Multi-modal skin atlas identifies a multicellular immune-stromal community associated with altered cornification and specific T cell expansion in atopic dermatitis

In healthy skin, a cutaneous immune system maintains the balance between tolerance towards innocuous environmental antigens and immune responses against pathological agents. In atopic dermatitis (AD), barrier and immune dysfunction result in chronic tissue inflammation. Our understanding of the skin tissue ecosystem in AD remains incomplete with regard to the hallmarks of pathological barrier formation, and cellular state and clonal composition of disease-promoting cells. Here, we generated a multi-modal cell census of 310,691 cells spanning 86 cell subsets from whole skin tissue of 19 adult individuals, including non-lesional and lesional skin from 11 AD patients, and integrated it with 396,321 cells from four studies into a comprehensive human skin cell atlas in health and disease. Reconstruction of human keratinocyte differentiation from basal to cornified layers revealed a disrupted cornification trajectory in AD. This disrupted epithelial differentiation was associated with signals from a unique immune and stromal multicellular community comprised of MMP12 + dendritic cells (DCs), mature migratory DCs, cycling ILCs, NK cells, inflammatory CCL19 + IL4I1 + fibroblasts, and clonally expanded IL13 + IL22 + IL26 + T cells with overlapping type 2 and type 17 characteristics. Cell subsets within this immune and stromal multicellular community were connected by multiple inter-cellular positive feedback loops predicted to impact community assembly and maintenance. AD GWAS gene expression was enriched both in disrupted cornified keratinocytes and in cell subsets from the lesional immune and stromal multicellular community including IL13 + IL22 + IL26 + T cells and ILCs, suggesting that epithelial or immune dysfunction in the context of the observed cellular communication network can initiate and then converge towards AD. Our work highlights specific, disease-associated cell subsets and interactions as potential targets in progression and resolution of chronic inflammation.

A novel likely pathogenic CLCN5 variant in Dent's disease

BACKGROUND

The majority of cases of Dent's disease are caused by pathogenic variants in the CLCN5 gene, which encodes a voltage-gated chloride ion channel (ClC-5), resulting in proximal tubular dysfunction. We present three members of the same family and one unrelated paediatric patient with the same insertion-deletion CLCN5 variant. The identification of these patients and positive familial segregation led to the re-classification of this variant from one of unknown significance to one of likely pathogenicity.

CASE PRESENTATION

A 41 year old male presented with end stage kidney failure, proteinuria and haematuria. Whole genome sequencing identified an insertion-deletion variant in CLCN5, resulting in a missense change (c.1744_1745delinsAA p.(Ala582Lys)). His brother and nephew, who both exhibited renal impairment, haematuria, proteinuria, glycosuria and nephrocalcinosis, were found to have the same variant. In addition, genetic testing of an unrelated paediatric patient who presented with proteinuria and hypercalciuria, demonstrated the same variant.

CONCLUSIONS

The identification of this novel variant in four individuals with features of Dent's disease, has led to the re-classification of the variant to one of likely pathogenicity. As a result, our patients and any future patients with the same variant can be offered a likely diagnosis, without the need for kidney biopsy, and their family members can be offered genetic screening.

An Evidence-Based Guideline Improves Outcomes for Patients With Hemophagocytic Lymphohistiocytosis and Macrophage Activation Syndrome

OBJECTIVE

To compare clinical outcomes in children with hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) who were managed before and after implementation of an evidence-based guideline (EBG).

METHODS

A management algorithm for MAS-HLH was developed at our institution based on literature review, expert opinion, and consensus building across multiple pediatric subspecialties. An electronic medical record search retrospectively identified hospitalized patients with MAS-HLH in the pre-EBG (October 15, 2015, to December 4, 2017) and post-EBG (January 1, 2018, to January 21, 2020) time periods. Predetermined outcome metrics were evaluated in the 2 cohorts.

RESULTS

After the EBG launch, 57 children were identified by house staff as potential patients with MAS-HLH, and rheumatology was consulted for management. Ultimately, 17 patients were diagnosed with MAS-HLH by the treating team. Of these, 59% met HLH 2004 criteria, and 94% met 2016 classification criteria for MAS complicating systemic juvenile idiopathic arthritis. There was a statistically significant reduction in mortality from 50% before implementation of the EBG to 6% in the post-EBG cohort (P = 0.02). There was a significant improvement in time to 50% reduction in C-reactive protein level in the post-EBG vs pre-EBG cohorts (log-rank P < 0.01). There were trends toward faster time to MAS-HLH diagnosis, faster initiation of immunosuppressive therapy, shorter length of hospital stay, and more rapid normalization of MAS-HLH-related biomarkers in the patients post-EBG.

