Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial

Background

Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness.

Objectives

Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects.

Design

Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase.

Setting

Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.

Participants

In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.

Interventions

Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress.

Main outcome measures

Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale.

Results

Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention.

Conclusions

Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.

Limitations

Uncontrolled design and self-selecting sample.

Future work

Definitive trial determining intervention effects.

Trial registration

This trial is registered as ISRCTN12826685 (closed to recruitment).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information.

Context

Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives

Background

Violence and other harms that result from conflict in forensic inpatient mental health settings are an international problem. De-escalation approaches for reducing conflict are recommended, yet the evidence-base for their use is limited. For the first time, the present study uses implementation science and behaviour change approaches to identify the specific organisational and individual behaviour change targets for enhanced de-escalation in low and medium secure forensic inpatient settings. The primary objective of this study was to identify and describe individual professional, cultural and system-level barriers and enablers to the implementation of de-escalation in forensic mental health inpatient settings. The secondary objective was to identify the changes in capabilities, opportunities and motivations required to enhance de-escalation behaviours in these settings.

Methods

Qualitative design with data collection and analysis informed by the Theoretical Domains Framework (TDF). Two medium secure forensic mental health inpatient wards and one low secure mental health inpatient ward participated. 12 inpatients and 18 staff participated across five focus groups and one individual interview (at participant preference) guided by a semi-structured interview schedule informed by the TDF domains. Data were analysed via Framework Analysis, organised into the 14 TDF domains then coded inductively within each domain.

Results

The capabilities required to enhance de-escalation comprised relationship-building, emotional regulation and improved understanding of patients. Staff opportunities for de-escalation are limited by shared beliefs within nursing teams stigmatising therapeutic intimacy in nurse-patient relationships and emotional vulnerability in staff. These beliefs may be modified by ward manager role-modelling. Increased opportunity for de-escalation may be created by increasing service user involvement in antipsychotic prescribing and modifications to the physical environment (sensory rooms and limiting restrictions on patient access to ward spaces). Staff motivation to engage in de-escalation may be increased through reducing perceptions of patient dangerousness via post-incident debriefing and advanced de-escalation planning.

Conclusions

Interventions to enhance de-escalation in forensic mental health settings should enhance ward staff’s understanding of patients and modify beliefs about therapeutic boundaries which limit the quality of staff-patient relationships. The complex interactions within the capabilities-opportunities-motivation configuration our novel analysis generated, indicates that de-escalation behaviour is unlikely to be changed through knowledge and skills-based training alone. De-escalation training should be implemented with adjunct interventions targeting: collaborative antipsychotic prescribing; debriefing and de-escalation planning; modifications to the physical environment; and ward manager role-modelling of emotional vulnerability and therapeutic intimacy in nurse-patient relationships.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00735-6.

Individual and group-based parenting programmes for the treatment of physical child abuse and neglect

BACKGROUND

Child physical abuse and neglect are important public health problems and recent estimates of their prevalence suggest that they are considerably more common than had hitherto been realised. Many of the risk factors for child abuse and neglect are not amenable to change in the short term. Intervening to change parenting practices may, however, be important in its treatment. Parenting programmes are focused, short-term interventions aimed at improving parenting practices in addition to other outcomes (many of which are risk factors for child abuse e.g. parental psychopathology, and parenting attitudes and practices), and may therefore be useful in the treatment of physically abusive or neglectful parents.

OBJECTIVES

To assess the efficacy of group-based or one-to-one parenting programmes in addressing child physical abuse or neglect.

SEARCH STRATEGY

A range of biomedical and social science databases were searched including MEDLINE, EMBASE, CINAHL, PsychINFO, Sociofile, Social Science Citation Index, ASSIA, the Cochrane Library, Campbell Library (including SPECTR and CENTRAL), National Research Register (NRR) and ERIC, from inception to May 2005.

SELECTION CRITERIA

Only randomised controlled trials or randomised studies that compared two treatments were included. Studies had to include at least one standardised instrument measuring some aspect of abusive or neglectful parenting. In the absence of studies using objective assessments of child abuse, studies reporting proxy measures of abusive parenting were included. Only studies evaluating the effectiveness of standardised group-based or one-to-one parenting programmes aimed at the treatment of physical child abuse or neglect were included. Studies were also only eligible for inclusion if they had targeted parents of children aged 0-19 years who had been investigated for physical abuse or neglect.

DATA COLLECTION AND ANALYSIS

The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group by the pooled standard deviation, to obtain an effect size. The results for each outcome in each study have been presented, with 95% confidence intervals. It was not possible to combine any results in a meta-analysis.

MAIN RESULTS

A total of seven studies of variable quality were included in this review. Only two studies assessed the effectiveness of parenting programmes on the incidence of child abuse or number of injuries. One study showed that there were no reports of abuse in the intervention group compared with one report of abuse in the control group. In the second study the small number of injuries sustained precluded the possibility of statistical analysis. Data were also extracted on over fifty outcomes that are used as proxy measures of abusive parenting. These were on the whole diverse and measured a range of aspects of parenting (e.g. parental child management, discipline practices, child abuse potential and mental health), child health (e.g. emotional and behavioural adjustment) and family functioning, thereby precluding the possibility of undertaking a meta-analysis for most outcomes for which data were extracted. While none of the programmes were effective across all of the outcomes measured, many appeared to have improved some outcomes for some of the participating parents, although many failed to achieve statistical significance.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of parenting programmes to treat physical abuse or neglect (i.e. such as the incidence of child abuse using reports of child abuse/linjuries or children on the children protection register). There is, however, limited evidence to show that some parenting programmes may be effective in improving some outcomes that are associated with physically abusive parenting. There is an urgent need for further rigorous evaluation of the effectiveness of parenting programmes that are specifically designed to treat physical abuse and neglect, either independently or as part of broader packages of care. Such evaluation should include the use of objective measures of outcome such as independent assessments of parenting and the number of instances of physical abuse. In order to do this, future studies need to include long-term follow-up.

