Use of standardized flow cytometric determinants of multidrug resistance to analyse response to remission induction chemotherapy in patients with acute myeloblastic leukaemia

We have used a combination of flow cytometric assays to define multidrug resistance (MDR) positive and negative blasts in cryopreserved samples from 47 MRC trial patients with acute myeloblastic leukaemia (AML). Our primary test is a standardized assay for daunorubicin accumulation. Confirmatory assays for MDR comprised the cyclosporin modulation assay for rhodamine-123 uptake as a measure of functional P-glycoprotein and the measurement of lung resistance protein and multidrug resistance associated protein (with LRP-56 and MRPr1 respectively). 57% of samples had both low accumulation and at least one positive confirmatory test. 32% were MDR negative in all four assays. 15% of patients had primary chemo-resistant disease. Resistant disease rates were 22% for confirmed MDR-positive patients and 0% for confirmed MDR-negative patients (P=0.07). Complete remission was achieved in 74% of patients, with rates of 63% in confirmed MDR-positive patients and 93% in confirmed MDR-negative patients (P=0.06). The use of a standardized method for daunorubicin uptake, combined with the use of confirmatory tests, should reduce the uncertainty that is currently characteristic of MDR evaluation in leukaemia. In comparison with daunorubicin uptake, p-gp expression, measured using MRK-16 antibody, was more closely associated with remission rates (P =0.01). This suggests an additional role for p-glycoprotein in mediating drug resistance beyond that of a drug efflux pump.

Prevalence of substance misuse in first-episode psychosis

BACKGROUND

Reports suggest a high prevalence of substance misuse in psychotic disorders but few studies examine comorbidity at onset of psychosis.

AIMS

To identify the prevalence and pattern of substance use and misuse in first-episode psychosis, and relationships with diagnosis, mode of presentation and demographic variables.

METHOD

Consensus diagnoses for 168 subjects presenting with first-episode psychosis were made using ICD-10 diagnostic criteria. Information on substance use and misuse was obtained from multiple sources. We examined associations between substance misuse, diagnosis and demographic factors.

RESULTS

Criteria for drug use, drug misuse or alcohol misuse were met by 37% of the sample. One-year prevalence rates were 19.5% (drug misuse) and 11.7% (alcohol misuse). Thirteen subjects (8.4%) received a primary diagnosis of substance-related psychotic disorder; a significant increase compared with an earlier cohort from the same catchment area. Drug misuse was associated with younger age of onset of psychosis, male gender and non-African-Caribbean ethnicity.

CONCLUSIONS

This study confirms high rates of substance misuse at onset of psychosis. There is evidence for an increase in diagnosis of substance-related psychotic disorders over time. Those most at risk of substance misuse are young males.

Utility of cytokeratin 7 and 20 subset analysis as an aid in the identification of primary site of origin of malignancy in cytologic specimens

This study was undertaken to assess the utility of combined cytokeratin (CK) 7/20 immunoprofile determination in malignant cytologic cell blocks as an aid to the identification of tumor primary site of origin. Fifty-one cases in which CK 7/20 immunocytochemistry was performed as part of the initial workup were retrieved. Their contribution to the final cytologic diagnosis of tumor primary site of origin was analyzed. CK reactivity patterns were 7+/20- (n = 34), 7-/20+ (n = 9), 7-/20- (n = 7), and 7+/20+ (n = 1). The CK 7+/CK 20- immunophenotype was the most common one obtained, and due to its wide expression in a number of common carcinomas, the least informative. The second most common immunophenotype was CK 7-/20+, which is associated with colorectal origin, and as such was very useful when obtained. The CK immunoprofile was more useful in the setting of a prior carcinoma, being a major diagnostic determinant in 13 cases (55%) from group 1 (those with a prior history of malignancy), compared to 8 cases (29%) from group 2 (those with no prior history of malignancy). In the setting of prior carcinoma, the CK immunoprofile is most useful when carcinomas under consideration have different expected immunoprofiles (e.g., CK 7+/CK20- carcinomas, including lung, breast, ovary, endometrium, and others, vs. CK 7-/CK 20+ carcinomas, primarily colorectal). When similar immunoprofiles are obtained, their usefulness is greater if they are immunoprofiles other than the most common 7+/20- pattern. Similarly, in newly diagnosed carcinomas, the CK immunoprofile either helps to narrow the differential diagnosis or points to a specific diagnosis.

Outcome for children with relapsed acute myeloid leukaemia following initial therapy in the Medical Research Council (MRC) AML 10 trial. MRC Childhood Leukaemia Working Party

Between May 1988 and March 1995, 359 children with acute myeloid leukaemia (AML) were treated in the MRC AML 10 trial. Three risk groups were identified based on cytogenetics and response to treatment. One hundred and twenty-five children relapsed--103 in the bone marrow only, 12 in the bone marrow combined with other sites, and six had isolated extramedullary relapses (site was not known in four cases). Eighty-seven children received further combination chemotherapy, one all-trans retinoic acid for acute promyelocytic leukaemia, and one a matched unrelated donor allograft in relapse, and 61 achieved a second remission. One patient with no details on reinduction therapy also achieved second remission. Treatment in second remission varied--44 children received a BMT (22 autografts, 12 matched unrelated donor allografts, 10 family donor allografts), and 17 were treated with chemotherapy alone. The overall survival rate for all children (treated and untreated) was 24% at 3 years, with a disease-free survival of 44% for those achieving a second remission. Length of first remission was the most important factor affecting response rates--children with a first remission of less than 1 year fared poorly (second remission rate 36%, 3 year survival 11%), whereas those with longer first remissions had a higher response rate (second remission rate 75%, 3 year survival 49%, P < 0.0001).

