Socioemotional self- and co-regulation in functional seizures: comparing high and low posttraumatic stress

Functional seizures (FS) are seizure-like symptoms without electroencephalogram (EEG)-based epileptic activity. Those with FS often show emotion-related dysfunction and disrupted interpersonal relationships, in which posttraumatic stress disorder symptoms (PTS) may play a role. We sought to better understand trauma comorbidities and socioemotional processes in FS, including affectionate touch, a form of social connection linked to emotion regulation and awareness. We administered questionnaires online to a community sample of 89 trauma-exposed FS participants (FS diagnoses were self-reported), 51 with and 38 without clinical-level PTS (FS-PTShi, FS-PTSlo) and 216 seizure-free matched trauma-exposed controls (TCs), 91 with and 125 without clinical-level PTS (TC-PTShi, TC-PTSlo) per the Posttraumatic Stress Disorder Symptom Checklist (PCL). As hypothesized, both FS-PTShi and FS-PTSlo reported more emotional avoidance (Brief Experiential Avoidance Questionnaire), more emotion regulation difficulties (Difficulties in Emotion Regulation Scale), and more perceived stress (Perceived Stress Scale) than PTS-matched counterparts. FS-PTShi also reported less reappraisal (Emotion Regulation Questionnaire), more loneliness (UCLA Loneliness Scale), and less frequent affectionate touch (Physical Affection Scale) during waking and surrounding sleep than TC-PTShi, whereas FS-PTSlo and TC-PTSlo did not differ. Neither FS group differed from PTS-matched controls in emotion suppression (Emotion Regulation Questionnaire) or comfort with social touch (Social Touch Questionnaire). Among FS, FS-PTShi reported more difficulties than FS-PTSlo on nearly all measures (non-significant trend for social support). Findings underscore potential synergistic effects of FS and PTS clinical symptoms in shaping experiences of one's emotions and social world, suggesting fostering meaningful connections with others, including via affectionate touch, is an important treatment target.

An interdisciplinary approach to the screening, diagnosis, and treatment of OEF/OIF Veterans with mild traumatic brain injury

OBJECTIVE

To implement an Integrated TBI Screening Clinic (ITSC) during the mandatory TBI evaluation process at the Department of Veterans Affairs. Referral outcomes were examined regarding Veterans who were determined to need a full neuropsychological evaluation versus those for whom mental health treatment was clinically indicated. Correlations among cognitive measures, posttraumatic stress disorder (PTSD), anxiety, depression, and insomnia symptoms were also examined.

METHOD

This study was a retrospective chart review study that included 138 Veterans seen between 2011 and 2014 in a post-deployment primary care clinic. Descriptive statistics and correlations were completed using the: screening Module of the Neuropsychological Assessment Battery (S-NAB), PTSD Checklist-Military version (PCL-M), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and Insomnia Severity Index (ISI).

RESULTS

19.8% of Veterans required a referral for a full neuropsychological exam and 72.7% were referred for additional mental health services (with some Veterans being referred to both). Significant correlations were found among higher PTSD, depression, anxiety symptoms, with poorer attention and memory (all p < .05). Only PTSD was significantly correlated with poorer executive functioning (r = 0.19, p < .05).

CONCLUSION

Integration of a multidisciplinary neuropsychological screening exam during a primary care visit with OEF/OIF Veterans may assist in better delineating symptoms.

Affective Experience and Regulation via Sleep, Touch, and "Sleep-Touch" Among Couples

Touch associated with sleep (sleep-touch; reported physical contact during or shortly before/after sleep) is underexplored as a distinct contributor to affect regulatory processes associated with adult sleep. Given the affect-regulating effects of interpersonal touch, we theorized that among healthy co-sleeping adults, sleep-touch would add to sleep-related effects on affective "resetting," resulting in the experience of calmer, more regulated states. We studied 210 married heterosexual couples (aged 20-67 years, 79% non-Hispanic white, 13% Latinx) assigned 14 days of twice-daily (morning/evening) sleep/mood diaries. Multilevel daily (within-couple) mediation analyses showed that as hypothesized, more reported sleep-touch was associated with happier/calmer and less angry/irritable morning mood. In turn, happier/calmer mood was associated with greater enjoyment of time with spouse (for both spouses). Sleep-touch also was linked directly to both evening positive spousal events and enjoyment ratings. Sleep-touch was associated indirectly with fewer negative spousal events and less spouse-related stress via less angry/irritable morning mood (both spouses). Further, wives' sleep-touch was related to happier/calmer husband mood and evening enjoyment; husbands' sleep-touch was unrelated to wives' reports. All associations with sleep-touch were present while accounting for subjective sleep quality, prior evening mood, non-sleep-related physical affection, day in study, and weekend versus weekday. We speculate that among relatively healthy satisfied couples, physical touch during and surrounding sleep may add to sleep's restorative and affect-regulatory functions, suggesting a pathway through which co-sleeping can improve affect regulation and ultimately relationships and health.

Shame in patients with psychogenic nonepileptic seizure: A narrative review

Psychogenic Nonepileptic Seizures (PNES) have been linked to dysregulated emotions and arousal. However, the question which emotions may be most relevant has received much less attention. In this multidisciplinary narrative review, we argue that the self-conscious emotion of shame is likely to be of particular importance for PNES. We summarize current concepts of the development of shame processing and its relationship with other emotional states. We demonstrate the potential of acute shame to cause a sudden disruption of normal cognitive function and trigger powerful behavioral, cognitive, physiological and secondary emotional responses which closely resemble key components of PNES. These responses may lead to the development of shame avoidance strategies which can become disabling in themselves. We discuss how excessive shame proneness and shame dysregulation are linked to several psychopathologies often associated with PNES (including depression and PTSD) and how they may predispose to, precipitate and perpetuate PNES disorders, not least by interacting with stigma. We consider current knowledge of the neurobiological underpinnings of shame and PNES. We explore how shame could be the link between PNES and a heterogeneous range of possible etiological factors, and how it may link historical aversive experiences with individual PNES events occurring much later and without apparent external trigger. We argue that, in view of the potential direct links between shame and PNES, the well-documented associations of shame with common comorbidities of this seizure disorder and the well-characterized relationship between chronic shame and stigma, there is a compelling case to pay greater attention to shame in relation to PNES. Its role in the treatment of patients with PNES is discussed in a separate, linked review incorporating case vignettes to highlight the complex interactions of different but interlinked shame-related issues in individual patients.

