Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project

INTRODUCTION

Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM.

METHODS

Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ).

RESULTS

44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083).

CONCLUSIONS

None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.

Traumatic Bilateral Self-Enucleation With Subarachnoid Hemorrhage

We present a rare case of traumatic self-enucleation of the bilateral globes resulting in traumatic subarachnoid and intraventricular hemorrhages. This case highlights the critical importance of multidisciplinary trauma care, starting with recognition of the potential for less obvious injuries such as contralateral optic nerve injury in unilateral enucleation, intracranial hemorrhage, and cerebrovascular injuries. We highlight the role of a thorough trauma assessment and workup, especially in the context of highly distracting injuries in patients who may also have severe mental illness. The trauma and acute care surgeon, who also serves as the critical care specialist, should be well prepared to facilitate care between multiple subspecialists including neurosurgeons, interventional radiologists, vascular surgeons, and psychiatrists, with a high index of suspicion for occult trauma in seemingly isolated injuries.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

A Systematic Review of Clinical Practice Guidelines for Identification and Management of Frailty

OBJECTIVE

This study aims to appraise and summarize consistent recommendations from clinical practice guidelines (CPGs) for identification and management of frailty to maintain and improve functional independence of elderly population.

METHODS

A systematic search of Ovid MEDLINE, Embase, PubMed, PsycINFO, and CINAHL electronic databases using database-specific search terms in two broad areas "guidelines" and "frailty", and a manual search of websites with the key phrase "frailty guideline" was performed. The inclusion criteria included CPGs focusing on identifying and managing frailty in population >65 years old, published in English since January 2010. Three reviewers independently assessed guideline quality using the AGREE II instrument. Data extraction was performed, followed by compilation and comparison of all recommendations to identify the key consistent recommendations.

RESULTS

Six CPGs met the inclusion criteria; however, only three CPGs had high methodological quality in accordance with AGREE II appraisal. The average AGREE II scores of all six CPGs were: 84.5%, 68%, 46.5%, 81.5%, 56.3%, and 60.2% for domains 1-6 (scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence) respectively. A total of 54 recommendations were identified, with 12 key recommendations suggested frequently by the CPGs.

CONCLUSION

The AGREE II instrument identified strengths and weaknesses of the CPGs, but failed to assess clinical implications and feasibility of the guidelines. Further research is needed to improve clinical relevance of CPGs in the identification and management of frailty. The feasibility in implementing these guidelines with regards to cost-effectiveness of frailty screening warrants further investigation.

Engaging Men in Psychosocial Cancer Support

Background: Despite increasing rates of cancer survivorship, there is still evidence to suggest men are less likely to access information services, health services and cancer screening. Men may be more reticent to express their emotions in relation to health and specifically in relation to cancer; and so it is important to ensure that services offer different routes to inclusion. Maggie´s ( www.maggiescentres.org ) is an innovative, multidisciplinary, health professional led model of holistic supportive cancer care, widely regarded as an exemplar of best practice in cancer rehabilitation and supported self-management. In 2017 Maggie´s received 249,247 visits across their network of twenty-three centres in the UK, Hong Kong and Tokyo. One of the key challenges for Maggie´s and others is to develop sustainable, innovative and equitable approaches to supportive care. Aim: To explore whether male-specific facilitated support groups provide a constructive environment within which men can engage with health professional led holistic cancer services. Methods: Men (n=39) with a range of cancers (including curative and noncurative) from varied socioeconomic backgrounds, attending male-specific facilitated support groups at eight Maggie's Centres in the UK completed questionnaires to give feedback on the social, emotional, practical and informational support the groups aim to provide. A smaller subset of group members (n=12) participated in focus group discussions to capture themes about why men attend the groups. The group facilitators were interviewed to provide observations about the impact of the groups on both the participants and themselves. Results: Men in the facilitated support groups report high levels of satisfaction in relation to practical (94.8%), emotional (95.2%) and social (90.47%) and informational support (92.50%). Thematic analysis of the smaller subset of focus group data suggest reasons why men attend male-specific support groups including “reducing isolation and developing a sense of belonging”, “creating shared experience and understanding”, “safely expressing emotion”, “protecting loved ones from distress” and “use of male specific language and humor”. Conclusion: Globally, the supportive care needs of men affected by cancer are changing but the Maggie´s model of care offers valuable lessons that can be generalized across varied support settings to meet these emerging needs. The current study underlines the importance of engaging and supporting men throughout the cancer experience through the use of professionally facilitated support groups that discuss themes tailored to the challenges the men face and maximize the opportunity for acceptable social support. Further controlled longitudinal research is required to build on these findings.

