The IRE1α-XBP1 arm of the unfolded protein response is a host factor activated in SARS-CoV-2 infection

SARS-CoV-2 infection can cause severe pneumonia, wherein exacerbated inflammation plays a major role. This is reminiscent of the process commonly termed cytokine storm, a condition dependent on a disproportionated production of cytokines. This state involves the activation of the innate immune response by viral patterns and coincides with the biosynthesis of the biomass required for viral replication, which may overwhelm the capacity of the endoplasmic reticulum and drive the unfolded protein response (UPR). The UPR is a signal transduction pathway composed of three branches that is initiated by a set of sensors: inositol-requiring protein 1 (IRE1), protein kinase RNA-like ER kinase (PERK), and activating transcription factor 6 (ATF6). These sensors control adaptive processes, including the transcriptional regulation of proinflammatory cytokines. Based on this background, the role of the UPR in SARS-CoV-2 replication and the ensuing inflammatory response was investigated using in vivo and in vitro models of infection. Mice and Syrian hamsters infected with SARS-CoV-2 showed a sole activation of the Ire1α-Xbp1 arm of the UPR associated with a robust production of proinflammatory cytokines. Human lung epithelial cells showed the dependence of viral replication on the expression of UPR-target proteins branching on the IRE1α-XBP1 arm and to a lower extent on the PERK route. Likewise, activation of the IRE1α-XBP1 branch by Spike (S) proteins from different variants of concern was a uniform finding. These results show that the IRE1α-XBP1 system enhances viral replication and cytokine expression and may represent a potential therapeutic target in SARS-CoV-2 severe pneumonia.

Virus-like particles of louping ill virus elicit potent neutralizing antibodies targeting multimers of viral envelope protein

Louping ill virus (LIV) is a tick-borne flavivirus that predominantly causes disease in livestock, especially sheep in the British Isles. A preventive vaccine, previously approved for veterinary use but now discontinued, was based on an inactivated whole virion that likely provided protection by induction of neutralizing antibodies recognizing the viral envelope (E) protein. A major disadvantage of the inactivated vaccine was the need for high containment facilities for the propagation of infectious virus, as mandated by the hazard group 3 status of the virus. This study aimed to develop high-efficacy non-infectious protein-based vaccine candidates. Specifically, soluble envelope protein (sE), and virus-like particles (VLPs), comprised of the precursor of membrane and envelope proteins, were generated, characterized, and studied for their immunogenicity in mice. Results showed that the VLPs induced more potent virus neutralizing response compared to sE, even though the total anti-envelope IgG content induced by the two antigens was similar. Depletion of anti-monomeric E protein antibodies from mouse immune sera suggested that the neutralizing antibodies elicited by the VLPs targeted epitopes spanning the highly organized structure of multimer of the E protein, whereas the antibody response induced by sE focused on E monomers. Thus, our results indicate that VLPs represent a promising LIV vaccine candidate.

Suspected tick-borne flavivirus meningoencephalomyelitis in dogs from the UK: six cases (2021)

OBJECTIVES

Tick-borne encephalitis virus and louping ill virus are neurotropic flaviviruses transmitted by ticks. Epidemiologically, tick-borne encephalitis is endemic in Europe whereas louping ill's predominant geographical distribution is the UK. Rarely, these flaviviruses affect dogs causing neurological signs. This case series aimed to describe the clinical, clinicopathological, and imaging findings, as well as the outcomes in six dogs with meningoencephalitis and/or meningomyelitis caused by a flavivirus in the UK in 2021.

MATERIALS AND METHODS

Observational retrospective case-series study. Clinical data were retrieved from medical records of dogs with positive serological or immunohistochemical results from three different institutions from spring to winter 2021.

RESULTS

Six dogs were included in the study. All dogs presented an initial phase of pyrexia and/or lethargy followed by progressive signs of spinal cord and/or intracranial disease. Magnetic resonance imaging showed bilateral and symmetrical lesions affecting the grey matter of the thalamus, pons, medulla oblongata, and thoracic or lumbar intumescences with none or mild parenchymal and meningeal contrast enhancement. Serology for tick-borne encephalitis virus was positive in five dogs with the presence of seroconversion in two dogs. The viral distinction between flaviviruses was not achieved. One dog with negative serology presented positive immunohistochemistry at post-mortem examination. Three dogs survived but presented neurological sequelae. Three dogs were euthanased due to the rapid progression of the clinical signs or static neurological signs.

CLINICAL SIGNIFICANCE

These cases raise awareness of the presence of tick-borne encephalitis as an emergent disease or the increased prevalence of louping ill virus affecting dogs in the UK.

Para-infectious brain injury in COVID-19 persists at follow-up despite attenuated cytokine and autoantibody responses

To understand neurological complications of COVID-19 better both acutely and for recovery, we measured markers of brain injury, inflammatory mediators, and autoantibodies in 203 hospitalised participants; 111 with acute sera (1-11 days post-admission) and 92 convalescent sera (56 with COVID-19-associated neurological diagnoses). Here we show that compared to 60 uninfected controls, tTau, GFAP, NfL, and UCH-L1 are increased with COVID-19 infection at acute timepoints and NfL and GFAP are significantly higher in participants with neurological complications. Inflammatory mediators (IL-6, IL-12p40, HGF, M-CSF, CCL2, and IL-1RA) are associated with both altered consciousness and markers of brain injury. Autoantibodies are more common in COVID-19 than controls and some (including against MYL7, UCH-L1, and GRIN3B) are more frequent with altered consciousness. Additionally, convalescent participants with neurological complications show elevated GFAP and NfL, unrelated to attenuated systemic inflammatory mediators and to autoantibody responses. Overall, neurological complications of COVID-19 are associated with evidence of neuroglial injury in both acute and late disease and these correlate with dysregulated innate and adaptive immune responses acutely.

Mpox vaccine and infection-driven human immune signatures: an immunological analysis of an observational study

BACKGROUND

Monkeypox virus has recently infected more than 88 000 people, raising concerns about our preparedness against this emerging viral pathogen. Licensed and approved for mpox, the JYNNEOS vaccine has fewer side-effects than previous smallpox vaccines and has shown immunogenicity against monkeypox in animal models. This study aims to elucidate human immune responses to JYNNEOS vaccination compared with mpox-induced immunity.

METHODS

Peripheral blood mononuclear cells and sera were obtained from ten individuals vaccinated with one or two doses of JYNNEOS and six individuals diagnosed with monkeypox virus infection. Samples were obtained from seven individuals before vaccination to serve as a baseline. We examined the polyclonal serum (ELISA) and single B-cell (heavy chain gene and transcriptome data) antibody repertoires and T-cell responses (activation-induced marker and intracellular cytokine staining assays) induced by the JYNNEOS vaccine versus monkeypox virus infection.

