A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Coordinate-based cluster analysis

A new approach to cluster analysis of structures based on collective superpositions rather than pairwise superpositions is presented. The method is fast and rigorous and is illustrated by application to 21 structures derived from NMR experiments. Source code, suitable for most laboratory machines, is available from the author, and a CCP4 version is in preparation.

Primary care physicians' experience with mental health consultation

A total of 684 primary care physicians in Wisconsin participated in a survey designed to explore their experiences of consulting with and referring patients to mental health care professionals. The respondents indicated that they had only moderate access to mental health care professionals, and even less access when a patient was covered by Medicare or Medicaid or had no insurance. Physicians in group practices that included at least one mental health professional reported having better access to care than those in practices that did not include mental health services. Perceived access to mental health care services was not related to community size or to a managed care setting.

Video-capture teleradiology for the after-hours reading of computerized tomography scans

We evaluated the after-hours support that radiologists could provide from their homes to an urban hospital for reading emergency computerized tomography (CT) scans. During a six-month study period, 36 CT scans were acquired using a video-capture card in a PC and transmitted via an ordinary telephone line. The teleradiology interpretation and the formal report (from the hard copy) were compared with a reference or gold standard interpretation made by a radiologist and an emergency physician for 31 of the 36 cases. In comparison with the gold standard, there were 26 correct diagnoses by teleradiology (84%) and five incorrect (16%). Head CT scans accounted for 74% of the transmitted scans and all five of the cases with discrepant diagnoses. The cause of the single clinically relevant discrepancy was found to be unrelated to the use of teleradiology. In comparison with the formal report, the accuracy of the teleradiologist was not significantly different for all categories combined or for head CT scans alone. Video-capture technology provided a reliable means of transmitting CT scans for after-hours interpretation in emergency cases.

The Wisconsin Quality of Life Index: a multidimensional model for measuring quality of life

The Wisconsin Quality of Life Index (W-QLI) is a multidimensional model for measuring quality of life. This model assumes that quality of life is comprised of 9 dimensions: life satisfaction, occupational activities, psychological well-being, physical health, social relations, economics, activities of daily living, symptoms, and the patient's own goals. The W-QLI takes into account the different perspectives of the patient, the patient's family, and the clinician, both currently and over time. An accompanying taxonomy and patient outcome report can be used in clinical practice to group the patient's goals and to track the attainment of the goals over time, as well as to show the agreements and disagreements between the patient and clinician in terms of how satisfied each is with the patient's progress. The W-QLI, taxonomy, and outcome report can also incorporate the service provider's goals and can be used to examine program results.

Assessment of the safety of supplementation with different amounts of vitamin E in healthy older adults

We showed previously that supplementation for 30 d with 800 IU (727 mg) vitamin E/d did not adversely affect healthy elderly persons. We have now assessed the effects of 4 mo of supplementation with 60, 200, or 800 IU (55, 182, or 727 mg) all-rac-alpha-tocopherol/d on general health, nutrient status, liver enzyme function, thyroid hormone concentrations, creatinine concentrations, serum autoantibodies, killing of Candida albicans by neutrophils, and bleeding time in 88 healthy subjects aged >65 y participating in a double-blind, placebo-controlled trial. No side effects were reported by the subjects. Vitamin E supplementation had no effect on body weight, plasma total proteins, albumin, glucose, plasma lipids or the lipoprotein profile, total bilirubin, alkaline phosphatase, serum aspartate aminotransferase, serum alanine aminotransferase, lactate dehydrogenase, serum urea nitrogen, total red blood cells, white blood cells or white blood cell differential counts, platelet number, bleeding time, hemoglobin, hematocrit, thyroid hormones, or urinary or serum creatinine concentrations. Values from all supplemented groups were within normal ranges for older adults and were not significantly different from values in the placebo group. Vitamin E supplementation had no significant effects on plasma concentrations of other antioxidant vitamins and minerals, glutathione peroxidase, superoxide dismutase, or total homocysteine. There was no significant effect of vitamin E on serum nonspecific immunoglobulin concentrations or anti-DNA and anti-thyroglobulin antibodies. The cytotoxic ability of neutrophils against Candida albicans was not compromised. Thus, 4 mo of supplementation with 60-800 IU vitamin E/d had no adverse effects. These results are relevant for determining risk-to-benefit ratios for vitamin E supplementation.