A survey of international antisepsis procedures for neuraxial catheterisation in labour

BACKGROUND

Neuraxial analgesia during labour is a mainstay of anaesthetic practice globally. Despite the potential for significant neurological and infectious complications, international antisepsis practices for neuraxial anaesthesia vary widely.

AIMS

The primary aim of this study was to clarify international antisepsis practices prior to neuraxial analgesia in labour. The secondary aim was to determine an approximate international incidence of neuraxial infections and neurological complications secondary to neuraxial analgesia techniques in labour.

MATERIALS AND METHODS

Heads of Departments of Anaesthesiology were invited to complete an online questionnaire exploring antisepsis practices and complications of neuraxial catheterisation. Data from 151 institutions in 13 countries were collected over 11months.

RESULTS

Data were collected for an estimated 6008540 deliveries and 3770800 neuraxial catheterisations. The average annual birth rate per institution was 3979 births, with an average of 2497 neuraxial catheterizations (representing 62.8% of deliveries). Forty-nine percent of responders reported always wearing sterile gowns for the procedure, whereas 47.7% never wear gowns. Chlorhexidine was used by 88.1% of those surveyed, and 96.7% always wore facemasks. Thirty-four percent of institutions reported infectious complications over a 10-year period. Ninety neuraxial infections were estimated, giving an approximate incidence of 1:41898 catheterisations (2.39 infections per 100000 catheterisations). A total of 202 neurological complications were reported, with an approximate incidence of 1:18667 catheterisations (5.36 neurological complications per 100000 catheterisations).

CONCLUSION

The survey demonstrated marked variation in aseptic practice between both responding centres and countries. The incidence of infectious and neurological complications secondary to neuraxial catherisation in labour has been approximated.

Lawyers' Perception of Psychologists Who Do Forensic Work

In South Africa there is a lack of empirical data regarding the quality of the testimony of psychologists. In order to fill this gap, 252 South African lawyers were surveyed to determine their perception of the value of the testimony of psychologists, and of psychologists' knowledge, conduct, and adherence to the rules of expert testimony. For the purpose of comparison a group of 75 psychologists who do forensic work, were also surveyed. The findings was that lawyers generally did not believe that the potential value, or actual contribution, of psychological testimony was high. Their ratings of the actual knowledge of psychologists were significantly lower than their expectations in this regard. However, they rated the conduct and adherence of psychologists to the rules of expert testimony as satisfactory. The implications of these findings are discussed.

A Profile of Forensic Psychologists in South Africa

Forensic psychology is more exposed to the scrutiny of other professionals and the media than most other fields in psychology. Unfortunately the discipline often falls short of the expectations in this regard. In order to compile a profile of forensic psychologists in South Africa 153 questionnaires were distributed to psychologists who render psycholegal services in court. Aspects covered in the questionnaire were experience and the work setting of the participants, number of reports submitted and appearance as witnesses, types of forensic activities, referral sources, qualifications, other fields of expertise, assessment techniques used by the participants, perception of the legal environment, and forensic training. The findings and implications for forensic psychology in South Africa are discussed.

The role of the nurse in screening asymptomatic male and female patients in a sexual health clinic

We allocated 278 patients, who said they were asymptomatic and agreed to be randomized to a nurse or doctor clinic, to appointments using a random number system. In all, 35 patients did not attend and 16 were excluded because they did not meet the entry criteria. We used a screening protocol which excluded microscopy from the immediate assessment of patients. The outcome measures were completeness of documentation, proportion of patients accepting HIV tests, infections detected and patient satisfaction. Overall, 3% of items were not completed by doctors and 6% by nurses. HIV tests were carried out on 65% of patients who saw a doctor and 52% who saw a nurse. Thirteen infections were detected by doctors and 27 by nurses. No new cases of gonorrhoea, syphilis or HIV infection were identified. Eighty-eight patients completed a questionnaire after their attendance. Almost all patients were very satisfied with the service and most were prepared to see a nurse on a subsequent visit. We concluded that there are few differences between the performance of doctors and nurses in routine screening of asymptomatic patients.