FINDINGS

All participants were men between the ages of 21 and 60 years, except for one woman in the group of mpox-convalescent individuals, and none had previous orthopoxvirus exposure. All mpox cases were mild. Vaccinee samples were collected 6-33 days after the first dose and 5-40 days after the second dose. Mpox-convalescent samples were collected 20-102 days after infection. In vaccine recipients, gene-level plasmablast and antibody responses were negligible and sera displayed moderate binding to recombinant orthopoxviral proteins (A29L, A35R, E8L, A30L, A27L, A33R, B18R, and L1R) and native proteins from the 2022 monkeypox outbreak strain. By contrast, recent monkeypox virus infection (within 20-102 days) induced robust serum antibody responses to monkeypox virus proteins and to native monkeypox virus proteins from a viral isolate obtained during the 2022 outbreak. JYNNEOS vaccine recipients presented robust orthopoxviral CD4+ and CD8+ T-cell responses.

INTERPRETATION

Infection with monkeypox virus resulted in robust B-cell and T-cell responses, whereas immunisation with JYNNEOS elicited more robust T-cell responses. These data can help to inform vaccine design and policies for preventing mpox in humans.

FUNDING

National Cancer Institute (National Institutes of Health), National Institute of Allergy and Infectious Diseases (National Institutes of Health), and Icahn School of Medicine.

Amino acids 1811-1960 of myosin heavy chain 9 is involved in murine gammaherpesvirus 68 infection

Myosin heavy chain 9 (MYH9) has been identified as a crucial factor in gammaherpesvirus infection. Murine gammaherpesvirus 68 (MHV-68) was used as an appropriate viral model for investigating gammaherpesviruses in vivo and developing antiviral treatments. However, the roles of MYH9 in MHV-68 infection have not been documented. In the study, the relationship between the expression of MYH9 and MHV-68 infection and MYH9 as the antiviral target were analyzed. The results revealed that MYH9 was enriched on the cell surface and co-localized with MHV-68 upon viral infection. Knocking down MYH9 with siRNA or using the specific inhibitor of MYH9 activity, Blebbistatin, resulted in the decreasing of MHV-68 infection. Furthermore, polyclonal antibodies against MYH9 reduced infection by approximately 74% at a dose of 100 μg/ml. The study determined that MYH9 contributes to MHV-68 infection by interacting with viral glycoprotein 150 (gp150) in the BHK-21 cell membrane. The specific region of MYH9, amino acids 1811-1960 (C-150), was identified as the key domain involved in the interaction with MHV-68 gp150 and was found to inhibit MHV-68 infection. Moreover, C-150 was also shown to decrease HSV-1 infection in Vero cells by approximately 73%. Both C-150 and Blebbistatin were found to inhibit MHV-68 replication and reduce histopathological lesions in vivo in C57BL/6J mice. Taken together, these findings suggested that MYH9 is crucial for MHV-68 infection through its interaction with viral gp150 and that C-150 may be a promising antiviral target for inhibiting MHV-68 infection in vitro and in vivo.

The Stereotypic Response of the Pulmonary Vasculature to Respiratory Viral Infections: Findings in Mouse Models of SARS-CoV-2, Influenza A and Gammaherpesvirus Infections

The respiratory system is the main target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 19 (COVID-19) where acute respiratory distress syndrome is considered the leading cause of death. Changes in pulmonary blood vessels, among which an endothelialitis/endotheliitis has been particularly emphasized, have been suggested to play a central role in the development of acute lung injury. Similar vascular changes are also observed in animal models of COVID-19. The present study aimed to determine whether the latter are specific for SARS-CoV-2 infection, investigating the vascular response in the lungs of mice infected with SARS-CoV-2 and other respiratory viruses (influenza A and murine gammaherpesvirus) by in situ approaches (histology, immunohistology, morphometry) combined with RNA sequencing and bioinformatic analysis. Non-selective recruitment of monocytes and T and B cells from larger muscular veins and arteries was observed with all viruses, matched by a comparable transcriptional response. There was no evidence of endothelial cell infection in any of the models. Both the morphological investigation and the transcriptomics approach support the interpretation that the lung vasculature in mice mounts a stereotypic response to alveolar and respiratory epithelial damage. This may have implications for the treatment and management of respiratory disease in humans.

Neuroinvasion and Neurotropism by SARS-CoV-2 Variants in the K18-hACE2 Mouse

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) not only affects the respiratory tract but also causes neurological symptoms such as loss of smell and taste, headache, fatigue or severe cerebrovascular complications. Using transgenic mice expressing human angiotensin-converting enzyme 2 (hACE2), we investigated the spatiotemporal distribution and pathomorphological features in the CNS following intranasal infection with SARS-CoV-2 variants, as well as after prior influenza A virus infection. Apart from Omicron, we found all variants to frequently spread to and within the CNS. Infection was restricted to neurons and appeared to spread from the olfactory bulb mainly in basally oriented regions in the brain and into the spinal cord, independent of ACE2 expression and without evidence of neuronal cell death, axonal damage or demyelination. However, microglial activation, microgliosis and a mild macrophage and T cell dominated inflammatory response was consistently observed, accompanied by apoptotic death of endothelial, microglial and immune cells, without their apparent infection. Microgliosis and immune cell apoptosis indicate a potential role of microglia for pathogenesis and viral effect in COVID-19 and the possible impairment of neurological functions, especially in long COVID. These data may also be informative for the selection of therapeutic candidates and broadly support the investigation of agents with adequate penetration into relevant regions of the CNS.

A potent SARS-CoV-2 neutralising nanobody shows therapeutic efficacy in the Syrian golden hamster model of COVID-19

SARS-CoV-2 remains a global threat to human health particularly as escape mutants emerge. There is an unmet need for effective treatments against COVID-19 for which neutralizing single domain antibodies (nanobodies) have significant potential. Their small size and stability mean that nanobodies are compatible with respiratory administration. We report four nanobodies (C5, H3, C1, F2) engineered as homotrimers with pmolar affinity for the receptor binding domain (RBD) of the SARS-CoV-2 spike protein. Crystal structures show C5 and H3 overlap the ACE2 epitope, whilst C1 and F2 bind to a different epitope. Cryo Electron Microscopy shows C5 binding results in an all down arrangement of the Spike protein. C1, H3 and C5 all neutralize the Victoria strain, and the highly transmissible Alpha (B.1.1.7 first identified in Kent, UK) strain and C1 also neutralizes the Beta (B.1.35, first identified in South Africa). Administration of C5-trimer via the respiratory route showed potent therapeutic efficacy in the Syrian hamster model of COVID-19 and separately, effective prophylaxis. The molecule was similarly potent by intraperitoneal injection.

