The use of cerebral computed tomographic angiography as an ancillary investigation to support a clinical diagnosis of death using neurological criteria: a consensus guideline

This multidisciplinary consensus statement was produced following a recommendation by the Faculty of Intensive Care Medicine to develop a UK guideline for ancillary investigation, when one is required, to support the diagnosis of death using neurological criteria. A multidisciplinary panel reviewed the literature and UK practice in the diagnosis of death using neurological criteria and recommended cerebral CT angiography as the ancillary investigation of choice when death cannot be confirmed by clinical criteria alone. Cerebral CT angiography has been shown to have 100% specificity in supporting a diagnosis of death using neurological criteria and is an investigation available in all acute hospitals in the UK. A standardised technique for performing the investigation is described alongside a reporting template. The panel were unable to make recommendations for ancillary testing in children or patients receiving extracorporeal membrane oxygenation.

218 DEVELOPING CONSENSUS-BASED INTEGRATED NUTRITION CARE PATHWAYS TO PREVENT, IDENTIFY AND MANAGE MALNUTRITION IN IRELAND

Background

The expected policy and standards of nutritional care in acute settings in Ireland has recently been developed (Department of Health, 2020). Based on these and international guidelines, integrated care pathways have been proposed by a panel of experts for (i) the transition of nutrition care of adult patients (>18 years) from hospital to community and, (ii) screening and identifying nutrition risk among community dwelling older adults (>65 years). The purpose of this study was to develop a consensus amongst diverse stakeholders for the proposed integrated nutrition care pathways.

Methods

A cross-sectional online survey collected data to identify pathway practices for retention. The survey was adapted to the Irish context based on previous research. Relevant stakeholders including healthcare professionals working in hospital, community and primary care, general practitioners, nurses, registered dietitians, healthcare workers from voluntary community services, and patients/patient advocates were recruited. Participants responded on the relevance and importance of discreet care practices in the proposed Nutrition Care Pathway and a consensus was set at ≥ 80%.

Results

Ninety-seven healthcare professionals and eight patient/patient advocates completed the survey. There was no response from healthcare workers from voluntary community services. Most of the discreet care practices gained consensus ratings ≥80% from healthcare professionals. Among the patient/patient advocates, only 3 pathway elements gained consensus ≥80%.

Conclusion

Healthcare professionals’ agreement with the relevance and importance of the proposed integrated nutrition care pathways offer guidance to prevent, identify, and manage malnutrition among older adults transitioning between care settings or living at home. The opinion of patients/patient advocates and healthcare workers of voluntary community services providers requires further engagement using alternative methodologies.

Quantitative EEG (qEEG) guided transcranial magnetic stimulation (TMS) treatment for depression and anxiety disorders: An open, observational cohort study of 210 patients

BACKGROUND

Major depression and anxiety disorders represent a substantial burden of morbidity. Neither antidepressant medication nor psychological interventions are fully effective, the former beset with side effects, interactions and compliance issues, and the latter requiring patient engagement, effort and a degree of psychological mindedness. Both treatments are lengthy. TMS by contrast is virtually free of side effects and compliance issues, relatively brief, and requires no patient effort. Nevertheless, remission rates are only about 1 in 3 with standard left frontal rapid (rTMS) stimulation, and up to 30 treatment sessions may be required. Our aim was to improve the effectiveness of TMS treatment using bespoke as opposed to standard left frontal rTMS, including theta burst stimulation (TBS).

METHODS

210 male and female patients were treated: regions and frequencies of TMS were guided by quantitative EEG analysis (qEEG) to elicit recognisable phenotypes, neuromarkers integral to the genesis of major depression and anxiety disorder, dictating treatment parameters.

RESULTS

98 patients (47%) achieved at least 50% reduction in Hamilton depression rating scale scores, while a further 60 (29%) patients achieved a 30-50% reduction, over a mean of 7.03 ± 0.3 treatment sessions. Theta burst stimulation (TBS) almost halved treatment time within session compared to rTMS. The effect size (Cohen's d) for both treatments was large (>0.8) with rTMS at 1.43 (1.16-1.70) and TBS at 1.87 (1.48-2.25).

CONCLUSIONS

qEEG guided TMS treatment is a safe and effective treatment in depression and anxiety disorders.