Vulnerability to climate change: people, place and exposure to hazard

Abstract. The Human Dimension of the Twinning European and South Asian River Basins to Enhance Capacity and Implement Adaptive Management Approaches Project (EC-Project BRAHMATWINN) is aimed at developing socio-economic tools and context for the effective inclusion of the "Human Dimension" or socio-economic vulnerability into the overall assessment of climate risk in the twinned basins of the Upper Brahmaputra River Basin (UBRB), and the Upper Danube River Basin (UDRB) . This work is conducted in the light of stakeholder/actor analysis and the prevailing legal framework. In order to effectively achieve this end, four key research and associated activities were defined: 1. Identifying stakeholders and actors including: implement an approach to ensure a broad spread of appropriate stakeholder input to the assessment of vulnerability undertaken in Asia and Europe within the research activities of the project. 2. Contextualising legal framework: to provide an assessment of the governance framework relating to socio-environmental policy development within the study site administrative areas leading to the specific identification of related policy and legal recommendations. 3. Spatial analysis and mapping of vulnerability: providing a spatial assessment of the variation of vulnerability to pre-determined environmental stressors across the study areas with an additional specific focus on gender. 4. Inclusion of findings with the broader context of the BRAHMATWINN risk of climate change study through scenarios of hazard and vulnerability (subsequent chapters). This study utilises stakeholder inputs to effectively identify and map relative weightings of vulnerability domains, such as health and education in the context of pre-specified hazards such as flood. The process is underpinned by an adaptation of the IPCC (2001) which characterizes Risk as having the components of Hazard (physiographic component) and Vulnerability (socio-economic component).

Anthocyanin production as a potential visual selection marker during plant transformation

A mutant allele of the transcription factor gene MYB10 from apple induces anthocyanin production throughout the plant. This gene, including its upstream promoter, gene coding region and terminator sequence, was introduced into apple, strawberry and potato plants to determine whether it could be used as a visible selectable marker for plant transformation as an alternative to chemically selectable markers, such as kanamycin resistance. After transformation, red coloured calli, red shoots and red well-growing plants were scored. Red and green shoots were harvested from apple explants and examined for the presence of the MYB10 gene by PCR analysis. Red shoots of apple explants always contained the MYB10 gene but not all MYB10 containing shoots were red. Strawberry plants transformed with the MYB10 gene showed anthocyanin accumulation in leaves and roots. No visible accumulation of anthocyanin could be observed in potato plants grown in vitro, even the ones carrying the MYB10 gene. However, acid methanol extracts of potato shoots or roots carrying the MYB10 gene contained up to four times higher anthocyanin content than control plants. Therefore anthocyanin production as result of the apple MYB10 gene can be used as a selectable marker for apple, strawberry and potato transformation, replacing kanamycin resistance.

Use of W-plasty in stenotic stoma: a new solution for an old problem

INDICATION

Amongst late complications of stomas, stenosis can be difficult to treat. Repeated dilatations rarely achieve long-term resolution and re-fashioning is not always successful. Application of an existing plastic surgical technique to treat stomal stenosis is described.

METHOD

After marking the skin, a W-plasty is made with a number of consecutive small triangular flaps through the skin. The corresponding mucosal margin is then made to interdigitate with this configuration and fixed using a Gillies corner stich with 5/0 Vycril rapide on a compound curved needle.

RESULTS

Five patients underwent W-plasty reconstruction for a stenotic stoma. Median follow up was 12.5 months (range 11-15). No patient had stenosis of the stoma on review and the patient satisfaction rate was high.

CONCLUSION

The W-plasty technique is a new treatment for stenotic stoma.

Prospective randomised study of urgent haemorrhoidectomy compared with non-operative treatment in the management of prolapsed thrombosed internal haemorrhoids

OBJECTIVE

To compare the outcome of urgent haemorrhoidectomy with conservative treatment for prolapsed thrombosed internal haemorrhoids.

METHODS

A prospective randomised study of 50 patients with prolapsed thrombosed internal haemorrhoids was carried out using clinical and ultrasonic outcome measures. Peri-operative bed occupancy and the presence of symptoms at 6 and 24 months were compared. Endoanal ultrasonic scanning was carried out to investigate anal sphincter integrity in those patients willing to be studied.

RESULTS

The median length of hospital stay for the group treated conservatively; 2 nights (range 1-9 nights) was significantly shorter than for the group treated by urgent haemorrhoidectomy; 4 nights (range 1-12 nights, P < 0.01). There was no difference between treatment groups in the number of patients with symptoms at six or 24 months. Urgent haemorrhoidectomy was associated with a significantly higher incidence of endosonographically detected anal sphincter damage in 18 patients: 66%vs 0% (P = 0.009).