Cranial venous outflow obstruction in the pseudotumour syndrome: incidence, nature and relevance

This study reports a retrospective analysis of the evidence of cranial venous outflow pathology in 188 patients with pseudotumour syndrome (PTS) investigated over the period 1968-1999. Standard methods of investigation appropriate to the period were used, i.e. cerebral angiography, CT and MR scanning. Recently, some patients had specific venous studies including intraluminal cranial venous sinus pressure measurements. A sub-group (25 patients) was investigated for haematological abnormalities. The overall incidence of cranial venous outflow abnormality was 19.7% (37 cases). In decades, related to the predominant investigative method, the figures were: to 1979, 4.2% (2 cases); to 1989, 15.0% (8 cases); to 1999, 31.0% (27 cases). A cause of the venous abnormality was identified in 20 cases, most commonly haematological and iatrogenic. In 17 patients (all females) no cause was identified. Fifteen of the 25 patients (60%) tested specifically were found to have a haematological abnormality, although no correlation was shown between this and a demonstrable venous outflow abnormality. The conclusion was drawn that there is a high incidence (close to one-third) of venous outflow abnormalities in PTS with detailed investigation. Issues of mechanism and therapy are discussed.

BDCA-2, a novel plasmacytoid dendritic cell-specific type II C-type lectin, mediates antigen capture and is a potent inhibitor of interferon alpha/beta induction

Plasmacytoid dendritic cells are present in lymphoid and nonlymphoid tissue and contribute substantially to both innate and adaptive immunity. Recently, we have described several monoclonal antibodies that recognize a plasmacytoid dendritic cell-specific antigen, which we have termed BDCA-2. Molecular cloning of BDCA-2 revealed that BDCA-2 is a novel type II C-type lectin, which shows 50.7% sequence identity at the amino acid level to its putative murine ortholog, the murine dendritic cell-associated C-type lectin 2. Anti-BDCA-2 monoclonal antibodies are rapidly internalized and efficiently presented to T cells, indicating that BDCA-2 could play a role in ligand internalization and presentation. Furthermore, ligation of BDCA-2 potently suppresses induction of interferon alpha/beta production in plasmacytoid dendritic cells, presumably by a mechanism dependent on calcium mobilization and protein-tyrosine phosphorylation by src-family protein-tyrosine kinases. Inasmuch as production of interferon alpha/beta by plasmacytoid dendritic cells is considered to be a major pathophysiological factor in systemic lupus erythematosus, triggering of BDCA-2 should be evaluated as therapeutic strategy for blocking production of interferon alpha/beta in systemic lupus erythematosus patients.

The historical development of the pseudotumor concept

The author outlines the history of the development of the pseudotumor concept, first specifically formulated by Nonne in 1904 but implicit in earlier descriptions. A scheme of periodization is applied, identifying otological, neurosurgical, neurological, and neuroophthalmological periods; he relates theoretical and practical developments in the understanding of the condition to the concerns of the dominant speciality involved in diagnosis and management. Key studies from each period are discussed in relation to the issues of mechanism, origin, nomenclature, diagnosis, and treatment. During the otological period, approaches to the condition were heavily influenced by its common association with middle ear infection, often with venous sinus involvement, and this led to the idea of disturbed cerebrospinal fluid dynamics as the cause. The advent of neuroradiological systems ushered in the neurosurgical period in which the significant but unfinished debate began: which intracranial compartment is primarily implicated in the intracranial hypertension? By the time of the neurological period cerebral edema was implicated as the cause, and this coincided with the availability of appropriate treatment methods and steroidal and diuretic agents. Toward the end of this period additional major advances in investigative methods again brought the issue of mechanism into contention, although a resolution was not to follow. The neuroophthalmological period is characterized by an increased awareness of the significance of visual loss and a return to one of the original methods of treatment. Finally, the possible significance of impaired cranial venous outflow, a thread running through all periods, is considered.

Endovascular treatment of cranial venous sinus obstruction resulting in pseudotumor syndrome. Report of three cases

It is probable that a significant number of cases of pseudotumor syndrome (PTS) occur because of cranial venous outflow obstruction, yet reports of direct treatment of the obstruction are few and inconclusive. In this study the authors report three cases of PTS with angiographically confirmed venous sinus obstruction treated by direct, endovascular procedures; urokinase infusion in two and balloon venoplasty in one. Two patients suffered transient complications that resolved satisfactorily. All three showed initial resolution of the signs and symptoms of PTS but one relapsed after 8 months and required surgical treatment. The possible role and methods of treatment of cranial venous outflow obstruction in PTS are discussed.

Presynaptic neuronal antigens expressed by a small cell lung carcinoma cell line

Small cell lung carcinoma (SCLC) is a tumour of neuroendocrine origin often found in association with autoimmune paraneoplastic neurological disorders. We established a SCLC cell line from a woman with Lambert-Eaton myasthenic syndrome (LEMS) who developed antibodies to both the P/Q-type voltage-gated calcium channels (VGCC) and the muscle acetycholine receptor (AChR). We used a range of techniques to establish which neuronal antigens were expressed in her tumour cell line. The results show that many proteins involved in exocytosis are present in the SCLC cells, and that depolarisation-dependent release of [(3)H]-serotonin is linked to calcium influx through P/Q-type VGCCs. In addition, some of the subunits encoding the AChR and both agrin and ARIA, molecules released from the motor nerve during development, were expressed. These results suggest that many potential antigenic targets are present in SCLC, and indicate a surprising 'motor nerve terminal'-like characteristic of this line.