Single-dose immunisation with a multimerised SARS-CoV-2 receptor binding domain (RBD) induces an enhanced and protective response in mice

The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, has triggered a worldwide health emergency. Here, we show that ferritin-like Dps from hyperthermophilic Sulfolobus islandicus, covalently coupled with SARS-CoV-2 antigens via the SpyCatcher system, forms stable multivalent dodecameric vaccine nanoparticles that remain intact even after lyophilisation. Immunisation experiments in mice demonstrated that the SARS-CoV-2 receptor binding domain (RBD) coupled to Dps (RBD-S-Dps) elicited a higher antibody titre and an enhanced neutralising antibody response compared to monomeric RBD. A single immunisation with RBD-S-Dps completely protected hACE2-expressing mice from serious illness and led to viral clearance from the lungs upon SARS-CoV-2 infection. Our data highlight that multimerised SARS-CoV-2 subunit vaccines are a highly efficacious modality, particularly when combined with an ultra-stable scaffold.

Generation of a reporter yellow fever virus for high throughput antiviral assays

Yellow fever virus (YFV), a member of the Flaviviridae family, is an arthropod-borne virus that can cause severe disease in humans with a lethality rate of up to 60%. Since 2017, increases in YFV activity in areas of South America and Africa have been described. Although a vaccine is available, named strain 17D (Theiler and Smith, 1937), it is contraindicated for use in the elderly, expectant mothers, immunocompromised people, among others. To this day there is no antiviral treatment against YFV to reduce the severity of viral infection. Here, we used a circular polymerase extension reaction (CPER)-based reverse genetics approach to generate a full-length reporter virus (YFVhb) by introducing a small HiBit tag in the NS1 protein. The reporter virus replicates at a similar rate to the parental YFV in HuH-7 cells. Using YFVhb, we designed a high throughput antiviral screening luciferase-based assay to identify inhibitors that target any step of the viral replication cycle. We validated our assay by using a range of inhibitors including drugs, immune sera and neutralizing single chain variable fragments (scFv). In light of the recent upsurge in YFV and a potential spread of the virus, this assay is a further tool in the development of antiviral therapy against YFV.

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Bacteria-free approach to rescue yellow fever virus.

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Novel tagged yellow fever virus that permits quantifiable assays.

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Usage of the novel tagged virus for screening of antivirals and immune sera.

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Novel antiviral compounds against YFV were identified.

Population genomics of louping ill virus provide new insights into the evolution of tick-borne flaviviruses

The emergence and spread of tick-borne arboviruses pose an increased challenge to human and animal health. In Europe this is demonstrated by the increasingly wide distribution of tick-borne encephalitis virus (TBEV, Flavivirus, Flaviviridae), which has recently been found in the United Kingdom (UK). However, much less is known about other tick-borne flaviviruses (TBFV), such as the closely related louping ill virus (LIV), an animal pathogen which is endemic to the UK and Ireland, but which has been detected in other parts of Europe including Scandinavia and Russia. The emergence and potential spatial overlap of these viruses necessitates improved understanding of LIV genomic diversity, geographic spread and evolutionary history. We sequenced a virus archive composed of 22 LIV isolates which had been sampled throughout the UK over a period of over 80 years. Combining this dataset with published virus sequences, we detected no sign of recombination and found low diversity and limited evidence for positive selection in the LIV genome. Phylogenetic analysis provided evidence of geographic clustering as well as long-distance movement, including movement events that appear recent. However, despite genomic data and an 80-year time span, we found that the data contained insufficient temporal signal to reliably estimate a molecular clock rate for LIV. Additional analyses revealed that this also applied to TBEV, albeit to a lesser extent, pointing to a general problem with phylogenetic dating for TBFV. The 22 LIV genomes generated during this study provide a more reliable LIV phylogeny, improving our knowledge of the evolution of tick-borne flaviviruses. Our inability to estimate a molecular clock rate for both LIV and TBEV suggests that temporal calibration of tick-borne flavivirus evolution should be interpreted with caution and highlight a unique aspect of these viruses which may be explained by their reliance on tick vectors.

Tick-borne pathogens represent a major emerging threat to public health and in recent years have been expanding into new areas. LIV is a neglected virus endemic to the UK and Ireland (though it has been detected in Scandinavia and Russia) which is closely related to the major human pathogen TBEV, but predominantly causes disease in sheep and grouse. The recent detection of TBEV in the UK, which has also emerged elsewhere in Europe, requires more detailed understanding of the spread and sequence diversity of LIV. This could be important for diagnosis and vaccination, but also to improve our understanding of the evolution and emergence of these tick-borne viruses. Here we describe the sequencing of 22 LIV isolates which have been sampled from several host species across the past century. We have utilised this dataset to investigate the evolutionary pressures that LIV is subjected to and have explored the evolution of LIV using phylogenetic analysis. Crucially we were unable to estimate a reliable molecular clock rate for LIV and found that this problem also extends to a larger phylogeny of TBEV sequences. This work highlights a previously unknown caveat of tick-borne flavivirus evolutionary analysis which may be important for understanding the evolution of these important pathogens.

Inherent versus induced protein flexibility: Comparisons within and between apo and holo structures

Understanding how ligand binding influences protein flexibility is important, especially in rational drug design. Protein flexibility upon ligand binding is analyzed herein using 305 proteins with 2369 crystal structures with ligands (holo) and 1679 without (apo). Each protein has at least two apo and two holo structures for analysis. The inherent variation in structures with and without ligands is first established as a baseline. This baseline is then compared to the change in conformation in going from the apo to holo states to probe induced flexibility. The inherent backbone flexibility across the apo structures is roughly the same as the variation across holo structures. The induced backbone flexibility across apo-holo pairs is larger than that of the apo or holo states, but the increase in RMSD is less than 0.5 Å. Analysis of χ1 angles revealed a distinctly different pattern with significant influences seen for ligand binding on side-chain conformations in the binding site. Within the apo and holo states themselves, the variation of the χ1 angles is the same. However, the data combining both apo and holo states show significant displacements. Upon ligand binding, χ1 angles are frequently pushed to new orientations outside the range seen in the apo states. Influences on binding-site variation could not be easily attributed to features such as ligand size or x-ray structure resolution. By combining these findings, we find that most binding site flexibility is compatible with the common practice in flexible docking, where backbones are kept rigid and side chains are allowed some degree of flexibility.