The importance of diagnostic cytogenetics on outcome in AML: analysis of 1,612 patients entered into the MRC AML 10 trial. The Medical Research Council Adult and Children's Leukaemia Working Parties

Cytogenetics is considered one of the most valuable prognostic determinants in acute myeloid leukemia (AML). However, many studies on which this assertion is based were limited by relatively small sample sizes or varying treatment approach, leading to conflicting data regarding the prognostic implications of specific cytogenetic abnormalities. The Medical Research Council (MRC) AML 10 trial, which included children and adults up to 55 years of age, not only affords the opportunity to determine the independent prognostic significance of pretreatment cytogenetics in the context of large patient groups receiving comparable therapy, but also to address their impact on the outcome of subsequent transplantation procedures performed in first complete remission (CR). On the basis of response to induction treatment, relapse risk, and overall survival, three prognostic groups could be defined by cytogenetic abnormalities detected at presentation in comparison with the outcome of patients with normal karyotype. AML associated with t(8;21), t(15;17) or inv(16) predicted a relatively favorable outcome. Whereas in patients lacking these favorable changes, the presence of a complex karyotype, -5, del(5q), -7, or abnormalities of 3q defined a group with relatively poor prognosis. The remaining group of patients including those with 11q23 abnormalities, +8, +21, +22, del(9q), del(7q) or other miscellaneous structural or numerical defects not encompassed by the favorable or adverse risk groups were found to have an intermediate prognosis. The presence of additional cytogenetic abnormalities did not modify the outcome of patients with favorable cytogenetics. Subgroup analysis demonstrated that the three cytogenetically defined prognostic groups retained their predictive value in the context of secondary as well as de novo AML, within the pediatric age group and furthermore were found to be a key determinant of outcome from autologous or allogeneic bone marrow transplantation (BMT) in first CR. This study highlights the importance of diagnostic cytogenetics as an independent prognostic factor in AML, providing the framework for a stratified treatment approach of this disease, which has been adopted in the current MRC AML 12 trial.

Quantos somos? The second national population census of Mozambique

"Between 1 and 15 of August [1997], Mozambique had its second country-wide population census. This briefing will outline how the census ran--an operation of considerable scale in an extremely poor and war-damaged country--and will also raise some broader questions which relate the census to Mozambique's contemporary politics."

Adjunctive use of inhaled nitric oxide during implantation of a left ventricular assist device

BACKGROUND

The aim of this study was to evaluate the efficacy of inhaled nitric oxide in the prevention and reversal of pulmonary hypertension during and after left ventricular assist device implantation.

METHODS

Inhaled nitric oxide (20 ppm) was administered to seven consecutive patients undergoing implantation of a left ventricular assist device at the time of implantation and for the first 24 hours after operation.

RESULTS

Withdrawal of inhaled nitric oxide at 24 hours after operation was associated with a significant rise in both the transpulmonary gradient (from 8+/-1 to 14+/-2 mm Hg, p < 0.01) and in pulmonary vascular resistance (from 110+/-19 to 196+/-32 dynes x sec x cm[-5], p < 0.01). In two patients, the rise in pulmonary vascular resistance resulted in a critical fall in left ventricular assist device flow and hemodynamic deterioration, necessitating urgent reinstitution of inhaled nitric oxide.

CONCLUSION

The administration of inhaled nitric oxide at the time of left ventricular assist device implantation prevents rises in pulmonary vascular resistance that in some patients result in critical reductions in left ventricular assist device flow. We suggest that inhaled nitric oxide is a useful adjunctive treatment that should be routinely available at the time of left ventricular assist device implantation.

The Ty1-copia group of retrotransposons in plants: genomic organisation, evolution, and use as molecular markers

The genomic organisation and diversity of the Ty1-copia group retrotransposons has been investigated in several crop plants and their relatives from both dicotyledonous and monocotyledonous families, including potato (Solanum tuberosum), faba beans (Vicia faba), Vicia melanops, Vicia sativa, barley (Hordeum vulgare), rye (Secale cereale), and onion (Allium cepa). Extreme heterogeneity in the sequence of the Ty1-copia retrotransposons from all these plants was revealed following sequence analysis of reverse transcriptase fragments. The estimated copy numbers of the Ty1-copia group retrotransposons for the genomes of S. tuberosum, L. esculentum, A. cepa, S. cereale, and V. faba is highly variable, ranging from a few hundred to approximately a million copies per genome. In situ hybridisation data from metaphase and prophase chromosomes of V. faba, S. cereale, and H. vulgare suggest that retrotransposon sequences are dispersed throughout the euchromatic regions of the genome but are almost undetectable in most heterochromatic regions. In contrast, similar data from metaphase chromosomes of A. cepa suggests that although retrotransposon sequences are dispersed throughout the euchromatic regions of the genome, they are predominantly concentrated in the terminal heterochromatin. These results are discussed in the context of the role played by the Ty1-copia group retrotransposons in the evolution of the plant genome. Lastly, the application of retrotransposon sequences as genetic markers for mapping genomes and for studying genetic biodiversity in plants is presented.

Perceived ethnicity and the risk of compulsory admission

Black-Caribbean patients are more often admitted compulsorily to psychiatric wards than patients from other ethnic groups. We tested the hypothesis that perceived ethnicity of a patient had no independent effect on the risk of compulsory admission. For all consecutive admissions over a 6-month period to acute psychiatric wards in Nottingham, medical officers responsible for the decision to admit completed a questionnaire recording clinical details of the patients and reasons for admission. The results showed that 43.2% of Black-Caribbean patients and 18.8% of White patients were admitted compulsorily (unadjusted odds ratio 3.29, 95% CI 1.71-6.33). Perceived ethnicity (Black-Caribbean) was significantly associated with being young, receiving a diagnosis of psychosis, and being perceived to be at a risk of violent acting out. A forced entry logistic regression model was used to adjust for hypothesised confounding variables such as age, sex, diagnosis, risk, socio-economic status and level of social support. A diagnosis of psychosis, risk of committing violence and being Black-Caribbean had independent effects on the risk of being compulsorily detained. The odds ratio for compulsory detention of Black-Caribbean patients was 2.16 (95% CI 1.03-4.52) after adjusting for the hypothesised confounding variables.