CONCLUSION

Conservative treatment for prolapsed thrombosed internal haemorrhoids is associated with shorter in patient stay and less anal sphincter damage compared with operative treatment.

Australian lawyers' views on competency issues in older adults

Lawyers are often called upon by their older clients to draft contracts, make up wills or powers of attorney, or provide other forms of legal advice or service. With the increasing numbers of older people in the population, the numbers of older clients for legal practitioners is likely to increase. Older people are also at increased risk for impaired cognitive processes that can affect their ability to make reasoned judgements in civil contracts and other legal arrangements. Here we report on the results of a survey of 302 Australian solicitors as to their experience and practices in determining the capacity of older clients to make legal decisions. The responses, reflecting a 20.7% return rate, showed a wide range of experience in conducting capacity assessments, with a mean of 15.7 years (SD = 10.59). There was a very wide range of practices in determining capacity with no consensus. The most frequent form of questions older clients were asked related to personal and family history. Less than one-quarter asked for the rationale of the decision: the most appropriate form of question in the literature. The results suggest a need for further training of solicitors in the assessment of the capacity of older clients to make legal decisions.

Diarrhoea, vomiting and ACE inhibitors:--an important cause of acute renal failure

The occurrence of severe acute renal failure in 3 patients who developed diarrhoea while taking angiotensin converting enzyme (ACE) inhibitors led us to undertake a retrospective cohort survey to determine the frequency with which diarrhoea and vomiting are associated with acute renal failure in patients taking this class of drug. Serum creatinine was measured as part of the diagnostic workup of 2398 consecutive admissions to an acute medical receiving unit in a district general hospital. Outcome measures were the presence of diarrhoea and/or vomiting, and whether taking an ACE inhibitor, NSAID or diuretic at the time of admission, also previous, initial and follow up serum creatinine concentrations. Peak serum creatinine in the 3 cases was 1159, 989 and 765 micromol/l. None of the 3 required dialysis and all recovered renal function completely after receiving large volumes of intravenous fluid. In the cohort study, 89 of 2398(3.7%) admissions had serum creatinine >/=200 micromol/l. Nine were regular dialysis patients. Of the remaining patients, 30 (37.5%) were taking an ACE inhibitor. Six of 30 (20%) gave a history of diarrhoea and/or vomiting. Median creatinine concentration in this group was 135 (range 111-209) micromol/l before admission, 292 (216-724) micromol/l when first seen in hospital, and 134 (94-219) micromol/l following the withdrawal of drug therapy and fluid replacement. In conclusion, volume depletion causing acute renal failure in patients taking ACE inhibitors is not uncommon. Such patients and their general practitioners should be aware that reversible renal impairment may occur during intercurrent illnesses, particularly if characterised by diarrhoea and/or vomiting.

Managing the very young patient: a conflict between the requirements of the Children Act and the VD regulations?

We describe the case of a 12 year old girl who presented requesting screening for sexually transmitted infections and discuss a conflict between concerns of clinicians to maintain confidentiality and concerns of social workers to investigate the possibility of sexual abuse.

High incidence of renal failure requiring short-term dialysis: a prospective observational study

BACKGROUND

Previous estimates of incidence of acute renal failure (ARF) requiring renal replacement therapy have varied from 18 to 75 patients per million per year, but have been beset by problems of definition.

AIM

To investigate whether the '90-day rule' provides a more reliable, reproducible and robust estimate of the need for short-term dialysis.

SETTING

District general hospital serving a population of 147 000.

DESIGN

Prospective observational study.

METHODS

Patients who received renal replacement therapy in Dumfries and Galloway between 01/01/94 and 31/12/2000 were divided into two groups: long-term dialysis (> or =90 days) and short-term dialysis (<90 days).

RESULTS

Of 302 patients, 193 received short-term dialysis, giving an incidence for short-term dialysis of 187 patient episodes per million per year (95%CI 170-203). Use of a more conventional definition for ARF (including all ARF and acute-on-chronic renal failure, but excluding patients with chronic renal failure who present acutely) produced a similar estimate at 176 patients per million per year (95%CI 160-193).