Blast-related disinhibition and risk seeking in mice and combat Veterans: Potential role for dysfunctional phasic dopamine release

Mild traumatic brain injury (mTBI) caused by exposure to high explosives has been called the "signature injury" of the wars in Iraq and Afghanistan. There is a wide array of chronic neurological and behavioral symptoms associated with blast-induced mTBI. However, the underlying mechanisms are not well understood. Here we used a battlefield-relevant mouse model of blast-induced mTBI and in vivo fast-scan cyclic voltammetry (FSCV) to investigate whether the mesolimbic dopamine system contributes to the mechanisms underlying blast-induced behavioral dysfunction. In mice, blast exposure increased novelty seeking, a behavior closely associated with disinhibition and risk for subsequent maladaptive behaviors. In keeping with this, we found that veterans with blast-related mTBI reported greater disinhibition and risk taking on the Frontal Systems Behavior Scale (FrSBe). In addition, in mice we report that blast exposure causes potentiation of evoked phasic dopamine release in the nucleus accumbens. Taken together these findings suggest that blast-induced changes in the dopaminergic system may mediate aspects of the complex array of behavioral dysfunctions reported in blast-exposed veterans.

Inhibition of type I interferon induction and signalling by mosquito-borne flaviviruses

The Flavivirus genus (Flaviviridae family) contains a number of important human pathogens, including dengue and Zika viruses, which have the potential to cause severe disease. In order to efficiently establish a productive infection in mammalian cells, flaviviruses have developed key strategies to counteract host immune defences, including the type I interferon response. They employ different mechanisms to control interferon signal transduction and effector pathways, and key research generated over the past couple of decades has uncovered new insights into their abilities to actively decrease interferon antiviral activity. Given the lack of antivirals or prophylactic treatments for many flaviviral infections, it is important to fully understand how these viruses affect cellular processes to influence pathogenesis and disease outcome. This review will discuss the strategies mosquito-borne flaviviruses have evolved to antagonise type I interferon mediated immune responses.

Full Genome Sequence and sfRNA Interferon Antagonist Activity of Zika Virus from Recife, Brazil

BACKGROUND

The outbreak of Zika virus (ZIKV) in the Americas has transformed a previously obscure mosquito-transmitted arbovirus of the Flaviviridae family into a major public health concern. Little is currently known about the evolution and biology of ZIKV and the factors that contribute to the associated pathogenesis. Determining genomic sequences of clinical viral isolates and characterization of elements within these are an important prerequisite to advance our understanding of viral replicative processes and virus-host interactions.

METHODOLOGY/PRINCIPAL FINDINGS

We obtained a ZIKV isolate from a patient who presented with classical ZIKV-associated symptoms, and used high throughput sequencing and other molecular biology approaches to determine its full genome sequence, including non-coding regions. Genome regions were characterized and compared to the sequences of other isolates where available. Furthermore, we identified a subgenomic flavivirus RNA (sfRNA) in ZIKV-infected cells that has antagonist activity against RIG-I induced type I interferon induction, with a lesser effect on MDA-5 mediated action.

CONCLUSIONS/SIGNIFICANCE

The full-length genome sequence including non-coding regions of a South American ZIKV isolate from a patient with classical symptoms will support efforts to develop genetic tools for this virus. Detection of sfRNA that counteracts interferon responses is likely to be important for further understanding of pathogenesis and virus-host interactions.

Recent improvements to Binding MOAD: a resource for protein-ligand binding affinities and structures

For over 10 years, Binding MOAD (Mother of All Databases; http://www.BindingMOAD.org) has been one of the largest resources for high-quality protein-ligand complexes and associated binding affinity data. Binding MOAD has grown at the rate of 1994 complexes per year, on average. Currently, it contains 23,269 complexes and 8156 binding affinities. Our annual updates curate the data using a semi-automated literature search of the references cited within the PDB file, and we have recently upgraded our website and added new features and functionalities to better serve Binding MOAD users. In order to eliminate the legacy application server of the old platform and to accommodate new changes, the website has been completely rewritten in the LAMP (Linux, Apache, MySQL and PHP) environment. The improved user interface incorporates current third-party plugins for better visualization of protein and ligand molecules, and it provides features like sorting, filtering and filtered downloads. In addition to the field-based searching, Binding MOAD now can be searched by structural queries based on the ligand. In order to remove redundancy, Binding MOAD records are clustered in different families based on 90% sequence identity. The new Binding MOAD, with the upgraded platform, features and functionalities, is now equipped to better serve its users.

Single incision Nuss procedure for pectus excavatum

PURPOSE

To describe a unique single incision modification of the Nuss procedure and compare results to a historical cohort of standard Nuss patients.

METHODS

A retrospective review of 32 patients who underwent the Nuss procedure at a tertiary academic medical center over a 4-year period (2007-2010). Fourteen consecutive patients who underwent the modified technique (MN) were compared to the previous 18 patients who underwent the standard procedure (SN). We evaluated for differences between group demographics, operative variables, and postoperative course. The major technical modification was performing the entire procedure through a single right lateral thoracic incision. The dissection for bar placement on the left side of the chest was performed in a subcutaneous, pre-sternal and pre-muscular plane from the right-sided incision. The bar was placed from the right side and positioned in the standard fashion. Thoracoscopy was preformed via the same incision using a 45-degree thoracoscope and multiple trocar positions. The bar was anchored to the chest wall with a unilateral bar stabilizer.

RESULTS

There were no statistically significant differences between the study groups in any of the patient, operative or postoperative care parameters.

CONCLUSION

The single incision modified Nuss procedure is as safe and efficacious as the standard technique.

Dioxin furan blood lipid and attic dust concentrations in populations living near four wood treatment facilities in the United States

To evaluate historical exposure from wood treatment facilities, attic dust samples were collected from residential structures and blood samples were collected from current and past residents of four communities surrounding wood treatment facilities throughout the United States. The pattern of dioxin/furan congeners detected in both attic dust and blood samples was found to be consistent with exposure to contaminants generated during the wood treatment process. Levels in the U.S. population of 2,3,7,8-tetrachloro-p-dibenzodioxin toxic equivalents (2,3,7,8-TCDD TEQs) for all 17 carcinogenic dioxin/furan congeners as well as octa-chlorinated dibenzo-p-dioxin (OCDD) adjusted to its TEQ value and 1,2,3,4,6,7,8-hepta-chlorinated dibenzo-p-dioxin (1,2,3,4,6,7,8-HpCDD) adjusted to its TEQ value were compared to the TEQ levels in the combined data set for all four communities and in the data sets for each individual community. TEQ concentrations in these communities were found to be significantly greater than in the general U.S. population. The levels of dioxins in attic dust were compared to the U.S. Environmental Protection Agency's regional screening levels and found to far exceed the levels that are regarded as safe for the general population. These findings reveal that a very significant potential for contaminant-related health risks exists in communities surrounding wood treatment facilities.