CONCLUSION

While the observed improvements may be partially attributed to advances in treatment of MAS-HLH that have accumulated over time, this analysis also suggests that a multidisciplinary treatment pathway for MAS-HLH contributed meaningfully to favorable patient outcomes.

The haemodynamics of the human placenta in utero

We have used magnetic resonance imaging (MRI) to provide important new insights into the function of the human placenta in utero. We have measured slow net flow and high net oxygenation in the placenta in vivo, which are consistent with efficient delivery of oxygen from mother to fetus. Our experimental evidence substantiates previous hypotheses on the effects of spiral artery remodelling in utero and also indicates rapid venous drainage from the placenta, which is important because this outflow has been largely neglected in the past. Furthermore, beyond Braxton Hicks contractions, which involve the entire uterus, we have identified a new physiological phenomenon, the ‘utero-placental pump’, by which the placenta and underlying uterine wall contract independently of the rest of the uterus, expelling maternal blood from the intervillous space.

MRI provides important new insights into the function of the human placenta, revealing slow net flow and high, uniform oxygenation in healthy pregnancies, detecting changes that will lead to compromised oxygen delivery to the fetus in preeclampsia, and identifying a new physiological phenomenon, the ‘utero-placental pump’.

Heuristic neural network approach in histological sections detection of hydatidiform mole

A heuristic-based, multineural network (MNN) image analysis as a solution to the problematical diagnosis of hydatidiform mole (HM) is presented. HM presents as tumors in placental cell structures, many of which exhibit premalignant phenotypes (choriocarcinoma and other conditions). HM is commonly found in women under age 17 or over 35 and can be partial HM or complete HM. Appropriate treatment is determined by correct categorization into PHM or CHM, a difficult task even for expert pathologists. Image analysis combined with pattern recognition techniques has been applied to the problem, based on 15 or 17 image features. The use of limited data for training and validation set was optimized using a k -fold validation technique allowing performance measurement of different MNN configurations. The MNN technique performed better than human experts at the categorization for both the 15- and 17-feature data, promising greater diagnostic consistency, and further improvements with the availability of larger datasets.

Differential Effects of Tra2ß Isoforms on HIV-1 RNA Processing and Expression

Balanced processing of HIV-1 RNA is critical to virus replication and is regulated by host factors. In this report, we demonstrate that overexpression of either Tra2α or Tra2β results in a marked reduction in HIV-1 Gag/ Env expression, an effect associated with changes in HIV-1 RNA accumulation, altered viral splice site usage, and a block to export of HIV-1 genomic RNA. A natural isoform of Tra2β (Tra2ß3), lacking the N-terminal RS domain, also suppressed HIV-1 expression but had different effects on viral RNA processing. The functional differences between the Tra2β isoforms were also observed in the context of another RNA substrate indicating that these factors have distinct functions within the cell. Finally, we demonstrate that Tra2ß depletion results in a selective reduction in HIV-1 Env expression as well as an increase in multiply spliced viral RNA. Together, the findings indicate that Tra2α/β can play important roles in regulating HIV-1 RNA metabolism and expression.

Gene hunting in the genomic era: approaches to diagnostic dilemmas in patients with primary immunodeficiencies

There are more than 180 different genetic causes of primary immunodeficiencies identified to date. Approaches for identifying causative mutations can be broadly classified into 3 strategies: (1) educated guesses based on known signaling pathways essential for immune cell development and function, (2) similarity of clinical phenotypes to mouse models, and (3) unbiased genetic approaches. Next-generation DNA sequencing permits efficient sequencing of whole genomes or exomes but also requires strategies for filtering vast amounts of data. Recent studies have identified ways to solve difficult cases, such as diseases with autosomal dominant inheritance, incomplete penetrance, or mutations in noncoding regions. This review focuses on recently identified primary immunodeficiencies to illustrate the strategies, technologies, and potential pitfalls in finding novel causes of these diseases.

