Balint groups: an Australasian perspective for psychiatrists

OBJECTIVE

This paper aims to provide a brief overview of the history and scope of the Balint movement; to outline how Balint groups work; to describe what is entailed in leading a Balint group; and to give a brief overview of the current state of Balint work in Australia and New Zealand.

CONCLUSIONS

Balint groups provide a unique setting in which clinicians can learn how to deal well with challenging doctor-patient relationships and the feelings evoked in clinical practice. Balint work is relatively undeveloped in Australasia. There is scope for involvement by psychiatrists and trainees as both participants and facilitators.

PRACTICAL PARALLEL IMAGING COMPRESSED SENSING MRI: SUMMARY OF TWO YEARS OF EXPERIENCE IN ACCELERATING BODY MRI OF PEDIATRIC PATIENTS

For the last two years, we have been experimenting with applying compressed sensing parallel imaging for body imaging of pediatric patients. It is a joint-effort by teams from UC Berkeley, Stanford University and GE Healthcare. This paper aims to summarize our experience so far. We describe our acquisition approach: 3D spoiled-gradient-echo with poisson-disc random undersampling of the phase encodes. Our re-construction approach: ℓ₁-SPIRiT, an iterative autocalibrating parallel imaging reconstruction that enforces both data consistency and joint-sparsity in the wavelet domain. Our implementation: an on-line parallelized implementation of ℓ₁-SPIRiT on multi-core CPU and General Purpose Graphics Processors (GPGPU) that achieves sub-minute 3D reconstructions with 8-channels. Clinical results showing higher quality reconstruction and better diagnostic confidence than parallel imaging alone at accelerations on the order of number of coils.

Balint groups--an Australian perspective

Balint groups are an important, internationally established method of training general practitioners in the psychological aspects of their work. Small groups of GPs meet regularly with a trained leader to discuss clinical material from their practices, with a focus on the doctor-patient relationship. This article explains the Balint group model and its benefits and describes what is known about Balint groups in Australia, including avenues for Balint group experience available to Australian GPs.

Metronidazole improves intestinal microcirculation in septic rats independently of bacterial burden

To explore the effects of metronidazole (Me) on intestinal microcirculation in septic rats, intravital microscopy (IVM) following 16 hours of colon ascendens stent peritonitis (CASP model) was used. Four groups of animals were studied: control group (sham operation) and CASP group, each with and without Me treatment (10 mg/kg i.v.). In order to investigate the substance-specific effects of Me independently of the antibacterial effects within a pathologically altered microcirculation, a second experimental series with lipopolysaccharide challenge (LPS model) was carried out. The LPS model consisted of the four groups (control animals and LPS animals (15 mg/kg i.v. LPS from E. coli) with and without Me). IVM in the LPS experiments was performed following a two hour observation period. Me treated CASP or LPS animals, as compared with untreated, demonstrated significant improvement of functional capillary density (FCD) of the intestinal wall. The increase in the number of leukocytes firmly adhered to the endothelium (leukocyte sticking) in the untreated CASP or LPS animals within the V1 venules of the intestinal submucosal layer, was significantly reduced in the Me treated animals. In conclusion, Me exerts beneficial anti-bacterial and anti-inflammatory effects within the septic microcirculation.

Nr-CAM and neurofascin interactions regulate ankyrin G and sodium channel clustering at the node of Ranvier

Voltage-dependent sodium (Na(+)) channels are highly concentrated at nodes of Ranvier in myelinated axons and play a key role in promoting rapid and efficient conduction of action potentials by saltatory conduction. The molecular mechanisms that direct their localization to the node are not well understood but are believed to involve contact-dependent signals from myelinating Schwann cells and interactions of Na(+) channels with the cytoskeletal protein, ankyrin G. Two cell adhesion molecules (CAMs) expressed at the axon surface, Nr-CAM and neurofascin, are also linked to ankyrin G and accumulate at early stages of node formation, suggesting that they mediate contact-dependent Schwann cell signals to initiate node development. To examine the potential role of Nr-CAM in this process, we treated myelinating cocultures of DRG (dorsal root ganglion) neurons and Schwann cells with an Nr-CAM-Fc (Nr-Fc) fusion protein. Nr-Fc had no effect on initial axon-Schwann cell interactions, including Schwann cell proliferation, or on the extent of myelination, but it strikingly and specifically inhibited Na(+) channel and ankyrin G accumulation at the node. Nr-Fc bound directly to neurons and clustered and coprecipitated neurofascin expressed on axons. These results provide the first evidence that neurofascin plays a major role in the formation of nodes, possibly via interactions with Nr-CAM.