Factors affecting stress placement for English nonwords include syllabic structure, lexical class, and stress patterns of phonologically similar words

Seventeen native English speakers participated in an investigation of language users' knowledge of English main stress patterns. First, they produced 40 two-syllable nonwords of varying syllabic structure as nouns and verbs. Second, they indicated their preference for first or second syllable stress of the same words in a perception task. Finally, they indicated words they considered to be phonologically similar to the nonwords. Analyses of variance on the production and perception data indicated that both syllabic structure and lexical class (noun or verb) had an effect on main stress assignment. In logistic regression analyses on the production and perception responses. predictions of stress placement made by (1) syllable structure, (2) lexical class, and (3) stress patterns of phonologically similar words all contributed significantly and uniquely to the prediction of main stress assignment. The results indicate that phonological theories of English word stress need to allow for multiple, competing, probabilistic factors in accounts of main stress placement including syllabic structure (most notably vowel length), lexical class, and stress patterns of phonologically similar words.

The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being

OBJECTIVE

To identify the prevalence of three mental disorders (Depressive Disorder, Conduct Disorder and Attention-Deficit/Hyperactivity Disorder), the prevalence of mental health problems, the health-related quality of life of those with problems, and patterns of service utilisation of those with and without mental health problems, among 4-17-year-olds in Australia. To identify rates of health-risk behaviours among adolescents with mental health problems.

METHOD

The mental disorders were assessed using the parent-version of the Diagnostic Interview Schedule for Children Version IV. Parents completed the Child Behaviour Checklist to identify mental health problems and standard questionnaires to assess health-related quality of life and service use. The Youth Risk Behaviour Questionnaire completed by adolescents was employed to identify health-risk behaviours.

RESULTS

Fourteen percent of children and adolescents were identified as having mental health problems. Many of those with mental health problems had problems in other areas of their lives and were at increased risk for suicidal behaviour. Only 25% of those with mental health problems had attended a professional service during the six months prior to the survey.

CONCLUSION

Child and adolescent mental health problems are an important public health problem in Australia. The appropriate balance between funding provided for clinical interventions focusing on individual children and families and funding for interventions that focus on populations, requires careful study. The latter are an essential component of any strategy to reduce mental health problems as the high prevalence of problems makes it unlikely that individual care will ever be available for all those needing help. Clinical and population health interventions must take into account the comorbid problems experienced by children with mental disorders.

Depression among Australian adolescents

OBJECTIVES

To examine the prevalence and factors associated with depression in Australian adolescents.

DESIGN

A representative, multistage probability sample of Australian households conducted in 1998 (part of the National Survey of Mental Health and Well-being). Adolescents completed self-report questionnaires and parents were interviewed using a lay-administered, structured psychiatric interview and several questionnaires.

PARTICIPANTS

1,490 adolescents aged 13-17 years and their parent or main caregiver.

MAIN OUTCOME MEASURES

Prevalence of depression in adolescents, as reported by parents and by adolescents themselves; demographic factors; health-risk behaviours; and rate of use of support services.

RESULTS

Of the 1,490 adolescents originally sampled, 150 (10%) did not complete responses to questions on depression and were excluded from the analysis. Seventy of the remaining 1340 adolescents (5.2%; 95% CI, 4.0%-6.4%) met criteria for self-reported depression. Agreement between parent- and adolescent-reported depression was poor (kappa=0.27). Adolescent-reported depression was associated with increased suicide plans (odds ratio [OR], 2.83; 95% CI, 1.19-6.70) and attempts (OR, 9.05; 95% CI, 3.49-23.50) in the previous year, use of marijuana 10 or more times in the previous month (OR, 2.88; 95% CI, 1.25-6.64), having conduct disorder (OR, 4.09; 95% CI, 1.23-13.63) and use of school support services (OR, 4.71; 95% CI, 1.82-12.22). Those who used any kind of support service (24/70; 34%) used a mean of 2.9 services (mode, 2; range, 1-5). Three per cent (2/70) of depressed adolescents had been treated with antidepressants.

CONCLUSIONS

Depressed adolescents exhibit higher rates of health-risk behaviours and psychosocial impairment than non-depressed adolescents, but only a small number receive appropriate treatment. Staff working in school-based services should be trained to identify adolescents with depression and facilitate referral for treatment.

Consumer satisfaction with services in a regional psychiatric hospital: a collaborative research project in Kentucky

Consumer satisfaction with mental health services is a dimension of outcome. This report is on a university and state mental health department research project that involved development of the Kentucky Consumer Satisfaction Instrument (KY-CSI) and a retrospective, cross-sectional study designed to measure consumer satisfaction with services at a regional psychiatric hospital. Triangulation of methods guided the survey of participants (N = 189) near discharge from the hospital during a 6-month period. Research associates, who were former consumers of mental health services, collected data during face-to-face interviews. Most participants were unemployed White men. Factor analysis indicated the 19-item instrument was unidimensional; Cronbach's alpha was 0.90. Multiple regression indicated predictors of satisfaction were levels of education and diagnosis. As education increased, satisfaction decreased; participants with a diagnosis of bipolar disorder tended to be more satisfied than those with other diagnoses. Analysis of qualitative data combined with standardized summary of KY-CSI items indicated participants were most satisfied with opportunities to talk with other patients and least satisfied about lack of involvement of people with whom they lived in discharge planning. Study findings guided recommendations for quality of care and additional studies at other hospital sites.

Novel method for the quantitative assessment of cell migration: a study on the motility of rabbit anterior cruciate (ACL) and medial collateral ligament (MCL) cells

A novel method of quantitating cell migration has been proposed for the potential utilization of tissue engineered scaffolds. Applying Alt's conservation law to describe the motion of first passage ACL and MCL cells, we have developed a quantitative method to assess innate differences in the motility of cells from these two ligamentous tissues. In this study, first passage ACL and MCL cells were cultured from four mature New Zealand white rabbits. One side of the cell monolayer was scraped completely away to create a wound model. The cell moved into the cell-free area, and cell density profiles were analyzed at 6 h and 12 h. Values of the random motility coefficient (mu) were then estimated by curve fitting the 6 h and 12 h data to a mathematical model, derived from the conservation law of cell flux. During 6 h of incubation in medium supplemented with 1% FBS, MCL cells (mu(MCL) = 4.63 +/- 0.65 X 10(-6) mm(2)/sec) were significantly (p < 0.05) more mobile than ACL cells (mu(ACL) = 2.51 +/- 0.31 X 10(-6) mm(2)/sec). At 12 h, the MCL cells also appeared to move faster (mu(ACL) = 4.39 +/- 0.63 X 10(-6) mm(2)/sec, mu(MCL) = 6.59 +/- 1.47 X 10(-6) mm(2)/sec), but the difference was not statistically significant (p = 0.18). Exposure of the cells to growth factors PDGF-BB or bFGF for 6 h had no significant effect on the migration of the ACL and MCL cells. However, exposure of the ACL cells (p < 0.05) and the MCL cells (p = 0.19) to 1 ng/mL of PDGFBB for 12 h enhanced their migration. Incubation with a high concentration (100 ng/mL) of PDGF-BB or bFGF at concentrations tested (1 or 100 ng/mL) for 12 h, produced little or no migratory stimulation on these ligament cells. Our findings support the previous qualitative observations made by numerous investigators. The novel methodology developed in this study may provide a basis for tissue engineering, and the results may be applied to tissue reconstruction techniques of the knee ligaments.