How to do things with words Two seminars on the naming of functional (psychogenic, non-epileptic, dissociative, conversion, …) seizures

Amongst the most important conditions in the differential diagnosis of epilepsy is the one that manifests as paroxysms of altered behaviour, awareness, sensation or sense of bodily control in ways that often resemble epileptic seizures, but without the abnormal excessive or synchronous electrical activity in the brain that defines these. Despite this importance, there remains little agreement - and frequent debate - on what to call this condition, known inter alia as psychogenic non-epileptic seizures (PNES), dissociative seizures (DS), functional seizures (FS), non-epileptic attack disorder (NEAD), pseudoseizures, conversion disorder with seizures, and by many other labels besides. This choice of terminology is not merely academic - it affects patients' response to and understanding of their diagnosis, and their ability to navigate health care systems.This paper summarises two recent discussions hosted by the American Epilepsy Society and Functional Neurological Disorders Society on the naming of this condition. These discussions are conceptualised as the initial step of an exploration of whether it might be possible to build consensus for a new diagnostic label.

Emotional Reactivity as a Vulnerability for Psychogenic Nonepileptic Seizures? Responses While Reliving Specific Emotions

OBJECTIVE

Dysfunction in emotional processes is a hypothesized contributor to functional neurological disorders (FNDs), yet few studies have evoked real-time emotion during multimethod assessment incorporating subjective, behavioral, and psychophysiological indicators. This approach may reveal clinical and neurobiological vulnerability to FND and clarify how dysfunctional emotional processes serve as perpetuating factors.

METHODS

Eleven participants with video-EEG-confirmed diagnoses of psychogenic nonepileptic seizures (PNES) were compared with 49 seizure-free trauma control subjects (TCs) with or without clinically elevated posttraumatic stress symptoms (25 clinically elevated [TC-clin], 24 not clinically elevated [TC-nonclin]). Participants recalled and described memories evoking anger, shame, happiness, and neutral feelings.

RESULTS

Even though PNES patients and TCs reported similar amounts of emotional experience, PNES patients reported more difficulty reliving emotions and were less likely to complete the relived shame task. During and after reliving happiness, PNES and TC-clin groups showed respiratory sinus arrhythmia (RSA) decreases, indicating parasympathetic withdrawal, whereas the TC-nonclin group showed RSA increases.

CONCLUSIONS

Findings from this pilot study are consistent with previous research and clinical observations that emotional engagement may be more effortful for PNES patients. Patterns of RSA change, which may also point to greater effortful engagement, were similar in PNES and TC-clin groups, suggesting that traumatic stress reactions may play a part. At the same time, experience of greater difficulty or avoidance may be even greater among PNES patients. Especially when regulatory resources are already limited, accumulated effort, coupled with self-threatening contexts such as shame, may be particularly problematic for those with PNES and perhaps other FNDs.

A framework for understanding the pathophysiology of functional neurological disorder

The symptoms of functional neurological disorder (FND) are a product of its pathophysiology. The pathophysiology of FND is reflective of dysfunction within and across different brain circuits that, in turn, affects specific constructs. In this perspective article, we briefly review five constructs that are affected in FND: emotion processing (including salience), agency, attention, interoception, and predictive processing/inference. Examples of underlying neural circuits include salience, multimodal integration, and attention networks. The symptoms of each patient can be described as a combination of dysfunction in several of these networks and related processes. While we have gained a considerable understanding of FND, there is more work to be done, including determining how pathophysiological abnormalities arise as a consequence of etiologic biopsychosocial factors. To facilitate advances in this underserved and important area, we propose a pathophysiology-focused research agenda to engage government-sponsored funding agencies and foundations.

Brain boosters: Evaluating a pilot program for memory complaints in veterans

This study investigated the feasibility and preliminary effectiveness of a pilot program designed to address subjective memory complaints among Veterans. The program, Brain Boosters, consisted of 10 once-weekly group sessions, during which psychoeducation and cognitive enhancement strategies were used to target memory concerns and related processes, specifically attentional difficulties. Given that memory complaints often are associated with psychiatric comorbidities, sessions also incorporated strategies for reducing symptoms of depression, posttraumatic stress, and insomnia. Controlling for age, we examined pre- to posttreatment change in symptom ratings for 96 Veterans (aged 22 to 87 years) who participated in the Brain Boosters program. The effect of Brain Boosters on memory complaints interacted with age: younger (but not older) Veterans reported reductions in memory impairment from pre- to posttreatment. Additionally, irrespective of age, from pre- to posttreatment Veterans reported fewer attentional difficulties and fewer depression symptoms. Ratings of posttraumatic stress and insomnia symptoms did not change, although insomnia was negatively associated with age. Linear regression controlling for age revealed that reductions in attention problems predicted reductions in perceived memory impairment. Findings from this exploratory, uncontrolled pilot study suggest that a psychoeducational cognitive enhancement group is feasible to conduct in a heterogeneous Veteran population, and may be associated with improvements in perceived memory functioning for younger Veterans, and in attention and depression symptoms for Veterans across age groups. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Convergence in feeling, divergence in physiology: How culture influences the consequences of disgust suppression and amplification among European Americans and Asian Americans

Much empirical work documents the downsides of suppressing emotions. Emerging research points to the need for a more sophisticated and culturally informed approach to understanding the consequences of emotion regulation. To that end, we employed behavioral, self-report, and psychophysiological measures to examine the consequences of two types of emotion regulation (suppression and amplification) in a sample of 28 Asian Americans and 31 European Americans. Participants were shown a neutral film and then a series of disgust-eliciting films during which they were asked to regulate their response by suppressing or amplifying their emotional behavior (counterbalanced). Despite self-reporting equal levels of disgust, European Americans showed greater skin conductance reactivity than Asian Americans in both regulation conditions, but not in response to a neutral film. These findings extend work on divergence in the consequences of emotion regulation across different cultural groups, which could help identify optimal emotion regulation strategies for health and well-being.

Prospective follow-up study of elderly patients discharged from an accident and emergency department

One hundred patients aged 75 years and over who were discharged from an accident and emergency department were selected at random for follow-up at home. Over half of the patients had suffered minor trauma, but 26 had increased dependency in one or more activities of daily living. Increased support was provided by the relatives for the majority of patients, by friends and neighbours in seven cases, and by a district nurse in 14, whilst only one patient received increased home help. Eight patients were known to be readmitted to hospital within 14 days of discharge. Staff in accident and emergency departments need to be aware that the functional consequences of an apparently minor injury in an elderly person may be severe, and that discharge must be carefully planned.