Overlapping functions of the cell adhesion molecules Nr-CAM and L1 in cerebellar granule cell development

The structurally related cell adhesion molecules L1 and Nr-CAM have overlapping expression patterns in cerebellar granule cells. Here we analyzed their involvement in granule cell development using mutant mice. Nr-CAM-deficient cerebellar granule cells failed to extend neurites in vitro on contactin, a known ligand for Nr-CAM expressed in the cerebellum, confirming that these mice are functionally null for Nr-CAM. In vivo, Nr-CAM-null cerebella did not exhibit obvious histological defects, although a mild size reduction of several lobes was observed, most notably lobes IV and V in the vermis. Mice deficient for both L1 and Nr-CAM exhibited severe cerebellar folial defects and a reduction in the thickness of the inner granule cell layer. Additionally, anti-L1 antibodies specifically disrupted survival and maintenance of Nr-CAM-deficient granule cells in cerebellar cultures treated with antibodies. The combined results indicate that Nr-CAM and L1 play a role in cerebellar granule cell development, and suggest that closely related molecules in the L1 family have overlapping functions.

Nr-CAM expression in the developing mouse nervous system: ventral midline structures, specific fiber tracts, and neuropilar regions

Nr-CAM is a member of the L1 subfamily of cell adhesion molecules (CAMs) that belong to the immunoglobulin superfamily. To explore the role of Nr-CAM in the developing nervous system, we prepared specific antibodies against both chick and mouse Nr-CAM using recombinant Fc fusion proteins of chick Nr-CAM and mouse Nr-CAM, respectively. First, we show the specificity of the new anti-chick Nr-CAM antibody compared with a previously employed antibody using the expression patterns of Nr-CAM in the chick spinal cord and floor plate and on commissural axons, where Nr-CAM has been implicated in axon guidance. Using the anti-mouse Nr-CAM antibody, we then studied the expression patterns of Nr-CAM in the developing mouse nervous system along with the patterns of two related CAMs, L1, which labels most growing axons, and TAG-1, which binds to Nr-CAM and has a more restricted distribution. Major sites that are positive for Nr-CAM are specialized glial formations in the ventral midline, including the floor plate in the spinal cord, the hindbrain and midbrain, the optic chiasm, and the median eminence in the forebrain. Similar to what is seen in the chick spinal cord, Nr-CAM is expressed on crossing fibers as they course through these areas. In addition, Nr-CAM is found in crossing fiber pathways, including the anterior commissure, corpus callosum, and posterior commissure, and in nondecussating pathways, such as the lateral olfactory tract and the habenulointerpeduncular tract. Nr-CAM, for the most part, is colocalized with TAG-1 in all of these systems. Based on in vitro studies indicating that the Nr-CAM-axonin-1/TAG-1 interaction is involved in peripheral axonal growth and guidance in the spinal cord [Lustig et al. (1999) Dev Biol 209:340-351; Fitzli et al. (2000) J Cell Biol 149:951-968], the expression patterns described herein implicate a role for this interaction in central nervous system axon growth and guidance, especially at points of decussation. Nr-CAM also is expressed in cortical regions, such as the olfactory bulb. In the hippocampus, however, TAG-1-positive areas are segregated from Nr-CAM-positive areas, suggesting that, in neuropilar regions, Nr-CAM interacts with molecules other than TAG-1.

Contactin-associated protein (Caspr) and contactin form a complex that is targeted to the paranodal junctions during myelination