Soluble TNF-R1, VEGF and other cytokines as markers of disease activity in systemic lupus erythematosus and lupus nephritis

Background

Current non-invasive methods of assessing disease activity in systemic lupus erythematosus (SLE) are of limited sensitivity and specificity. Testing includes acute phase markers, autoantibodies and complement levels. Although measurements of dsDNA antibodies and complement C3/C4 levels are routine, they remain of limited value. Improved blood and urine markers may help in early detection of flare, distinction between flare and chronic damage, and monitoring response to therapy.

Methods

A total of 87 patients with SLE were tested for the following cytokines in serum and urine: monocyte chemoattractant protein 1 (MCP-1), regulated upon activation, normal T cell expressed and secreted (RANTES), soluble tumour necrosis factor receptor 1 (sTNF-R1), interferon-inducible protein 10 (IP-10), monocyte inhibitory protein 1α (MIP-1α) and vascular endothelial growth factor (VEGF). Patients attending the Lupus Unit at St Thomas’ Hospital, London, UK were divided into active lupus nephritis (LN), inactive LN and non-renal SLE groups based on their renal pathology and SLE disease activity index (SLEDAI). Cytokine testing was performed using the FIDIS multiplex bead assay.

Results

The mean level of serum sTNF-R1 was higher in the active LN group compared with both inactive LN and non-renal SLE groups ( p < 0.001). For urine measurements there were significant differences between active LN and non-renal SLE for VEGF ( p = 0.016), after statistical correction for multiple testing. Both urinary and serum sTNF-R1 and IP-10 levels correlated with SLEDAI scores ( p < 0.001), while serum VEGF correlated weakly with SLEDAI ( p = 0.025). The optimum combination for differentiating active from inactive LN patients was serum VEGF, sTNF-R1, MCP-1 and glomerular filtration rate plus urinary sTNF-R1 and protein-creatinine ratio.

Conclusion

These results indicate that for active LN, sTNF-R1 could be a useful serum cytokine marker, with potential for VEGF in the urine. This study has confirmed the ability of the multiplex bead technique to detect cytokines in a good analytical range, including very low and high levels, in both serum and urine. Combining serum and urine markers provided additional sensitivity in distinguishing active from inactive LN.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Mortality from Listeria monocytogenes meningoencephalitis following escalation to alemtuzumab therapy for relapsing-remitting Multiple Sclerosis

We report the case of a patient who died from the rare complication of Listeriosis in the immediate phase following alemtuzumab administration one month after discontinuing dimethyl fumarate (DMF). There is considerable overlap with typical post-infusion symptoms therefore high surveillance and low threshold for empirical or possible prophylactic antibiotic therapy is advocated.

Thyroid Function Screening of Psychiatric Inpatient Admissions: A Worthwhile Procedure?

A thyroid function screening programme of admissions to a general psychiatric service was established. Over a 22-week period 588 patients were admitted and thyroid function tests were performed on 336, a screening rate of 57.1%. Initial investigation showed that 21.3% had a total thyroxine outside the range 75–130 nmol/l. On further investigation only 9 patients (1 thyrotoxic, 8 hypothyroid) had confirmed thyroid disease. In 7 of the 9 patients the disease had been clinically suspected. Thus the screening programme identified only 2 unsuspected cases of thyroid dysfunction and we conclude that this level of detection does not warrant a formal screening programme.

Common variants in the chromosome 2p23 region containing the SLC30A3 (ZnT3) gene are associated with schizophrenia in female but not male individuals in a large collection of European samples

Previously, we found a significant gender-specific association of schizophrenia, in a UK case/control study, with SLC30A3, a candidate that is consistently down-regulated in schizophrenia in two independent cohorts. In view of the potential significance of this finding, we extended this study to a larger cohort using GWAS data from the Psychiatric Genetic Consortium (PGC). Meta-analysis was performed for the only two SLC30A3 SNP variants (rs11126936 and rs11126929) available in most PGC cohorts. A significant association with schizophrenia was found for both variants. When meta-analysis was performed in male and female case-control subsets, an increased and gender-specific effect of allele on risk of disease was found in females for both SNPs with no significant effect in males, which was further associated with a gender-specific effect on gene expression. In conclusion, using a large European-wide sample we were able to replicate the gender-specific association previously found in a UK cohort.

Evaluation of two minimal-preparation regimes for CT colonography: optimising image quality and patient acceptability

OBJECTIVE

To compare a 2 day bowel preparation regime of barium, iodine and a mild stimulant laxative with a 1 day iodine-only regime for CT colonography (CTC).

