Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Differential Item Functioning Analysis of United States Medical Licensing Examination Step 1 Items

PURPOSE

Previous studies have examined and identified demographic group score differences on United States Medical Licensing Examination (USMLE) Step examinations. It is necessary to explore potential etiologies of such differences to ensure fairness of examination use. Although score differences are largely explained by preceding academic variables, one potential concern is that item-level bias may be associated with remaining group score differences. The purpose of this 2019-2020 study was to statistically identify and qualitatively review USMLE Step 1 exam questions (items) using differential item functioning (DIF) methodology.

METHOD

Logistic regression DIF was used to identify and classify the effect size of DIF on Step 1 items meeting minimum sample size criteria. After using DIF to flag items statistically, subject matter expert (SME) review was used to identify potential reasons why items may have performed differently between racial and gender groups, including characteristics such as content, format, wording, context, or stimulus materials. USMLE SMEs reviewed items to identify the group difference they believed was present, if any; articulate a rationale behind the group difference; and determine whether that rationale would be considered construct relevant or construct irrelevant.

RESULTS

All identified DIF rationales were relevant to the constructs being assessed and therefore did not reflect item bias. Where SME-generated rationales aligned with statistical differences (flags), they favored self-identified women on items tagged to women's health content categories and were judged to be construct relevant.

CONCLUSIONS

This study did not find evidence to support the hypothesis that group-level performance differences beyond those explained by prior academic performance variables are driven by item-level bias. Health professions examination programs have an obligation to assess for group differences, and when present, investigate to what extent, if any, measurement bias plays a role.

1074 Fear Reactivity And Sleep In Trauma-Exposed Males And Females With And Without PTSD

Introduction

Sleep disturbance is considered central to mechanisms of PTSD development and maintenance, and fear learning protocols have been used as laboratory models to understand PTSD disease mechanisms. Some research indicates that fear learning may influence subsequent sleep, especially REM sleep, and that sleep may influence subsequent extinction. In this study, we examined the relationship of startle reactivity during conditioning and later extinction with objectively-measured sleep in PTSD-positive and negative subjects.

Methods

These analyses were performed as part of a larger study of PTSD and sleep. Thirty-four (34) trauma-exposed male and female participants with and without PTSD completed a fear-potentiated startle conditioning procedure at 9:45am, followed by a PSG-monitored nap (13:30-15:30), followed by an extinction protocol at 4:30pm. All visits were preceded by an adaptation nap visit at least 7 days prior. Eye-blink EMG was used to measure startle reactivity. Mixed-model analyses were performed in SPSS.

Results

PTSD-positive subjects had higher REM sleep duration (p<.05) and a trend towards shorter REM sleep latency (p=.06). There were no other group or sex effects on standard PSG sleep parameters. During conditioning, PTSD-positive status was associated with higher startle reactivity across stimulus types (p<.01), driven by increased reactivity in PTSD-positive vs. PTSD-negative females. A PTSD x sex interaction effect on startle reactivity showed the opposite effect in males (p<.01). Higher startle reactivity during conditioning predicted longer sleep latency during the subsequent nap (p<.05), but reactivity during conditioning and extinction did not otherwise show a relationship to standard PSG sleep measures.

Conclusion

These findings are consistent with previous research indicating REM sleep abnormalities as well as heightened fear responses in PTSD. While the observed relationship between higher startle and longer sleep latency is consistent with studies indicating that stress affects subsequent sleep, further research in larger samples is needed to understand causal mechanisms and to advance our understanding of sleep-PTSD mechanisms.

Support

VA Career Development Award-5IK2CX000871-05

Incidence of supraventricular tachycardia after inhaled short-acting beta agonist treatment in children

INTRODUCTION

Albuterol can trigger supraventricular tachycardia (SVT). The clinical characteristics, incidence, and risk factors of SVT after inhaled SABA treatment in children are currently unknown. Through review of regional care delivery, we will describe cases of SVT during asthma treatment in hospital-based settings, define the incidence of SVT in our population, and evaluate risk factors of SABA-induced SVT.