Specialized paranodal junctions form between the axon and the closely apposed paranodal loops of myelinating glia. They are interposed between sodium channels at the nodes of Ranvier and potassium channels in the juxtaparanodal regions; their precise function and molecular composition have been elusive. We previously reported that Caspr (contactin-associated protein) is a major axonal constituent of these junctions (Einheber et al., 1997). We now report that contactin colocalizes and forms a cis complex with Caspr in the paranodes and juxtamesaxon. These proteins coextract and coprecipitate from neurons, myelinating cultures, and myelin preparations enriched in junctional markers; they fractionate on sucrose gradients as a high-molecular-weight complex, suggesting that other proteins may also be associated with this complex. Neurons express two contactin isoforms that differ in their extent of glycosylation: a lower-molecular-weight phosphatidylinositol phospholipase C (PI-PLC)-resistant form is associated specifically with Caspr in the paranodes, whereas a higher-molecular-weight form of contactin, not associated with Caspr, is present in central nodes of Ranvier. These results suggest that the targeting of contactin to different axonal domains may be determined, in part, via its association with Caspr. Treatment of myelinating cocultures of Schwann cells and neurons with RPTPbeta-Fc, a soluble construct containing the carbonic anhydrase domain of the receptor protein tyrosine phosphatase beta (RPTPbeta), a potential glial receptor for contactin, blocks the localization of the Caspr/contactin complex to the paranodes. These results strongly suggest that a preformed complex of Caspr and contactin is targeted to the paranodal junctions via extracellular interactions with myelinating glia.

Gender-specific effects of NAT2 and GSTM1 in bladder cancer

One approach for risk assessment of cancer is the evaluation of polymorphic enzymes involved in cancer using molecular tools. Phase II enzymes are involved in the detoxification of several drugs, environmental substances and carcinogenic compounds. Here, we analyzed enzymes for their putative relevance in urinary bladder cancer. The hereditable enzyme polymorphism of arylamine N-acetyltransferase 2 (NAT2) and glutathione S-transferase M1 (GSTM1) and T1 (GSTT1) was studied in 157 hospital-based patients and in 223 control subjects. Slow acetylation was not observed to be a significant risk factor of developing bladder cancer (OR: 1.33; 95% CI 0.85-2.09). One genotype responsible for slow acetylation (NAT2*5B/*6A) was observed significantly more frequently in bladder cancer patients compared with control subjects (OR: 1.63; 95% CI 1.03-2.58). Gender-specific effects were observed when patients were divided into subgroups. In male patients, slow acetylators were identified as carrying a significant increased risk of developing bladder cancer, in particular when the genotype NAT2*5B/*6A was combined with the GSTM1 null genotype (OR: 4.39; 95% CI 1.98-9.74). By contrast, the same genotype combination significantly protected female patients from bladder cancer (OR: 0.21; 95% CI 0.06-0.80).

Evidence for striatal modulation in the presence of fixed cortical injury in obsessive-compulsive disorder (OCD)

A patient with obsessive-compulsive disorder (OCD) onset resulting from a traumatic head injury underwent longitudinal brain imaging evaluation. Structural and functional brain imaging studies were repeatedly performed before and after treatment. Computerized tomography (CT) demonstrated bilateral prefrontal contusions immediately following the trauma and prior to the onset of OCD. Magnetic resonance imaging (MRI) demonstrated bilateral cortical abnormalities in the prefrontal and anterior-temporal regions a few months following the onset of OCD. Almost concurrently, single photon emission computerised tomography (SPECT) demonstrated bilateral perfusion deficits in fronto-temporal regions, and asymmetric increased perfusion in the anterior striatum. Six months later, after clinical improvement, a second SPECT study demonstrated improvement of brain perfusion, mostly in the striatum. The reflection of these results on a possible model of brain pathogenesis in OCD, and the role of brain imaging in neuropsychiatric evaluation, are demonstrated.

Ventral midline cells are required for the local control of commissural axon guidance in the mouse spinal cord

Specialized cells at the midline of the central nervous system have been implicated in controlling axon projections in both invertebrates and vertebrates. To address the requirement for ventral midline cells in providing cues to commissural axons in mice, we have analyzed Gli2 mouse mutants, which lack specifically the floor plate and immediately adjacent interneurons. We show that a Dbx1 enhancer drives tau-lacZ expression in a subpopulation of commissural axons and, using a reporter line generated from this construct, as well as DiI tracing, we find that commissural axons projected to the ventral midline in Gli2(−/−) embryos. Netrin1 mRNA expression was detected in Gli2(−/−) embryos and, although much weaker than in wild-type embryos, was found in a dorsally decreasing gradient. This result demonstrates that while the floor plate can serve as a source of long-range cues for C-axons in vitro, it is not required in vivo for the guidance of commissural axons to the ventral midline in the mouse spinal cord. After reaching the ventral midline, most commissural axons remained clustered in Gli2(−/−) embryos, although some were able to extend longitudinally. Interestingly, some of the longitudinally projecting axons in Gli2(−/−) embryos extended caudally and others rostrally at the ventral midline, in contrast to normal embryos in which virtually all commissural axons turn rostrally after crossing the midline. This finding indicates a critical role for ventral midline cells in regulating the rostral polarity choice made by commissural axons after they cross the midline. In addition, we provide evidence that interactions between commissural axons and floor plate cells are required to modulate the localization of Nr-CAM and TAG-1 proteins on axons at the midline. Finally, we show that the floor plate is not required for the early trajectory of motoneurons or axons of the posterior commissure, whose projections are directed away from the ventral midline in both WT and Gli2(−/−) embryos, although they are less well organized in Gli2(−/−)mutants.