METHODS

100 consecutive patients underwent CTC. The first 50 patients (Regime 1) ingested 1 bisacodyl tablet twice a day 3 days before CTC and 1 dose each of 50 ml of barium and 20 ml of iodinated contrast per day starting 2 days before CTC. The second 50 patients (Regime 2) ingested 3 doses of iodinated contrast over 24 h prior to CTC. Volumes of residual stool and fluid, and the effectiveness of stool and fluid tagging, were graded according to methods established by Taylor et al (Taylor S, Slaker A, Burling D, Tam E, Greenhalgh R, Gartner L, et al. CT colonography: optimisation, diagnostic performance and patient acceptability of reduced-laxative regimens using barium-based faecal tagging. Eur Radiol 2008; 18: 32-42). A 3 day low-residue diet was taken by both cohorts. Questionnaires rating the side-effects and burden of the bowel preparation were compared to a control cohort of patients undergoing barium enema.

RESULTS

The proportion of colons producing none/scattered stool (score 1) was 90.3% with Regime 1 and 65.0% with Regime 2 (p<0.005). Any residual stool was significantly better tagged with Regime 1 (score 5), with 91.7% of Regime 1 exhibiting optimum tagging vs 71.3% of Regime 2 (p<0.05). No significant differences in side-effects between the bowel preparation regimes for CTC were elicited. Bowel preparation for barium enema was tolerated significantly worse than both of the CTC bowel preparation regimes.

CONCLUSION

Regime 1, containing a 3 day preparation of a mild laxative, barium and iodine, produced a significantly better prepared colon, with no difference in patient acceptability.

Estrogen for schizophrenia

BACKGROUND

In terms of clinical outcomes, women with schizophrenia seem to fare better then men, but appear more vulnerable to psychotic illness in the period after birth and menopause. As these vulnerable periods to psychosis are associated with estrogen withdrawal, this hormone has been proposed as a treatment for schizophrenia.

OBJECTIVES

To evaluate the clinical effects of estrogens alone or in combination with progesterone, as a sole treatment or as an adjunctive therapy, for the treatment of schizophrenia or schizophrenia-like illnesses.

SEARCH STRATEGY

Electronic searches of the Cochrane Schizophrenia Group's Register (October 2003) was supplemented with manual reference inspection of all identified studies. Authors of trials were contacted for further material and archive information.

SELECTION CRITERIA

All randomised clinical trials comparing estrogens with or without progesterone, as a sole or adjunctive treatment for people with schizophrenia or other similar serious, non-affective psychotic illness.

DATA COLLECTION AND ANALYSIS

We evaluated data independently and analysed on an intention to treat basis. For binary data we calculated the fixed effect relative risk (RR) and its 95% confidence interval (CI). For continuous non-skewed data, we calculated weighted mean differences.

MAIN RESULTS

All available evidence relates to women. Four studies (n=108) compared estrogen only with placebo. Short-term scores for general mental state showed no significant difference between groups (n=24, 1 RCT, WMD PANSS for 100mcg comparison -2.26 CI -15.4 to 10.9). Data from all four studies showed overall loss from the studies was low ( 5%), with no significant differences between groups (n=96, 4 RCTs, RR 0.95 CI 0.2 to 6.1). Skewed continuous data from two studies showed no clear differences in ratings of movement disorders. One medium-term unpublished study (n=14) compared estrogen and progesterone with placebo. Data at six months showed no difference between groups for total scores (n=9, WMD PANSS -25.3 CI -51 to 0.1). For negative symptoms, results favoured the estrogen and progesterone group (n=9, WMD PANSS negative subscale -9.0 CI -17 to -0.9). For loss to follow up there was no difference between groups (n=10, RR 0.33 CI 0.02 to 6.7). This trial used many cognitive tests and one visual retention test showed statistically significant differences favouring the treatment group: total scores (n=8, WMD -3.5 CI -5.7 to -1.3).

AUTHORS' CONCLUSIONS

Adjunctive estrogen with or without progesterone does not appear to offer convincing advantages over placebo. Before any more research is undertaken in this area, all completed and unpublished work should be made available in order to ensure that more trials are justified.

A Canadian high-energy neutron spectrometry system for measurements in space

Bubble Technology Industries Inc. (BTI), with the support of the Canadian Space Agency, has finished the construction of the Canadian High-Energy Neutron Spectrometry System (CHENSS). This spectrometer is intended to measure the high energy neutron spectrum (approximately 1-100 MeV) encountered in spacecraft in low earth orbit. CHENSS is designed to fly aboard a US space shuttle and its scientific results should facilitate the prediction of neutron dose to astronauts in space from readings of different types of radiation dosimeters that are being used in various missions.