Implicit and explicit self-esteem discrepancies in people with psychogenic nonepileptic seizures

PURPOSE

Self-esteem (SE), or one's sense of competence and worth, is reduced in many mental and physical disorders. Low SE is associated with perceived stigma and disability and poor treatment outcomes. The present study examined implicit and explicit SE (automatic and deliberate views about the self) in people with epilepsy and people with psychogenic nonepileptic seizures (PNESs). Discrepancies between implicit SE and explicit SE have been found to correlate with psychological distress in disorders often associated with PNESs but are relatively unexplored in PNESs. We hypothesized that, compared with epilepsy, PNESs would be associated with lower self-reported SE and greater discrepancies between implicit SE and explicit SE.

METHODS

Thirty adults with PNESs, 25 adults with epilepsy, and 31 controls without a history of seizures were asked to complete the Rosenberg Self-esteem Scale as a measure of explicit SE and an Implicit Relational Assessment Procedure as a measure of implicit SE. The State-Trait Anxiety Inventory and Patient Health Questionnaire-15 (a somatic symptom inventory) were also administered.

RESULTS

We found significant group differences in explicit (p<0.001) but not implicit SE. Patients with PNESs reported lower SE than the other groups. No group differences were found in implicit SE. Implicit-explicit SE discrepancies were larger in the group with PNESs than in the other groups (p<0.001). Higher frequency of PNESs (but not epileptic seizures) was associated with lower explicit SE (rs=-.83, p<0.01) and greater SE discrepancies (i.e., lower explicit relative to implicit SE; rs=.65, p<0.01). These relationships remained significant when controlling for anxiety and somatization.

CONCLUSION

Patients with PNESs had lower explicit SE than those with epilepsy or healthy controls. In keeping with our expectations, there were greater discrepancies between implicit SE and explicit SE among patients with PNESs than in the other groups. Our results, including the strong relationship between PNES frequency, anxiety, and explicit-implicit SE discrepancies, support the interpretation that PNESs serve to reduce cognitive dissonance, perhaps protecting patients' implicit SE.

Control of the diffracted response of a metallic wire array with double period: experimental demonstration

In recent papers, it has been theoretically shown that by using dual-period wire gratings, it is possible to control the relative efficiencies of the diffracted orders, regardless of the wires' material, incident polarization and wavelength. In this Letter, we experimentally demonstrate, for the first time, that by appropriately choosing the geometrical parameters of a nanometric periodic structure, it is possible to control the optical response in the visible range. We show examples of nanostructures designed to cancel out or to intensify a particular diffraction order. Such nanostructures allow a broad control over the directionality and the intensity of the diffracted light, which makes them useful for applications such as highly directional optical nanoantennas and photonic multiplexers.

Anxiety and avoidance in psychogenic nonepileptic seizures: the role of implicit and explicit anxiety

This study examined implicit and explicit anxiety in individuals with epilepsy and psychogenic nonepileptic seizures (PNESs) and explored whether these constructs were related to experiential avoidance and seizure frequency. Based on recent psychological models of PNESs, it was hypothesized that nonepileptic seizures would be associated with implicit and explicit anxiety and experiential avoidance. Explicit anxiety was measured by the State-Trait Anxiety Inventory; implicit anxiety was measured by an Implicit Relational Assessment Procedure; and experiential avoidance was measured with the Multidimensional Experiential Avoidance Questionnaire. Although both groups with epilepsy and PNESs scored similarly on implicit measures of anxiety, significant implicit-explicit anxiety discrepancies were only identified in patients with PNESs (p<.001). In the group with PNESs (but not in the group with epilepsy), explicit anxiety correlated with experiential avoidance (r=.63, p<.01) and frequency of seizures (r=.67, p<.01); implicit anxiety correlated with frequency of seizures only (r=.56, p<.01). Our findings demonstrate the role of implicit anxiety in PNESs and provide additional support for the contribution of explicit anxiety and experiential avoidance to this disorder.

Hierarchical nanoparticle ensembles synthesized by liquid phase directed self-assembly

A liquid metal filament supported on a dielectric substrate was directed to fragment into an ordered, mesoscale particle ensemble. Imposing an undulated surface perturbation on the filament forced the development of a single unstable mode from the otherwise disperse, multimodal Rayleigh-Plateau instability. The imposed mode paved the way for a hierarchical spatial fragmentation of the filament into particles, previously seen only at much larger scales. Ultimately, nanoparticle radius control is demonstrated using a micrometer scale switch.

Alterations of consciousness in psychogenic nonepileptic seizures: emotion, emotion regulation and dissociation

Impairment of consciousness and reduced self-control are key features of most psychogenic nonepileptic seizures (PNESs), although, compared with patients with epilepsy, those with PNESs demonstrate greater conscious awareness during their seizures. The neurobiological underpinnings of PNESs and of alterations of awareness associated with PNESs remain relatively unknown. We suggest that an understanding of conscious experiences and discrepancies between subjective impairment of consciousness and the lack of objectifiable neurobiological changes in PNESs may benefit from an examination of emotion processing, including understanding sensory, situational, and emotional triggers of PNESs; emotional and physiological changes during the attacks; and styles of emotional reactivity and regulatory capacity. We also suggest that in addition to the typical comparisons between patients with PNESs and those with epilepsy, studies of PNESs would benefit from the inclusion of comparison groups such as those with PTSD, dissociation, and other forms of psychopathology where dissociative and emotion regulatory mechanisms have been explored more fully. We conclude that current evidence and theory suggest that impairment of consciousness in PNESs is only "dissociative" in one subgroup of these seizures, when consciousness is suppressed as a collateral effect of the excessive inhibition of emotion processing. We propose that PNES behaviors and experiences of reduced control or awareness may also represent direct behavioral manifestation of overwhelming emotions, or that minor emotional fluctuations or relatively neutral stimuli may trigger PNESs through conditioning or other preconscious processes. Future studies exploring the neurobiological mechanisms underpinning PNESs are likely to be more fruitful if researchers bear in mind that it is unlikely that all PNESs result from the same processes in the brain.