METHODS

We identified hospital-based care episodes of children 0-18 years old between 2006 and 2015 recorded in the Intermountain Healthcare EDW with either 1) diagnosis codes for both asthma and SVT or 2) both SABA and adenosine listed as billed medications. Controls were matched with cases by age and sex to determine risk factors for SVT after SABA using conditional logistic regression.

RESULTS

Of 93 care episodes meeting criteria, we found 7 cases of SVT after SABA treatment in 6 patients over 10 years. In our population, the incidence of SVT is 3.9 per 10,000 episodes of SABA treatment, and 5.1 per 10,000 children with asthma receiving hospital-based asthma care. Two episodes of SVT followed treatment with only levalbuterol, three after only albuterol, and two after both albuterol and levalbuterol treatment. Five cases of SVT were converted to sinus rhythm with adenosine, one converted with synchronized electrical cardioversion, and one resolved spontaneously. No cases of SVT led to death. No examined variables were associated with SABA-induced SVT.

CONCLUSIONS

SVT is rare during hospital-based treatment for acute asthma using inhaled SABAs and has low morbidity and mortality.

Identification of Pediatric Patients With Celiac Disease Based on Serology and a Classification and Regression Tree Analysis

BACKGROUND & AIMS

Celiac disease is detected using serology and endoscopy analyses. We used multiple statistical analyses of a geographically isolated population in the United States to determine whether a single serum screening can identify individuals with celiac disease.

METHODS

We performed a retrospective study of 3555 pediatric patients (18 years old or younger) in the intermountain West region of the United States from January 1, 2008, through September 30, 2013. All patients had undergone serologic analyses for celiac disease, including measurement of antibodies to tissue transglutaminase (TTG) and/or deamidated gliadin peptide (DGP), and had duodenal biopsies collected within the following year. Modified Marsh criteria were used to identify patients with celiac disease. We developed models to identify patients with celiac disease using logistic regression and classification and regression tree (CART) analysis.

RESULTS

Single use of a test for serum level of IgA against TTG identified patients with celiac disease with 90% sensitivity, 90% specificity, a 61% positive predictive value (PPV), a 90% negative predictive value, and an area under the receiver operating characteristic curve value of 0.91; these values were higher than those obtained from assays for IgA against DGP or IgG against TTG plus DGP. Not including the test for DGP antibody caused only 0.18% of celiac disease cases to be missed. Level of TTG IgA 7-fold the upper limit of normal (ULN) identified patients with celiac disease with a 96% PPV and 100% specificity. Using CART analysis, we found a level of TTG IgA 3.2-fold the ULN and higher to most accurately identify patients with celiac disease (PPV, 89%). Multivariable CART analysis showed that a level of TTG IgA 2.5-fold the ULN and higher was sufficient to identify celiac disease in patients with type 1 diabetes (PPV, 88%). Serum level of IgA against TTG in patients with versus those without trisomy 21 did not affect diagnosis predictability in CART analysis.

CONCLUSIONS

In a population-based study, we found that serum level of IgA against TTG can identify patients with celiac disease with PPVs of about 90%. Predictive values increase greatly when levels are markedly above the ULN or when the assay is used in combination with other variables. Measurement of IgG against TTG or DGP does not increase the accuracy of detection of celiac disease based against TTG IgA levels. There is a low risk of false-positive results from serologic analysis in patients with type I diabetes or persistent increases in antibody against TTG on repeat testing.

The relationship between performance on the Infectious Diseases In-Training and Certification Examinations

BACKGROUND

The Infectious Diseases Society of America In-Training Examination (IDSA ITE) is a feedback tool used to help fellows track their knowledge acquisition during fellowship training. We determined whether the scores on the IDSA ITE and from other major medical knowledge assessments predict performance on the American Board of Internal Medicine (ABIM) Infectious Disease Certification Examination.