Inversion upstream of FOXF1 in a case of lethal alveolar capillary dysplasia with misalignment of pulmonary veins

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACDMPV) is a congenital malformation that leads to severe pulmonary hypertension and respiratory failure. It has been associated with deletion of, or mutation in, FOXF1 on 16q24.1, a gene encoding a forkhead transcription factor expressed in the mesenchyme of the developing lung. Here we report on the identification of a pericentric inversion on chromosome 16 (p11.2q24.1) in a case of lethal ACDMPV with atrioventricular septal defect and duodenal atresia. Array-CGH indicated that the inversion is balanced, and FISH showed that the q-arm breakpoint occurs 134 ± 10 kb upstream (5'; centromeric) of FOXF1. This is suggestive of cis-regulatory elements located more than 130 kb 5' of FOXF1, and analysis of genome-wide data sets of chromatin modifications in two different cell types suggested that the FOXF1 regulatory domain covers more than 300 kb, and perhaps up to 433 kb, upstream of the gene, but only 3 kb downstream. The 588 kb gene-free region between FOXF1 and the next gene in the centromeric direction, IRF8, is highly conserved between species and divided into two distinct regulatory domains by an insulator element. Another putative insulator occurs just downstream of FOXF1. Our results further strengthen the association between FOXF1 and a spectrum of malformations that include ACDMPV, atrioventricular septal defects, and gastrointestinal atresia. Furthermore, the presented analysis aids in defining the critical genomic region for this syndrome.

Inflammasome-activating nanoparticles as modular systems for optimizing vaccine efficacy

Innate immune system activation is a critical step in the initiation of an effective adaptive immune response; therefore, activation of a class of innate pathogen receptors called pattern recognition receptors (PRR) is a central feature of many adjuvant systems. It has recently been shown that one member of an intracellular PRR, the NLRP3 inflammasome, is activated by a number of classical adjuvants including aluminum hydroxide and saponins [Eisenbarth SC, Colegio OR, O'Connor W, Sutterwala FS, Flavell RA. Crucial role for the Nalp3 inflammasome in the immunostimulatory properties of aluminium adjuvants. Nature 2008;453(June (7198)):1122-6; Li H, Willingham SB, Ting JP, Re F. Cutting edge: inflammasome activation by alum and alum's adjuvant effect are mediated by NLRP3. J Immunol 2008;181(July (1)):17-21]. Inflammasome activation in vitro requires signaling of both the Toll-like receptor (TLR) and NLRP3 in antigen-presenting cells. Here we present a class of nanomaterials endowed with these two signals for rapid optimization of vaccine design. We constructed this system using a simple approach that incorporates lipopolysaccharides (LPS) onto the surface of nanoparticles constructed from a biocompatible polyester, poly(lactic-co-glycolic acid) (PLGA), loaded with antigen. We demonstrate that LPS-modified particles are preferentially internalized by dendritic cells compared to uncoated nanoparticles and the system, when administered to mice, elicits potent humoral and cellular immunity against a model antigen, ovalbumin. Wild-type macrophages pulsed with LPS-modified nanoparticles resulted in production of the proinflammatory cytokine IL-1beta consistent with inflammasome activation. In comparison, NLRP3-deficient and caspase-1-deficient macrophages showed negligible production of IL-1beta. Furthermore, when endocytosis and lysosomal destabilization were inhibited, inflammasome activity was diminished, supporting the notion that nanoparticles rupture lysosomal compartments and behave as 'danger signals' [Hornung V, Bauernfeind F, Halle A, Samstad EO, Kono H, Rock KL, et al. Silica crystals and aluminum salts activate the NALP3 inflammasome through phagosomal destabilization. Nat Immunol 2008;9(August (8)):847-56]. The generality of this vaccination approach is tested by encapsulation of a recombinant West Nile envelope protein and demonstrated by protection against a murine model of West Nile encephalitis. The design of such an antigen delivery mechanism with the ability to stimulate two potent innate immune pathways represents a potent new approach to simultaneous antigen and adjuvant delivery.

Review of singleton fetal and neonatal deaths associated with cranial trauma and cephalic delivery during a national intrapartum-related confidential enquiry

OBJECTIVE

To review delivery details of intrapartum-related fetal and neonatal deaths with singleton cephalic presentation and birthweight of 2500 g or more in which traumatic cranial or cervical spine injury or substantial difficulty at delivery of the head was a dominant feature.

DESIGN

Review of freestyle summary reports and standard questionnaire responses submitted to the national secretariat for the Confidential Enquiry into Stillbirths and Death in Infancy (CESDI) during the 1994/1995 intrapartum-related mortality enquiry following regional multidisciplinary panel review.

SETTING

United Kingdom.

SAMPLE

Of the 873 cases of intrapartum-related deaths reported in the 1994-1995 national enquiry, 709 weighed more than 2499 g.