Job stress and dyadic synchrony in police marriages: a preliminary investigation

Despite reports documenting adverse effects of stress on police marriages, few empirical studies focus on actual emotional behaviors of officers and spouses. In this preliminary investigation, 17 male police officers and their nonpolice wives completed daily stress diaries for 1 week and then participated in a laboratory-based discussion about their respective days. Conversations were video-recorded and coded for specific emotional behaviors reflecting hostility and affection, which are strong predictors of marital outcomes. We examined associations between officers' job stress (per diaries and the Police Stress Survey) and couples' emotional behavior (mean levels and behavioral synchrony) using a dyadic repeated measures design capitalizing on the large number of observations available for each couple (1020 observations). When officers reported more job stress, they showed less hostility, less synchrony with their wives' hostility, and more synchrony with their wives' affection; their wives showed greater synchrony with officers' hostility and less synchrony with officers' affection. Therefore, for officers, greater job stress was associated with less behavioral negativity, potentially less attunement to wives' negativity, but potentially greater attunement to wives' affection-perhaps a compensatory strategy or attempt to buffer their marriage from stress. These attempts may be less effective, however, if, as our synchrony findings may suggest, wives are focusing on officers' hostility rather than affection. Although it will be important to replicate these results given the small sample, our findings reveal that patterns of behavioral synchrony may be a key means to better understand how job stress exacts a toll on police marriages.

Processes linking cultural ingroup bonds and mental health: the roles of social connection and emotion regulation

Cultural and ethnic identities influence the relationships individuals seek out and how they feel and behave in these relationships, which can strongly affect mental and physical health through their impacts on emotions, physiology, and behavior. We proposed and tested a model in which ethnocultural identifications and ingroup affiliations were hypothesized explicitly to enhance social connectedness, which would in turn promote expectancy for effective regulation of negative emotions and reduce self-reported symptoms of depression and anxiety. Our sample comprised women aged 18-30 currently attending college in the Southwestern US, who self-identified as Hispanic of Mexican descent (MAs; n = 82) or as non-Hispanic White/European American (EAs; n = 234) and who completed an online survey. In the full sample and in each subgroup, stronger ethnocultural group identity and greater comfort with mainstream American culture were associated with higher social connectedness, which in turn was associated with expectancy for more effective regulation of negative emotions, fewer depressive symptoms, and less anxiety. Unexpectedly, preference for ingroup affiliation predicted lower social connectedness in both groups. In addition to indirect effects through social connection, direct paths from mainstream comfort and preference for ingroup affiliation to emotion regulation expectancy were found for EAs. Models of our data underscore that social connection is a central mechanism through which ethnocultural identities-including with one's own group and the mainstream cultural group-relate to mental health, and that emotion regulation may be a key aspect of this linkage. We use the term ethnocultural social connection to make explicit a process that, we believe, has been implied in the ethnic identity literature for many years, and that may have consequential implications for mental health and conceptualizations of processes underlying mental disorders.

Synthesis and electroplating of high resolution insulated carbon nanotube scanning probes for imaging in liquid solutions

High resolution and isolated scanning probe microscopy (SPM) is in demand for continued development of energy storage and conversion systems involving chemical reactions at the nanoscale as well as an improved understanding of biological systems. Carbon nanotubes (CNTs) have large aspect ratios and, if leveraged properly, can be used to develop high resolution SPM probes. Isolation of SPM probes can be achieved by depositing a dielectric film and selectively etching at the apex of the probe. In this paper the fabrication of a high resolution and isolated SPM tip is demonstrated using electron beam induced etching of a dielectric film deposited onto an SPM tip with an attached CNT at the apex.

Elevated Baseline Anxiety Among African Americans in Laboratory Research Settings

We tested the hypothesis that African Americans would show greater anxiety than their European American counterparts when entering laboratory research settings. We examined subjective and physiological anxiety measures obtained both inside and outside the research laboratory from 126 African Americans and 147 European Americans in three separate studies. Consistent with our hypotheses, African Americans reported experiencing significantly more baseline anxiety and showed greater baseline physiological arousal consistent with anxiety than European Americans. These differences were evident when controlling for anxiety observed outside of the research setting as well as baseline differences in overall emotional experience. Our findings highlight the need to consider laboratory-induced anxiety as a potential confound in studies involving African Americans. This may be especially important in race comparison studies in which undetected baseline anxiety could alter the interpretation of subsequent race comparisons.

Competing liquid phase instabilities during pulsed laser induced self-assembly of copper rings into ordered nanoparticle arrays on SiO2

Nanoscale copper rings of different radii, thicknesses, and widths were synthesized on silicon dioxide thin films and were subsequently liquefied via a nanosecond pulse laser treatment. During the nanoscale liquid lifetimes, the rings experience competing retraction dynamics and thin film and/or Rayleigh-Plateau types of instabilities, which lead to arrays of ordered nanodroplets. Surprisingly, the results are significantly different from those of similar experiments carried out on a Si surface. We use hydrodynamic simulations to elucidate how the different liquid/solid interactions control the different instability mechanisms in the present problem.

Dynamics of choice during estimation of subjective value

This study characterized preferential choice in binary trials and investigated intra-session variations in response time (RT). In Experiment 1, participants (N=77) were asked to choose the preferred of two images of body wash; all unique combinations of 19 images were presented. The results showed: (a) marked and consistent individual preferences for specific stimuli; (b) RT decreased monotonically with increasing exposure to each stimulus; (c) RT decreased exponentially as a function of relative preference ranking of the 2 images in a trial; and (d) a regression model efficiently predicted trial RT as a function of exposure and relative preference. Experiment 2 (N=112) explored the effect of amount of exposure on RT, and relative preference as a function of the type of choice task (a previously completed vs. a new choice task). The results showed that: (a) within a single choice task, amount of exposure and relative preference between the stimuli predicted the systematic changes in RT observed in Exp. 1; and (b) when the choice task changed, the effects of previous amount of exposure, and relative stimulus preference did not transfer to the new task.

Emotion Control Values and Responding to an Anger Provocation inAsian-American and European-American Individuals

The present research examined whether Asian-American (AA) versus European-American (EA) women differed in experiential, expressive, or autonomic physiological responding to a laboratory anger provocation and assessed the mediating role of values about emotional control. Results indicate that AA participants reported and behaviorally displayed less anger than EA participants, while there were no group differences in physiological responses. Observed differences in emotional responses were partially mediated by emotion control values, suggesting a potential mechanism for effects of cultural background on anger responding.