METHODS

The sample was 1021 second-year fellows who took the IDSA ITE and ABIM Infectious Disease Certification Examination from 2008 to 2012. Multiple regression analysis was used to determine if ABIM Infectious Disease Certification Examination scores were predicted by IDSA ITE scores, prior United States Medical Licensing Examination (USMLE) scores, ABIM Internal Medicine Certification Examination scores, fellowship director ratings of medical knowledge, and demographic variables. Logistic regression was used to evaluate if these same assessments predicted a passing outcome on the certification examination.

RESULTS

IDSA ITE scores were the strongest predictor of ABIM Infectious Disease Certification Examination scores (β = .319), followed by prior ABIM Internal Medicine Certification Examination scores (β = .258), USMLE Step 1 scores (β = .202), USMLE Step 3 scores (β = .130), and fellowship directors' medical knowledge ratings (β = .063). IDSA ITE scores were also a significant predictor of passing the Infectious Disease Certification Examination (odds ratio, 1.017 [95% confidence interval, 1.013-1.021]).

CONCLUSIONS

The significant relationship between the IDSA ITE score and performance on the ABIM Infectious Disease Certification Examination supports the use of the ITE as a valid feedback tool in fellowship training.

Regional scale gradients of climate and nitrogen deposition drive variation in ectomycorrhizal fungal communities associated with native Scots pine

Ectomycorrhizal fungi commonly associate with the roots of forest trees where they enhance nutrient and water uptake, promote seedling establishment and have an important role in forest nutrient cycling. Predicting the response of ectomycorrhizal fungi to environmental change is an important step to maintaining forest productivity in the future. These predictions are currently limited by an incomplete understanding of the relative significance of environmental drivers in determining the community composition of ectomycorrhizal (ECM) fungi at large spatial scales. To identify patterns of community composition in ECM fungi along regional scale gradients of climate and nitrogen deposition in Scotland, fungal communities were analysed from 15 seminatural Scots pine (Pinus sylvestris L.) forests. Fungal taxa were identified by sequencing of the ITS rDNA region using fungal-specific primers. Nonmetric multidimensional scaling was used to assess the significance of 16 climatic, pollutant and edaphic variables on community composition. Vector fitting showed that there was a strong influence of rainfall and soil moisture on community composition at the species level, and a smaller impact of temperature on the abundance of ectomycorrhizal exploration types. Nitrogen deposition was also found to be important in determining community composition, but only when the forest experiencing the highest deposition (9.8 kg N ha(-1)  yr(-1) ) was included in the analysis. This finding supports previously published critical load estimates for ectomycorrhizal fungi of 5-10 kg N ha(-1)  yr(-1) . This work demonstrates that both climate and nitrogen deposition can drive gradients of fungal community composition at a regional scale.

Myocardial, smooth muscle, nephron, and collecting duct gene targeting reveals the organ sites of endothelin A receptor antagonist fluid retention

Endothelin-1 binding to endothelin A receptors (ETA) elicits profibrogenic, proinflammatory, and proliferative effects that can promote a wide variety of diseases. Although ETA antagonists are approved for the treatment of pulmonary hypertension, their clinical utility in several other diseases has been limited by fluid retention. ETA blocker-induced fluid retention could be due to inhibition of ETA activation in the heart, vasculature, and/or kidney; consequently, the current study was designed to define which of these sites are involved. Mice were generated with absence of ETA specifically in cardiomyocytes (heart), smooth muscle, the nephron, the collecting duct, or no deletion (control). Administration of the ETA antagonist ambrisentan or atrasentan for 2 weeks caused fluid retention in control mice on a high-salt diet as assessed by increases in body weight, total body water, and extracellular fluid volume (using impedance plethysmography), as well as decreases in hematocrit (hemodilution). Mice with heart ETA knockout retained fluid in a similar manner as controls when treated with ambrisentan or atrasentan. Mice with smooth muscle ETA knockout had substantially reduced fluid retention in response to either ETA antagonist. Mice with nephron or collecting duct ETA disruption were completely prevented from ETA blocker-induced fluid retention. Taken together, these findings suggest that ETA antagonist-induced fluid retention is due to a direct effect of this class of drug on the collecting duct, is partially related to the vascular action of the drugs, and is not due to alterations in cardiac function.