REPORTS

from 181 (89 from 1994 and 92 from 1995) with a chance of meeting criteria for cranial or cervical trauma as significant contributors to death were examined in detail. Thirty-seven were judged to meet the criteria stated in the objectives (23 from 1994 and 14 from 1995) and form the basis for this review.

METHODS

Electronic and hand search of CESDI records relating to intrapartum-related deaths.

MAIN OUTCOME MEASURES

Intrapartum events and features of care.

RESULTS

There was evidence of fetal compromise present before birth in 33 of the 37 (89%) study group cases reviewed. One delivery was performed vaginally without instrumentation, and in one there was no attempt at vaginal delivery before caesarean section (CS) in the second stage of labour. Twenty-four cases (65%) were delivered vaginally and 11 (30%) by CS after failure to deliver vaginally with instruments. A single instrument was used in six cases of vaginal delivery (four ventouse and two Kjelland's forceps). At least two separate attempts with different instruments were made in 24 cases. Overall, the ventouse was used in 27 cases and forceps in 29 cases. In six cases, three separate attempts were made with at least two different instruments, all of which included use of ventouse. The grade of operator was recorded in 27 cases. Of these, a consultant obstetrician was present at only one delivery and no consultant was recorded to have made the first attempt to deliver a baby. In six cases, shoulder dystocia was also reported.

CONCLUSIONS

This study suggests a lower incidence of death from difficult cephalic delivery and cranial trauma than previously reported. The CESDI studies were believed to have achieved high levels of ascertainment for all intrapartum-related deaths from which the cases reported here were selected. Strictly applied entry criteria used in this study could have restricted the number of cases considered as could limited in vivo or postmortem investigations and lack of detailed autopsy. When cranial traumatic injury was observed, it was almost always associated with physical difficulty at delivery and the use of instruments. The use of ventouse as the primary or only instrument did not prevent this outcome. Some injuries occurred apparently without evidence of unreasonable force, but poorly judged persistence with attempts at vaginal delivery in the presence of failure to progress or signs of fetal compromise were the main contributory factor regardless of which instruments were used.

Fatal and life threatening rupture of splenic artery aneurysms in children with portal hypertension

Aneurysms of the splenic artery (SAAs) are a rare complication of portal hypertension in adults. Although the risk of rupture is small, associated mortality is high. Furthermore, circulatory changes that occur following liver transplantation (OLT) may increase the risk of SAA rupture. The incidence in children with portal hypertension is unknown and thus we present our experience with two children who had ruptured SAA, one of whom died. Although there are no accepted methods for routine screening, hepatic angiography should be considered in children with long-standing portal hypertension (more than 10 yr), in order to detect and consider resection of the aneurysms, either before or at the time of liver transplantation.

Control of HIV-1 env RNA splicing and transport: investigating the role of hnRNP A1 in exon splicing silencer (ESS3a) function

The control of HIV-1 viral RNA splicing and transport plays an important role in the successful replication of the virus. Previous studies have identified both an exon splicing enhancer (ESE) and a bipartite exon splicing silencer (ESS3a and ESS3b) within the terminal exon of HIV-1 that are involved in modulating both splicing and Rev-mediated export of viral RNA. To define the mechanism of ESS3a function, experiments were carried out to better define the cis and trans components required for ESS3a activity. Mutations throughout the 30-nt element resulted in partial loss of ESS function. Combining mutations was found to have an additive effect, suggesting the presence of multiple binding sites. Analysis of interacting factors identified hnRNP A1 as one component of the complex that modulates ESS3a activity. However, subsequent binding analyses determined that hnRNP A1 interacts with only one portion of ESS3a, suggesting the involvement of another host factor. Parallel analysis of the effect of the mutations on Rev-mediated export determined that there is not a direct correlation between the effect of the mutations on splicing and RNA transport. Consistent with this hypothesis, replacement of ESS3a with consensus hnRNP A1 binding sites was found to be insufficient to block Rev-mediated RNA export.