Integrating Functional Analytic Psychotherapy and Behavioral Activation for the Treatment of Relationship Distress

The following case study demonstrates the potential for an integrated behavioral treatment to improve interpersonal functioning, specifically within a romantic relationship. This integrated treatment utilizes strategies from both Functional Analytic Psychotherapy (FAP) and Behavioral Activation (BA), and thus is termed FAP-Enhanced BA (FEBA). This case study represents an initial attempt to apply FEBA to a 22-year-old female undergraduate, Megan, presenting with relationship distress. Megan and her partner both completed a pretreatment and posttreatment assessment that included self-report questionnaires in addition to a conflict-interaction task that was later coded for the presence of specific emotions. After the pretreatment assessment, Megan participated in 8 sessions of FEBA. Session-by-session descriptions and data will be presented, as well as data from the pretreatment and posttreatment assessments.

Cardiovascular costs of emotion suppression cross ethnic lines

Previous research has shown that inhibiting emotion-expressive behavior (emotion suppression) leads to increased sympathetic activation of the cardiovascular system [Gross, J.J. and Levenson, R.W. (1993). Emotional suppression: physiology, self-report, and expressive behavior. J. Pers. Soc. Psychol. 64(6), 970-986]. Ethnic differences have been reported in how frequently suppression is used as an emotion regulation strategy [Gross, J.J. and John, O. (2003). Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J. Pers. Soc. Psychol. 85(2), 348-362]; however, it remains unknown whether there are ethnic differences in the physiological consequences of suppression. To test this, 168 participants from four ethnic groups (African American, Chinese American, European American, Mexican American) watched a disgust-eliciting film clip; half were instructed to suppress their emotions and half simply watched the film. Consistent with previous research, suppression was associated with decreased facial behavior, increased cardiovascular activation, and no impact on subjective emotional experience. Ethnicity failed to moderate these effects, indicating the generality of the cardiovascular consequences of emotion suppression across ethnic background.

Acute Intermittent Porphyria: Some Diagnoses are Only Made If Thought of

A 20-year-old Asian, female, student nurse of thin body habitus (Body Mass Index 16.5) but otherwise previously well had numerous admissions to our centre under a variety of surgical sub-specialities over a 5-month period. Each month, coinciding with menses, she complained of non-specific abdominal discomfort in the absence of any other symptoms. With the exception of the presence of a sinus tachycardia coupled with incidental hyponatraemia full physical examinations and routine baseline investigations were unremarkable.

Emotional reactivity and emotion recognition in frontotemporal lobar degeneration

BACKGROUND

Frontotemporal lobar degeneration (FTLD) is associated with a profound decline in social and emotional behavior; however, current understanding regarding the specific aspects of emotional functioning that are preserved and disrupted is limited.

OBJECTIVE

To assess preservation of function and deficits in two aspects of emotional processing (emotional reactivity and emotion recognition) in FTLD.

METHODS

Twenty-eight FTLD patients were compared with 16 controls in emotional reactivity (self-reported emotional experience, emotional facial behavior, and autonomic nervous system response to film stimuli) and emotion recognition (ability to identify a target emotion of fear, happy, or sad experienced by film characters). Additionally, the neural correlates of emotional reactivity and emotion recognition were investigated.

RESULTS

FTLD patients were comparable to controls in 1) emotional reactivity to the fear, happy, and sad film clips and 2) emotion recognition for the happy film clip. However, FTLD patients were significantly impaired compared with controls in emotion recognition for the fear and sad film clips. Volumetric analyses revealed that deficits in emotion recognition were associated with decreased lobar volumes in the frontal and temporal lobes.

CONCLUSIONS

The socioemotional decline typically seen in frontotemporal lobar degeneration patients may result more from an inability to process certain emotions in other people than from deficits in emotional reactivity.

In-vitro and in-vivo efficacy of influenza neuraminidase inhibitors

Influenza continues to be a major health concern and there is always the threat of a pandemic due to the emergence of a viral strain new to the human population, as exemplified by the avian influenza A/H5N1 virus which was responsible for six deaths in Hong Kong last year. Data reported in the past year, based on in-vitro, in-vivo (animal) and clinical studies, suggest that a new class of antiviral compounds targeting the viral neuraminidase is likely to be useful for the treatment and prevention of influenza virus infections in humans.

Subjective, behavioral, and physiological reactivity to ethnically matched and ethnically mismatched film clips

This study examined whether individuals from 4 major ethnic groups within the United States (African American, Chinese American, European American, and Mexican American) showed greater subjective, behavioral, and physiological responses to emotional film clips (amusement, sadness, and disgust) with actors from their own ethnic group (ethnically matched) compared with actors from the other 3 ethnic groups (ethnically mismatched). Evidence showed greater responsivity to ethnically matched films for African Americans and European Americans, with the largest effect for African Americans. These findings were consistent across both sex and level of cultural identification. Findings of ethnic difference notwithstanding, there were many areas in which ethnic differences were not found (e.g., little or no evidence was found of greater response to ethnically matched films in Chinese-American or Mexican- American participants). These findings indicate that the emotional response system clearly reacts to stimuli of diverse ethnic content; however, the system is also amenable to subtle "tuning" that allows for incrementally enhanced responding to members of one's own ethnic or cultural group.

Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients

This article describes a case formulation-driven approach to the treatment of anxious depressed outpatients and presents naturalistic outcome data evaluating its effectiveness. Fifty-eight patients who received case formulation-driven cognitive-behavior therapy (CBT) in a private practice setting were studied. All received individual CBT guided by a case formulation and weekly outcome monitoring; in addition, 40 patients received adjunct therapies, including pharmacotherapy, which were added as indicated by the case formulation and the results of weekly outcome monitoring. Patients treated with case formulation-driven CBT showed statistically and clinically significant changes in anxiety and depression that were generally comparable to those reported in published randomized controlled trials of empirically supported therapies (ESTs) for single mood and anxiety disorders. Findings support the proposal that anxious depressed patients who have multiple comorbidities and require multiple therapies can benefit from empirically supported treatments guided by a case formulation and weekly outcome monitoring.