Biogeographical patterns and determinants of invasion by forest pathogens in Europe

A large database of invasive forest pathogens (IFPs) was developed to investigate the patterns and determinants of invasion in Europe. Detailed taxonomic and biological information on the invasive species was combined with country-specific data on land use, climate, and the time since invasion to identify the determinants of invasiveness, and to differentiate the class of environments which share territorial and climate features associated with a susceptibility to invasion. IFPs increased exponentially in the last four decades. Until 1919, IFPs already present moved across Europe. Then, new IFPs were introduced mainly from North America, and recently from Asia. Hybrid pathogens also appeared. Countries with a wider range of environments, higher human impact or international trade hosted more IFPs. Rainfall influenced the diffusion rates. Environmental conditions of the new and original ranges and systematic and ecological attributes affected invasiveness. Further spread of established IFPs is expected in countries that have experienced commercial isolation in the recent past. Densely populated countries with high environmental diversity may be the weakest links in attempts to prevent new arrivals. Tight coordination of actions against new arrivals is needed. Eradication seems impossible, and prevention seems the only reliable measure, although this will be difficult in the face of global mobility.

Effects of large-scale Amazon forest degradation on climate and air quality through fluxes of carbon dioxide, water, energy, mineral dust and isoprene

Loss of large areas of Amazonian forest, through either direct human impact or climate change, could exert a number of influences on the regional and global climates. In the Met Office Hadley Centre coupled climate–carbon cycle model, a severe drying of this region initiates forest loss that exerts a number of feedbacks on global and regional climates, which magnify the drying and the forest degradation. This paper provides an overview of the multiple feedback process in the Hadley Centre model and discusses the implications of the results for the case of direct human-induced deforestation. It also examines additional potential effects of forest loss through changes in the emissions of mineral dust and biogenic volatile organic compounds. The implications of ecosystem–climate feedbacks for climate change mitigation and adaptation policies are also discussed.

The Met Office Hadley Centre climate modelling capability: the competing requirements for improved resolution, complexity and dealing with uncertainty

Predictions of future climate change require complex computer models of the climate system to represent the full range of processes and interactions that influence climate. The Met Office Hadley Centre uses 'families' of models as part of the Met Office Unified Model Framework to address different classes of problems. The HadGEM family is a suite of state-of-the-art global environment models that are used to reduce uncertainty and represent and predict complex feedbacks. The HadCM3 family is a suite of well established but cheaper models that are used for multiple simulations, for example, to quantify uncertainty or to test the impact of multiple emissions scenarios.

Traumatic stress disorders following first-trimester spontaneous abortion

Provide counsel and support to women after a spontaneous abortion. Research indicates that many women will talk with their physician about their emotional distress and that physicians provide good information after the spontaneous abortion. Evaluate women for acute stress disorder (ASD) after a spontaneous abortion. Research found that women reporting physical, emotional, or sexual abuse are more likely to experience ASD. Patients should be assessed for post-traumatic stress disorder in follow-up visits 1 month after the initial visit. Research has found that up to 25% of women meet criteria for PTSD 1 month post the spontaneous abortion and 7% met criteria at 4 months. Physicians should refer women who are experiencing traumatic stress to a behavioral health professional.

Learning and sharing safety lessons to improve patient care

Nurses are at the forefront of patient safety and are constantly reviewing their practice to improve care delivery. When things go wrong in health care the consequences can be distressing for patients and staff. Lessons need to be learned and acted on to minimise the likelihood of reoccurrence. The 'root cause analysis' approach provides nurses and other healthcare staff with a consistent and structured methodology to investigate incidents. It enables staff to identify where systems are failing and where improvements in patient care and safety can be made.