Case management and behavioral contracting. Components of rural substance abuse treatment

This article presents a model of case management with rural clients entering drug and alcohol treatment. As part of a larger treatment protocol called Structured Behavioral Outpatient Rural Therapy, behavioral contracting is combined with strengths perspective case management to help rural clients motivate themselves to engage and complete drug and alcohol treatment. This combined approach is designed to continually communicate and teach an "A-B-C" cognitive-behavioral approach to problem-solving and change. While not a panacea for addressing the myriad problems facing clients with drug use problems, such an approach promises to improve "treatment as usual" formats, which often ignore the formidable obstacles to human change experienced by rural clients and clinicians.

Heading off boundary problems: clinical supervision as risk management

The effective management of risk in clinical practice includes steps to limit harm to clients resulting from ethical violations or professional misconduct. Boundary problems constitute some of the most damaging ethical violations. The authors propose an active use of clinical supervision to anticipate and head off possible ethical violations by intervening when signs of boundary problems appear. The authors encourage a facilitative, Socratic method, rather than directive approaches, to help supervisees maximize their learning about ethical complexities. Building on the idea of a slippery slope, in which seemingly insignificant acts can lead to unethical patterns of behavior, the authors discuss ten cues to potential boundary problems, including strong feelings about a client; extended sessions with clients; gift giving between clinician and client; loans, barter, and sale of goods; clinician self-disclosures; and touching and sex. The authors outline supervisory interventions to be made when the cues are detected.

Spatial attention and latencies of saccadic eye movements

Recent theories of visual attention, such as the oculomotor readiness theory of Klein (1980) (Does oculomotor readiness mediate cognitive control of the visual attention. In: R. Nickerson, Attention and performance, Hillsdale: Erlbaum), the premotor theory of Rizzolati (1983) (Mechanisms of selective attention in mammals. In: J.P. Ewart, R.R. Capranica, D.J. Ingle, Advances in vertebrate Neuroethology (pp. 261-297). New York: Plenum) and the sequential attention theory of Henderson (1992) (Visual attention and eye movement control during reading and scene perception. In K. Rayner, Eye movements and visual cognition (260-283). New York: Springer-Verlag), propose a link between shifts in spatial attention and the generation of saccadic eye movements. In this paper we show that a winner-take-all model of spatial attention, combined with a simple model for the link between attention and eye movements, can account for the variation in saccadic latency observed in many oculomotor phenomena. These phenomena include the gap effect (Saslow M.G. (1967). Effects of components of displacement-step stimuli upon latency for saccadic eye movement. Journal of the Optical Society of America, 57, 1024-1029), the effect of target jumps on saccadic latency (Becker W. & Jurgens R. (1979). An analysis of the saccadic system by means of double step stimuli. Vision Research, 19, 967-983), the increase of saccadic latency as target eccentricity drops (Kalesnykas R.P. & Hallett P.E. (1994). Retinal eccentricity and the latency of eye saccades. Vision Research, 34, 517-531), and the modulation of saccadic accuracy using target predictability and saccadic latency (Coëffé C. & O'Regan J.K. (1987). Reducing the influence of non-target stimuli on saccade accuracy: predictability and latency effects. Vision Research, 27 (2), 227-240).

Word ambiguity and the optimal viewing position in reading

The optimal viewing position phenomenon discovered by (O'Regan, J. K., Lévy-Schoen, A., Pynte, J., Brugaillère, B. (1984). Convenient fixation location within isolated words of different length and structure. Journal of Experimental Psychology: Human Perception and performance. 10 (2), 250-257) is characterized by a minimization of gaze duration on a word and maximization of word recognition rates when the eye fixates a word near its center. Subsequent studies (Holmes, V. M., & O'Regan, J. K. (1987). Decomposing french words. In J. K. O'Regan, & A. Lévy-Schoen, Eye movements: from physiology to cognition, North-Holland, Amsterdam, 459-466; O'Regan, J. K., & Lévy-Schoen, A. (1987). Eye movement strategy and tactics in word recognition and reading. In M. Coltheart, Attention and performance XII: the psychology of reading, Erlbaum, Hillsdale N.J., 363-383) have shown that lexical structure can affect the location of the optimal viewing position. In this paper we show that the optimal viewing position is near to the position which minimizes word ambiguity arising from incomplete recognition of the letters in the word. This conclusion is supported by a statistical analysis based on inter-letter correlations in English and French word corpuses.

The relationship of family structure and conflict to levels of intimacy and parental attachment in college students

Randomly selected college juniors and seniors completed questionnaires concerning marital conflict, parental attachment, and attitudes about love and sex. Results indicated that intimacy was negatively correlated with parental conflict and divorce. Divorce and higher levels of conflict were associated with lower levels of intimacy in students' romantic relationships.

Social skills training for primary school children: a 1-year follow-up study

OBJECTIVE

To evaluate the effectiveness of the Rochester Social Problem Solving Program to reduce emotional and behavioural problems amongst primary school children.

METHODOLOGY

Children in years 3 and 4 at primary school were assessed prior to receiving the program, immediately after the program and 1 year after the program. At each assessment, the functioning of the children who received the program was compared to the functioning of children enrolled in years 3 and 4 at a comparable school who did not receive the program.

RESULTS

The program improved the ability of children to cope with potentially difficult social situations. However, the program did not reduce the prevalence of teacher-reported or mother-reported childhood emotional and behavioural problems.

CONCLUSIONS

School-based social skills programs may be more effective in reducing childhood emotional and behavioural problems if they include components which focus specifically on childhood behaviour problems as well as components focusing on social skills and peer relationships.