Effect of anticoagulation protocol on outcome in patients undergoing CABG with heparin-bonded cardiopulmonary bypass circuits

BACKGROUND

We have demonstrated that the use of heparin-bonded cardiopulmonary bypass circuits (HBCs) combined with a lower anticoagulation protocol as an adjunct to an integrated blood conservation strategy decreases the incidence and magnitude of homologous transfusion and improves clinical outcome in patients undergoing primary coronary artery bypass grafting. It is not known whether it is the lower anticoagulation protocol that influences outcome in patients treated with HBCs. Furthermore, the thrombogenic risk of using lower anticoagulation with HBCs still is debated.

METHODS

To answer these questions, a prospective randomized study was conducted in which 244 patients undergoing primary coronary artery bypass grafting were treated with HBCs and randomized to undergo either a full (activated clotting time, > 450 seconds) or a lower (activated clotting time, > 250 seconds) anticoagulation protocol. In addition to clinical outcome, levels of thrombin generation markers during and after cardiopulmonary bypass were assessed in a consecutive subset of 58 patients (full anticoagulation profile = 28, lower anticoagulation profile = 30) by measuring thrombin-antithrombin complexes and prothrombin fragment 1.2. Levels of these markers also were correlated with the activated clotting time during cardiopulmonary bypass.

RESULTS

Preoperative and intraoperative risk profiles and other characteristics were similar in both groups, with more than 60% of patients undergoing nonelective operation. Compared with the full anticoagulation protocol group, patients in the lower anticoagulation protocol group were less likely to require blood products (24.2% versus 35.8%, respectively; p = 0.047) and received substantially fewer homologous donor units (0.50 +/- 0.92 versus 1.08 +/- 2.10 U, respectively; p = 0.005). Clinical outcomes were uniformly outstanding (but similar) in both treatment groups, with a modest reduction in the length of the hospital stay in the lower anticoagulation protocol group (5.26 +/- 1.23 versus 5.63 +/- 1.73 days, respectively; p = 0.05). The use of HBCs with a lower anticoagulation protocol was not associated with any adverse clinical events. Thrombin generation increased during cardiopulmonary bypass in both treatment groups, but was unrelated to the anticoagulation protocol or the activated clotting time (r2 = 0.03). No differences between the full and lower anticoagulation protocol groups were noted in the number of microemboli detected by transcranial Doppler analyses during cardiopulmonary bypass (n = 40) or in the postoperative neurologic and neuropsychologic outcomes (n = 30).

CONCLUSIONS

This study definitively demonstrates that, when used appropriately, patients who are treated with HBCs and a lower anticoagulation protocol have a lower incidence and magnitude of homologous transfusion and are not at any added risk for clinical, hematologic (thrombin-antithrombin complex and fragment 1.2 measurements), or microscopic (transcranial Doppler analyses) thromboembolic complications or for neurologic or neuropsychologic deficits.

Two divergent catalase genes are differentially regulated during Aspergillus nidulans development and oxidative stress

Catalases are ubiquitous hydrogen peroxide-detoxifying enzymes that are central to the cellular antioxidant response. Of two catalase activities detected in the fungus Aspergillus nidulans, the catA gene encodes the spore-specific catalase A (CatA). Here we characterize a second catalase gene, identified after probing a genomic library with catA, and demonstrate that it encodes catalase B. This gene, designated catB, predicts a 721-amino-acid polypeptide (CatB) showing 78% identity to an Aspergillus fumigatus catalase and 61% identity to Aspergillus niger CatR. Notably, similar levels of identity are found when comparing CatB to Escherichia coli catalase HPII (43%), A. nidulans CatA (40%), and the predicted peptide of a presumed catA homolog from A. fumigatus (38%). In contrast, the last two peptides share a 79% identity. The catalase B activity was barely detectable in asexual spores (conidia), disappeared after germination, and started to accumulate 10 h after spore inoculation, throughout growth and conidiation. The catB mRNA was absent from conidia, and its accumulation correlated with catalase activity, suggesting that catB expression is regulated at the transcription level. In contrast, the high CatA activity found in spores was lost gradually during germination and growth. In addition to its developmental regulation, CatB was induced by H2O2, heat shock, paraquat, or uric acid catabolism but not by osmotic stress. This pattern of regulation and the protective role against H2O2 offered by CatA and CatB, at different stages of the A. nidulans life cycle, suggest that catalase gene redundancy performs the function of satisfying catalase demand at the two different stages of metabolic and genetic regulation represented by growing hyphae versus spores. Alternative H2O2 detoxification pathways in A. nidulans were indicated by the fact that catA/catB double mutants were able to grow in substrates whose catabolism generates H2O2.