Fourier transform-infrared spectroscopy as a new method for evaluating host resistance in the Dutch elm disease complex

Resistance of elms (Ulmus spp.) to the pathogenic fungus Ophiostoma novo-ulmi Brasier depends on chemical and anatomical factors that confine the spread of the pathogen in the vascular system of the host. This study focused on detecting chemical differences in 4-year-old Ulmus minor Mill. seedlings before and after inoculation with a virulent O. novo-ulmi isolate. According to symptom development over 60 days, the trees were divided into resistant (0-33% wilting) and susceptible (67-100% wilting) groups. Histochemical tests and Fourier transform-infrared (FT-IR) spectroscopy analysis were performed on transverse sections of 2-year-old twigs, 2 days before and 40 days after inoculation. Although histochemical tests did not clearly discriminate susceptible from resistant elms, chemical differences between resistant, susceptible and control trees were detected by FT-IR. The average spectrum for resistant tree samples had higher absorbance peaks than the spectra from the susceptible and control samples, indicating increased formation of lignin and suberin. The roles of lignin and suberin in the resistance of the elms against O. novo-ulmi and the usefulness and sensitivity of the FT-IR technique for analyzing metabolic changes caused by pathogens in plants are discussed.

Microglial activation by uptake of fDNA via a scavenger receptor

The fate of the fragmented DNA (fDNA) observed in neuronal nuclei in Alzheimer brain is unknown. However, its fate is suggested as fDNA is found in the cytoplasm of adjacent activated microglia. After a brief incubation with fDNA, approximately 70% of microglia had fDNA in their cytoplasm, were activated, and overexpressed interleukin-1beta. Microglial activation enhanced uptake whereas blocking scavenger receptors suppressed this uptake. These results suggest that the brain rids itself of fDNA from dying neurons through microglial uptake, activation, and overexpression of IL-1. Such overexpression of IL-1 in Alzheimer brain has been linked to Alzheimer pathogenesis.

Benchmarking best practice for external ventricular drainage

Sharing of best practice and use of all available evidence is important in developing effective clinical guidelines for nursing practice. This can be achieved through benchmarking. Sharing of good practice and achieving consensus guidelines can avoid repetition of effort by nurses engaged in similar fields of practice. The Pan London Neuroscience Practice Development Forum was established in 1998 to share best practice within the field of neuroscience nursing across London. The Pan London Forum has now achieved consensus and developed evidence-based clinical guidelines for the management of external ventricular drainage. Within the scope of this article, the principles of external ventricular drainage will be highlighted, before identifying the evidence base for nursing management of patients. Approaches for troubleshooting common problems will also be discussed and the benchmarked clinical guidelines will be presented.

Temperamental contributions to the affect family of anxiety

The discovery of pharmacologic interventions that mute the intensity of anxiety and guilt in some individuals has been a benevolent gift to those who suffer from these disabling states. Although some commentators have wondered about the social consequences of large numbers of asymptomatic persons taking these drugs, few have questioned the advantages for the smaller group of anguished patients. It is likely, however, that, during the next century, scientists will discover a drug that eliminates the feeling components of guilt and remorse while leaving intact the semantic knowledge that certain acts are ethically improper. An individual who took this drug regularly would continue to know that deceiving a friend, lying to a client, and stealing from an employer are morally wrong but would be protected from the uncomfortable feeling of guilt or remorse that accompanies a violation of a personal moral standard. It is reasonable to wonder, therefore, whether our society would be changed in a major way if many citizens were protected from guilt and remorse. Most Western philosophers, especially Kant, made reason the bedrock of conscience. People acted properly, Kant believed, because they knew that the behavior was morally right. All individuals wish to regard the self as virtuous and try to avoid the uncertainty that follows detection of the inconsistency that is created when they behave in ways that are not in accord with their view of the self's desirable attributes. Kant believed that, although the moral emotions restrain asocial acts, they were not necessary for the conduct of a moral life. On the other hand, some philosophers, such as Peirce and Dewey, argued that anticipation of anxiety, shame, and guilt motivate a continued loyalty to one's ethical standards. A person who was certain that he or she was protected from these uncomfortable emotions would find it easier to ignore the moral imperatives acquired during childhood and adolescence. It is not obvious that a drug that blocks remorse also will eliminate the mutual social obligations that make a society habitable; nonetheless, a posture of vigilance that is appropriate for--unlike gorillas--humans can hold representations of envy, anger, and dislike toward people they have never met for a very long time. While we wait for future inquiry to resolve this issue, it is useful to acknowledge that a satisfying analysis of this problem will require a deeper appreciation of the differences between the representations of the biological events that are the foundation of an emotion and the representations that define the semantic networks for the concepts good and bad.