Characterization and genomic organization of Ty1-copia group retrotransposons in rye (Secale cereale)

The genomic organisation of the Ty1-copia retrotransposons in rye (Secale cereale) has been studied. We have used the polymerase chain reaction (PCR) to amplify sequences from a conserved domain of the reverse transcriptase gene of the Ty1-copia retrotransposons in this species. Sequence analysis of 26 of these PCR products shows them to be a highly heterogeneous population, a feature that is common in plants. Slot blot analysis shows that there are about 100,000 individual Ty1-copia retrotransposons in rye. In situ hybridization of a heterogeneous probe, representing the whole population of rye Ty1-copia retrotransposon sequences, to chromosome spreads of triticale (xTriticosecale), a rye-wheat hybrid, shows that these sequences are present throughout all the rye chromosomes but absent from the centromeric regions and, in particular, from the terminal heterochromatin. Southern analysis of oat, barley, wheat, and rye, using as a probe R9, one of the rye sequences that is closely similar to the BARE-1 element of barley, shows that close relatives of this retrotransposon subgroup are present in all these species in high copy number. Northern analysis on RNAs from seedlings shows that the BARE-1 subgroup is transcribed in all these cereal plants but in variable amounts: high in barley, moderate in wheat and rye, and extremely low in oat.

Continuing (maintenance) therapy in lymphoblastic leukaemia: lessons from MRC UKALL X. Medical Research Council Working Party in Childhood Leukaemia

The relationship between the prescribed dose of drugs during continuing (maintenance) therapy, the degree of marrow suppression caused, and subsequent event-free survival was examined in a cohort of 740 children with lymphoblastic leukaemia treated on MRC UKALL X. Girls, younger children, and patients who had received intensification treatment, were prescribed lower doses of mercaptopurine, became neutropenic more readily, and had more interruptions of treatment. Children who had one or more episodes of neutropenia with a count of <0.5 x 10(9)/l had a better prognosis than those who never became neutropenic. We conclude that early intensification treatment influences the probability of neutropenia during continuing treatment and that patients exhibiting myelosuppression during this phase of treatment have a better chance of prolonged remission.

Structural and functional characterisation of two proteolytic fragments of the bacterial protein toxin, pneumolysin

Proteolytic cleavage of the bacterial protein toxin pneumolysin with protease K creates two fragments of 37 and 15 kDa. This paper describes the purification of these two fragments and their subsequent physical and biological characterisation. The larger fragment is directly involved in the cytolytic mechanism of this pore-forming protein, via membrane binding and self-association. The smaller fragment lacks ordered structure or discernible activity.

Incidence of schizophrenia in Nottingham. A comparison of two cohorts, 1978-80 and 1992-94

BACKGROUND

Several studies have reported a decline of up to 50% in the incidence of schizophrenia over recent decades. We aimed to measure changes in the incidence and diagnostic patterns of first-episode psychosis by comparing two Nottingham cohorts, identified in two equal periods separated by 14 years.

METHOD

Two prospectively ascertained cohorts of first-episode psychotic disorder were identified over the time periods 1978-80 and 1992-94. The earlier cohort was of the World Health Organization Determinants of Outcome of Severe Mental Disorder (DOSMD) ten-country study. The later cohort was obtained using similar methodology. Both groups were diagnosed using ICD-10 diagnostic criteria and age-standardised incidence rates were compared.

RESULTS

The standardised incidence rate for all psychotic disorders rose slightly from 2.49 to 2.87 per 10000 population per year, but the F20 classification fell significantly by over a third (1.41 to 0.87 per 10000 per year). The second study group (1992-1994) included a greater diversity of psychotic diagnoses compared with the first, in particular an increased proportion of acute and drug-related psychoses.

CONCLUSIONS

Methodological considerations call for caution in interpreting such data, but we conclude that the significant fall in the narrowly defined diagnostic category of schizophrenia reflects a real change in the syndromal presentation of psychotic disorders.

Increased incidence of psychotic disorders in migrants from the Caribbean to the United Kingdom

BACKGROUND

Several studies have replicated the finding of increased incidence of schizophrenia and related psychoses in first and second generation migrants from the Caribbean. The finding has remained consistent in studies employing different methods, but concern has been expressed about indirect methods of calculating the population at risk. This study aims to overcome these short-comings.

METHOD

A further prospective study was undertaken in Nottingham assembling an inception cohort of psychotic patients (N = 168) presenting from a defined catchment area. The 1991 census, which includes codings for self-ascribed ethnic origin, was used to calculate the denominator, employing correction factors for potential under-enumeration. Case-ascertainment was based upon all service contacts and subjects had in-depth assessments including the SCAN. Collateral history was obtained from informants.

RESULTS

Subjects born in the Caribbean, or who had one or both parents born in the Caribbean, had a greatly elevated risk (incidence ratios above 7) for all psychotic disorders and for ICD-10 (DCR)-defined F20 Schizophrenia.

CONCLUSIONS

The size of the increase and the methodological safeguards employed support the validity of this now highly replicated finding. A personal or family history of migration from the Caribbean is a major risk factor for psychosis; the consistency of this finding justifies a systematic evaluation of potential aetiological factors. Any hypothesis derived from the evidence so far must explain: increased incidence in first and second generation migrants; increased risk for all psychoses (including affective psychoses); and an effect specifically associated with a migration history from the Caribbean to Northern Europe.

The predictive validity of a diagnosis of schizophrenia. A report from the International Study of Schizophrenia (ISoS) coordinated by the World Health Organization and the Department of Psychiatry, University of Nottingham

BACKGROUND

Outcome is important in the validation of psychiatric diagnosis, as most disorders lack clinicopathological correlates. We describe the predictive validity of four definitions of schizophrenia (DSM-III-R, ICD-10, ICD-9 and CATEGO S+), in a representative cohort of patients selected during their first episode of psychosis.