Disorders of CSF hydrodynamics

This article reviews the range of hydrodynamic disorders affecting the CSF circulation. Initially consideration is given to questions of definition and classification. A scheme for the practical, clinical analysis for the diagnosis of such disorders is then presented. The physiology and pathophysiology of the CSF circulation is reviewed, with particular emphasis on issues that remain unresolved. This provides a background to consideration of the adverse consequences of abnormal CSF hydrodynamics, again focusing on areas where further information is required. Methods of clinical investigation of CSF hydrodynamics are reviewed, followed by general considerations of treatment. Finally, each of the main, clinically important, forms of disordered CSF hydrodynamics is briefly considered, with particular emphasis, again, on areas where current knowledge is deficient. The conditions considered include hydrocephalus of various forms (childhood, adult, arrested, multi-compartment), infantile macrocephaly, arachnoid and glioependymal cysts, syringo- and hydromyelia, pseudotumour cerebri, impaired cranial venous outflow, altered CSF composition, shunt obstruction without ventricular enlargement and low-CSF-pressure states.

Transcriptional regulation of cell invasion: AP-1 regulation of a multigenic invasion programme

The focus of this review will be on the regulation of the multigenic invasion programme by activator protein-1 (AP-1). Investigation of AP-1-regulated gene expression in transformed cells can be used to identify the genes in the multigenic invasion programme and to validate them as targets for diagnosis or therapy.

Increased risk of fibrosing alveolitis associated with interleukin-1 receptor antagonist and tumor necrosis factor-alpha gene polymorphisms

Fibrosing alveolitis (FA) is characterized by persistent inflammation and elevated production of tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1beta), and interleukin-1 receptor antagonist (IL-1ra) in the lung. Single base variations at position +2018 in the IL-1ra gene (IL-1RN) and position -308 in the TNF-alpha gene (TNF-A) are overrepresented in other chronic inflammatory disease populations. We have tested the hypothesis that predisposition to FA may also be influenced by these polymorphisms by genotyping 88 cases and matched controls from England and 61 cases and 103 unmatched controls from Italy. The rarer allele for IL-1RN and TNF-A was designated allele 2 in each case. For IL-1RN allele 2, in the English group, the relative odds of FA were increased in homozygous subjects by an odds ratio (OR) of 10.2 (95% confidence intervals [CI], 1.26 to 81.4; p = 0.03) and for carriers by an OR of 1.85 (95% CI, 0.94 to 3.63; p = 0.075). In the Italian population, the risk of FA was increased, in IL-1RN allele 2 homozygotes (OR, 2.54; 95% CI, 0.68 to 9.50; p = 0.2) and in carriers (OR 2.40; 95% CI, 1.26 to 4.60; p = 0.008). Carriage of TNF-A allele 2 was also associated with increased risk of FA in the English (OR, 1.85; 95% CI, 0.94 to 3.63; p = 0.075) and Italian (OR, 2.50; 95% CI, 1.14 to 5.47; p = 0.022) populations. These data suggest IL-1RN (+2018) allele 2 and TNF-A (-308) allele 2 confer increased risk of developing FA and, therefore, that unopposed IL-1beta and/or excessive TNF-alpha may play a pathophysiologic role in this condition.

Krp1, a novel kelch related protein that is involved in pseudopod elongation in transformed cells

We have previously shown that the transcription factor AP-1 regulates the expression of genes which allow neoplastically transformed rat fibroblasts to become invasive. Searches for further AP-1 target genes led to the identification of a gene encoding a novel rat kelch family member, named kelch related protein 1 (Krp1). Kelch family members are characterized by a series of repeats at their carboxyl terminus and a BTB/POZ domain near their amino terminus. Rat Krp1 has a primarily cytoplasmic localization, and a small fraction appears to accumulate and co-localize with F-actin at membrane ruffle-like structures in the tips of pseudopodia. Overexpression of Krp1 in transformed rat fibroblasts led to the formation of dramatically elongated pseudopodia, while expression of truncated Krp1 polypeptides resulted in a reduction in the length of pseudopodia. We propose that the transformation-specific expression of Krp1 is required for pseudopod elongation, which are structures that are required for cell motility and invasion.

Risk of cryptogenic fibrosing alveolitis in metal workers

We report increased proportional mortality from cryptogenic fibrosing alveolitis in the workforce of a major UK engineering company. Measures of metal exposure from unbiased historical occupational records showed that among employees who have worked with metal, the risk of death from or with cryptogenic fibrosing alveolitis increased in relation to the duration of metal-working.

The 5'-end of the porcine perinatal myosin heavy chain gene shows alternative splicing and is clustered with repeat elements

The porcine perinatal myosin heavy chain (MyHC) is a major isoform in foetal skeletal muscles. We report here on its cDNA and genomic isolation, molecular characterisation and expression. Exon 2 and the first 4 bases of exon 3 of the perinatal MyHC gene. both part of the 5'-end untranslated region, showed differential splicing. About 2% of all perinatal MyHC transcripts of a 50-day-old foetus were without exon 2 and about half were without the 4 bases at the 5'-end of exon 3. Perinatal MyHC mRNA was expressed in all hind limb muscles of a 45-day-old foetus along with the slow and embryonic MyHC isoforms in the same fibres. Unlike other sarcomeric MyHCs reported to date, the porcine perinatal promoter is clustered with repeat elements (4 SINEs and 1 microsatellite) and is without a consensus TATA box at the predicted site upstream of exon 1. Nonetheless, in reporter gene transfections, its promoter was found to be highly muscle-specific. The absence of a TATA box may point to a fundamental difference in the regulatory function between the perinatal and adult MyHC isoforms.