Treatment of NOE constraints involving equivalent or nonstereoassigned protons in calculations of biomacromolecular structures

Two modifications to the commonly used protocols for calculating NMR structures are developed, relating to the treatment of NOE constraints involving groups of equivalent protons or nonstereoassigned diastereotopic protons. Firstly, a modified method is investigated for correcting for multiplicity, which is applicable whenever all NOE intensities are calibrated as a single set and categorised in broad intensity ranges. Secondly, a new set of values for 'pseudoatom corrections' is proposed for use with calculations employing 'centre-averaging'. The effect of these protocols on structure calculations is demonstrated using two proteins, one of which is well defined by the NOE data, the other less so. It is shown that failure to correct for multiplicity when using 'r(-6) averaging' results in overly precise structures, higher NOE energies and deviations from geometric ideality, while failure to correct for multiplicity when using 'r(-6) summation' can cause an avoidable degradation of precision if the NOE data are sparse. Conversely, when multiplicities are treated correctly, r(-6) averaging, r(-6) summation and centre averaging all give closely comparable results when the structure is well defined by the data. When the NOE data contain less information, r(-6) averaging or r(-6) summation offer a significant advantage over centre averaging, both in terms of precision and in terms of the proportion of calculations that converge on a consisten result.

Mild head injury and post concussion syndrome: does anyone really suffer?

There is some controversy in the scientific literature regarding the rate and extent of recovery from mild closed head injury. Most clinicians agree that there is a potential constellation of symptoms which has been labeled the post concussive syndrome, and that this disorder does affect, at least temporarily, a subset of this mild head trauma population. The rate and extent of recovery from mild head injury is dependent upon a number of complicating factors such as extent of injury, age, education, vocational skills, cognitive abilities, psychosocial functioning, and general physical health. This article attempts to answer the question, does anyone really suffer after experiencing a mild head injury and, if so, what are the problems, how do we identify these individuals, and what intervention may we offer?

Validation of the NES2 in patients with neurologic disorders

Performance on the Neurobehavioral Evaluation System (NES) has been demonstrated to be affected by exposure to a variety of neurotoxicants. However, the relation of NES subtests to CNS function has not yet been documented in patients diagnosed with neurologic disorders known to implicate specific brain substrates. A validation study of the NES2 was carried out in patients with multiple sclerosis (MS) and Parkinson's disease (PD), disorders exhibiting neuropathology at loci (white matter in MS, basal ganglia in PD) believed to be the sites of action of several known neurotoxicants. The results indicated that performance on certain NES2 subtests was affected in expected ways in both types of patients. However, performance on many more subtests was impaired, relative to controls, in MS than in PD. The relative insensitivity to PD suggests that expansion and refinement of the battery are required if it is to serve well in detecting the effects of toxicants in subjects without frank physical symptoms. These are the goals of a new version of the instrument currently under development (NES3).

A comparison of NES2 and traditional neuropsychological tests in a neurologic patient sample

The Neurobehavioral Evaluation System (NES), a computer-assisted battery of behavioral tests, has been widely used to detect central nervous system dysfunction in occupational and environmental settings and has recently been adapted for testing of neurological patients. The purpose of the present study was to assess the relationship between NES tasks and the traditional neuropsychological tests from which many of the NES tests were developed. For this purpose, comparisons were made between scores on NES tests and traditional neuropsychological tests designed to measure functioning in the same cognitive domains in a sample of patients with idiopathic Parkinson's disease (PD). As has been found in prior studies with normal subjects, correlations between traditional and NES2 tests varied from low to moderate. Correlations tended to be low when the modality of stimulus presentation or responses was different in the NES tests from the traditional tasks (e.g., verbal rather than visual) or when divergent and highly specific cognitive functions were being measured by the tests.

Judgments of quality of life of individuals with severe mental disorders: Patient self-report versus provider perspectives

OBJECTIVE

This study was an investigation of judgments regarding quality of life of individuals with severe mental disorders from two different perspectives: patient self-report versus provider.

METHOD

Judgments on several dimensions of quality of life were collected from a convenience sample of 37 schizophrenic patients and their primary clinicians by using the well-known Quality of Life Index of Spitzer et al. and the more recently developed Quality of Life Index-Mental Health. Both indexes capture judgments on a number of dimensions. Patterns of concordance for the patient-provider pairs were tested by using Cohen's kappa and Pearson correlation coefficients.