METHOD

Each definition of schizophrenia was applied to 99 patients. Their respective ability to predict 13-year outcome (Global Assessment of Functioning scales) was assessed.

RESULTS

DSM-III-R and ICD-10 diagnoses of schizophrenia have high predictive validity for long-term outcome, and both provide relatively stable diagnoses. ICD-9 is reasonably good at predicting disability, but not symptoms, and CATEGO S+ showed no predictive validity. Adding six-month duration criteria to ICD-10, ICD-9 and CATEGO S+ improved their predictive validity, and removing the six-month duration criterion from DSM-III-R commensurately reduced predictive validity.

CONCLUSIONS

Modern diagnostic systems (DSM-III-R and ICD-10) have high predictive validity, and are superior to ICD-9. The six-month duration criterion of DSM-III-R schizophrenia accounts for its predictive validity and stability over 13 years, but restricts its use in first-episode studies. The one-month duration criterion of ICD-10 is less restrictive, without major compromises in predictive validity or stability.

Annexin V-mediated calcium flux across membranes is dependent on the lipid composition: implications for cartilage mineralization

Annexin V is a major component of matrix vesicles and has a role in mediating the influx of Ca2+ into these vesicles, thus promoting the initiation of hypertrophic cartilage matrix mineralization. However, the mechanisms and factors regulating annexin V-mediated Ca2+ influx into these vesicles are not well understood. Since the lipid composition of matrix vesicles differs from that of the plasma membrane of chondrocytes and is rich in phosphatidylserine, we asked whether the lipid composition may regulate annexin V function. We prepared liposomes containing different concentrations of phosphatidylserine and determined how the lipid composition affected (a) the interactions between annexin V and liposomes and (b) annexin V-mediated Ca2+ influx into the liposomes. We found that annexin V was able to bind to every liposome tested. However, we observed the most prominent increases in tryptophan 187 emission intensity, a measure of the degree of interactions between annexin V and lipid bilayers, only with liposomes containing a high concentration of phosphatidylserine. In addition, a significant fraction of annexin V associated with phosphatidylserine-rich liposomes was not extractable by EDTA treatment but required a detergent, indicating that annexin V inserts into bilayers of these liposomes. Chemical cross-linking analysis revealed that matrix vesicles and phosphatidylserine-rich liposomes induced the formation of the annexin V hexamer. Interestingly, a significant Ca2+ influx in the presence of annexin V occurred only in liposomes containing a high phosphatidylserine content. Moreover, annexin V-mediated Ca2+ influx into these liposomes was inhibited (i) by anti-annexin V antibodies and (ii) by treatment with zinc and cadmium, indicating the essential role of the protein in Ca2+ influx. The results of this study indicate that phosphatidylserine-rich bilayers induce the formation of a hexameric annexin V, possibly leading to a Ca2+-dependent insertion of annexin V into the bilayer and establishment of annexin V-mediated Ca2+ influx into matrix vesicles or liposomes. The phosphatidylserine-rich membrane of matrix vesicles in vivo may thus offer an ideal specialized environment in which the biological function of annexin V is optimized, leading to rapid Ca2+ influx, intralumenal crystal growth, and cartilage matrix mineralization.

Cytogenetics adds independent prognostic information in adults with acute lymphoblastic leukaemia on MRC trial UKALL XA. MRC Adult Leukaemia Working Party

Cytogenetic classification of 350 adults with acute lymphoblastic leukaemia on MRC UKALL XA trial showed the following statistically significant associations: t(9;22) (11%) increased with increasing age and leucocyte counts (WBC) and most had a C/pre-B immunophenotype. t(4;11) (3%) was associated with higher WBCs, increasing age and null immunophenotype. Other abnormalities of 11q (abn11q) (4%) were associated with male sex and T-cell ALL. High hyperdiploidy (7%) and abn9p (5%) decreased with increasing WBC. High hyperdiploid patients were younger and tended to have C/pre-B ALL. Triploidy/tetraploidy (3%) decreased and pseudodiploidy (11%) increased with increasing WBC. Cytogenetic classification was prognostically important (chi-square for heterogeneity of classification = 53.56; P < 0.0001) and added significance to age, sex and WBC. A poor prognosis for patients classed as t(9;22) (13% disease-free survival at 3 years), as t(4;11) 24% at 3 years) and hypodiploid (11% at 3 years), and good prognosis for abn12p (4% of subjects) and high hyperdiploidy (74% and 59% at 3 years respectively) were statistically significant, but the 54% 3-year disease-free survival for patients with t(1;19) was not. The prognosis of patients classed as t(9;22) was independent of other single variables. Abn12p, abnormalities of 11q (including t(4;11) cases) and hypodiploidy added prognostic significance to all other variables combined.

The Nottingham Acute Bed Study: alternatives to acute psychiatric care

BACKGROUND

Although modern psychiatric services seek alternatives to hospitalisation wherever appropriate, the national trend toward higher bed occupancies on acute psychiatric wards has refocused attention on community-based alternatives and methods of assessing reed for acute care.

METHOD

We surveyed key decision makers in a community-oriented district service with a low acute psychiatric bed to population ratio, in order to examine alternatives to hospitalisation in a cohort of consecutive admissions over a six-month period.

RESULTS

Alternatives to acute ward hospitalisation were identified for 29% of admissions, and for 42% of those with an admission duration of more than 60 days. Residential options were chosen more often than intensive community support. Simulated bed day savings were considerable.

CONCLUSIONS

In a community-oriented service, key decision-makers could identify further alternatives to acute ward hospitalisation, although relatively few non-residential, community support options were chosen. Although this methodology has limitations, data based upon keyworker judgements probably have greater local 'ownership', and the option appraisal process itself may challenge stereotyped patterns of resource use.