The acquired Chiari malformation and syringomyelia following spinal CSF drainage: a study of incidence and management

Firstly, 14 patients are described who developed either an acquired Chiari malformation (ACM) alone (7 cases) or ACM and syringomyelia (7 cases) after lumbar subarachnoid space (SAS) shunting or in one case, epidural anaesthesia with SAS penetration. Four groups are considered: 3 cases with craniofacial dysostosis and communicating hydrocephalus (CH), 4 cases with CH alone, 3 cases with pseudotumour cerebri (PTC) and a miscellaneous group (4 cases). Initial treatment was varied: resiting the shunt to ventricle or cisterna magna [6], adding an H-V valve [1], syrinx shunting [4] and posterior fossa decompression [3]. Further treatment was required in 6 cases. Secondly, incidence was examined in 87 patients with PTC initially treated either by lumbar SAS shunting [70] or cisterna magna shunting [17]. In the first sub-group, 11 cases (15.7 per cent) developed an ACM, 3 symptomatic (as above) and eight asymptomatic with 1 case also having syringomyelia whereas 1 case occurred in the second group with a questionanably symptomatic ACM. While accurate for symptomatic lesions, these figures are tentative with respect to asymptomatic lesions due to inadequate pre-treatment radiology and detailed MR follow-up. The main conclusions are, first, that the incidence of symptomatic ACM and/or syringomyelia is not high enough to warrant abandoning SAS shunting; second that asymptomatic lesions need not necessarily be treated and third, that when treatment is required, shunt resiting is the first choice.

Exposure to commonly prescribed drugs and the etiology of cryptogenic fibrosing alveolitis: a case-control study

Cryptogenic fibrosing alveolitis is an interstitial lung disease of unknown etiology. Since pulmonary fibrosis is a recognized, if rare, complication of certain drug exposures, including antidepressants, betablockers, antibiotics, anticonvulsants, and nonsteroidal antiinflammatory drugs (NSAIDs), we tested the hypothesis that exposure to these drugs might contribute to the etiology of cryptogenic fibrosing alveolitis. Lifetime drug exposure data were collected from general practitioner records for 141 cases of cryptogenic fibrosing alveolitis and 246 age-, sex-, and community-matched control subjects from the Trent region of England. Additional data on lifetime smoking habits were obtained by postal questionnaire. The odds of disease in relation to ever exposure to antidepressants, betablockers, antibiotics, anticonvulsants, and NSAIDs were calculated by conditional logistic regression. For drug groups significantly associated with cryptogenic fibrosing alveolitis, subset analyses were performed to investigate the effects of individual drugs. Cryptogenic fibrosing alveolitis was associated with exposure to antidepressants (odds ratio [OR] 1.79 [95% CI 1.09-2.95], p = 0.022) and specifically to imipramine (OR 4.79 [1.50-15.3], p = 0.01), dothiepin (OR 2.37 [0.99-5.69], p = 0.05), and mianserin (OR 3.27 [1.11-9.61], p = 0.03). The magnitude of the overall effect of antidepressants was not changed by excluding all drug exposures within the 5 yr preceding the diagnosis of cryptogenic fibrosing alveolitis (OR 1.62 [0.94-2.77], p = 0.081), nor were the strong individual effects of imipramine (OR 5.72 [1.54-21.2], p = 0.009) and dothiepin (OR 5.58 [1.12-27.8], p = 0.036). These estimates were not appreciably affected by controlling for smoking history. The attributable risk for antidepressant exposure was in the region of 9-14%. No significant association was noted between cryptogenic fibrosing alveolitis and the four other drug groups in the primary hypothesis. The results of this study suggest that some antidepressant drugs can cause cryptogenic fibrosing alveolitis.

Embryonic temperature modulates muscle growth characteristics in larval and juvenile herring

The influence of embryonic and larval temperature regime on muscle growth was investigated in Atlantic herring (Clupea harengus L.). Eggs of spring-spawning Clyde herring were incubated at 5 degrees C, 8 degrees C or 12 degrees C until hatching and then reared until after metamorphosis at rising temperatures to simulate a seasonal warming. Metamorphosis to the juvenile stage was complete at 37 mm total length (TL), after an estimated 177 days as a larva at 5 degrees C, 117 days at 8 degrees C and 101 days at 12 degrees C. Growth rate and the development of median fins were retarded in relation to body length at 5 degrees C compared with 8 degrees C and 12 degrees C. Between hatching (at 8-9 mm TL) and 16 mm TL, there was a threefold increase in total muscle cross-sectional area, largely due to the hypertrophy of the embryonic red and white muscle fibres. The recruitment of additional white muscle fibres started at approximately 15 mm TL at all temperatures, and by 37 mm was estimated to be 66 fibres day-1 at 5 degrees C and 103 fibres day-1 at 8 degrees C and 12 degrees C. Peptide mapping studies revealed a change in myosin heavy chain composition in white muscle fibres between 20 and 25 mm TL. Embryonic red muscle fibres expressed fast myosin light chains until 24-28 mm TL at 5 degrees C and 22 mm TL at 12 degrees C, and new red fibres were added at the horizontal septum starting at the same body lengths. Following metamorphosis, the total cross-sectional area of muscle was similar at different temperatures, although the number of red and white fibres per myotome was significantly greater at the warmest than at the coldest regime. For example, the mean number of white muscle fibres per myotome in 50 mm TL juveniles was calculated to be 23.4 % higher at 12 degrees C (12 065) than at 5 degrees C (9775). In other experiments, spring-spawning (Clyde) and autumn-spawning (Manx) herring were reared at different temperatures until first feeding and then transferred to ambient seawater temperature and fed ad libitum for constant periods. These experiments showed that, for both stocks, the temperature of embryonic development influenced the subsequent rate of muscle fibre recruitment and hypertrophy as well as the density of muscle nuclei. Labelling experiments with 5'-bromo-2-deoxyuridine showed that both the hypertrophy and recruitment of muscle fibres involved a rapidly proliferating population of myogenic precursor cells. The cellular mechanisms underlying the environmental modulation of muscle growth phenotype are discussed.