The impact of orbital prefrontal cortex damage on emotional activation to unanticipated and anticipated acoustic startle stimuli

Damage to the orbital prefrontal cortex has been implicated in selectively diminishing electrodermal autonomic nervous system responses to anticipated punishing stimuli (e.g., losing money; Bechara, Damasio, & Damasio, 2000), but not to unanticipated punishing stimuli (e.g., loud noises; Damasio, Tranel, & Damasio, 1990). We extended this research by examining the effects of orbitofrontal damage on emotional responses to unanticipated and anticipated acoustic startles and collecting a more extensive set of physiological measures, emotional facial behavior, and self-reported emotional experience. Consistent with previous research, patients showed intact physiology to an unanticipated startle but failed to show appropriate anticipatory cardiovascular responses (patients' heart rates decreased, controls' increased). In addition, patients displayed more surprise facial behavior and reported marginally more fear than did controls in response to the unanticipated startle. Thus, orbitofrontal damage may compromise the ability to anticipate physiologically the onset of aversive stimuli, despite intact or enhanced emotional responses when such stimuli occur unexpectedly.

The H274Y mutation in the influenza A/H1N1 neuraminidase active site following oseltamivir phosphate treatment leave virus severely compromised both in vitro and in vivo

Oseltamivir carboxylate is a potent and specific inhibitor of influenza A and B neuraminidase (NA). Oseltamivir phosphate, the ethyl ester prodrug of oseltamivir carboxylate, is the first orally active NA inhibitor available for the prophylaxis and treatment of influenza A and B. It offers an improvement over amantadine and rimantadine which are active only against influenza A and rapidly generate resistant virus. The emergence of virus resistant to oseltamivir carboxylate in the treatment of naturally acquired influenza infection is low (about 1%). The types of NA mutation to arise are sub-type specific and largely predicted from in vitro drug selection studies. A substitution of the conserved histidine at position 274 for tyrosine in the NA active site has been selected via site directed mutagenesis, serial passage in culture under drug pressure in H1N1 and during the treatment of experimental H1N1 infection in man. Virus carrying H274Y NA enzyme selected in vivo has reduced sensitivity to oseltamivir carboxylate. The replicative ability in cell culture was reduced up to 3 logs, as was infectivity in animal models of influenza virus infection. Additionally, pathogenicity of the mutant virus is significantly compromised in ferret, compared to the corresponding wild type virus. Virus carrying a H274Y mutation is unlikely to be of clinical consequence in man.

Treatment of influenza with neuraminidase inhibitors: virological implications

Evaluation of the emergence of influenza virus resistance to neuraminidase inhibitors (NAIs) is now demanded following experience with amantadinamines. Preliminary data have indicated that NAI-resistant virus is unlikely to emerge readily in the clinic and this is consistent with the difficulty experienced in selecting resistant virus in vitro. Resistance mutations can occur in both neuraminidase and haemagglutinin genes. The neuraminidase mutations are viral subtype specific and, therefore, clinically relevant subtypes must be employed for in vitro studies if pre-clinical data are to have predictive value. Haemagglutinin mutations generated in vitro are probably both subtype and cell culture system specific and, therefore, may not be predictive of clinical findings. Analysis of influenza-positive samples from NAI-treated patients in the clinical setting must include samples from late treatment time-points (day 4 and later) in order for resistant virus to be detected as in vitro studies and current clinical experience have indicated that resistant virus is slow to emerge and is transient.

Rate of emergence of cytomegalovirus (CMV) mutations in leukocytes of patients with acquired immunodeficiency syndrome who are receiving valganciclovir as induction and maintenance therapy for CMV retinitis

The emergence of mutations conferring ganciclovir resistance was evaluated in an open-label randomized clinical trial that compared oral valganciclovir with intravenous ganciclovir as induction therapy, followed by maintenance with valganciclovir, for newly diagnosed cytomegalovirus (CMV) retinitis in 148 patients with acquired immunodeficiency syndrome. The presence of CMV mutations was directly assessed in patient leukocytes by polymerase chain reaction, followed by restriction fragment-length polymorphism (RFLP) for detection of the most common UL97 mutations associated with ganciclovir resistance and by sequencing of the viral UL97 gene. The cumulative percentages of patients with UL97-mutant viruses at 3, 6, 12, and 18 months (based on the number of patients on treatment at each time point) was 2.2%, 6.5%, 12.8%, and 15.3%, respectively. Of the 20 relevant UL97 mutations found by sequencing in 14 patients, 14 (70%) were detected by RFLP analysis. The rate of emergence of ganciclovir-resistant viruses with use of oral valganciclovir is no greater than that reported with use of intravenous ganciclovir.

Anti-influenza drugs and neuraminidase inhibitors

Each year, influenza viruses are responsible for considerable illness, complications and mortality. An effective treatment will have a major impact on the severe personal and economic burden that this disease incurs. There are several points in the influenza life cycle that may be potentially inhibited. One critical point is the release of newly synthesized virions from the host cell surface. Viral neuraminidase (NA) cleaves the virus from host cell sialic acid residues allowing infection of other host cells. Rationally designed NA inhibitors that block the viral life cycle are now in the clinic and these molecules are effective and safe for the treatment of influenza. Compared with other anti-influenza agents the NA inhibitors are well tolerated, effective against all influenza types and there has been little evidence of the emergence of viral resistance. NA inhibitors provide an important new therapeutic weapon for the management of influenza infection.

Anti-influenza drugs and neuraminidase inhibitors

Each year, influenza viruses are responsible for considerable illness, complications and mortality. An effective treatment will have a major impact on the severe personal and economic burden that this disease incurs. There are several points in the influenza life cycle that may be potentially inhibited. One critical point is the release of newly synthesized virions from the host cell surface. Viral neuraminidase (NA) cleaves the virus from host cell sialic acid residues allowing infection of other host cells. Rationally designed NA inhibitors that block the viral life cycle are now in the clinic and these molecules are effective and safe for the treatment of influenza. Compared with other anti-influenza agents the NA inhibitors are well tolerated, effective against all influenza types and there has been little evidence of the emergence of viral resistance. NA inhibitors provide an important new therapeutic weapon for the management of influenza infection.