Impact of side-effects of atypical antipsychotics on non-compliance, relapse and cost

Atypical antipsychotics generally have milder side-effects than conventional antipsychotics, but also differ among themselves in this respect. This study aimed to compare the impact of different side-effect profiles of individual atypical antipsychotics on non-compliance, relapse and cost in schizophrenia. A state-transition model was built using literature data supplemented by expert opinion. The model found that quetiapine and ziprasidone were similar in estimated non-compliance and relapse rates. Olanzapine and risperidone had higher estimated non-compliance and relapse rates, and incremental, 1-year, per-patient direct costs, using US-based cost data, of approximately $530 (95% confidence interval [CI] approximately $275, $800), and approximately $485 (95% CI approximately $235, $800), respectively, compared with quetiapine. Incremental costs attributable to different side-effect profiles were highly significant. This study shows that differing side-effect profiles of the newer antipsychotic agents are likely to lead to different compliance rates, and consequent variation in relapse rates. The cost implications of these heterogenous clinical outcomes are substantial.

beta-Scission of C-3 (beta-carbon) alkoxyl radicals on peptides and proteins: a novel pathway which results in the formation of alpha-carbon radicals and the loss of amino acid side chains

Exposure of proteins to radicals in the presence of O(2) brings about multiple changes in the target molecules. These alterations include oxidation of side chains, fragmentation, cross-linking, changes in hydrophobicity and conformation, altered susceptibility to proteolytic enzymes, and formation of new reactive groups, including hydroperoxides. These processes can result in the loss of structural or enzymatic activity. Backbone fragmentation is known to occur via a number of mechanisms, most of which involve hydrogen abstraction from the alpha-carbon site on the backbone. In this study, we demonstrate that initial attack at a side chain site, the beta-position (C-3), can give rise to formation of alpha-carbon radicals, and hence backbone cleavage, via the formation and subsequent beta-scission of C-3 alkoxyl radicals. This beta-scission reaction is rapid (k estimated to be >10(7) s(-)(1)) even with primary alkoxyl radicals derived from Ala residues, and occurs when the alkoxyl radicals are generated from a variety of precursors, including hydroperoxides and nitrate esters. These reactions release the former side chain as a reactive aldehyde or ketone; thus, Ala peptides release high yields of methanal (formaldehyde). This product has been quantified with a number of oxidized peptides and proteins, and can account for up to 64% of the initial attacking radicals with some Ala peptides. When quantified together with the hydroperoxide precursors, these species account for up to 80% of the initial radicals, confirming that this is a major process. Methanal causes cell toxicity and DNA damage and is an animal carcinogen and a genotoxic agent in human cells. Thus, the formation and subsequent reaction of alkoxyl radicals formed at the C-3 position on aliphatic amino acid side chains on peptides and proteins can give rise to both backbone fragmentation and the release of further reactive species which can cause cell toxicity and mutagenicity.

Similar mutant frequencies observed between pairs of monozygotic twins

The relative contribution of both genetic and environmental factors to spontaneous mutation frequency in humans is unknown. We have investigated the contribution of genetic factors to this phenomenon by determining the in vivo mutant frequency at the hypoxanthine-guanine phosphoribosyltransferase (hprt) locus in circulating T-lymphocytes obtained from pairs of monozygotic twins. hprt mutant frequencies were determined three times over fourteen days in six sets of monozygotic male twins (mean age 30) taking part in a Russian Space Program inclined bed rest experiment. Blood samples were obtained prior to, during, and immediately following the experiment. Mononuclear cells were separated, frozen, and flown to Canada for analysis using the hprt T-lymphocyte clonal assay. There is no evidence within this data set to demonstrate that the period of inclined bed rest to simulate the effects of weightlessness had any effect on the observed mutant frequency. However, the average mutant frequency for the six sets of Russian twins was found to be three times higher than that of Western counterparts. More surprisingly, the spontaneous mutant frequency of monozygotic twins was found to be much more similar within pairs than between pairs of twins. These data suggest that the contribution of genetics in the determination of mutation frequency is substantial. However, whether high concordance within twin pairs reflects shared environmental experience as well as common genetic factors is not entirely clear. More data will be required to distinguish genetic from environmental factors and to determine the degree to which mutant frequency is genetically determined.