Neuronal DNA damage correlates with overexpression of interleukin-1beta converting enzyme in APPV717F mice

Transgenic APPV717F mice, homozygous for a human minigene encoding the V717F familial Alzheimer's disease mutation, develop Abeta plaques similar to those seen in Alzheimer patients and show evidence of neuronal cell drop out in CA2-3 regions of the hippocampus at 8 months of age and older. Interleukin-1 (IL-1)beta (IL-1beta) converting enzyme (ICE) is a cysteine protease (caspase-1) that processes inactive (33 kDa) pro-IL-1beta to the active (17 kDa) inflammatory cytokine. We used immunohistochemistry, RT-PCR, and DNA cleavage (TUNEL) analysis to show progressive, age-associated increases in ICE mRNA levels, in the numbers of ICE-immunoreactive glia, and in the numbers of neurons showing evidence of DNA damage in APPV717F mice that commenced months prior to the appearance of Abeta plaques. Moreover, there were significant correlations between these parameters over an age range of 1-17 months. These findings are consistent with the idea that increases in ICE activity and expression contribute to neuronal injury in Alzheimer's disease.

Troubleshooting common problems associated with long-term catheters

A catheter complications survey study, carried out over a 2-year period in three Bristol health districts, recorded 506 emergency referrals during a 6-month period (Kohler-Ockmore and Feneley, 1996). A further detailed study on 54 of the patients showed that 48% experienced catheter blockage and 37% reported urine bypassing. Urinary catheterization can cause many health problems; bacteriuria is inevitable in long-term catheterized patients (Cravens and Zweig, 2000). This article identifies some of the common problems that can occur with long-term catheters, makes recommendations and applies an evidence-based approach to catheter care. In order to identify and treat the associated problems, it is necessary to understand the anatomy and functions of the bladder. The article addresses this before examining the problems, which include: catheter blockage; bypassing of urine; catheter rejection and balloon non-deflation; and latex allergy. The psychological and social aspects, although not covered in this article, are also important and should always be considered along with all other aspects of care.

Enantioselective reduction of prochiral ketones by catecholborane catalysed by chiral group 13 complexes

LiGaH4, in combination with the S,O-chelate 2-hydroxy-2'-mercapto-1,1'-binaphthyl (MTBH2), forms an active catalyst for the asymmetric reduction of prochiral ketones, with catecholborane as the hydride source. Enantioface differentiation is on the basis of the steric requirements of the ketone substituents. Aryl/ n-alkyl ketones are reduced in 90-93% ee and RC(O)Me (e.g. R = iPr, cycloC6H11, tBu) in 60-72% ee. Other borane sources and alternative catalyst structures based on indium do not form enantioselective catalysts.