Non-specific antiviral activity of antisense molecules targeted to the E1 region of human papillomavirus

Antisense phosphorothioate oligonucleotides (ODN1 0x5 OMe) directed against the E1 start region of human papillomavirus 11 (HPV11) can inhibit papillomavirus induced growth of implanted human foreskin in a mouse xenograft model. Administration of a mismatch control oligonucleotide (ODN9 0x5 OMe), in which guanine was replaced with adenine in the same model, had no effect on papilloma induced growth. However, the apparent antiviral activity of ODN1 0x5 OMe was also shown in a lethal mouse cytomegalovirus (CMV) model, in which the oligonucleotides are not expected to have antisense activity. To understand the mechanisms of action of these oligonucleotides, a mismatch oligonucleotide (ODN61 0x5 OMe) was prepared which retained the CpG motifs of ODN1 0x5 OMe. This was tested in the mouse xenograft model and shown to have moderate inhibitory activity. As a definitive experiment, a comparison was made between the efficacy of the active oligonucleotide ODN1 0x5 OMe against two papilloma viruses HPV11 and HPV40. Both these viruses cause benign genital warts, but differ by four bases in their E1 sequence that was the target for ODN1 0x5 OMe. Papillomavirus induced growth in the mouse xenograft model was inhibited by ODN1 0x5 OMe in both cases, suggesting that oligonucleotide molecules have a non-specific antiviral activity that is not directly related to their antisense sequence.

RNA and DNA hydrolysis are catalyzed by the influenza virus endonuclease

The influenza virus polymerase complex contains a metal ion-dependent endonuclease activity, which generates short capped RNA primer molecules from capped RNA precursors. Previous studies have provided evidence for a two-metal ion mechanism of RNA cleavage, and the data are consistent with a direct interaction of a divalent metal ion with the catalytic water molecule. To refine the model of this active site, we have generated a series of DNA, RNA, and DNA-RNA chimeric molecules to study the role of the 2'-hydroxy groups on nucleic acid substrates of the endonuclease. We could observe specific cleavage of nucleic acid substrates devoid of any 2'-hydroxy groups if they contained a cap structure (m7GpppG) at the 5'-end. The capped DNA endonuclease products were functional as primers for transcription initiation by the influenza virus polymerase. The apparent cleavage rates were about 5 times lower with capped DNA substrates as compared with capped RNA substrates. Cleavage rates with DNA substrates could be increased to RNA levels by substituting the deoxyribosyl moieties immediately 5' and 3' of the cleavage site with ribosyl moieties. Similarly, cleavage rates of RNA substrates could be lowered to DNA levels by exchanging the same two ribosyl groups with deoxyribosyl groups at the cleavage site. These results demonstrate that the 2'-hydroxy groups are not essential for binding and cleavage of nucleic acids by the influenza virus endonuclease, but small differences of the nucleic acid conformation in the endonuclease active site can influence the overall rate of hydrolysis. The observed relative cleavage rates with DNA and RNA substrates argue against a direct interaction of a catalytic metal ion with a 2'-hydroxy group in the endonuclease active site.

The role of endogenous interleukin-12 in resistance to murine cytomegalovirus (MCMV) infection and a novel action for endogenous IL-12 p40

Biologically active interleukin-12 (IL-12), comprising a 40 kDa subunit (p40) covalently linked to a 35 kDa subunit (p35), is produced in response to a range of infectious stimuli. Here, we demonstrate that mice deficient in either IL-12 p40 (p40-/-) or IL-12 p35 (p35-/-) are susceptible to murine cytomegalovirus (MCMV) infection in terms of survival (Balb/c p35-/-) and viral clearance (Balb/c p35-/- and Balb/c p40-/-), and this susceptibility may be correlated to a deficiency in serum interferon-gamma (IFN-gamma) levels. These data support a role for endogenous IL-12 in controlling MCMV infection. The IL-12 p40 subunit is produced in excess of IL-12 p35, and to date the function of the excess endogenous p40 has been assumed to be one of IL-12 antagonism, as demonstrated by experiments with exogenous p40 both in vivo and in vitro. We show that Balb/c p35-/- alone are significantly compromised in survival of a sublethal infection and in clearance of virus from the spleen. These mice produce a very early IFN-gamma spike (8 h after infection) and an aberrant tumor necrosis factor-alpha (TNF-alpha) spike (day 2 after infection). MCMV infection has revealed an altered Balb/c p35-/- phenotype compared with Balb/c p40-/-, and this indicates that endogenous p40 may have an activity independent of and additional to IL-12 antagonism in vivo.

Haemopoietic progenitor cell lines generated by the myeloproliferative leukaemia virus: a model system to analyse murine and human lineage-affiliated genes

Multipotential progenitor and stem cells occur with a low frequency in haemopoietic tissue. As a result, it is often difficult to obtain sufficient numbers of cells to undertake many of the assays that would be informative about the molecular events involved in the regulation of lineage-affiliated genes within these multipotent cells. To circumvent this problem, we have used the myeloproliferative leukaemia virus (MPLV) to generate a phenotypically diverse array of haemopoietic progenitors from adult mouse bone marrow and embryonic blood. These cells could be expanded to perform a variety of analyses that would not previously have been possible using analogous primary cells. The validity of these assays was supported by the observation that the phenotype of several MPLV-infected lines was very similar to previously described primary haemopoietic progenitor cells. By using mice transgenic for the human alpha and beta globin gene clusters, we have shown that human genes may also be investigated. In addition, this strategy has a wide potential applicability including the rescue of haemopoietic progenitors from mouse embryos lacking genes critical for their survival as well as the study of any haemopoietic gene for which an appropriate transgenic mouse is available.

Metal ion catalysis of RNA cleavage by the influenza virus endonuclease

The influenza virus RNA-dependent RNA polymerase protein complex contains an associated RNA endonuclease activity, which cleaves host mRNA precursors in the cell nucleus at defined positions 9-15 nucleotides downstream of the cap structure. This reaction provides capped oligoribonucleotides, which function as primers for the initiation of viral mRNA synthesis. The endonuclease reaction is dependent on the presence of divalent metal ions. We have used a number of divalent and trivalent metal ions alone and in combination to probe the mechanism of RNA cleavage by the influenza virus endonuclease. Virus-specific cleavage was observed with various metal ions, and maximum cleavage activity was obtained with 100 microM Mn2+ or 100 microM Co2+. This activity was about 2-fold higher than that observed with Mg2+ at the optimal concentration of 1 mM. Activity dependence on metal ion concentration was cooperative with Hill coefficients close to or larger than 2. Synergistic activation of cleavage activity was observed with combinations of different metal ions at varying concentrations. These results support a two-metal ion mechanism of RNA cleavage for the influenza virus cap-dependent endonuclease. The findings are also consistent with a structural model of the polymerase, in which the specific endonuclease active site is spatially separated from the nucleotidyl transferase active site of the polymerase module.