Expression and regulation of LRP-2/megalin in epithelial cells lining the efferent ducts and epididymis during postnatal development

Low density lipoprotein receptor-related protein-2/megalin (LRP-2) is a receptor belonging to the low density lipoprotein receptor family that mediates endocytosis and lysosomal degradation of a variety of ligands including apolipoprotein J (Apo J)/clusterin/SGP-2. LRP-2 has been shown to be expressed regionally in the adult rat epididymis. In this study, we describe the pattern of expression of LRP-2 in the efferent ducts and epididymis during postnatal development of the rat and examine the role of testicular luminally derived substances on its expression. The expression of LRP-2 was analyzed immunocytochemically in tissues of normal animals ranging in age from postnatal day 7-90 and in 15-day-old efferent-duct-ligated animals sacrificed at later ages. In the efferent ducts, LRP-2 expression, appearing as a dense band on the apical surface of the nonciliated epithelial cells, was noted as early as day 7, well before the entry of sperm, Sertoli-cell-derived secretory products, and high levels of androgens. Efferent duct ligation studies further revealed that expression under this condition was comparable to controls at all later ages examined, suggesting that the factor regulating its expression was not a luminally derived testicular substance. In normal untreated animals, LRP-2 expression was not apparent at any of the ages examined in the proximal initial segment of the epididymis. By comparison, the distal initial segment, although having no LRP-2 expression from 7-15 days, showed expression in principal cells by day 21 which intensified at days 29 and 39. However, by day 49 and at later ages (56 and 90), LRP-2 immunoreactivity over principal cells became spotty or with weak or moderate reactivity in some cells and none in others. LRP-2 expression in the intermediate zone, proximal caput, corpus, and cauda regions also appeared in principal cells by day 21, intensified at days 29 and 39 and persisted as such at all later ages examined, correlating with high levels of androgens shown to occur by day 39. Although LRP-2 expression in the distal caput region was evident in principal cells at days 21 and 29, it became spotty with weak, moderate, or absent reactivity over principal cells at all later ages. These data suggest that LRP-2 expression is under the influence of both stimulatory and region-specific inhibitory factors. Analysis of 15-day-old efferent-duct-ligated animals at all later ages examined revealed that there was no change in LRP-2 expression along the entire epididymis, suggesting that both the stimulatory and inhibitory factors are not luminally derived testicular substances. The observed pattern of LRP-2 expression in all regions of the epididymis, except the distal caput region, was similar to that described for Apo J internalization by principal cells during postnatal development, showing a correlation between LRP-2 expression and its ligand, Apo J. In summary, LRP-2 expression in the epididymis undergoes region-specific changes during postnatal development and appears to be influenced by both stimulatory and inhibitory factors.

Nr-CAM promotes neurite outgrowth from peripheral ganglia by a mechanism involving axonin-1 as a neuronal receptor