DISCUSSION

The 90-day rule estimated the incidence of short-term dialysis/ARF at nearly twice the incidence of chronic renal failure requiring dialysis, and more than twice the most recent estimate of the incidence of ARF in the UK. The main attraction of the 90-day rule is its simplicity. If the high level of short-term dialysis/ARF found in our study is confirmed by other centres, there are significant resource implications for the provision of renal care.

Sulphide-induced energy deficiency in colonic cells is prevented by glucose but not by butyrate

BACKGROUND

In ulcerative colitis, hydrogen sulphide is postulated to impair colonocyte butyrate metabolism, leading to cellular energy deficiency and dysfunction.

AIMS

To determine the effects of sulphide exposure on butyrate metabolism and adenosine triphosphate levels of HT29 colonic epithelial cancer cells, and to establish whether energy deficiency can be prevented by increased butyrate concentrations or the presence of glucose.

METHODS

HT29 cells were maintained in medium containing 3 mM butyrate, 5 mM glucose, or both substrates. Oxidation rates were measured by 14CO2 release from 14C-labelled substrates. Cellular adenosine triphosphate was assayed using the luciferin/luciferase chemiluminescent method. The effects of sulphide (0-5 mM) on substrate oxidation and adenosine triphosphate levels and of increasing butyrate concentration (0-30 mM) with sulphide were observed.

RESULTS

HT29 cells showed similar energy substrate usage to primary colonocyte cultures. Sulphide exposure inhibited butyrate oxidation and led to a reduction in cellular adenosine triphosphate. This fall was prevented by co-incubation with glucose, but not by increasing concentrations of butyrate.

CONCLUSIONS

HT29 cells utilize butyrate as an energy substrate and represent a useful in vitro model of the effects of sulphide on colonocytes. Sulphide inhibits butyrate oxidation and leads to demonstrable energy deficiency, prevented by the presence of glucose but not by increased butyrate concentrations.

Haemodialysis in a rural area: a demanding form of treatment

OBJECTIVE

To determine distances travelled and time spent waiting for transport among hospital haemodialysis patients living in a rural area.

DESIGN

Cross sectional survey comparing the subregional dialysis unit in south west Scotland with 12 of the other 13 Scottish Adult Renal Units.

SUBJECTS

Forty three Dumfries and Galloway patients and 935 other Scottish patients receiving hospital haemodialysis in November 1999.

RESULTS

At the time of the survey 8/43 (19%) Dumfries patients travelled in excess of 100 miles per dialysis day (15,000 miles per year) solely for the purpose of dialysis, compared to 20/935 (2%) elsewhere in Scotland (p < 0.001). Twenty seven (63%) Dumfries and 594 (64%) patients in other Scottish Units relied on hospital car, Patient Transport Service bus or ambulance for the journey home after treatment. Dumfries patients who travelled by Patient Transport Service or hospital ambulance had to wait twice as long before they left the renal unit as patients using a dedicated hospital car or private car.

CONCLUSION

Haemodialysis in a rural area has every reason to be considered a demanding form of treatment. Greater promotion of home based treatment would improve the quality of life for many of these patients, while dedicated hospital cars would reduce 'car to needle time' for those who remain on hospital haemodialysis.

Differential effects of transforming growth factor-beta1, a fibrogenic factor, on macrophage-like cells (HS-P) and myofibroblastic cells (MT-9) in vitro

Transforming growth factor-beta1 (TGF-beta1) produced by infiltrating macrophages plays a role in fibrotic disorders through the induction of myofibroblasts. To explore possible mechanisms by which TGF-beta1 may act in this context, we investigated effects of TGF-beta1 on macrophage-like (HS-P) and myofibroblastic (MT-9) cells, two novel cell lines developed by us. Immunocytochemically, the addition of TGF-beta1 (0, 0.1, 0.5, and 1.0 ng/ml) dose-dependently suppressed the expressions of antigens recognized by macrophage/histiocyte-specific antibodies (ED1 and ED2) in HS-P cells, whereas the addition concomitantly increased the number of anti-alpha-smooth muscle actin antibody-positive myofibroblastic cells, suggesting a possible phenotypical modulation of macrophages into myofibroblasts in the fibrotic lesions. By contrast, MT-9 cells did not show such immunophenotypical changes following TGF-beta1 addition. DNA synthesis, measured by tritiated thymidine-incorporation, was inhibited in a dose-dependent manner in MT-9 cells by TGF-beta1 addition (0, 0.1, 0.2, 0.5, 1.0, 5, and 10 ng/ml), but that in HS-P cells was unchanged. Northern blot analysis revealed that expressions of cell cycle-related early genes, c-jun and c-myc, were increased in HS-P cells after TGF-beta1 (1 ng/ml) addition, with c-jun showing peak expression prior to c-myc. By contrast, the peak expressions of c-jun and c-myc were delayed in TGF-beta1 (1 ng/ml)-added MT-9 cells, and their levels were less in MT-9 cells than in HS-P cells. Furthermore, TGF-beta1 (1 and 10 ng/ml) induced DNA laddering in MT-9 cells, but did not in HS-P cells. Based on these findings, it was speculated that TGF-beta1 could have induced G1 arrest in cell cycle and apoptosis in MT-9 cells. The present study showed that there were significant differences in the effects of TGF-beta1 between macrophage-like HS-P cells and myofibroblastic MT-9 cells, presumably depending on divergent susceptibilities to TGF-beta1 between both cell types. Because such cell types are key cells in the fibrogenesis, HS-P and MT-9 might be useful models for investigating the pathogenesis of fibrosis in vitro.

