader proteinase of foot-and-mouth disease virus as well as a model of the structure of the HRV2 2A proteinase are compared with those of chymotrypsin, papain and streptomyces griseus A proteinase, respectively.

Mutations in XPB and XPD helicases found in xeroderma pigmentosum patients impair the transcription function of TFIIH

As part of TFIIH, XPB and XPD helicases have been shown to play a role in nucleotide excision repair (NER). Mutations in these subunits are associated with three genetic disorders: xeroderma pigmentosum (XP), Cockayne syndrome (CS) and trichothiodystrophy (TTD). The strong heterogeneous clinical features observed in these patients cannot be explained by defects in NER alone. We decided to look at the transcriptional activity of TFIIH from cell lines of XP individuals. We set up an immunopurification procedure to isolate purified TFIIH from patient cell extracts. We demonstrated that mutations in two XP-B/CS patients decrease the transcriptional activity of the corresponding TFIIH by preventing promoter opening. The defect of XPB in transcription can be circumvented by artificial opening of the promoter. Western blot analysis and enzymatic assays indicate that XPD mutations affect the stoichiometric composition of TFIIH due to a weakness in the interaction between XPD-CAK complex and the core TFIIH, resulting in a partial reduction of transcription activity. This work, in addition to clarifying the role of the various TFIIH subunits, supports the current hypothesis that XP-B/D patients are more likely to suffer from transcription repair syndromes rather than DNA repair disorders alone.

Haemoptysis after breath-hold diving

Pulmonary oedema has been described in swimmers and self-contained underwater breathing apparatus (Scuba) divers. This study reports three cases of haemoptysis secondary to alveolar haemorrhage in breath-hold divers. Contributory factors, such as haemodynamic modifications secondary to immersion, cold exposure, exercise and exposure to an increase in ambient pressure, could explain this type of accident. Furthermore, these divers had taken aspirin, which may have aggravated the bleeding.

Transcription factor IIH: a key player in the cellular response to DNA damage

TFIIH (transcription factor IIH) is a multiprotein complex consisting of nine subunits initially characterized as a basal transcription factor required for initiation of protein-coding RNA synthesis. TFIIH was the first transcription factor shown to harbor several enzymatic activities, likely indicative of functional complexity. This intricacy was further emphasized with the cloning of the genes encoding the different subunits which disclosed direct connections between transcription, DNA repair and cell cycle regulation. In this review, we emphasize those functions of TFIIH involved in DNA repair, as well as their relationship to TFIIH's roles in transcription, cell cycle control and apoptosis. These connections may prove to be essential for the cellular response to DNA damage.

Haemoconcentration in neurological decompression illness

Decompression illness (DCI) is attributed to the formation of bubbles, resulting from the reduction of the ambient pressure. Circulating bubbles lead to capillary leak syndrome, extravasation of plasma and haemoconcentration. Experimental model on animals has shown that a haemoconcentration carried a poor prognosis. We measured the haematocrit level in fifty-eight consecutive sport divers, victims of neurological DCI, admitted to our hyperbaric center, and in sixteen control divers. No significant difference was found in the haematocrit values between the divers with neurological DCI (median 42.5%) and the controls (median 41.75%). The median haematocrit level was significantly higher for divers with neurological sequelae when compared with control (p = 0.01) or with divers without sequelae (p < 0.05). A haematocrit level > or = 48% was correlated with persistent neurological sequelae one month after the accident (p = 0.01). However, a haematocrit < 48% had no prognostic value.

[Prognosis in iatrogenic gas embolism]

Prognosis of iatrogenic air embolism is various according to previous studies. The purpose of this study was to determine the risks factors associated with the prognosis of iatrogenic air embolism. We conducted a retrospective analysis of 113 patients treated with HBO therapy in our hyperbaric center from 1979 to 1993. Initial symptomatology consisted in neurological disorders (71% of cases), respiratory disorders (43% of cases) and hemodynamic disorders (33% of cases). When neurological disorders were observed, HBO therapy included immediate compression to 6 atm abs for 10 to 15 mn with air followed by decompression to 2 atm abs where the patients received 100% oxygen during 1 hour. When no neurological disorders was observed, HBO therapy consisted in an oxygenation for 1 h, 2 atm abs, FiO2 = 1. Overall outcome was: recovery: 69 per cent of cases, sequelae: 26 per cent of cases, death: 5 per cent of cases. Prognosis was very different according to etiologies and existence of neurological disorders. Venous emboli had a better improvement than arterial emboli. In conclusion, patterns of air embolism can be divided clinically into two major categories, cerebral and pulmonary air embolism, which should be individualised in clinical studies. The studies must also individualised etiologies.

[Intra-alveolar hemorrhage. An uncommon accident in a breath holding diver]

To date, pulmonary oedema in breath hold divers has only been reported after dives below 50 meters, hypoxaemic syncope being the most common risk. We recently observed a 35-year-old well-trained breath hold diver who was unable to achieve deep inspiration during a high-level competition. After two hours of repeated dives to a depth of 25 meters for approximately 2-minute periods with intermittent recovery the patient developed cough and haemoptysis. The chest X-ray revealed lung images suggestive of intra-alveolar haemorrhage. The patient had taken 1 g of aspirin per os for three days prior to diving. Symptoms subsided spontaneously in 48 hours and one month later all haematology tests were normal except for minimal alteration of platelet aggregation. Pulmonary oedema in breath hold divers is usually attributed to blood shift to the pulmonary circulation related to the lowered intra-thoracic pressure. In our case, oedema was secondary to intra-alveolar haemorrhage favoured by aspirin which should be avoided before breath hold diving.

[Frequency analysis for promoting public health goals--III: Potential abbreviation of longevity]

The article presents different mathematical algorithms intending to quantify the "potential years of life lost" based on life table models, and on real age-structured populations, respectively. Applying these algorithms to accident and cardiovascular mortality data from Berlin (West) demonstrates their individual and specific relevance.

Job analysis 1992: infection control practitioner

The Certification Board of Infection Control directed its Research Subcommittee to compose a Job Analysis Committee in 1991. This 9-member Job Analysis Committee, in collaboration with Applied Measurement Professionals, Inc., conducted a job analysis of ICPs during 1992. The reassessment of the previous Certification Board of Infection Control task analysis, formation of a job-analysis survey tool, and the actual job-analysis process and its results are described in this article. The previous and newly revised test specification outlines are compared. The national Certification Examination for Infection Control for November 1993 will reflect the efforts of this endeavor.