Overexpression of the neuritotrophic cytokine S100beta precedes the appearance of neuritic beta-amyloid plaques in APPV717F mice

Homozygous APPV717F transgenic mice overexpress a human beta-amyloid precursor protein (betaAPP) minigene encoding a familial Alzheimer's disease mutation. These mice develop Alzheimer-type neuritic beta-amyloid plaques surrounded by astrocytes. S100beta is an astrocyte-derived cytokine that promotes neurite growth and promotes excessive expression of betaAPP. S100beta overexpression in Alzheimer's disease correlates with the proliferation of betaAPP-immunoreactive neurites in beta-amyloid plaques. We found age-related increases in tissue levels of both betaAPP and S100beta mRNA in transgenic mice. Neuronal betaAPP overexpression was found in cell somas in young mice, whereas older mice showed betaAPP overexpression in dystrophic neurites in plaques. These age-related changes were accompanied by progressive increases in S100beta expression, as determined by S100beta load (percent immunoreactive area). These increases were evident as early as 1 and 2 months of age, months before the appearance of beta-amyloid deposits in these mice. Such precocious astrocyte activation and S100beta overexpression are similar to our earlier findings in Down's syndrome. Accelerated age-related overexpression of S100beta may interact with age-associated overexpression of mutant betaAPP in transgenic mice to promote development of Alzheimer-like neuropathological changes.

The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States

OBJECTIVES

This study estimates the contribution of smoke-free workplaces to the recent national declines in cigarette consumption in Australia and the United States.

METHODS

Nineteen studies of the impact of smoke-free workplaces on workday cigarette consumption were reviewed. The number and cost of cigarettes forgone were calculated and extrapolated to a scenario in which all indoor work areas were smoke-free.

RESULTS

Of the 19 studies, 18 reported declines in daily smoking rates, and 17 reported declines in smoking prevalence. Smoke-free workplaces are currently responsible for an annual reduction of some 602 million cigarettes, or 1.8% of all cigarettes that might otherwise be consumed, in Australia, and an annual reduction of 9.7 billion cigarettes (2%) in the United States. Approximately 22.3% of the 2.7 billion decrease in cigarette consumption in Australia between 1988 and 1995 can be attributed to smoke-free workplaces, as can 12.7% of the 76.5 billion decrease in the United States between 1988 and 1994.

CONCLUSIONS

If workplaces were universally smoke-free, the number of cigarettes forgone annually would increase to 1.14 billion (3.4%) in Australia and 20.9 billion (4.1%) in the United States.

Community perceptions about the tobacco industry and tobacco control funding

OBJECTIVES

To determine community views about the believability and standards of honesty and ethics of tobacco companies, related policy options, and mechanisms for tobacco control funding.

METHOD

A representative population survey of 808 South Australians aged 18 years and older, contacted by telephone, using an electronic white pages sampling frame, with a response rate of 72%.

RESULTS

80% of respondents and 74% of smokers thought tobacco companies mostly did not or never told the truth about smoking and health, children and smoking and addictiveness of tobacco. With regard to perceived standards of honesty and ethics, tobacco company executives were rated the lowest of all professional groups, with 74% of respondents judging them to have low or very low standards. 89% of smokers would support full product information on the pack about chemicals and additives in cigarettes. 77% thought shopkeepers should pay back the amount they gain from children smoking cigarettes and 80% thought tobacco companies should do so, or be fined or taxed accordingly. 53% agreed the government should spend an amount equal to the amount gained from children's smoking and 21% indicated a higher expenditure.

CONCLUSION

Tobacco companies are held in low regard by the public and by smokers who are their customers. There is a high degree of support for tobacco control efforts to be financed by being indexed to the level of children's smoking in the community, through the amount made by shopkeepers, manufacturers and the government from children's cigarette consumption.

Complications of allergies to latex urinary catheters

Latex products are widely used both in our homes and in hospitals. Latex allergy is an increasingly worrying problem for health professionals, not least allergy to latex urinary catheters. The pathophysiology of latex allergy is discussed with reference to catheter allergy. Other known problems of latex catheters are also highlighted, including toxicity leading to urethritis and stricture formation, and encrustation. Nurses need to be aware of the increasing incidence of latex allergy and the importance of screening patients specifically for this risk factor.