RESULTS

The results suggest that patients' and providers' judgments are more likely to coincide on clinical aspects, such as symptoms and function, than on social aspects. Specifically, there was moderate agreement on symptoms and function, less agreement on physical health, and little to no agreement on social relations and occupational aspects of quality of life.

CONCLUSIONS

Such differences support the notion that treatment strategies and mental health services should address a wide range of needs reflecting different aspects of quality of life perceived as important by different patients.

An infertility primer for family therapists: I. Medical, social, and psychological dimensions

A seemingly "self-evident truth" in most people's lives is that one day they will have children. This universal, biopsychosocial assumption goes unchallenged until a couple faces infertility. Although the effects of such a challenge are profound, infertility is often treated as a nonevent--both within our society as a whole, and within the field of family therapy in particular. To assist clinicians who work with this numerically increasing population, and the many others who have been affected by their encounter with infertility in the past, this article discusses the biological/medical, psychological, and social factors that shape the experience of infertility in our society.

An infertility primer for family therapists: II. Working with couples who struggle with infertility

The distress of infertility and its medical treatments are profound, and the effects reverberate in each partner, the couple dyad, and the couple's relationships with family, friends, and medical systems. Yet family therapists, like others in our society, are often uninformed or misinformed about the experience of infertility. While the legacies of infertility may be painful and enduring, they often remain unspoken, and hence may be overlooked in standard interviews. This article describes the experiences of couples struggling with infertility, most of whom have sought medical intervention, and it provides treatment interventions for guiding couples through this difficult and often uncharted terrain. Case vignettes derived from 2 years of this clinical research study are included.

Apoptosis induced by serum deprivation of PC12 cells is not preceded by growth arrest and can occur at each phase of the cell cycle

Previous studies have shown that PC12 cells undergo apoptosis (programmed cell death) when deprived of serum. In the present study, we examined the relationship of this death process to the cell cycle. PC12 cell populations synchronized at different, specific phases of the cell cycle exhibit similar kinetics of cell death following deprivation of serum. Flow cytometry analysis was used to examine the levels of apoptotic death in these cell populations in relationship to their progression in the cell cycle during the course of serum deprivation. Such analysis revealed that the cells die during the G0-G1, S, and perhaps G2-M phases and at the G2 to G1 transition. These results, therefore, suggest that the death of synchronized, serum-deprived PC12 cells occurs throughout the cell cycle and is not dependent on growth arrest. Flow cytometry methodology (acridine orange staining), which determines the RNA content of cells in relationship to their position in the cell cycle, was used to address these questions in nonsynchronized cells. These experiments revealed that, upon serum deprivation, an immediate loss of RNA occurred from cells in G1, S, and G2-M phases. This loss is accompanied by a slower appearance of cells with degraded DNA content. These results show that cells from all phases of the cell cycle are damaged upon serum deprivation and thus suggest that the apoptotic cell death of nonsynchronized PC12 cells may occur from each phase of the cell cycle.

A new patient focused index for measuring quality of life in persons with severe and persistent mental illness

The quality of life in persons with severe and persistent mental illness is often poor. Most treatment programmes have the goal of increasing quality of life. Unfortunately, existing methods to assess quality of life are cumbersome and oriented towards research rather than clinical settings. This study describes preliminary steps in the development, testing and application of a new patient focused index for measuring quality of life in persons with severe mental illness. The Quality of Life Index for Mental Health (QLI-MH) differs from existing instruments in that it is based on an easy to use, self-administered questionnaire that assesses nine separate domains that together encompass quality of life. Each domain can be individually weighted depending on its relative importance to the patient. Different parts of the instrument solicit information from the patient, the primary clinician, and, when available, the family. The instrument and its scoring system address limitations of previous approaches to quality of life measurement.

Residual cognitive deficits 50 years after lead poisoning during childhood

The long term neurobehavioural consequences of childhood lead poisoning are not known. In this study adult subjects with a documented history of lead poisoning before age 4 and matched controls were examined with an abbreviated battery of neuropsychological tests including measures of attention, reasoning, memory, motor speed, and current mood. The subjects exposed to lead were inferior to controls on almost all of the cognitive tasks. This pattern of widespread deficits resembles that found in children evaluated at the time of acute exposure to lead rather than the more circumscribed pattern typically seen in adults exposed to lead. Despite having completed as many years of schooling as controls, the subjects exposed to lead were lower in lifetime occupational status. Within the exposed group, performance on the neuropsychological battery and occupational status were related, consistent with the presumed impact of limitations in neuropsychological functioning on everyday life. The results suggest that many subjects exposed to lead suffered acute encephalopathy in childhood which resolved into a chronic subclinical encephalopathy with associated cognitive dysfunction still evident in adulthood. These findings lend support to efforts to limit exposure to lead in childhood.