Renin gene expression in fetal kidneys of pregnancies complicated by twin-twin transfusion syndrome

Twin-twin transfusion syndrome (TTTS) complicates one in five monochorionic pregnancies and is generally associated with high mortality and morbidity. One twin (the recipient) grows appropriately and has polyhydramnios while the other (the donor) may have a reduced growth velocity and severe oligohydramnios. The disparities in amniotic fluid volumes represent differences in fetal urine output. These differences occur secondary to hemodynamic changes, in which the vascular arrangement of placental anastomoses in TTTS leads to unidirectional flow from the donor to the recipient twin. A better understanding of the pathophysiology may contribute to improved management of this morbid condition. We studied three consecutive prospectively diagnosed stillborn twin pairs affected by early-onset TTTS. Renin gene expression was studied in sections of fetal kidneys with immunocytochemistry using a renin antiserum and with in situ hybridization using riboprobes complementary to renin mRNA, and renin-secreting cells (RCC) were counted. The overall maturation of the renal cortex was assessed by the percentage of immature glomeruli. The donor twin kidneys were smaller than those of the recipients, but the maturation of the renal cortex was not significantly different (28.2% immature glomeruli in the donor and 24.4% in the recipient kidney). The donor kidney showed increased renin gene expression with hyperplastic juxtaglomerular apparatuses (JGAs) that contained excess RCCs (median 20.02 [25th-75th centiles, 5.4, 25.1 RCCs per 100 glomeruli]). In contrast, the recipient kidney was virtually devoid of these cells (0.04 [0, 0.36] RCCs per 100 glomeruli; P < 0.05). In the donor kidney, increased renin release may, by a local action, contribute to renal vasoconstriction and oliguria. Increased renin and/or angiotensin II in the blood passing through the placental anastomoses may, by an endocrine action, suppress renin synthesis in the recipient kidney, thereby increasing renal blood flow and causing polyuria and polyhydramnios. These changes in the renal RAS could thus contribute to the pathogenesis of TTTS. The renal renin changes noted here may represent a contributory or compensating mechanism, the success of which may dictate the overall survival of the twin pregnancy and allow better understanding of the pathophysiology and perhaps therapy that may be employed in this condition.

Structure and function in the saccule of the goldfish (Carassius auratus): a model of diversity in the non-amniote ear

The vertebrate inner ear is comprised of a remarkable diversity of cell types, including several types of sensory hair cells. In amniotes (reptiles, birds, and mammals), the morphological and physiological characteristics that distinguish these cell types have been well documented, while cellular variation in the ears of non-amniotes (all other vertebrate groups) has remained underrecognized. Since non-amniotes have become increasingly popular models for developmental and genetic research, a more comprehensive understanding of structure and function in the inner ears of these species is warranted. This paper first reviews the large body of data describing the morphology and physiology of hair cells and afferent neurons in the inner ear of the goldfish (Carassius auratus). In particular, we examine the structure of the goldfish saccule, an endorgan that has been the subject of numerous investigations on audition. New data on the structural variation of synaptic bodies in saccular hair cells are also presented, and the functional implications of these data are discussed. Finally, we conclude that hair cell structure varies along the length of the goldfish saccule in a manner consistent with known physiological characteristics of the endorgan. The saccule provides an excellent model for investigating structure-function relationships in the vertebrate inner ear, as well as the development of auditory and vestibular sensory epithelia.

Effect of a boil water notice on behaviour in the management of a water contamination incident

In late 1998, the water supply of 878 households was affected by possible sewage contamination. A notice was issued to advise residents of the need to boil their water. This provided an opportunity to assess to what extent the boil water notice led people to avoid activities that might put them at risk of waterborne infection. A postal questionnaire sent to 350 randomly selected households in the affected area asked about timing and mode of receipt of the notice, risk behaviour (boiling water, brushing teeth, washing dishes, drinks for pets, preparation of food), and subsequent changes in drinking water consumption habits. Eighty-one per cent of the households surveyed engaged in behaviour likely to increase the risk of waterborne infection. Comments were collected from consumers on how to improve the management of future water contamination incidents.

Is universal screening for lead in children indicated? An analysis of lead results in Augusta, Georgia in 1997

Pediatricians have a dilemma about whether they should do universal or targeted screening for lead in children. In order to determine whether we should continue our institution's present policy of universal screening, we analyzed 962 lead samples obtained by routine screening in the calendar year 1997, 83 children (8.6%) had elevated levels (over 10 mcg/dl) by capillary samples; of the 57 children who had follow up tests by venipuncture, 35 had abnormal levels making the incidence of elevated leads in our screened children 3.6%. Most of the abnormal levels were in African-American children living in two downtown zip codes. Based on recent AAP recommendations, in our community, targeted screening should replace universal screening.