Survival in patients with cryptogenic fibrosing alveolitis: a population-based cohort study

STUDY OBJECTIVES

To determine the median survival of patients with cryptogenic fibrosing alveolitis, in comparison to that expected of individuals of the same age and sex from the general population. To estimate the effect of survival bias incurred by studying both incident and prevalent cases. To identify factors associated with survival.

DESIGN

Cohort study.

SETTING

Nine hospitals from the Trent Region of England.

PATIENTS

Two hundred forty-four cases of cryptogenic fibrosing alveolitis: 168 patients were alive on day 1 of the study (prevalent cases), and 76 patients had newly diagnosed conditions over a prospective 18-month period of patient recruitment (incident cases).

MEASUREMENTS

Age, sex, date of diagnosis, lung function at presentation, and details of treatment prescribed were extracted from hospital clinical records. Data on lifetime smoking habits were collected by postal questionnaire. Vital status was established from the general practitioner. The expected survival of each case was extracted from the English life tables.

RESULTS

Median survival for incident cases was 2.9 years and for prevalent cases 9 years, compared to expected values of 10 and 13 years, respectively. Incident cases had significantly worse survival than prevalent cases, even after adjustment for the effects of age, sex, smoking history, lung function at presentation, and treatment (hazard ratio, 4.53 [95% confidence interval, 2.71 to 7.56]; p<0.001). Lower FVC at presentation and the use of corticosteroid treatment were both associated with worse survival.

CONCLUSIONS

The inclusion of prevalent cases leads to significant overestimation of the median survival for patients with cryptogenic fibrosing alveolitis. In newly diagnosed cases of cryptogenic fibrosing alveolitis, median survival is only 2.9 years, and expected life span is reduced by approximately 7 years.

Dural arteriovenous fistula in association with heterotopic brain nodule in the transverse sinus

We describe a 56-year-old woman with a dural arteriovenous fistula involving the transverse sinus in association with a nodule of heterotopic brain tissue in the sinus. This finding is discussed in light of a recent radiologic study of nodules in the transverse sinus.

Latitudinal variation in the abundance and oxidative capacities of muscle mitochondria in perciform fishes

The abundance, distribution and oxidative capacities of mitochondria have been investigated in the red pectoral fin adductor muscles of fish (Order Perciformes) that use a predominantly labriform style of swimming. Mediterranean Sea species from the families Labridae, Serranidae, Sparidae and Antarctic Nototheniidae and non-Antarctic Nototheniidae and Channichthyidae were studied. Sub-Antarctic species from the Beagle Channel, Tierra del Fuego, included the pelagic haemoglobin-less icefish (Champsocephalus esox) and the robalo (Eleginops maclovinus), which occurs as far north as 35 degrees S. In Champsocephalus esox, the mitochondrial volume density of red muscle was 0.51 and mitochondrial cristae surface density (43. 9 microm2 microm-3) was higher than reported for Antarctic icefishes. In the red-blooded, active pelagic or semi-pelagic species, mitochondrial volume density was within the range 0.27-0.33 regardless of habitat temperature. Amongst less active demersal species, mitochondrial volume density ranged from 0.29-0.33 in polar species to 0.08-0.13 in Mediterranean species. In Antarctic species and Champsocephalus esox, myofibrils occurred in ribbons or clusters one fibril thick entirely surrounded by mitochondria. The volume density of intracellular lipid droplets was not correlated with activity patterns or habitat temperature. In a comparison of Eleginops maclovinus caught in summer (approximately 10 degrees C) and winter (approximately 4 degrees C), mitochondrial volume density did not differ, whereas the surface density of mitochondrial clusters was higher in summer fish. The temperature-dependence of the state 3 respiration rate of isolated mitochondria with pyruvate as substrate was described by a single quadratic relationship for all species, indicating no significant up-regulation of the maximum rate of oxygen uptake per milligram mitochondrial protein in Antarctic species. Our results support the conclusion that increasing the volume and surface density of mitochondrial clusters is the primary mechanism for enhancing the aerobic capacity of muscle in cold-water fish.

Alpha1-antitrypsin phenotypes in patients with cryptogenic fibrosing alveolitis: a case-control study

Cryptogenic fibrosing alveolitis (CFA) is an interstitial lung disease, which by definition is of unknown aetiology. Recent evidence has suggested that smoking and occupational exposure to dusts may be environmental risk factors for the disease, but there has been little research into potential host risk factors. One previous study has suggested that the prevalence of abnormal alpha1-antitrypsin phenotypes may be increased in patients with CFA. Since alpha1-antitrypsin is important in regulating inflammation within the lung in response to environmental exposures, such abnormalities may be of aetiological importance in this disease. We have compared the alpha1-antitrypsin phenotypes of 189 patients with CFA with 189 age-, sex-, and community-matched controls. This sample size was sufficient to provide more than 95% power to detect an odds ratio (OR) of 2.5. Alpha1-antitrypsin phenotype was established by isoelectric focusing, and the prevalence of abnormal phenotypes in cases and controls was compared by conditional logistic regression. Personal smoking histories were obtained by postal questionnaire. The prevalence of abnormal alpha1-antitrypsin phenotypes was similar in cases and controls (12.7 versus 15.3%; OR 0.88; 95% confidence interval 0.49-1.57; p=0.66). No interaction was found between the presence of abnormal alpha1-antitrypsin phenotypes and a history of smoking. We conclude that cryptogenic fibrosing alveolitis is not associated with abnormal alpha1-antitrypsin phenotypes.