How many psychiatric beds: towards a needs based portfolio of residential care

In theory, the utilization of health resources would vary with need. In an ideal world, health care providers would configure their resources and target their treatment programmes according to validated predictors of need. Such models would be based upon socio-demographic variables in the population known to correlate closely with psychiatric morbidity, which had been derived from large data sets having wide applicability and generalizability. They would include technology allowing locality adjustments for small areas with high densities of homelessness, residential accommodation for the severely ill, or areas with problems of substance abuse. Our ideal model would be continually monitored against reliable data derived from real time service use, fed back to providers and ‘fine tuned’ to reflect secular trends in socio-demographic risk factors and changing patterns of need.

Pre-operative oral administration of morphine in day-case gynaecological laparoscopy

The analgesic effect of morphine sulphate 10 mg by mouth given pre-operatively on pain after gynaecological laparoscopy was studied in a randomised, prospective, double-blind, placebo-controlled comparison. Two groups of 56 patients were studied one group undergoing diagnostic laparoscopy and the other laparoscopic sterilisation. All patients received a standard anaesthetic after premedication with morphine or placebo 1 h before the operation. Morphine premedication did not significantly influence postoperative pain as assessed on a visual analogue scale in either group and postoperative opioid consumption was unaffected. Premedication with morphine 10 mg orally does not significantly decrease pain after day-case gynaecological laparoscopy.

The course of schizophrenia over 13 years. A report from the International Study on Schizophrenia (ISoS) coordinated by the World Health Organization

BACKGROUND

This paper describes the 13 year course of illness in an epidemiologically defined and representative cohort of patients selected when they were experiencing their first episode of schizophrenia.

METHOD

In a 13-year follow-up study of 67 patients with ICD-9 schizophrenia, identified in Nottingham in 1978-80, the course of illness (symptoms, disability and hospitalisation) was assessed using standardised instruments, applied at onset, 1,2, and 13 years. Time to first relapse and first readmission were calculated and plotted as survival curves and patients were assigned to the course types described by Ciompi.

RESULTS

The survival curves show that first relapses and first readmissions occur during the first five years. The amount of time spent in psychotic episodes and in hospital is greatest in the first year of follow-up, but stable thereafter. Social adjustment improves from entry to the study to the first follow-up year, but there is a small deterioration in social adjustment between 2 and 13 years.

CONCLUSIONS

The findings reported suggest that after the initial episode the course of schizophrenia is relatively stable. The data support neither concepts of progressive deterioration nor progressive amelioration. There was no evidence of a "late recovery'.

Long-term follow-up of schizophrenia in 16 countries. A description of the International Study of Schizophrenia conducted by the World Health Organization

An unexpected finding of the International Pilot Study of Schizophrenia, launched by the World Health Organization (WHO) in 1967, was that patients in countries outside Europe and the United States have a more favourable short- and medium-term course of the disease than those seen in developed countries. Since then, WHO has intensified its schizophrenia research programme and has initiated a set of international studies that have confirmed these initial findings and explored possible reasons for such differences in the course and outcome of schizophrenia. While such work has provided important findings and has generated additional pertinent hypotheses, it did not explain the differences in outcome. The present paper describes a new initiative in which approximately 2500 subjects involved in previous WHO multicentre schizophrenia studies are being followed up for between 15 and 25 years after initial examination. Nineteen research centres in 16 countries are taking part in this work. The research methodology is described.

The Ty1-copia group retrotransposons of Allium cepa are distributed throughout the chromosomes but are enriched in the terminal heterochromatin

The genomic organization and diversity of the Ty1-copia group retrotransposons has been investigated in a monocotyledonous plant, Allium cepa. We used the polymerase chain reaction (PCR) to generate sequences corresponding to a conserved domain of the reverse transcriptase gene of Ty1-copia retrotransposons in this plant. Sequence analysis of 27 of these PCR products shows that they are a highly heterogeneous population, a feature which is common in plants but not in yeast and Drosophila. Slot-blot analysis shows there are 100,000-200,000 copies of Ty1-copia group retrotransposons within the A. cepa genome (2C = 31.7 pg), indicating that they are a significant component of the genome of this plant. In situ hybridization to metaphase chromosomes reveals that Ty1-copia retrotransposons are distributed throughout the euchromatin of all chromosomes of A. cepa but are enriched in the terminal heterochromatic regions, which contain tandem arrays of satellite sequences. This is the first clear evidence for the presence of Ty1-copia retrotransposons in the terminal heterochromatin of plants and contrasts with the distribution of these elements in other plant species.

Predicting the long-term outcome of schizophrenia

Predictors of long-term (13 year) outcome of schizophrenia are reported for a representative cohort of 'treated incidence' patients ascertained on their first contact with Nottingham psychiatric services between 1978-80. An initial (baseline) model including previously reported predictors of 2-year outcome (age, gender, ever married, acuteness of onset) and length of untreated illness was used to predict a range of outcome measures covering the domains of disability, psychopathology, hospitalization, employment, social activity, and global outcome. This model demonstrated significant prognostic ability across all non-hospitalization outcomes under both ICD-10 and ICD-9 diagnoses of schizophrenia, but was attenuated under broad (ICD-9 and CATEGO S, P or O) and restrictive (S+) diagnostic classifications. Female gender predicted more favourable outcome under all diagnostic classifications except S+. In an extended analysis, the addition of initial 2-year course type substantially increased the prognostic ability of the model under all diagnostic classifications and enabled over 30% of the variance in global ratings of disability and symptoms to be predicted. In this extended model female gender predicted more favourable outcome over and above the effect of course type, across most domains under ICD-10, and for disability and psychopathology under other diagnostic classifications. The inclusion of measures of psychopathology at the time of first assessment, pre-morbid functioning, and duration of index admission conferred only marginal additional predictive ability for respective outcomes in the domains of psychopathology, social activity, employment and hospitalization. Hospitalization during the past year was the most difficult outcome to predict under any model suggesting that resource utilization represents the 'administrative outcome' of schizophrenia and serves as a poor proxy for broader concerns in the era of community care. These data demonstrate that key demographic variables and the mode of onset influence the long-term course of schizophrenia, but that early course type is a particularly strong predictor.