Dysregulation of cyclin dependent kinase 6 expression in splenic marginal zone lymphoma through chromosome 7q translocations

The increased or inappropriate expression of genes with oncogenic properties through specific chromosome translocations is an important event in the pathogenesis of B-cell lymphoproliferative diseases. Recent studies have found deletions or translocations of chromosome 7q to be the most common cytogenetic abnormality observed in SLVL, a leukemic variant of SMZL, with the q21-q22 region being most frequently affected. In three patients with translocations between chromosomes 2 and 7, the cloning of the breakpoints at 7q21 revealed that each was located within a small region of DNA 3.6 kb upstream of the transcription start site of cyclin dependent kinase 6 (CDK6). In each case the translocation event was consistent with aberrant VJ recombination between the immunoglobulin light chain region (Ig kappa) on chromosome 2p12 and DNA sequences at 7q21, resembling the heptamer recombination site. The t(7;21) breakpoint in an additional patient with splenic marginal zone lymphoma (SMZL), resided 66 kb telomeric to the t(2;7) breakpoints juxtaposing CDK6 to an uncharacterized transcript. In two of the SLVL patient samples, the CDK6 protein was found to be markedly over expressed. These results suggest that dysregulation of CDK6 gene expression contributes to the pathogenesis of SLVL and SMZL.

Prenatal diagnosis of mosaicism for partial trisomy 8: a case report including fetal pathology

A case of prenatally diagnosed partial trisomy 8 is described. The 'syndrome' is associated with skeletal and cardiac anomalies, as well as hepatic calcification. Differing proportions of 47,XY, +der(8) and 46 XY were present in the different fetal tissues sampled. The highest proportion of 47,XY,+der(8) cells was found in the placenta.

Substance abuse and dependence in physicians: the Missouri Physicians' Health Program

Substance abuse and dependence (alcohol and drugs) are behavioral disorders and treatable medical diseases. There is growing concern in the medical community for physicians impaired by these diseases. The Missouri Physicians' Health Program has been established to help impaired physicians return to healthy personal and professional lives. This confidential voluntary program of early referral, intervention, treatment, monitoring, and advocacy has been highly successful. The average recovery rate in this study of 146 participants was 94%.

Zebrafish inner ear sensory surfaces are similar to those in goldfish

The inner ear of the zebrafish (Brachydanio rerio) is very similar to that of the goldfish in its structural details, including the distribution and orientation of mechanosensory hair cell populations. Both species have been used in studying different aspects of the acoustic startle response. These structural similarities suggest that the zebrafish is a valid representative model for understanding peripheral hearing specializations in otophysan fishes.

Damage and regeneration of hair cell ciliary bundles in a fish ear following treatment with gentamicin

Sensory hair cells in the striolar regions of the utricle and lagena of a teleost fish, the oscar (Astronotus ocellatus), were damaged following intramuscular injections of gentamicin sulfate. In order to determine whether fish can regenerate hair cells, the time course of damage and recovery was followed over a period of four weeks by scanning electron microscopy. Maximum loss of ciliary bundles occurred at about day 10 after the first of four daily injections of gentamicin (20 mg/kg) in 4-6 cm long fish. The striolar regions were almost totally denuded of ciliary bundles, and there was evidence of considerable hair cell loss. The time course for damage was longer in larger fish, but the recovery of the ciliary bundles appeared to be complete about 10 days after maximal damage was seen in both the smaller and larger fish. These data indicate that Astronotus is able to repair damage to hair cells for an extended period of time post-embryonically.

An experiment in psychiatric community care in north Staffordshire: the experience of working with relatives of mentally-ill people

This paper describes the changing nature of the relationship between the consumers and providers of services, following the transition from a hospital to a community-based service. One aspect of this change, the development of a relatives' group, is considered in more detail. Those attitudes and approaches which help or hinder staff working with relatives are discussed.

Postural changes occurring during one month of vestibular compensation in goldfish

1. Postural behavioural changes during vestibular compensation were studied in goldfish. The tilting posture induced by directional light in the dorsal light reflex (DLR) was monitored by an automated camera system. Responses were measured over a 1-month period following a partial unilateral labyrinthectomy. 2. After the fish had recovered from the ataxic stage, the first observable DLR had shifted strongly towards the operated side. This early bias decreased rapidly, then more gradually. Mean values for the DLR reached a steady state within 2 weeks. 3. Recovery rates were slowest for DLR tilts elicited by light presented from the operated side. 4. The DLR did not recover to preoperative control values for light from either the intact or operated side. Shortly after the operation, light from the operated side produced DLR values nearly double the normal; light from the intact side had an effect very little different from normal. At steady state, the light effect from the operated side had decreased from the high immediately post-ataxic levels to a level roughly 1.5 times normal, but the light effect from the intact side had increased, also reaching a level roughly 1.5 times normal. Thus the final values again show symmetry. 5. Variability appears to be an important feature of the response.