Demonstration of membranous aqueduct occlusion by fast multiphase magnetic resonance imaging

Membranous aqueduct occlusion is one of the few causes of obstructive hydrocephalus that is amenable to direct surgical treatment. Conventional diagnostic methods may not delineate this entity. The advent of dynamic fast multiphase magnetic resonance imaging has improved the definition of the aqueductal membrane by enabling visualization of the obstructed cerebrospinal fluid flow within the ventricular system. We report a case of a 10-year-old boy in whom the diagnosis of membranous aqueduct occlusion was only achieved utilizing this new technique.

Incidence of serum anti-P/O-type and anti-N-type calcium channel autoantibodies in the Lambert-Eaton myasthenic syndrome

The Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disease in which autoantibodies are directed against voltage-gated calcium channels (VGCCs) at presynaptic nerve terminals. We first demonstrated the presence of P/Q-type and N-type VGCCs in digitonin extracts prepared from human and rabbit cerebellum using the specific ligands 125I-omega-conotoxin MVIIC (125I-omega-CmTx) and 125I-omega-conotoxin GVIA (125I-omega-CgTx), respectively. We then tested sera from 72 LEMS patients' 25 with proven small cell lung cancer (SCLC) and 66 healthy or other neurological, SCLC or autoimmune disease controls in an immunoprecipitation assay using 125I-omega-CmTx-labelled (P/Q-type) VGCCs in human cerebellar extract. Sixty-six of 72 LEMS serum samples (91.7%) were positive for the presence of VGCC antibodies, as defined as a titre greater than 3 standard deviations above the mean for the healthy controls (n = 22). Rabbit cerebellar extract as antigen gave similar results (r = 0.94, P < 0.001, n = 30). By contrast, only 24/72 (33%) LEMS sera were positive in the assay for anti-N-type VGCC antibodies using 125I-omega-CgTx. All these 24 were also positive in the 125I-omega-CmTx assay. All healthy and disease control sera were negative in both assays. The anti-P/Q-type VGCC antibody titres did not correlate with an electrophysiological index of disease severity across individuals; however, longitudinal studies in a LEMS patient with SCLC receiving chemotherapy, and in a non-SCLC LEMS patient receiving immunosuppressive therapy showed an inverse relation between antibody titre and disease severity. These results support the view that anti-P/Q-type VGCC antibodies are implicated in the motor disorder in LEMS, and show that the omega-CmTx radioimmunoassay is a highly specific and sensitive means of detecting them.

Temperature and developmental plasticity of muscle phenotype in herring larvae

Myogenesis, the expression of myofibrillar protein isoforms and the development of muscle innervation were investigated in Clyde herring (Clupea harengus L.) in two successive spawning seasons at temperatures ranging from 5 &deg;C to 15 &deg;C. Myotube formation occurred in a rostral to caudal progression at similar somite stages at all temperatures. Superficial mononuclear muscle pioneer fibres were present at the horizontal septum. Myofibrillogenesis was retarded with respect to somite stage at low temperatures; for example, by the 50-somite stage, myofibrils were observed in the muscle pioneers of the first 31 somites at 12 &deg;C, but only the first 20 somites at 5 &deg;C. In the electron microscope, the earliest stages of myofibril assembly were observed in the muscle pioneer cells and in a proportion of the multinucleated myotubes within the same somite. By the end of somitogenesis, the density of myofibrils in the rostral myotomes was much higher at 15 &deg;C than at 5 &deg;C. Embryonic isoforms of myosin light chain 2 (LC2), troponin I and troponin T were identified in the presumptive white muscle using two-dimensional gel electrophoresis. Expression of the embryonic isoforms was gradually switched off during the larval stages. The size range over which embryonic isoforms were present was inversely related to rearing temperature. For example, the adult pattern of myosin LC2 expression was established at 11 mm total length (TL) at 15 &deg;C, but not until 15 mm TL at 5 &deg;C. Acetylcholinesterase staining was apparent at the myosepta in 31-somite stage embryos at 15 &deg;C, but not until approximately the 40-somite stage at 5 &deg;C. The red muscle fibres of larvae were initially innervated only at their myoseptal ends. The temperature at which the red muscle fibres became multiply innervated was inversely related to body size, occurring at 12&shy;14 mm at 12 &deg;C, but not until 16&shy;19 mm at 5 &deg;C. We conclude that the temperature during early development determines the relative timing and degree of expression of the myogenic programme, resulting in significant phenotypic variation in the swimming muscles of the larval stages. Our results highlight a potential mechanism whereby early thermal experience could influence survival and hence the strength of particular year classes of fish.