The Ty1-copia group retrotransposons in Vicia species: copy number, sequence heterogeneity and chromosomal localisation

We present an in-depth study of the Ty1-copia group of retrotransposons within the plant genus Vicia, which contains species with widely differing genome sizes. We have compared the numbers and sequence heterogeneities of these genetic elements in three diploid Vicia species chosen to represent large (V. faba, 1C = 13.3 pg), medium (V. melanops, 1C = 11.5 pg) and small (V. sativa, 1C = 2.3 pg) genomes within the genus. The copy numbers of the retrotransposons are all high but vary greatly, with V. faba containing approximately 10(6) copies, V. melanops about 1000 copies and V. sativa 5000 copies. The degree of sequence heterogeneity of Ty1-copia group elements correlates with their copy number within each genome, but neither heterogeneity nor copy number are related to the genome size of the host. In situ hybridization to metaphase chromosomes shows that the retrotransposons in V.faba are distributed throughout all chromosomes but are much less abundant in certain heterochromatic regions. These results are discussed in the context of plant retrotransposon evolution.

Variability of post-void residual urine volume in the elderly

Residual urine volume, though clinically important as a diagnostic tool, is reported to be variable and unreliable. Variability was examined among 14 geriatric patients, mean age 77 years. Residual urine was measured by ultrasound at three different times of day on each of two visits separated by 2-4 weeks. Results were examined by analysis of variance. Mean residual urine was 154 ml. Between-patient variability was large [standard deviation (SD) 246 ml]. There was no significant difference between values in men and women, nor between visits. Within-patient variability was large because of a large systematic variation with time of day (SD 128 ml), with greatest volumes in the early morning. The inherent, random variability of the measurement was much smaller than this (SD 44 ml). If the physiological factors causing the temporal variation could be controlled, more reproducible measurements would be possible.

Psychological consequences of the Kegworth air disaster

BACKGROUND

The study sought to quantify psychiatric morbidity among survivors of a major air crash and to identify aetiological factors linked with post-traumatic stress disorder (PTSD).

METHOD

Sixty-eight of the 79 survivors (86%) were assessed at a clinical interview within one year of the disaster. The majority also completed the General Health Questionnaire, the Impact of Events Scale (IES) and the Zung Anxiety and Depression Scales.

RESULTS

Fifty-four of the study group (79%) met DSM-III-R criteria for a psychiatric disorder within one year of the disaster, of whom 27 (50%) had PTSD. Those who saw injured or dead people at the scene, or had sustained less severe injuries as measured by their Injury Severity Scores, or were under 35 years old, were significantly more likely to develop PTSD.

CONCLUSIONS

High rates of psychiatric morbidity are found in survivors of transportation disasters. Further studies are needed to identify those at most risk and to evaluate the benefits of psychological intervention.

Characteristics of outcome in schizophrenia at 13 years

BACKGROUND

This paper describes the 13-year outcome of an epidemiologically defined and representative cohort of patients selected when they were experiencing their first episode of schizophrenia.

METHOD

In a 13-year follow-up study of a cohort identified in Nottingham in 1978-80, the outcome (symptoms, disability, residence and treatment) was assessed using standardised instruments.

RESULTS

Four of the original 67 patients with ICD-9 schizophrenia were lost to follow-up and five were dead: 52% were without psychotic symptoms in the last two years of follow-up, 52% were without negative symptoms and 55% showed good/fair social functioning. However, only 17% were alive at follow-up, without symptoms and disability, and receiving no treatment.

CONCLUSIONS

The findings reported are similar to those of other long-term follow-up studies of schizophrenia and also to 5-year follow-up studies. Kraepelin's emphasis on the longitudinal implications of a diagnosis of schizophrenia are supported, but may be over-pessimistic.

Spatial disorientation episodes among F-15C pilots during Operation Desert Storm

Spatial Orientation (SO) under flight conditions is the accurate "integration" of sensory inputs from the dynamic aviation environment that result in safe and effective goal-oriented performance. Insidious sensory mismatches routinely occur during flight, impeding pilot performance. When this sensory dissonance occurs, if not appropriately resolved, it will result in perceived or actual errors in aircraft control that are estimated to cost the Air Force between $150 and $200M per annum in aircraft accidents. A scientific survey was created and administered to 96 F-16C combat pilots after their return from Desert Storm. The survey sought to determine where in the flight profile, and under what conditions, spatial disorientation (SD) episodes occurred. The survey consisted of multiple choice and open-ended questions. The analyses of the data revealed that visual transitions from inside to outside the cockpit (or the reciprocal) under different conditions of flight were associated with the occurrence of SD episodes. The frequency of SD episodes varied depending on visual transitions (or no visual transitions) and types of flight conditions (for example, nighttime and bad weather). This SD survey provided flight information that allowed us to direct research to those areas that were problematic during combat operations.

The phosphatidylinositol-glycolipid anchor on alkaline phosphatase facilitates mineralization initiation in vitro

Alkaline phosphatase (AP) is required for the proper mineralization of cartilage and bone. The enzyme is localized to the outer surface of cells through a phosphatidylinositol-glycolipid anchor, which is covalently attached to the carboxyl terminus of the protein. In calcifying cartilage, AP-rich matrix vesicles (MVs) are released into the matrix from chondrocytes, and apatite formation is initiated within and around these particles. In this paper we examine the role of the AP glycolipid anchor using an in vitro mineralization assay system. AP was purified to homogeneity, and the purified enzyme was used to drive mineral formation in vitro with and without the anchor. Mineral formation was initiated through phosphate release from beta-glycerol phosphate (beta-GP). The amount of PO4(-3) released was similar whether the anchor was present or absent. However, SEM and X-ray microanalysis revealed that the mineral produced by anchored AP was indistinguishable from that produced by MVs and that both of those minerals were more apatite-like than mineral formed by soluble AP or through spontaneous precipitation. Taken together, the data suggest that in addition to providing PO4(-3) to drive mineralization, AP influences the nature of the mineral formed. Further, AP containing its glycolipid anchor produces mineral comparable with that formed by tissue-derived MVs. Thus, in the absence of extracellular matrix, MV mineralization in vitro can be emulated by glycolipid-anchor containing AP.