Early abrupt recovery from ataxia during vestibular compensation in goldfish

1. Vestibular compensation was studied in goldfish that had had the utriculus and semicircular canal organs unilaterally removed. Characteristic postoperative behavioural deficits of postural asymmetry were quantitatively scored. Operated animals were compared with those subject to the same duration of anaesthesia and restraint during a sham operation. 2. The period of several minutes following the operation was characterized by severe postural asymmetry and locomotor ataxia. In the operated fish, but not the sham-operated ones, the eyes rolled tonically towards the operated side without nystagmus, the body was flexed towards the operated side, and any swimming was disoriented with rolling motion towards the operated side. These deficits lasted less than 30 min after revival from the anaesthesia. All three behavioral deficits ended abruptly within 1 min of each other for individual fish, and normal, nearly upright swimming was then maintained, even in the dark. 3. We interpret this recovery as one of the first stages in the central process of vestibular compensation. The unusually abrupt end of these deficits in adult goldfish compared with that in other vertebrates suggests a remarkable capacity for the central nervous system to adapt. The speed of recovery of three distinct motor outputs supports models of early compensation that utilize central modulation or gain control of existing pathways, rather than anatomical reorganization.

Anatomy and differential growth of the lateral line system of the mottled sculpin, Cottus bairdi (Scorpaeniformes: Cottidae)

Scanning electron microscopy and standard histological techniques were used to describe the basic anatomy and postembryonic growth of the lateral line system of Cottus bairdi. The gross anatomy and distribution of lateral line neuromasts in canals and superficially on the skin are similar to what has been reported for many primitive actinopterygian fishes. Both canal and superficial neuromasts showed postembryonic growth in the number of hair cells and size of neuromasts, but canal neuromasts grew more elongate whereas superficial neuromast grew symmetrically. Neuromasts in the mandibular canal grew significantly faster than any other neuromasts and superficial neuromasts on the head showed the least amount of growth. Differential growth of the sculpin lateral line system may be related to the feeding behavior of the animal and to differences in the ambient levels of water noise to which larval and adult fish are exposed.

Social class, underprivileged areas and psychiatric disorder in the city of Stoke-on-Trent

A survey of psychiatric disorder, based on hospital inpatient records, was conducted in the City of Stoke-on-Trent, England for the year 1983. This was used to test the hypothesis that areas of lower social class and greatest underprivilege would display higher rates of inpatient admissions for psychiatric disorder than the more privileged areas of the city. The results confirmed a significant positive correlation between extent of underprivilege of an area and rates of inpatient admissions. The link between lower social class and mental disorder was not directly demonstrated.

Retention of generalized hair cell patterns in the inner ear of the primitive flatfish Psettodes

Flatfish are a group of uniquely asymmetrical vertebrates, lying always on one side. This postural control depends on the vestibular receptors of the inner ear. From the most primitive living flatfish, orientations of sensory hair cells in the inner ear were mapped by scanning electron microscopy. The maps of the three otolith organs, the three semicircular cristae, and the macula neglecta (newly discovered here for flatfish) show patterns that are very similar to those in many upright teleosts, particularly perches. Thus, peripheral sensory structure does not require modification for the unusual postural control of flatfish.

Hair cell distribution and orientation in goldfish otolith organs

Structurally diverse sensory regions occur in the otolith organs of the goldfish inner ear. Scanning electron microscopy reveals regional distinctions based on three criteria. (1) Hair cells have different sizes of apical bundles, based on thickness. In all three maculae, two central regions have hair cells with bundles significantly thicker than those in surrounding regions. (2) Hair cell population density varies, with regional aggregations present. The central regions with thick bundles have two to three times the density of surrounding regions with thin bundles, and contain 40-80% of the total hair cell number in each macula. (3) Hair cell orientation maps show that each macula has two oppositely oriented cell populations that can be separated completely, not by a zone of interspersion, but apparently by a single unbroken line. The lagena is like the utricle in having hair cells with the kinocilium on the side of the cell toward the opposition line, but in the saccule the kinocilia face away from the line, and the small macula neglecta consists of two completely separate, oppositely oriented patches. The opposition line does not divide each macula simply down its midline; instead, the line divides the regions with thich bundles into nearly equal opposing areas, except for a remarkably abrupt large loop in the line in the anterior part of the saccule. The regional structural diversity in these organs may relate to localized functional diversity of responses to tilt, vibration and sound.