In vitro expression of resistance responses to Seiridium species in micropropagated shoots of Cupressus sempervirens and Chamaecyparis lawsoniana

Wounded and nonwounded micropropagated shoots of Cupressus sempervirens and Chamaecyparis lawsoniana were inoculated in vitro with the canker-causing pathogens Seiridium cardinale (Wag.) Sutton & Gibson, Seiridium cupressi (Guba) Boeswinkel and Seiridium unicorne (Cke & Ell.) Sutton. Seiridium cardinale was significantly more pathogenic on Cupressus sempervirens than on Chamaecyparis lawsoniana (Murr.) Parlatore, irrespective of the presence of wounds on the shoots. On wounded shoots, both S. cupressi and S. unicorne caused significantly larger lesions on Chamaecyparis lawsoniana than on Cupressus sempervirens by 20 days after inoculation. Superficial wounding of shoots prior to inoculation caused a significant increase in the lengths of lesions and numbers of shoots girdled by the pathogens on both hosts. These results broadly correlate with known virulence of the three pathogens on these two host tree species in field and glasshouse tests. Using histological methods, penetration of fungal hyphae through stomatal pores of both shoots and leaves into the substomatal cavity and the mesophyll space was observed. Penetration directly through the cuticle was also seen. Defence-related responses, including accumulation of oxidized polyphenols compounds and deposition of lignin and suberin in cell walls, were detected in inoculated tissues. These responses occurred predominantly in the epidermis, including stomatal guard cells, and the hypodermis and were particularly marked in Chamaecyparis lawsoniana inoculated with S. cardinale. The possible utility of these methods in the study and detection of host genotypes resistant to Seiridium spp. is discussed. Key words: Seiridium, Cupressus, Chamaecyparis, micropropagation, in vitro inoculation, defence.

Expression of the Zn finger gene, EVI-1, in acute promyelocytic leukemia

The EVI-1 gene encodes a Zn finger, DNA binding protein previously detected in some acute myelogenous leukemias (AML) and myelodysplasias (MDS), but not in normal marrow or cord blood cells. Experimental studies suggest EVI-1 blocks cellular differentiation by binding to GATA-1 or other specific DNA sequences controlling gene expression, and may be involved in the pathogenesis of some AMLs. To further define potential roles for EVI-1 in leukemia pathogenesis, we studied its regulation in acute promyelocytic leukemias (APL). Seven of 11 APL cases expressed EVI-1 RNA detected by RNA PCR at diagnosis, and expression was detected in two additional cases after treatment with all-trans retinoic acid (ATRA). Two of four cases studied at relapse also expressed EVI-1 RNA. To investigate regulation of EVI-1 expression in APL, we examined its expression in the NB4 APL cell line. NB4 cells did not express EVI-1 under basal conditions, but expressed EVI-1 after ATRA-induced differentiation. When NB4 cells were exposed to ATRA and transferred to cultures with N,N'-hexamethylene-bis-acetamide (HMBA), differentiation occurred but EVI-1 RNA was not detected, indicating that EVI-1 expression was not required for terminal, NB4 differentiation. ATRA-resistant NB4 cells were obtained by continuous culture in gradually increasing concentrations of ATRA. These cells did not express markers of differentiation but continued to express EVI-1 for several weeks even after ATRA withdrawal. To assess whether expression of the APL PML-RAR alpha fusion gene alone was sufficient for ATRA induction of EVI-1, the PML-RAR alpha gene cDNA was expressed in U937 histiocytic lymphoma cells. ATRA treatment of PML-RAR alpha-transfected or control U937 cells did not induce EVI-1 expression. In conclusion, this study demonstrates the EVI-1 gene is consistently expressed in APL cells either constitutively or after ATRA treatment. ATRA represents the first biologically active agent shown to specifically regulate EVI-1 expression in blood cells. In contrast to previous studies in AML and MDS, the pattern of EVI-1 expression suggests it may facilitate rather than inhibit myeloid differentiation during ATRA treatment. However, effects of EVI-1 expression are likely to be complex, and expression in ATRA-resistant APL cells may indicate multiple roles for this gene.