Evaluation of new antifungal drugs for the treatment of systemic fungal infections. Infectious Diseases Society of America and the Food and Drug Administration

These guidelines are applicable to all fungal pathogens that produce systemic infections in humans. Specific examples are provided whenever they might clarify special issues. Systemic fungal infections usually are divided into two broad categories: endemic systemic fungal diseases, which occur classically in healthy hosts, and opportunistic fungal diseases, which occur almost exclusively in patients with impaired host defenses. Both the increasing frequency of disseminated histoplasmosis and coccidioidomycosis in patients with AIDS and the occurrence of candidemia due to vascular-line infections have begun to blur this distinction. The fungi included in these guidelines are Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Candida species, Cryptococcus neoformans, Aspergillus species, and Sporothrix schenckii. Diagnosis of infections caused by these fungi should be based on culture of infected body fluids or tissues whenever possible. Cryptococcal and coccidioidal meningitis are exceptions. Amphotericin B remains the standard comparative agent for most new agents. Further studies of the efficacy of new oral agents used alone or after a hospital course of amphotericin B are needed. The agents currently available are usually inadequate for eradication of fungal infections in patients with AIDS, who may need prolonged treatment. Final assessment for these patients may need to be classified as clinical cure with presumed microbiologic persistence.

Evidence of presymptomatic cognitive decline in Huntington's disease

Asymptomatic persons at risk for Huntington's disease (HD) (N = 28) were assessed with neuropsychological, psychiatric, and neurologic tests while undergoing genetic linkage studies to determine their probability of carrying the HD gene. Those participants who were subsequently identified as probable gene carriers did not differ on neurologic or psychiatric examination from those subsequently identified as probable noncarriers. Neuropsychological data are presented for a subset of participants free of other conditions (such as alcoholism) putting them at risk for cognitive deficits. Among these subjects, probable gene carriers were inferior to probable noncarriers on the neuropsychological battery as a whole and on several individual tests involving learning and memory. The results suggest the presence of cognitive decline prior to identifiable motor impairments in HD.

On the multiple simultaneous superposition of molecular structures by rigid body transformations

A method of optimally superimposing n coordinate sets on each other by rigid body transformations, which minimizes the sum of all n (n - 1)/2 pairwise residuals, is presented. In the solution phase the work load is approximately linear on n, is independent of the size of the structures, is independent of their initial orientations, and terminates in one cycle if n = 2 of if the coordinate sets are exactly superposable, and otherwise takes a number of cycles dependent only on genuine shape differences. Enantiomorphism, if present, is detected, in which case the option exists to reverse or not to reverse the chirality of relevant coordinate sets. The method also offers a rational approach to the problem of multiple minima and has successfully identified four distinct minima in such a case. Source code, which is arranged to enable the study of the disposition of domains in multidomain structures, is available from the author.

The pharmacotherapy of depressive illness in adolescence: II. Effects of lithium augmentation in nonresponders to imipramine

The antidepressant value of lithium augmentation was assessed in a 3-week open trial involving 24 adolescents who remained highly depressed after 6 weeks of treatment with imipramine hydrochloride. Two patients responded dramatically during the first week, with an additional eight patients showing partial improvement during the 3-week trial. The overall magnitude of improvement in depression ratings was significantly greater than in an historical control group of nonresponders who continued to receive imipramine monotherapy during their hospital treatment. Results suggest the potential use of this adjunctive strategy in some tricyclic resistant adolescent depressives, although it appears less efficacious overall in this age group than in adults.

On the use of normal modes in thermal parameter refinement: theory and application to the bovine pancreatic trypsin inhibitor

A method is presented whereby the amplitude coefficients of molecular normal modes of vibration are treated as independent variables in the treatment of thermal effects in X-ray diffraction, and applied to the bovine pancreatic trypsin inhibitor, form II (P2(1)2(1)2(1), a = 74.1, b = 23.4, c = 28.9 A). It is shown that the description of molecular motion furnished by 892 isotropic temperature factors may be largely reproduced using only 19 molecular thermal parameters from which anisotropic temperature factors may be synthesised for every atom. The method shows that motions and/or disorders external to each molecule are the largest single source of apparent motion, and that the internal motions are comparable to those predicted by Levitt, Sander & Stern.