Central Control of Postural Orientation in Flatfish

1. Flatfish metamorphose from a larval form that swims upright like a standard fish to an adult that lies on one side, with both eyes on the upper side, having rotated posture 90° relative to gravity and the former normal posture. Adult Citharichthys stigmaeus and Hypsopsetta guttulata were used in behavioural and physiological experiments to determine whether the postural change is a peripheral or central phenomenon.

2. Cleared and sectioned specimens verify that the otolith organs, unlike the eyes, do not rotate within the skull, and so do not maintain the normal vertebrate orientation with respect to gravity.

3. Ocular compensation to lateral tilt shows that tactile cues, vision, and the semicircular canals are inadequate to produce tilt responses, but elimination of otolith function abolishes tilt responses. The major postural role of the otolith organs is not lost.

4. Selective removal of otoliths demonstrates that the flatfish utriculus has only a minor role in tilt responses, and that the sacculus-lagena is required, unlike the situation in other vertebrates. The details of the ocular compensation responses are similar to those of standard fishes. Each sacculus lies at an angle of up to 45° when in the normal position, but unilateral loss does not change the phase of the response curve, indicating that the null response is set for a non-zero value of gravitational shear, unlike the null at zero shear to the utriculus in other vertebrates.

5. Hysteresis effects suggest a differential sensitivity between tilts near the normal and the upside-down null positions. The narrowness of the effect argues against mechanical restrictions. Possibly the vertical utriculus is useful only near the normal, as an accessory organ, like the vertical lagena in other vertebrates.

6. Neural units recorded from both eighth nerve and medulla show the expected activity properties of regular and irregular rate, tonic and phasic responses to tilt, directional dependence and ‘multi-valuedness’, as in other vertebrates. No novel response types are found, nor any distinctive ‘into-level‘ types described for some vertebrates. Vibration sensitivity is associated with irregular rate, and exclusively vibration-sensitive units are apparent only in the utriculus. The shift in functional relations of the otolith organs relative to gravity is not apparently compensated for by any major change in peripheral afferent gravistatic unit properties.

7. An increasing distinction between the null at normal and the null upside-down shown by limited data on ocular compensation in three year-classes of flatfish. A central change in vestibular function is suggested that might be dependent on experience, as is gradual compensation to a vestibular lesion.

8. Since peripheral changes are not responsible for the postural change, alternative central mechanisms are proposed, including central weighting of input, recognition of a complex input pattern, and plasticity of connexions, all of which have received some supporting evidence from these results.

Central Control of Postural Orientation in Flatfish

1. Visual influences on postural responses mediated by the otolith organs were studied in behavioural and physiological experiments on two species of flatfish, the bothid Citharichthys stigmaeus and the pleuronectid Hypsopsetta guttulata.

2. Ocular compensation to lateral tilt is altered toward a directional light stimulus; the light effect is independent of the tilt effect, and sums with it. Maximum light effect is roughly one-fourth the magnitude of the maximum tilt response.

3. Single shocks to the optic tectum evoke up to three responses in the cut stump of the ipsilateral vestibular nerve, falling into three latency groups at roughly 5, 10 and 20 msec; all three follow stimulation of the anterior lateral tectum. The two later groups suggest by their delay and extinction at low stimulus rates that their path involves at least one synapse.

4. Some units determined as primary otolith-organ afferents by their response characteristics to lateral tilts show a change in rate following a burst of shocks to the tectum, but no response to single shocks. The usual effect is excitatory, with a latency of 50-100 msec, and lasting 200-500 msec after the stimulus.

5. Some of these units also show tonic alteration in rate while a light is shining into one eye. The alteration is either an increase with light to either eye, or a direction-dependent increase or decrease, with a latency of 50-100 msec, and lasting tonically during stimulation times of up to 1 min. The effect is independent of tilt.

6. While the proportion of affected units is small, the elimination of mechanical, muscular, autonomic or antidromic effects and the specificity of many of the responses demonstrate that optic-vestibular integration can involve an efferent control system from the tectum to the otolith organs.

7. The presence of such visual interactions with vestibular input in adult flatfish leads to the hypothesis that the central control of the 90° postural change occurring during flatfish metamorphosis may involve crucial optic influences during the period of eye migration.