Bb1-3, a transgenic hybrid cell line with erythroid and megakaryocytic differentiation potential that expresses high levels of human gamma-globin and human beta-globin

We have characterized a murine hybrid cell line, Bb1-3, generated by the fusion of mouse primary erythroblasts with MEL cells. It proliferated in serum-free medium and displayed a low level of spontaneous erythroid and megakaryocyte differentiation. Terminal erythroid differentiation could be induced with HMBA and DMSO and was enhanced by serum. Treatment with phorbol esters resulted in a high proportion of megakaryocytes and the expression of megakaryocytic specific lineage markers. Bb1-3 cells contain a human beta-globin transgene that was expressed at levels of 20-50% of the endogenous mouse globin genes. Initially, expression was largely limited to the beta-globin gene but after adaptation to serum free growth, equal expression of both the human gamma- and human beta-globin genes was observed. This cell line provides further evidence that the differentiation potential of mouse erythroleukaemia cells is not restricted to the erythroid lineage and should be useful to study the mechanisms underlying both developmental globin gene regulation and the terminal differentiation of bipotential erythroid/megakaryocytic progenitor cells.

Inhibition of virus-encoded thymidine kinase suppresses herpes simplex virus replication in vitro and in vivo

Both herpes simplex virus type 1 (HSV-1) and HSV-2 encode a thymidine kinase enzyme which differs from cellular thymidine kinase in substrate specificity. Viral thymidine kinase enables the virus to replicate in cells that lack cellular thymidine kinase, namely those of the sensory neurons where the virus establishes, and periodically reactivates from, a latent state. Thymidine kinase-dependent HSV replication following viral reactivation at the site of latency is thought to precede the emergence of virus at mucosal surfaces. The ability to inhibit such an essential viral enzyme would potentially prevent HSV from replicating within neuronal tissue, and thus stop the recurrent disease cycle. Ro 32-2313 was designed as a selective and competitive inhibitor of HSV thymidine kinase and in vitro studies have confirmed this mechanism of action. In vivo evaluation of a soluble prodrug of Ro 32-2313, Ro 32-4397, was undertaken in murine models where pathogenesis was dependent upon viral replication in neuronal tissue. It was shown that in vivo administration of Ro 32-4397 (i) significantly reduced the viral titre detected in isolated dorsal root ganglia; (ii) prevented HSV-2-induced lethality in a systemic infection model; and (iii) reduced zosteriform lesion development in a model of dermal infection. Administration of Ro 32-4397 produced dose-related changes in viral pathogenicity towards those of the phenotype of a thymidine kinase-deficient virus. Overall, the study confirmed that thymidine kinase inhibitors can suppress the replication of HSV in vivo, and suggest that such inhibitors may reduce reactivation of the virus from latency if used prophylactically in recurrent HSV infection.

Interleukin-12 exhibits potent antiviral activity in experimental herpesvirus infections

The prophylactic and therapeutic efficacy of interleukin-12 was studied by using murine models of herpes simplex virus infection. Prophylactic administration consisted of two intraperitoneal doses of interleukin-12 given 48 and 24 h prior to infection. Therapeutic intraperitoneal administration of interleukin-12 commenced 6 h after the mice were infected with herpes simplex virus and was continued daily for a total of 5 days. Interleukin-12 therapy improved the survival rates of mice with systemic herpes simplex virus infection compared with those of placebo-treated infected mice. Subcutaneous administration of interleukin-12 also improved the rate of survival of mice after systemic herpes simplex virus infection, although higher doses were required to give comparable effects. Combined prophylactic and therapeutic administration of interleukin-12 produced the greatest effect on survival after an otherwise lethal systemic infection. Intraperitoneal administration of interleukin-12 for 2 days before and 3 days after systemic infection with herpes simplex virus resulted in survival of 80% of the mice. These surviving mice were resistant to subsequent reinfection with herpes simplex virus. Such resistance was apparently specific for herpes simplex virus infection, since a second group of survivors succumbed to a lethal infection with murine cytomegalovirus. Infectious virus was recovered from lumbar ganglia explants dissected from survivors of prophylactic interleukin-12 therapy and cultured for 5 days in vitro, suggesting that interleukin-12 treatment did not prevent the establishment of latent herpes simplex virus infection. One action of interleukin-12 may be to enhance natural killer cell-mediated clearance of the virus. However, interleukin-12 therapy was also effective in mice carrying the beige mutation, which reduces natural killer cell lytic activity, suggesting that interleukin-12 has additional activities in vivo.

Globin gene switching in transgenic mice carrying HS2-globin gene constructs

We have examined the pattern of human globin gene switching in transgenic mice containing three different gamma and beta gene constructs (HS2G gamma A gamma delta beta, HS2A gamma beta neo, and HS2A gamma en beta) and compared the results with previously described transgenics (HS2A gamma beta, HS2G gamma A gamma-117 delta beta, and LCR epsilon G gamma A gamma delta beta). Developmental regulation was observed in all cases with identical patterns in lines bearing the same construct. Three different patterns of switching were observed: LCR epsilon G gamma A gamma delta beta and HS2A gamma beta neo mice switched rapidly, HS2G gamma A gamma delta beta and HS2G gamma A gamma-117 delta beta at an intermediate rate, and HS2A gamma beta and HS2A gamma en beta mice showed delayed switching, with a plateau in late fetal-early neonatal life and readily detectable levels of gamma mRNA in adults. No difference was observed in the time of switching of the HS2G gamma A gamma delta beta mice compared with those with the A gamma-117 hereditary persistence of fetal hemoglobin mutation, but adult levels of gamma mRNA were significantly higher (approximately 5%) in lines carrying the mutation than in those without (approximately 1%). Reversion to the rapid switch of the LCR epsilon G gamma A gamma delta beta mice was observed in three lines with the HS2A gamma beta neo construct in which expression of the tk-neo gene was approximately equal to that of the globin genes. The inclusion of the A gamma enhancer in HS2A gamma beta mice did not alter the pattern of switching, or reduce the relatively high levels of gamma mRNA in these lines. However, unlike other HS2 mice, the combination of HS2 and the A gamma enhancer resulted in copy number-dependent expression in HS2A gamma en beta lines, with intrauterine death at approximately 12.5 days gestation at high copy numbers. These results demonstrate that numerous elements throughout the beta globin gene cluster interact to produce the correct pattern of developmental regulation of these genes. Furthermore, extinction of gamma gene expression in adult life is not completely autonomous and is incomplete when HS2 is the only LCR element present.