The multicatalytic proteinase (proteasome) of the hawkmoth, Manduca sexta: catalytic properties and immunological comparison with the lobster enzyme complex

The proteasome plays a central role in ubiquitin-dependent and -independent proteolysis in eukaryotic cells. The hawkmoth proteasome was purified from larval body wall and characterized with respect to substrate specificity, sensitivity to protease inhibitors, and cross-reactivity with monoclonal antibodies (mAbs) raised against human placenta proteasome. Leupeptin selectively inhibited the trypsin-like activity (T-L) and N-ethylmaleimide inhibited both T-L and chymotrypsin-like activities, whereas 0.02% sodium dodecyl sulfate stimulated the peptidylglutamyl peptide hydrolase, branched-chain amino acid preferring, and caseinolytic activities 20-, 18-, and 3.8-fold, respectively. All four peptidase activities were inhibited by 3,4-dichloroisocoumarin. One-dimensional immunoblot analysis showed that the level and subunit composition of the proteasome varied between tissues. The relative levels of proteasome were high in intersegmental muscle and ovary, lower in Malpighian tubule, male accessory gland, and ventral nerve cord, and lowest in flight muscle and fat body. The tissues differed in the relative amount of a 41-kDa doublet; a 22-kDa subunit was present only in the male accessory gland. Two-dimensional polyacrylamide gel electrophoresis showed that the hawkmoth proteasome contained at least 26 subunits, compared with 28 subunits in lobster. Immunological analysis using four subunit-specific mAbs identified the putative homologs of the human zeta, C2, C3, and C8 alpha-type subunits in the hawkmoth and lobster enzymes. Two of the four mAbs reacted with three or more of the hawkmoth subunits and three of the mAbs reacted with two or more of the lobster subunits. In addition, two other mAbs that recognize epitopes shared by a number of alpha-type subunits indicated that at least 15 (lobster) or 16 (hawkmoth) subunits were alpha-type. These results suggest that much of the subunit complexity of the arthropod proteasomes is a consequence of extensive post-translational modifications.

Increasing the efficiency of emergency medical services by using criteria based dispatch

STUDY OBJECTIVES

To determine whether criteria based dispatch (CBD) improved the efficiency of the emergency medical services system.

DESIGN

A before and after design was used to measure effects of CBD. Data were reviewed from medical reports from January 1986 through June 1992.

SETTING

King County, Washington, excluding the city of Seattle.

PARTICIPANTS

Residents who called 911 to report a medical emergency.

INTERVENTIONS

Emergency medical dispatching (EMD), basic life support (BLS), and advanced life support (ALS).

RESULTS

Findings show a decrease in ALS responses for two tracer conditions that medical control physicians determined not require ALS intervention. The percentage of febrile seizures in which paramedics responded decreased from 41% to 21% (P < .001). The percentage of cerebrovascular accidents in which paramedics responded decreased from 41% to 28% (P < .001). CBD led to a decrease, from 4.7% to 3.8% (P < .001), in frequency of requests by BLS units for dispatch of ALS units. There was no increase in the time required to dispatch each call.

CONCLUSION

CBD increased the efficiency of the EMS system by significantly reducing ALS responses to incidents not requiring ALS intervention and reducing requests by BLS units for dispatch of ALS units while maintaining a consistent time from receipt of call to dispatch.

Accuracy of determining cardiac arrest by emergency medical dispatchers

STUDY OBJECTIVE

To identify and determine the rates of delivery and performance of telephone CPR in noncardiac arrest incidents.

DESIGN

We studied prospectively all out-of-hospital cardiac arrest and potential cardiac arrest incidents from July 1 through October 31, 1992.

SETTING

King County, Washington, excluding the city of Seattle.

PARTICIPANTS

Persons with cardiac arrest or an initial complaint resembling cardiac arrest who received emergency medical services.

INTERVENTIONS

Dispatcher-assisted telephone CPR.

MEASUREMENTS AND MAIN RESULTS

Three hundred fifty-eight incidents of cardiac arrest, respiratory arrest, and potential cardiac arrest were reviewed. Telephone CPR was offered appropriately in 61 of 87 cases (70%) and inappropriately in eight of 154 potential cardiac arrests (5.2%) (95% confidence interval, 1.7%, 8.7%). Ventilation instructions were performed appropriately in 52 of 87 cases (60%) and inappropriately in three of 154 potential cardiac arrests (1.9%) (95% confidence interval, 0%, 4.1%). Chest compressions were performed appropriately in 26 of 68 cardiac arrests (38.2%) and inappropriately in two of 173 potential cardiac arrests (1.2%) (95% confidence interval, 0%, 2.8%).

CONCLUSION

We found a low rate of performance of telephone CPR in King County for incidents resembling cardiac arrest. This finding suggests that the protocols designed for dispatcher-assisted telephone CPR effectively screen out those incidents that may initially resemble cardiac arrest.

Emotional and behavioural problems experienced by children living in single-parent families: a pilot study

This study compared the prevalence of emotional and behavioural problems experienced by 10-11 year old and 14-15 year old children living in single-parent and two-parent families in South Australia. The 10-11 year old male children living in single-parent families were found to have significantly more emotional and behavioural problems than 10-11 year old male children living in two-parent families. In particular, the younger male children living in single-parent families experienced more externalizing behaviour problems than younger male children living in two-parent families. It is suggested that paediatricians and general practitioners need to be aware of children who are at particular risk for developing emotional and behavioural problems, and the approaches which may be employed to provide help.

Childhood emotional and behavioural problems: a comparison of children's reports with reports from parents and teachers

Paediatricians are often asked to assess children with emotional and behavioural problems and are faced with the dilemma that reports about the children's behaviour obtained from the children, and from their parents and teachers, may differ. This study compares the number of childhood emotional and behavioural problems reported by children living in the community, with the number of problems reported by their parents and teachers. When describing both internalizing and externalizing problems, the children consistently reported that they had more problems than were reported by either their parents or teachers. This pattern was particularly evident with reports from older female children who reported many more internalizing problems than were reported by their parents and teachers. Possible reasons for the differences between reports from children and the other informants are discussed.

Incidence of agonal respirations in sudden cardiac arrest

STUDY OBJECTIVE

To discover the frequency of agonal respirations in cardiac arrest calls, the ways callers describe them, and discharge rates associated with agonal respirations.

DESIGN

We reviewed taped recordings of calls reporting cardiac arrests and emergency medical technician and paramedic incident reports for 1991. Arrests after arrival of emergency medical services were excluded.

SETTING

King County, Washington, excluding the city of Seattle.

PARTICIPANTS

Four hundred forty-five persons with out-of-hospital cardiac arrests receiving emergency medical services.

INTERVENTIONS

Telephone CPR, emergency medical technicians-defibrillation, and advanced life support by paramedics.