Why faces are and are not special: an effect of expertise

Recognition memory for faces is hampered much more by inverted presentation than is memory for any other material so far examined. The present study demonstrates that faces are not unique with regard to this vulnerability to inversion. The experiments also attempt to isolate the source of the inversion effect. In one experiment, use of stimuli (landscapes) in which spatial relations among elements are potentially important distinguishing features is shown not to guarantee a large inversion effect. Two additional experiments show that for dog experts sufficiently knowledgeable to individuate dogs of the same breed, memory for photographs of dogs of that breed is as disrupted by inversion as is face recognition. A final experiment indicates that the effect of orientation on memory for faces does not depend on inability to identify single features of these stimuli upside down. These experiments are consistent with the view that experts represent items in memory in terms of distinguishing features of a different kind than do novices. Speculations as to the type of feature used and neuropsychological and developmental implications of this accomplishment are offered.

Why faces are and are not special: An effect of expertise

Recognition memory for faces is hampered much more by inverted presentation than is memory for any other material so far examined. The present study demonstrates that faces are not unique with regard to this vulnerability to inversion. The experiments also attempt to isolate the source of the inversion effect. In one experiment, use of stimuli (landscapes) in which spatial relations among elements are potentially important distinguishing features is shown not to guarantee a large inversion effect. Two additional experiments show that for dog experts sufficiently knowledgeable to individuate dogs of the same breed, memory for photographs of dogs of that breed is as disrupted by inversion as is face recognition. A final experiment indicates that the effect of orientation on memory for faces does not depend on inability to identify single features of these stimuli upside down. These experiments are consistent with the view that experts represent items in memory in terms of distinguishing features of a different kind than do novices. Speculations as to the type of feature used and neuropsychological and developmental implications of this accomplishment are offered.

Treatment compliance in end-stage renal disease patients on dialysis

This paper reviews the current knowledge concerning treatment compliance in patients with end-stage renal disease (ESRD). Adult hemodialysis patient noncompliance with the treatment regimen is very common. Objective and subjective measures of compliance, however, are often weakly correlated. In addition, the patients may be compliant with some aspects of the treatment regimen, but noncompliant with others. Unfortunately, no current model of predicting the degree of hemodialysis patient compliance is very accurate. In spite of this, behavioral approaches to increase regimen compliance do have at least short-term efficacy. There is a paucity of published data on compliance in adult peritoneal dialysis patients and an almost complete absence of systematic studies of compliance in children and adolescent dialysis patients. A multidimensional nosology of compliance behavior in ESRD patients is, therefore, proposed, as well as an approach to the diagnosis of noncompliance in ESRD patients and to possible interventions.

Drugs and the quality of life: the patient's point of view

Although research has established the effectiveness of antipsychotic drugs in treating schizophrenic patients, the issue of the quality of life of patients on longterm medication has not been as clearly determined. The patient's and clinician's understanding of this criterion, both objective and subjective, is discussed. Social functioning, acceptance of dose, compliance or lack of compliance, and the relative benefits of medication are factors that contribute to treatment goals. Case examples are presented to demonstrate these variables and their impact on the outcome of treatment with antipsychotic medication and on the patient's quality of life.

Breaking force of the rabbit growth plate and its application to epiphyseal distraction

The in vitro breaking forces of the distal femoral growth plates of young rabbits were measured as a background to the design of a bone lengthening method, using epiphyseal distraction. The mean breaking force in 16 femora was 12.98 +/- 3.48 kg and the mean strain was 0.91 +/- 0.33 mm. The mean stress in 10 femora was 14.51 +/- 3.88 kg/cm2. The procedure was repeated, after applying a 1.0 kg dead weight to 6 femora for 24 hours and the breaking force was then 15.01 +/- 4.70 kg, with a mean strain of 0.85 +/- 0.62 mm. A further 8 rabbits then underwent epiphyseal distraction for 2 days in vivo, with 1 or 2 kg forces delivered to two parallel K wires by a pair of spring devices, whereupon the femora were removed and tested as before. The breaking force on the distracted side was now only 8.91 +/- 3.71 kg, compared with 13.99 +/- 3.40 kg on the control side. Although not fractured, these plates had obviously been weakened. The clinical implication of this is discussed.