Nr-CAM is a neuronal cell adhesion molecule (CAM) belonging to the immunoglobulin superfamily that has been implicated as a ligand for another CAM, axonin-1, in guidance of commissural axons across the floor plate in the spinal cord. Nr-CAM also serves as a neuronal receptor for several other cell surface molecules, but its role as a ligand in neurite outgrowth is poorly understood. We studied this problem using a chimeric Fc-fusion protein of the extracellular region of Nr-CAM (Nr-Fc) and investigated potential neuronal receptors in the developing peripheral nervous system. A recombinant Nr-CAM-Fc fusion protein, containing all six Ig domains and the first two fibronectin type III repeats of the extracellular region of Nr-CAM, retains cellular and molecular binding activities of the native protein. Injection of Nr-Fc into the central canal of the developing chick spinal cord in ovo resulted in guidance errors for commissural axons in the vicinity of the floor plate. This effect is similar to that resulting from treatment with antibodies against axonin-1, confirming that axonin-1/Nr-CAM interactions are important for guidance of commissural axons through a spatially and temporally restricted Nr-CAM positive domain in the ventral spinal cord. When tested as a substrate, Nr-Fc induced robust neurite outgrowth from dorsal root ganglion and sympathetic ganglion neurons, but it was not effective for tectal and forebrain neurons. The peripheral but not the central neurons expressed high levels of axonin-1 both in vitro and in vivo. Moreover, antibodies against axonin-1 inhibited Nr-Fc-induced neurite outgrowth, indicating that axonin-1 is a neuronal receptor for Nr-CAM on these peripheral ganglion neurons. The results demonstrate a role for Nr-CAM as a ligand in axon growth by a mechanism involving axonin-1 as a neuronal receptor and suggest that dynamic changes in Nr-CAM expression can modulate axonal growth and guidance during development.

Epidemiology of obsessive-compulsive disorder: a world view

The worldwide prevalence of obsessive-compulsive disorder (OCD) is approximately 2% of the general population. Symptoms of OCD include fear of contamination by dirt or germs; constant checking; repetitive, intrusive thoughts of a somatic, aggressive, or sexual nature; extreme slowness; and an inordinate concern with orderliness and symmetry. Differential diagnosis is sometimes complicated by the overlap between OCD and obsessive-compulsive personality disorder (OCPD). The most common complication of OCD is depression. However, while both serotonergic and nonserotonergic antidepressants are effective in treating patients with depression, only serotonergic medications are effective in treating OCD patients. Because OCD patients often attempt to conceal their symptoms, it is incumbent on clinicians to screen for OCD in every mental status examination, since appropriate treatment can often result in improved quality of life.

Cell adhesion molecules regulate guidance of dorsal root ganglion axons in the marginal zone and their invasion into the mantle layer of embryonic spinal cord

In order to elucidate the mechanisms regulating the projections of dorsal root ganglion (DRG) axons in the dorsal funiculus and invasion into target regions in the mantle layer (prospective gray matter) of the spinal cord, we examined the interactions between DRG axons and spinal cord. DRG neurons were dissociated from chick embryos and cultured for 1-2 days on cryostat sections of the spinal cord at embryonic day 5 (E5) or at E9. E5 and E9 DRG neurons extended neurites onto both marginal zone (prospective white matter) and mantle layer (prospective gray matter) of the spinal cord, suggesting that both of these regions are permissive for neurite growth. When E5 DRG neurites approached cryosections of E5 spinal cord from outside, most of them ran in the marginal zone without invading the mantle layer. In contrast, about half of E9 DRG neurites entered the mantle layer after crossing the marginal zone of E9 spinal cord. These growth patterns of DRG neurites on spinal marginal zone and mantle layer are similar to the pathway formation of DRG axons at comparable stages in vivo; DRG axons run exclusively in the prospective dorsal funiculus before E6, and enter the mantle layer (prospective dorsal horn) to reach the target regions by E9. Perturbation of functions of Ng-CAM, Nr-CAM, and axonin-1/SC2 by adding the specific antibodies in the culture medium increased the ratio of DRG neurites entering the mantle layer of E5 spinal cord, suggesting that these cell adhesion molecules are involved in keeping DRG neurites in the marginal zone. Taken together with the expression of Ng-CAM, Nr-CAM, and axonin-1/SC2, these CAMs on DRG axons may regulate the guidance of these axons in the marginal zone before E6, and the subsequent decrease in the relative levels of these CAMs might allow DRG axons to invade the target mantle layer.

Identification of a novel contactin-associated transmembrane receptor with multiple domains implicated in protein-protein interactions

Receptor protein tyrosine phosphatase beta (RPTPbeta) expressed on the surface of glial cells binds to the glycosylphosphatidylinositol (GPI)-anchored recognition molecule contactin on neuronal cells leading to neurite outgrowth. We describe the cloning of a novel contactin-associated transmembrane receptor (p190/Caspr) containing a mosaic of domains implicated in protein-protein interactions. The extracellular domain of Caspr contains a neurophilin/coagulation factor homology domain, a region related to fibrinogen beta/gamma, epidermal growth factor-like repeats, neurexin motifs as well as unique PGY repeats found in a molluscan adhesive protein. The cytoplasmic domain of Caspr contains a proline-rich sequence capable of binding to a subclass of SH3 domains of signaling molecules. Caspr and contactin exist as a complex in rat brain and are bound to each other by means of lateral (cis) interactions in the plasma membrane. We propose that Caspr may function as a signaling component of contactin, enabling recruitment and activation of intracellular signaling pathways in neurons. The binding of RPTPbeta to the contactin-Caspr complex could provide a mechanism for cell-cell communication between glial cells and neurons during development.