Muscle power output during escape responses in an Antarctic fish

Escape responses (C-shaped fast-starts) were filmed at 500 frames s-1 in the Antarctic rock cod (Notothenia coriiceps) at 0 &deg;C. The activation and strain patterns of the superficial fast myotomal muscle were measured simultaneously using electromyography and sonomicrometry respectively. In order to bend the body into the initial C-shape, the muscle fibres in the rostral myotomes (at 0.35L, where L is total length) shortened by up to 13 % of their resting length at a maximum velocity of 1.68 fibre lengths s-1. During the contralateral contraction, muscle fibres were stretched (by 5 % and 7 % at 0.35L and 0.65L, respectively) and were activated prior to the end of lengthening, before shortening by up to 12 % of resting fibre length (peak-to-peak strain). Representative strain records were digitised to create cyclical events corresponding to the C-bend and contralateral contraction. Isolated fibres were subjected to the abstracted strain cycles and stimulated at the same point and for the same duration as occurs in vivo. During the early phase of shortening, muscle shortening velocity (V) increased dramatically whilst the load was relatively constant and represented a substantial fraction of the maximum isometric stress. Pre-stretch of active muscle was associated with significant force enhancement. For the contralateral contraction, V exceeded that predicted by the steady-state force&shy;velocity relationship for considerable periods during each tailbeat, contributing to relatively high maximum instantaneous power outputs of up to 290 W kg-1 wet muscle mass. In vitro experiments, involving adjusting strain, cycle duration and stimulation parameters, indicated that in vivo muscle fibres produce close to their maximum power. During escape responses, the maximum velocity and acceleration recorded from the centre of gravity of the fish were 0.71&plusmn;0.03 m s-1 and 17.1&plusmn;1.4 m s-2, respectively (mean &plusmn; s.e.m., N=7 fish). Muscle performance was sufficient to produce maximum velocities and accelerations that were within the lower end of the range reported for temperate-zone fish.

Mortality rates from cryptogenic fibrosing alveolitis in seven countries

BACKGROUND

Registered mortality from cryptogenic fibrosing alveolitis (CFA) in England and Wales has increased substantially since the specific International Classification of Diseases code for CFA was introduced in 1979. However, since a significant proportion of deaths from CFA are misclassified as post inflammatory fibrosis (PIF), it is possible that the observed rise in CFA mortality is due to diagnostic transfer from this code. To investigate this, and to assess mortality trends in other countries, annual CFA and PIF mortality data from England and Wales, USA, Australia, Scotland, Canada, New Zealand, and Germany were analysed.

METHODS

Crude annual mortality rates were calculated and rates standardised by Poisson regression to allow assessment of changes over time and comparison between countries, sexes, and age groups. The relative trends in mortality from CFA and PIF were assessed by calculating the annual ratio of CFA to PIF deaths.

RESULTS

Men were more likely than women to die from both CFA and PIF in all countries. The highest standardised CFA mortality rate occurred in England and Wales, and the lowest in Germany. Since 1979 mortality from CFA has increased in England and Wales, Australia, Scotland and Canada, but there was no trend in CFA mortality in New Zealand or Germany. In the USA mortality from CFA was low and has fallen. Mortality from PIF increased in all countries except New Zealand and Germany, and the highest PIF mortality, together with the greatest increase over time, was seen in the USA. Changes over time in the annual ratio of CFA to PIF deaths in all countries were small, implying that diagnostic transfer is not a major cause of the increasing CFA mortality.

CONCLUSIONS

Mortality from CFA continues to increase in England and Wales and in many other countries. Diagnostic transfer from PIF does not appear to be a major cause of this.

Plasticity of fish muscle mitochondria with thermal acclimation

Short-horned sculpin Myoxocephalus scorpius were acclimated to 5 and 15 &deg;C to evaluate the impact of thermal acclimation upon maximal rates of substrate oxidation by mitochondria and upon the thermal sensitivity of their ADP affinity. Cold acclimation virtually doubled maximal rates of pyruvate oxidation at all experimental temperatures (2.5, 7.5, 12.5 and 20 &deg;C). Rates of palmitoyl carnitine oxidation were also enhanced by cold acclimation, but to a lesser degree. At their respective acclimation temperatures, the mitochondria attained similar rates of pyruvate oxidation. For warm-acclimated sculpin, the Q10 values for mitochondrial pyruvate and palmitoyl carnitine oxidation were higher between 2.5 and 7.5 &deg;C than between 7.5 and 12.5 &deg;C or between 12.5 and 20 &deg;C. In contrast, for cold-acclimated fish, the Q10 values did not differ over these thermal ranges. The Arrhenius activation energy for pyruvate oxidation was reduced by cold acclimation (from 70 to 55 kJ mol-1), whereas that for palmitoyl carnitine oxidation was unchanged (approximately 75 kJ mol-1). Cold acclimation did not alter the ADP affinity of mitochondria at low temperatures but markedly increased the apparent Km for ADP (Km,app) at 12.5 and 20 &deg;C. At the acclimation temperatures, mitochondrial ADP Km,app values did not differ. The loss of ADP affinity at higher temperatures may represent a cost of the enhanced maximal oxidative capacity achieved during cold acclimation.

Molecular mechanisms underlying the plasticity of muscle contractile properties with temperature acclimation in the marine fish Myoxocephalus scorpius