MEASUREMENTS AND MAIN RESULTS

Any attempts at breathing described by callers were identified, as well as whether agonal respirations could be heard by dispatcher, emergency medical technicians, or paramedics. Agonal respirations occurred in 40% of 445 out-of-hospital cardiac arrests. Callers described agonal breathing in a variety of ways. Agonal respirations were present in 46% of arrests caused by cardiac etiology compared with 32% in other etiologies (P < .01). Fifty-five percent of witnessed arrests had agonal activity compared with 16% of unwitnessed arrests (P < .001). Agonal respirations occurred in 56% of arrests with a rhythm of ventricular fibrillation compared with 34% of cases with a nonventricular fibrillation rhythm (P < .001). Twenty-seven percent of patients with agonal respirations were discharged alive compared with 9% without them (P < .001).

CONCLUSION

There is a high incidence of agonal activity associated with out-of-hospital cardiac arrest. Presence of agonal respirations is associated with increased survival. These findings have implications for public CPR training programs and emergency dispatcher telephone CPR programs.

Dispatcher-assisted telephone CPR: common delays and time standards for delivery

STUDY OBJECTIVES

To determine the rate of bystander CPR before and after implementation of a telephone CPR program in King County; to determine the reasons for dispatcher delays in identifying patients in cardiac arrest in delivering CPR instructions over the telephone; and to suggest time standards for delivery of the telephone CPR message.

DESIGN

An ongoing cardiac arrest surveillance system to calculate the annual bystander CPR rates from 1976 through 1988. Two hundred sixty-seven taped recordings of calls reporting cardiac arrests to nine emergency dispatch centers during 1988 were reviewed and timed.

SETTING

King County, Washington, excluding the city of Seattle.

PARTICIPANTS

Two hundred sixty-seven persons with out-of-hospital cardiac arrests receiving emergency medical services. Arrests in doctors' offices, clinics, or nursing homes were excluded.

INTERVENTIONS

Dispatcher-assisted telephone CPR.

MEASUREMENTS AND MAIN RESULTS

The rate of bystander CPR increased from 32% (1976 through 1981) to 54% (1982 through 1988) after implementation of the dispatcher-assisted telephone CPR program, although an increase in survival could not be demonstrated. The median time for dispatchers to identify the problem was 75 seconds; to deliver the early protocols, 19 seconds; to deliver the ventilation instructions, 25 seconds; and to deliver compression instructions, 30 seconds. The total time to deliver the entire CPR message was 2.3 minutes. The most frequent cause for delay was unnecessary questions (57%) with questions about patient age asked most frequently (32%). Other causes included the caller not being near the patient (29%) and deviations from protocol (22%).

CONCLUSION

In a metropolitan emergency medical services system, a dispatcher-assisted telephone CPR program was associated with an increase in bystander CPR. Delays in proper delivery of telephone CPR can be minimized through training.

Differential effects of oleic acid, sodium dodecyl sulfate, and protease inhibitors on the endopeptidase activities of the lobster multicatalytic proteinase

1. Lobster muscles contain a latent multicatalytic proteinase; heating at 60 degrees C for 1-2 min converts the latent form to a heat-activated form with enhanced proteolytic activity. Both forms have three endopeptidase activities, which are classified as the trypsin-like, chymotrypsin-like, and peptidylglutamylpeptide bond hydrolyzing activities. 2. Sulfhydryl reagents (mersalyl acid, N-ethylmaleimide, hemin, iodoacetamide, and p-chloromercurisulfonic acid), benzamidine, and chloromethyl ketones inhibited all three activities of the heat-activated form. Leupeptin and antipain inhibited only the trypsin-like activity, while the chymotrypsin-like activity was the most sensitive to diisopropyl fluorophosphate, phenylmethanesulfonyl fluoride, aprotinin, and soybean trypsin inhibitor. Pepstatin and L-trans-epoxysuccinylpeptides had little effect on the peptidase activities. 3. Sodium dodecyl sulfate and oleic acid preferentially activated the peptidylglutamyl-peptide hydrolyzing activity of the latent form, whereas N-ethylmaleimide stimulated both the trypsin-like and peptidylglutamyl-peptide hydrolases. These results suggest that the lobster enzyme is an atypical serine proteinase.

Physicians' and the public's attitudes on communication about death

We studied the preferences of physicians and the public as to how physicians should inform a family of a patient's unexpected death. When the family had to be reached by telephone, 72% of our 150 physician-respondents preferred telling the family that the patient was critically ill and asking the family to come to the hospital immediately (critical notification [CN]); 25% of the physicians preferred announcing the death over the telephone (death notification [DN]). When the news had to be announced in person, 58% of physicians preferred immediately announcing it (IA), and 33% preferred gradual announcement (GA). A Gallup poll commissioned by us showed that 64% of the adult population in the United States preferred CN, 26% DN, 79% IA, and 17% GA; CN and IA were preferred in all the demographic subgroups examined. We discuss our findings, the reasons for them, and their ethical and practical implications.

Psychosocial adjustment after renal retransplants

Twenty-four patients who underwent more than one kidney transplant were interviewed to assess their psychosocial adaptation. Of these 24, we found 15 patients with a functioning kidney and 9 patients with a nonfunctioning transplant who were back on hemodialysis. In both groups, approximately 50% of the patients had life satisfaction ratings of "good" and "very good." The groups differed in two respects. Those with a functioning kidney had a higher employment rate and a better sexual functioning than the group on dialysis. We found many similarities in all other scored parameters (optimism, object relationships, coping devices, psychologic functioning). Denial was commonly used by most of the patients, but the group of patients who scored "good" and "very good" on life satisfaction more frequently utilized other coping devices, such as altruism, "feeling chosen," inner control, and activity than patients with "fair" or "poor" life satisfaction.

Reluctance to accept life-saving treatment

The patient is a twenty-three-year-old man with end-stage kidney disease who has major conflicts about receiving maintenance hemodialytic treatment. These conflicts stem in part from the patient's hospitalization at the age of seven and the witnessing of heroic medical procedures used in an attempt to treat his father's eventually successful suicide. His unconscious doubts of his manliness result in a pseudoindependent behavior and a pose of hypermasculinity which induce a rejection of passivity and the dependent position necessitated by being a patient on hemodialysis. Rejection of hemodialysis may be a conscious or unconscious suicide attempt. In this patient, it may be a consequence of guilt in relation to his father's death and of other psycho-social factors. Effective treatment for this patient should include allowing him to exercise his independence in as many ways as is possible. Home dialysis and renal transplantation lend themselves to greater feelings of independence and may be preferable to center hemodialysis in this patient. The feelings surrounding the death of his father should be explored with a liaison physician or psychiatrist.

Headaches in an angry diabetic patient

A diabetic patient with headaches is interviewed and discussed with respect to his childhood problems in dealing with aggression and separation as well as the significance of his “choice” of symptom. Suggestions are made for the effective management of such a patient.