Induction of neurite outgrowth through contactin and Nr-CAM by extracellular regions of glial receptor tyrosine phosphatase beta

Receptor protein tyrosine phosphatase beta (RPTPbeta) is expressed as soluble and receptor forms with common extracellular regions consisting of a carbonic anhydrase domain (C), a fibronectin type III repeat (F), and a unique region called S. We showed previously that a recombinant Fc fusion protein with the C domain (beta C) binds to contactin and supports neuronal adhesion and neurite growth. As a substrate, betaCFS was less effective in supporting cell adhesion, but it was a more effective promoter of neurite outgrowth than betaCF. betaS had no effect by itself, but it potentiated neurite growth when mixed with betaCF. Neurite outgrowth induced by betaCFS was inhibited by antibodies against Nr-CAM and contactin, and these cell adhesion molecules formed a complex that bound betaCFS. NIH-3T3 cells transfected to express betaCFS on their surfaces induced neuronal differentiation in culture. These results suggest that binding of glial RPTPbeta to the contactin/Nr-CAM complex is important for neurite growth and neuronal differentiation.

Relapse and recurrence following a course of ECT: reasons for concern and strategies for further investigation

Patients treated with electroconvulsive therapy (ECT) have a more severe illness. This severity is evidenced in the clinical profile of the illness, in the course of the illness, in the resistance to pharmacotherapy, and in the high relapse and recurrence rates after the course of ECT. In this article the authors explore some of the issues, particularly those of biological correlates of severe mood disorders and the continuation of treatment after ECT, which may be factors in this increased severity. The authors propose avenues for the investigation and treatment of severe mood disorders treated with ECT.

Apoptosis during macrophage-dependent ocular tissue remodelling

We have characterized the nature and pattern of cell death during regression of the pupillary membrane, a developmentally transient capillary network found in the anterior chamber of the eye. This analysis has revealed that the cellular components of the pupillary membrane include vascular endothelial cells in an intricate network of fine capillaries as well as attendant macrophages. The capillaries are situated on the anterior surface of the lens and held in relative position by a cobweb-like meshwork of extracellular matrix fibres that regress along with the cellular components of this structure. Cell death during regression of the pupillary membrane is characteristic of apoptosis. Specifically, apoptotic bodies containing condensed chromatin can be observed in vascular endothelial cells and genomic DNA isolated from the pupillary membrane shows the nucleosomal fragmentation pattern typical of apoptotic cells. Using a method for labelling fragmented DNA in tissue preparations (TUNEL), we have assessed the overall pattern of apoptotic cell death during pupillary membrane regression. We find that apoptosis occurs either in single cells in healthy vessels or synchronously along the entire length of a capillary segment. Both morphological and TUNEL analysis indicate that capillary regression occurs from junction to junction one segment at a time. We propose a model to explain the pattern of capillary regression observed and conclude from these and previous experiments (Lang and Bishop (1993) Cell 74, 453–462), that during regression of the pupillary membrane, the macrophage elicits target cell death by inducing apoptosis.

[A slide ruler and nomogram for calculations in cumulation kinetics of cardiac glycosides (author's transl)]

1. Substance I, whose elimination we can approximate with an exponential function, is active in the organism. 2. At a given moment substance II with the same onset of action whose elimination we also can approximate with an exponential function but different from substance I, starts to be added at regular intervals. 3. The relative levels of the two substances can be added up. 4. The optimal dose-scheme for the most regular effect is to be sought.

RESULTS

According to the relations derived in repost (5) published previously a slide ruler and a nomogram are constructed by the authors for that purpose. The scales are described as well as how to work with them. Some examples are included. The slide ruler and the nomogram are suitable for some further calcaulations in cumulation kinetics, which is briefly mentioned. These expedients are mainly meant for the application of cardiac glycosides. The same principle can be used in all cases to which the assumptions mentioned above apply.