Effects of lipopolysaccharide on a macrophage-like cell line (HS-P) from a rat histiocytic sarcoma

Lipopolysaccharide (LPS) is a major modulator of macrophage functions. To characterize a newly established rat histiocytic sarcoma-derived cell line (HS-P), immunophenotypic changes and cellular growth responses of HS-P cells exposed to LPS were investigated and compared with those of MT-9 cells isolated from a rat malignant fibrous histiocytoma. MT-9 cells have somewhat histiocytic features, because occasional cells react to rat macrophage-specific antibodies. Addition of LPS to cultured HS-P cells increased the numbers of cells immunopositive to ED1 (rat macrophage-specific antibody) and ED2 (rat histiocyte-specific antibody) and stimulated the phagocytosis of latex beads, whereas LPS-treated MT-9 cells did not show such immunophenotypic changes. LPS-treated HS-P cells showed enhanced immunolabelling of alpha-smooth muscle actin, suggesting a possible modulation of macrophages towards myofibroblastic cells. To evaluate cellular growth after the addition of LPS or fetal bovine serum, DNA synthesis was examined by measuring tritiated thymidine incorporation, and the mRNA expression of c- jun and c- myc (immediate early genes in the cell cycle) was examined by Northern blot analysis. In HS-P cells, the addition of serum greatly increased DNA synthesis and induced high expression of c- jun and c- myc; in contrast, LPS markedly depressed DNA synthesis and reduced the expression of c- jun and c- myc. HS-P cells were more sensitive than MT-9 cells to the growth-promoting effect of serum and the growth-inhibiting effect of LPS. The study demonstrated that HS-P cells are highly LPS-responsive, indicating that they would be useful for studies of macrophage functions.

Neurosteroid hydroxylase CYP7B: vivid reporter activity in dentate gyrus of gene-targeted mice and abolition of a widespread pathway of steroid and oxysterol hydroxylation

The major adrenal steroid dehydroepiandrosterone (DHEA) enhances memory and immune function but has no known dedicated receptor; local metabolism may govern its activity. We described a cytochrome P450 expressed in brain and other tissues, CYP7B, that catalyzes the 7alpha-hydroxylation of oxysterols and 3beta-hydroxysteroids including DHEA. We report here that CYP7B mRNA and 7alpha-hydroxylation activity are widespread in rat tissues. However, steroids related to DHEA are reported to be modified at positions other than 7alpha, exemplified by prominent 6alpha-hydroxylation of 5alpha-androstane-3beta,17beta-diol (A/anediol) in some rodent tissues including brain. To determine whether CYP7B is responsible for these and other activities we disrupted the mouse Cyp7b gene by targeted insertion of an IRES-lacZ reporter cassette, placing reporter enzyme activity (beta-galactosidase) under Cyp7b promoter control. In heterozygous mouse brain, chromogenic detection of reporter activity was strikingly restricted to the dentate gyrus. Staining did not exactly reproduce the in situ hybridization expression pattern; post-transcriptional control is inferred. Lower level staining was detected in cerebellum, liver, and kidney, and which largely paralleled mRNA distribution. Liver and kidney expression was sexually dimorphic. Mice homozygous for the insertion are viable and superficially normal, but ex vivo metabolism of DHEA to 7alpha-hydroxy-DHEA was abolished in brain, spleen, thymus, heart, lung, prostate, uterus, and mammary gland; lower abundance metabolites were also eliminated. 7alpha-Hydroxylation of 25-hydroxycholesterol and related substrates was also abolished, as was presumed 6alpha-hydroxylation of A/anediol. These different enzyme activities therefore derive from the Cyp7b gene. CYP7B is thus a major extrahepatic steroid and oxysterol hydroxylase and provides the predominant route for local metabolism of DHEA and related molecules in brain and other tissues.