Helicobacter pylori eradication in patients with peptic ulcer disease: clinical consequences and financial implications

We assessed clinical consequences and financial implications of Helicobacter pylori eradication in 175 patients with peptic ulceration, of whom 106 had been free from H. pylori infection for a mean of 3.2 years, while 69 remained infected. We used quarterly questionnaires to examine consumption of ulcer-healing medication and antacids. In the 106 successfully treated patients, gastrointestinal haemorrhage as a complication of peptic ulcer complications during the 344 patient years after eradication (0.003 per patient year) was 18-fold lower than during the 912 patient years before eradication (0.056 per patient year). Of the H. pylori-negative patients, 12-18% used ulcer-healing medication during any one of the three-month periods of the survey, compared with 34-51% of the patients with residual H. pylori infection. The average cost of the ulcer-healing drugs consumed by the H. pylori-negative patients was 30.59 pounds during the 12 months of the survey, compared with 99.05 pounds for H. pylori-positive patients. Consumption of antacids was also lower in the H. pylori-negative group. Successful eradication of H. pylori significantly reduced the annual cost of ulcer-healing drugs consumed by the patients with ulcer disease. Maintenance of ulcer remission following successful eradication of H. pylori also significantly reduced ulcer complications.

Dentin ablation by Ho: YAG laser: correlation of energy versus volume using stereophotogrammetry

The future use of lasers in endodontics is dependent upon predictable and consistent ablation of dentin. In this pilot study we used an Ho:YAG laser fiberoptic delivery system to apply laser energy to prepared tooth sections in vitro. Longitudinally sectioned single-rooted human teeth were subjected to single-energy pulses varying from 25 to 1750 mJ at a focal length of 1 mm. At different energy levels we observed changes in the dentin surface ranging from minute surface pitting to the formation of large craters. Scanning electron microscopy and stereophotogrammetry were used to determine the relationship between the amount of energy applied to dentin and the extent of dentin ablation. Dentin crater formation was quantified by determining surface area, depth, and volume of craters produced. Increases in laser energy were compared with increases in surface area, depth, and volume of craters produced within the range of 150 to 1200 mJ. The Ho:YAG laser fiberoptic delivery system used in this study provides an effective means of ablating dentin. Three-dimensional stereophotogrammetry may prove to be a useful method for further studies on the effects of laser energy on mineralized tissues.

Residence of incident cohort of psychotic patients after 13 years of follow up

OBJECTIVE

To establish the residential history of an incident cohort of psychotic patients 13 years after their first contact with the psychiatric services.

DESIGN

Tracing of all patients admitted to the WHO study on determinants of outcome of severe mental disorders in Nottingham between 1978 and 1980. Patients were assessed using standardised and comparable instruments, and extra information was obtained from key informants and medical records.

SETTING

Catchment area of Nottingham psychiatric services.

MAIN OUTCOME MEASURES

Main place of residence over the previous two years and residential history over 13 years in terms of homelessness, imprisonment, and use of high dependency psychiatric facilities.

RESULTS

95 patients were traced. At the point of follow up no patients were in long stay psychiatric wards, two were in supervised residence, none was homeless, and none was in prison or a high security hospital. 85 patients were living either independently alone or with their family or friends in the community. Of these, 44 had had no contact with the psychiatric services at the point of follow up.

CONCLUSIONS

Although many patients experienced a difficult early course of illness, the longer term outcome of the disorder was associated with remarkably low periods of homelessness and imprisonment and low use of intensive care facilities. These findings offer some reassurance, given the concerns about the effectiveness of community oriented care for this potentially most vulnerable group of psychiatric patients.

Premorbid personality in first-onset psychosis

The data presented are those from a two-year prospective study of 69 patients identified in the Nottingham field centre of the WHO Study of Determinants of Outcome of Severe Mental Disorders. Premorbid personality, childhood adjustment and adolescent adjustment were assessed at the patients' first presentation to psychiatric services with a psychotic illness. Ratings were made blind to diagnosis. Premorbid explosive and paranoid traits were commoner in patients with schizophrenia than in patients with other non-organic psychoses, and these traits were associated with later onset of schizophrenia. Premorbid schizoid traits were significantly commoner in patients with schizophrenia compared to patients with other psychoses, but only in those patients for whom a parent was the informant. Schizoid traits were no commoner in men with schizophrenia than in women, and were not associated with earlier age of onset. The findings suggest that premorbid personality, in men and women, may shape the expression of symptoms produced during an illness episode.

Flow cytometric analysis of the cytotoxic effects of Actinobacillus actinomycetemcomitans leukotoxin on human natural killer cells

The goal of this investigation was to determine if human natural killer (NK) cells were susceptible to the cytolytic effects of the Actinobacillus actinomycetemcomitans leukotoxin (LTX). Following treatment with LTX (0-200 ng/ml), NK cell activation by interleukin-2 (IL-2) was evaluated. LTX inhibited the IL-2-induced expression of both CD69 and the IL-2 receptor. Furthermore, the up-regulation of CD56 was also impaired. To determine whether the observed functional deficits were the result of cell death, NK cell viability was evaluated by flow cytometry. Changes in forward and side light scatter patterns consistent with cell death were observed within 60 min. Direct analysis of cell viability by measuring propidium iodide exclusion, however, indicated little change in the viability of LTX-treated NK cells. Electron microscopic analysis of NK cells exposed to LTX revealed early nuclear alterations characterized by hyperchromaticity, nuclear fragmentation, and condensation of nucleoplasm. However, no change in membrane integrity was initially noted. Finally, LTX caused a rapid and sustained elevation in the intracellular levels of Ca2+. These morphological and biochemical changes are consistent with the notion of programmed cell death.