Study on genotoxic effects of the space environment: a comparison between experienced cosmonauts and unexposed Russian twins

The molecular analysis of T-lymphocytes from experienced cosmonauts and seven pairs of unexposed twins was performed [M. Khaidakov, D. Young, H. Erfle, A. Mortimer, Y. Voronkov, B.W. Glickman, Molecular analysis of mutations in T-lymphocytes from experienced soviet cosmonauts, Environ. Mol. Mutagen, 30 (1997) 21-30; J. Curry, G. Bebb, J. Moffat, D. Young, M. Khaidakov, A. Mortimer, B.W. Glickman, Similar mutant frequencies observed between monozygotic twins, Human Mutation, 9 (1997) 445-451]. Hprt mutant frequencies (MF) in both datasets were considerably higher (38.0+/-14.6x10(-6) in cosmonauts, and 18.5+/-8.9x10(-6) in twins) than in the background Western control (8-12x10(-6)), [A.D. Tates, F.J. van Dam, H. van Mossel, H. Shoemaker, J.C.P. Thijssen, V.M. Woldring, A.H. Zwinderman, A.T. Natarajan, Use of the clonal assay for the measurement of frequencies of HPRT mutants in T-lymphocytes from five control populations, Mutation Res., 253 (1991) 199-213; R.F. Branda, L.M. Sullivan, J.P. O'Neill, M.T. Falta, J.A. Nicklas, B. Hirsch, P.M. Vacek, R.J. Albertini, Measurement of HPRT mutant frequencies in T-lymphocytes from healthy human populations, Mutation Res., 285 (1993) 267-279]. The distribution of mutations by class in the twin dataset was essentially similar to the background Western control, whereas cosmonaut samples demonstrated a significant excess of splice errors and complex mutations. The distribution of base substitutions showed similar trends in both the cosmonaut and twin samples, which are quite distinct compared to those seen in the Western control. The differences observed between cosmonaut and twin samples (a 2-fold higher MF and an excess of complex mutations in cosmonaut mutational spectra) could be an indication of possible effects of the space environment. However, these changes could also be age-related because the twin group was, on average, 17 years younger. Moreover, very similar patterns of base substitution distribution in both datasets suggest the involvement of certain region-specific factors reflected in mutational spectra. In order to discriminate between occupation and region-specific factors contributing to mutagenesis, an additional study involving trainees and cosmonauts with recent long-term flight experience is required.

Active monitoring of 12,760 clozapine recipients in the UK and Ireland. Beyond pharmacovigilance

BACKGROUND

People prescribed clozapine for treatment-resistant schizophrenia have mandatory haematological monitoring through a case register for identifying reversible neutropenia.

AIMS

To quantify risk factors for agranulocytosis in subjects receiving clozapine.

METHOD

Data from 12,760 subjects registered to receive clozapine from January 1990 to April 1997 were analysed. Risk factors for agranulocytosis were quantified using a Cox proportional-hazards regression analysis.

RESULTS

The risk for agranulocytosis in Asian subjects was 2.4 times that in Caucasians (P = 0.03). There was an age-related increase in risk of 53% per decade (P = 0.0001).

CONCLUSIONS

The case register yielded valuable information for guiding research into the causes of the haematological reactions.

Symptom dimensions in old-age schizophrenics. Relationship to neuropsychological and motor abnormalities

In most factor analytical studies of schizophrenic symptomatology, a three-factor solution was found. The aim of this study was to investigate symptomatological dimensions in old age and to clarify whether the dimensions correlate differently with neuropsychological and motor parameters. One hundred and thirty-one DSM-III-R chronic schizophrenics (mean age 68 years) were assessed using SANS, SAPS, a neuropsychological test battery and motor scales. Exploratory and confirmatory factor analyses yielded a model with three dimensions (negative, disorganized, paranoid), two of which (negative, disorganized) showed different correlations with neuropsychological and motor phenomena. Thus, three symptomatological dimensions could also be demonstrated in a chronic, old-age schizophrenic sample. The pathophysiological significance of the different correlations with neuropsychological and motor parameters should be clarified in neuroimaging and neuropathological studies.