Intoxication, criminal offences and suicide attempts in a group of South African problem drinkers

BACKGROUND

Incidence rates of crime and alcohol abuse in South Africa are unacceptably high. Research suggests a relationship between alcohol and both crime and suicide. This study aims to add to the information base on this topic in South Africa.

METHODS

This is a cross-sectional record study of criminal offences and suicide attempts in 269 admissions to an alcohol rehabilitation unit in the Western Cape. Types of criminal offences and suicide attempts are described. Relationships are sought between crime, violent crime and suicide attempts on the one hand, and demographic and alcohol-related variables on the other.

RESULTS

One hundred and four subjects (39%) had criminal convictions, the majority of which were committed while the subjects were intoxicated. The commonest alcohol-related crimes were driving-related (17% of subjects) and crimes of violence (15%). Male gender, younger age at initiation of drinking, and earlier onset of problem drinking were significantly associated with criminal behaviour. Violent crime was associated with earlier onset of initial, regular and problem drinking, and maternal alcohol abuse. Suicide attempts (24% of subjects) were associated with female gender, white racial group, not being in a marital relationship, younger current age and early age of problem drinking.

CONCLUSIONS

There was an association between intoxication and both violent crime and suicide attempts. The importance of population studies and the need for intervention programmes aimed at teenagers who are drinking, are emphasised.

Macrophage-like cell line (HS-P) from a rat histiocytic sarcoma

With future exploration of macrophage properties in mind, we established a novel cell line (HS-P) from a transplantable histiocytic sarcoma, derived originally from a tumour in an aged F344 rat. HS-P was subjected to 70 serial passages, in which the mean doubling time was 15.7 h. The cells, which were round, oval or polygonal in shape, were arranged in a compact sheet. They reacted to varying degrees for lysosomal enzymes (acid phosphatase and non-specific esterase) and with the following antibodies: ED1/ED2 (rat macrophage/histiocyte-specific), OX6 (rat MHC class II-specific), lysozyme antibody and alpha1-antichymotrypsin antibody. Electron microscopically, HS-P cells showed lysosomes and prominent cell projections. These findings indicated that the cultured cells were macrophage-like. Syngeneic rats inoculated subcutaneously or intraperitoneally with HS-P cells invariably developed sarcomatous tumours consisting of monomorphic mononuclear cells, which exhibited cytochemical properties similar to those of cultured HS-P cells. Bioassay and reverse transcription-polymerase chain reaction methods revealed that tumour necrosis factor-alpha increased on addition of lipopolysaccharide (LPS), indicating that HS-P cells remained LPS-responsive. HS-P cells may prove to be a useful tool for in-vitro studies of macrophage function.

Truth and reconciliation: a psycholegal perspective

The South African Truth and Reconciliation Commission ('TRC') represents one model of dealing with human rights abuses at a national level. Such abuses, and the subsequent attempts to come to terms with them, can cause mental disorders and psychological pain. Consequently, mental health and mental health practitioners ('practitioners') will play an important role in the process of bodies such as the TRC. The aim of this article is to examine the TRC process from a psycholegal perspective and to recommend which aspects thereof can be improved in the future. For example, the use of terminology such as 'victim' and 'perpetrator' during the process may have influenced how participants were perceived and treated. Likewise, the emphasis on collective, rather than individual interests, restricted the role of survivors and amnesty seekers in the TRC process. This reduced the effectiveness of the TRC in bringing about reconciliation at an individual and a national level, and limited the TRC's potential as a therapeutic agent. Nevertheless, there were claims that the TRC process healed people. It is argued that the process in itself usually did not lead to healing. Instead, the TRC process highlighted great mental health needs, which were not adequately met. The article discusses the factors that make it difficult to meet mental health needs in countries where human rights abuses have taken place. The article then considers strategies to meet these needs and emphasizes how important it is that those who render mental health services are competent and seen to be credible by the consumers of such services. Finally, the article addresses the need for research in this field to be co-ordinated and professionally responsible.