Long-term changes in urodynamic studies of voiding in the elderly

Urodynamic studies were conducted in 80 incontinent elderly patients (27 men and 53 women; mean age, 77 years) and repeated 2-4 weeks later after patients had been subject to interventions. Interpretable voiding studies were performed in 84% of sessions. Interpretable initial and repeat studies were performed in 74% of patients. For detrusor pressure at maximum flow the intra-individual, between-sessions variability was +/- 11.7 cm H2O (SD) and the initial-repeat correlation coefficient was 0.61. For maximum flow rate the corresponding figures were +/- 4.7 ml/s and 0.44. Mean residual urine volume was 195 ml, with a between-sessions variability of +/- 113 ml (SD). These results suggest that there is substantial long-term variability in voiding function, including urethral resistance. Of the mean, 5% showed a change in obstruction classification (unobstructed/obstructed) between sessions. This variability and the modest proportion of interpretable studies should be taken into account when assessing urethral obstruction and designing clinical trials.

Helicobacter pylori eradication: efficacy and side effect profile of a combination of omeprazole, amoxycillin and metronidazole compared with four alternative regimens

We evaluated eradication of Helicobacter pylori infection in 263 patients by a new 14-day regimen of omeprazole 40 mg mane (a gastric secretory inhibitor) plus two antibiotics: amoxycillin 500 mg three-times daily (tds) plus metronidazole 400 mg tds. The comparative groups included updated results of our previous work with a 14-day course of either standard triple therapy (STT, colloidal bismuth subcitrate 120 mg four times daily (qds) plus tetracycline 500 mg qds and metronidazole 400 mg tds), omeprazole 40 mg once daily plus amoxycillin 500 mg tds (OA), or two modified triple therapy: either Borody's (BTT) of all three components (colloidal bismuth subcitrate 120 mg, tetracycline 500 mg, metronidazole 200 mg) qds instead of tds, or Logan's (LTT) seven-day therapeutic regimen of colloidal bismuth subcitrate 120 mg qds, amoxycillin 500 mg qds and, for the last three days, metronidazole 400 mg five times daily. Omeprazole/amoxycillin/metronidazole (OAM) therapy was better tolerated than STT (course completion 98.1% vs. 81.4%, p < 0.001). H. pylori was eradicated by OAM therapy in 53/55 (96.4%) patients with metronidazole-sensitive organisms and in 54/72 (75.0%) with metronidazole-resistant isolates (p < 0.01). The respective corresponding rates for STT and OA therapy were 20/22 (90.9%) and 14/29 (48.3%), (metronidazole-sensitive organisms) and 7/21 (33.3%) and 15/31 (48.4%) (infections resistant to metronidazole). BTT and LTT were also better tolerated than STT. The eradication rate for BTT was 23/26 (88.5%) but that for LTT, the best tolerated of the five treatment regimens, was only 19/28 (67.9%) when pretreatment isolates were metronidazole-sensitive.(ABSTRACT TRUNCATED AT 250 WORDS)

Schizophrenia in Nottingham: lifelong residential mobility of a cohort

The lifetime geographical mobility of a group of 67 patients suffering from schizophrenia was investigated and related to the ecological structure of the city of Nottingham, where they first presented between 1978 and 1980. The study aimed to investigate the processes leading to a threefold rate of schizophrenia in the most socioeconomically deprived area of the city compared to the area of least deprivation. Results suggest that this skewed distribution begins early in the lives of the patients and is well established at least five years before initial contact with the psychiatric services.

Schizophrenia--falling incidence and better outcome?

It has been suggested that schizophrenia is a disappearing disease. The evidence for this assertion is reviewed, and also for a parallel theory advanced in recent years that the disorder may be undergoing a benign metamorphosis in its course and outcome. It is concluded that the evidence is presently unconvincing given the methodological problems inherent in most follow-up studies; changes have taken place in clinicians' assumptions, in treatments, and in the quality of follow-up studies, rather than in the disorder itself. Nevertheless, possible time trends in the incidence and outcome of schizophrenia call for further scientific investigation.

Care-seeking for fatal illnesses in young children in Indramayu, west Java, Indonesia

To examine patterns of seeking care for gravely ill infants and children, we studied all deaths in children under 5 in 10,000 households in Indramayu, West Java, Indonesia, between July 1, 1991, and Dec 31, 1992. 141 deaths were identified (mortality rate 80.7 per 1000), of which 139 were due to causes other than trauma. No treatment of any kind was sought outside the home for 30 (22%) of the children who died from natural causes, and for 59 (42%) others only a traditional healer or other source of non-western medical advice was consulted. Whether or not a mother sought western medical care was strongly associated with the age of the child, the duration of the terminal illness, the previous attendance of the mother at a community-based maternal-and-child-health facility, and the mother's response to a prospectively asked question about what care should be sought for a hypothetical 1-month-old baby with signs of severe pneumonia. Household income, maternal age, and education, and distance between home and government health post were not associated with whether or not western medical care was sought.

A sensitive radioimmunoassay, incorporating solid-phase extraction, for fluticasone 17-propionate in plasma

Antibodies were produced in rabbits immunized with fluticasone 17-propionate (FP) conjugated to bovine thyroglobulin via its 3-carboxymethoxime with isobutylchloroformate. The antibodies were used to develop a sensitive and specific radioimmunoassay (RIA) for FP in human plasma. The limit of quantitation of the RIA is 50 pg per assay tube. This translates to 50 pg ml-1 plasma when a solid-phase extraction preceded the RIA. The interassay and intraassay relative standard deviations were < 15% in the centre of the assay concentration range rising to < 25% at the lower and upper limits (50 and 250 pg ml-1). No appreciable binding was seen between the antibodies and the metabolite of FP that has been identified in man. The RIA was used to study the time course of plasma concentrations in man following inhalation of FP.