[Dimensions of schizophrenia in the elderly. Correlations with cognitive and motor symptoms]

In most factor analytical studies of schizophrenic symptomatology a three-factor solution was found. The aim of this study was to investigate symptomatological dimensions in old age and to clarify whether the dimensions correlate differently with neuropsychological and motor parameters. A total of 131 DSM-III-R schizophrenics (mean age 68 years) were assessed using SANS, SAPS, a neuropsychological test battery and motor scales. A factor analysis yielded three dimensions (negative, disorganized, paranoid), two of which (negative, disorganized) showed different correlations with neuropsychological and motor phenomena. Thus, three symptomatological dimensions could also be demonstrated in a chronic, old-age schizophrenic sample. The pathophysiological significance of the different correlations with neuropsychological and motor parameters should be clarified in neuroimaging and neuropathological studies.

Perceived needs in chronic schizophrenia

Recent approaches to needs assessment involve patients themselves in the process, but little is known about the effects of mental illness on their ability to judge their own needs accurately. The needs of 30 subjects with schizophrenia in rehabilitation units were assessed in 19 different domains, by obtaining the views both of the subjects and their keyworkers. For each, the number of domains in which the subjects underestimated their level of need compared with the level estimated by their keyworker was calculated, to give a 'disparity score'. Disparity scores were positively correlated with severity of negative symptoms (r = 0.36; P = 0.048) but only nonsignificantly negatively correlated with insight (r = 0.31; P = 0.098). For the domains of alcohol misuse (P = 0.043) and quality of social life (P = 0.0005), subjects who underestimated their needs had poorer insight than those who did not do so. Subjects did not necessarily deny their need for help with psychosocial handicaps even if they denied having a mental illness or requiring medication. For the areas of alcohol misuse and social contact, however, additional objective means of assessment may be advisable in patients with poor insight into their illness. The effects of negative symptoms should also be taken into account when assessing needs collaboratively.

Prospective study into factors associated with aggressive incidents in psychiatric acute admission wards

BACKGROUND

Factors associated with aggression among psychiatric in-patients are still poorly understood. Inconsistent published findings are partly attributable to methodological problems. Much previous research has been under taken in specialist settings, where conditions are likely to differ from those in acute admission wards.

METHOD

Levels of aggression were ascertained weekly by staff report, using a reliable measure, for every patient on five acute admission wards and one locked intensive care ward at two hospitals prospectively over a five-month period.

RESULTS

Levels of aggression varied considerably among the admission wards. Aggression was more common on the locked ward and among younger patients. Factors associated with aggression changed with time since admission (seldom examined in previous studies). Complex associations were found with gender, ethnic group and diagnosis.

CONCLUSIONS

Some of the findings might be explicable by differences in ward environment, and staff-patient inter-actions. Further investigation into these is warranted.

Molecular analysis of mutations in T-lymphocytes from experienced Soviet cosmonauts

Somatic mutation in five cosmonauts who have completed spaceflights of 7 to 365 days was analyzed using the clonal HPRT assay. The doses received in space by the cosmonauts ranged from 4 to 127 mGy. hprt mutant frequencies were 2.4-5.0-fold higher than age-corrected values established for healthy, unexposed subjects in western countries [Tates et al. (1991): Mutat Res 253: 199-213; Branda et al. (1993): Mutat Res 285: 267-279] and 2- to 3-fold higher than those determined for unexposed individuals residing in Russia [Jones et al. (1995): Mutat Res 338: 129-139]. A total of 107 collected mutant clones were analyzed by multiplex PCR. No excess of deletions was detected and their frequency did not correlate with either accumulated dose or the age of the cosmonauts. In 62 mutants cDNA was isolated by RT-PCR and sequenced. Those with splicing errors, as well as the mutants that did not produce cDNA, were further analyzed by the sequencing of exon(s)-containing fragments amplified from genomic DNA. The mutational spectrum recovered from the cosmonauts differed substantially from that of unexposed healthy subjects (P = 0.042), and exhibited an increased incidence of splicing errors, frameshifts, and complex mutations. Higher frequencies of contribution of AT-->GC transitions and GC-->TA transversions were also observed. The increased mutant frequencies and observed shifts in mutational spectra likely indicate a combination of potential influences, including environment, lifestyle, and occupational exposures. Further elucidation of these potential influences will require a more extensive study involving the general population sharing similar environment, cosmonauts in training and cosmonauts participating in space flights.

NMDA receptor mRNA correlation with antemortem cognitive impairment in schizophrenia

We investigated the expression of the N-methyl-D-aspartate (NMDA) receptor, an important glutamate receptor, in brains from a population of well characterized schizophrenic patients who prospectively consented to tissue donation. Levels of NR-1 mRNA in tissue homogenates of superior temporal cortex were reduced by 30% in cognitively impaired schizophrenic patients compared with controls (p < 0.04), while levels in patients without cognitive impairment showed no such reduction. The NR-1 mRNA deficit was significantly correlated with general cognitive function as rated with the Global Deterioration scale (p < 0.001), the Mini-Mental State examination (p < 0.01) and the premorbid IQ determined using the National Adult Reading Test (NART, p < 0.01). NR-1 mRNA concentration was not correlated with age, sex, pH or postmortem delay in the control and schizophrenia group when analysed separately or combined. There was, therefore, a significant correlation between NR-1 mRNA loss and cognitive deterioration in patients with schizophrenia.

Cholecystokinin messenger RNA deficit in frontal and temporal cerebral cortex in schizophrenia

No consistent markers of pathology have been established yet in schizophrenia, although abnormalities in frontal and temporal structures are indicated from positron emission tomography (PET) studies. We have used in situ hybridization to investigate functional changes focusing on the quantitation of cholecystokinin (CCK) mRNA, whose product has been shown to be depleted in schizophrenia. CCK mRNA and G(o) alpha-subunit mRNA were measured in eight schizophrenic and eight control subjects matched for age and postmortem delay. The study revealed a marked decrease in CCK mRNA of 83% in frontal cortex (BA10) and 63% in superior temporal cortex (BA22) in schizophrenia with no change in G(o) alpha-subunit mRNA in either region. This study was extended to a further series of eight patients to determine the reproducibility of this effect and to quantitate laminar changes in CCK mRNA. Quantitation of CCK mRNA in inner cortical layers (layer V/VI) was carried out in frontal and temporal cortex in comparison with G(o) alpha-subunit mRNA, which is also concentrated in this region; this study showed a similar selective decrease in CCK mRNA in frontal and temporal cortex of 47% and 51%, respectively. A confirmatory decrease in CCK mRNA was also obtained by slot blot analysis of CCK mRNA in tissue extracts of frontal cortex by reference to levels of beta-tubulin mRNA, CCK mRNA:beta-tubulin mRNA was significantly decreased (67%) in schizophrenic tissue compared to control tissue. There was no significant correlation of CCK mRNA loss with neuroleptic treatment or duration of illness.

Elder abuse and dementia--a pilot study

An anonymous postal questionnaire was distributed to 200 members of a voluntary organisation providing information and support for the carers of dementia sufferers. Carers were asked about the possible occurrence of verbal, physical abuse and neglect. Those carers who admitted to any form of abuse were compared with those who did not and risk factors in both carers and patients were analysed to determine risk factors for abuse. Fifty-five per cent of carers admitted to some form of abuse with verbal abuse being the most common form. Verbal abuse was associated with a poor premorbid relationship and social isolation of the carer and was found to be a risk factor for physical abuse. Those carers who had high GHQ scores and who had been caring for longer were more likely to physically abuse the person they cared for. This study supports the hypothesis that various categories of abuse have different correlates.

Space radiation dosimetry using bubble detectors

Bubble detectors--a new development in radiation detection--has only recently been used for radiation measurements in space. One important characteristic of the bubble detector is that it operates on a phenomenon which bears considerable resemblance to biological response. Recent experimental results from irradiating bubble detectors with high-energy heavy ions point to the need to re-examine the methodology used for assessing space radiation and the relevance of conventional quantities such as dose equivalent for space dosimetry. It may be that biological hazard associated with the intensely ionizing events--associated with nuclear fragmentation but delivering relatively small dose equivalent--may be much more important than that associated with lightly ionizing events which comprise the bulk of the conventional radiation dose equivalent.

Pseudocyesis preceding psychosis

Pseudocyesis is an uncommon condition in which the psychological and somatic phenomena are usually thought to arise with neurotic rather than psychotic illness. We report a patient whose pseudocyesis took a course not previously described, culminating in an acute schizophrenic episode. Despite this she demonstrated many similarities with neurotic patients previously described in the literature. A phenomenological explanation, the belief of pregnancy as an overvalued idea, is discussed.

An instrument for ultrasonic biometry

A simple instrument has been developed for measurement of axial length and anterior chamber depth. It is pocket sized, and the digital output is easy to interpret. The long term accuracy of 0.2 mm is ideal in helping to eliminate errors of lens selection.