Single fibres were isolated from the fast myotomal muscle of the short-horned sculpin (Myoxocephalus scorpius L.). Fish were acclimated to either 5 &deg;C (10 h:14 h light:dark) or 15 &deg;C (12 h:12 h light:dark) for 1&shy;2 months. Isometric tension (Fmax) and unloaded contraction velocity (Vslack) were determined in maximally activated skinned fibres over the range 0 to 20 &deg;C. Fibres isolated from 5 &deg;C-acclimated and 15 &deg;C-acclimated fish failed to relax completely following activations at 15 &deg;C and 20 &deg;C respectively. In 5 &deg;C-acclimated fish, Fmax increased from 75 kN m-2 at 0 &deg;C to 123 kN m-2 at 10 &deg;C and was not significantly higher at 15 or 20 &deg;C. The relationship between Fmax and temperature was not significantly different for cold- and warm-acclimated fish. Vslack was around 2.8 fibre lengths s-1 in both acclimation groups at 0 &deg;C, but it increased at a significantly faster rate with temperature in 15 &deg;C- than in 5 &deg;C-acclimated fish. At 20 &deg;C, Vmax was significantly higher in 15 &deg;C-acclimated (8.7 fibre lengths s-1) than in 5 &deg;C-acclimated fish (5.3 fibre lengths s-1). In order to investigate the molecular mechanism(s) underlying changes in Vmax, myosin was purified by ion-exchange chromatography. No difference in myosin heavy chain composition could be detected on the basis of peptide mapping with four different proteolytic enzymes. Two-dimensional polyacrylamide gel electrophoresis revealed no myofibrillar protein isoforms unique to either acclimation temperature. However, the ratio of myosin alkali light chain contents (LC3f:LC1f), as determined by capillary electrophoresis, was significantly lower in muscle from 15 &deg;C-acclimated (0.73) than from 5 &deg;C-acclimated fish (1.66). The results suggest that changes in Vmax are achieved via altered expression of myosin light chains independently of myosin heavy chain composition. In support of this hypothesis, the myofibrillar ATPase activity of fast muscle was not altered by temperature acclimation.

Occupational exposure to metal or wood dust and aetiology of cryptogenic fibrosing alveolitis

BACKGROUND

We have previously suggested that cryptogenic fibrosing alveolitis (CFA) may be caused by occupational exposures, particularly to metal or wood dust. We have specifically investigated this hypothesis in a case-control study of patients with CFA.

METHODS

We obtained lifetime occupational histories by postal questionnaire from 218 patients with CFA and 569 controls matched for age, sex, and community, living in the Trent region of the UK. Information was subsequently verified by telephone interview in 165 cases and 408 controls. Serum IgE, rheumatoid factor, and antinuclear antibodies and skin sensitivity to common allergens were measured in cases and in one matched control for each.

FINDINGS

The relative risk of CFA, after adjustment for smoking, was significantly increased in relation to questionnaire-reported exposure to metal dust (odds ratio 1.68 [95% CI 1.07-2.65], p = 0.024) or to wood dust (1.71 [1.01-2.92], p = 0.048). Similar results were obtained with the telephone interview data. Significant exposure-response effects were found for both metal-dust and wood-dust exposure. CFA was also associated with the presence of rheumatoid factor or antinuclear antibodies, but not with positive allergen skin tests or raised IgE concentrations. There was no evidence of interaction between the effects of rheumatoid factor, antinuclear antibodies, positive skin allergen tests, or IgE concentrations and exposure to metal or wood dust. The combined aetiological fraction attributable to exposure to metal or wood dust was of the order of 20%.

INTERPRETATION

Occupational exposures to metal or wood dust are independent risk factors for CFA. Avoidance or limitation of these exposures may provide an opportunity to prevent the disease.

Life-span development of odor identification, learning, and olfactory sensitivity

In the first of three studies, children (aged 8 to 14 years) were found to perform worse than young and middle-aged adults in unprompted identification of doors, with average performance much like that of elderly adults. Comparisons on other tasks, specifically odor threshold, prompted odor identification, and object naming (Boston Naming Test), across the life span (five groups) revealed that children have the same excellent olfactory sensitivity as young adults and merely lack odor-specific knowledge that accumulates slowly through life. Such knowledge apparently accumulates so slowly that age-associated discriminative losses, measurable by early middle age, begin to wear away gains obtained through experience before odors can become overlearned. In the second study, a novel adaptive psychophysical method, the step procedure, confirmed the equivalent sensitivity of children and young adults. In the third study, a paired-associate task illustrated the sluggish course of odor learning. Young adults outperformed children, though the youngest group, first graders, made up ground relatively fast. For children and adults, common odors facilitated performance relative to novel odors. The outcome highlighted the relevance of semantic factors in odor learning irrespective of age.

Functionally significant allelic variation in myosin light chain composition in a tropical cichlid

Single fast muscle fibres in the tropical fish Oreochromis andersonii were found to contain two myosin light chains (LC1s; LC1f1* or LC1f2*). Breeding experiments confirmed that the different LC1s were of allelic origin and their inheritance patterns conformed to Mendelian expectations (1:2:1). The LC1s differed in apparent relative molecular mass by 800&shy;900. No other differences in myosin subunits were found between the LC1 genotypes. The molar ratios of LC3:LC1(total) in the fast muscle of O. andersonii homozygous for LC1f1* or LC1f2* and heterozygous for both alleles were 2.0:1, 2.1:1 and 2.2:1, respectively, as determined by capillary electrophoresis. The maximum contraction velocity (Vmax) of single skinned muscle fibres was determined at 20 &deg;C by the slack-test method. Vmax values (fibre lengths s-1) for fast muscle fibres from O. andersonii which were homozygous for either LC1f2* or LC1f1* were 5.3 and 3.3, respectively, compared with 3.8 when both alleles were present. Crosses between Oreochromis niloticus and O. andersonii produced F1 hybrids which were heterozygous for either LC1n/LC1f1* or LC1n/LC1f2*, where LC1n is the myosin light chain for O. niloticus. The distribution of myosin light chain genotypes in hybrid offspring was not significantly different from the expected Mendelian 1:1 ratio (47 %: 53 %). The Vmax (fibre lengths s-1) of muscle fibres containing LC1f2* from hybrid Oreochromis was 4.3 compared with 3.1 for the LC1f1* genotype. The results are consistent with a functionally significant allelic variation in myosin LC1 in fast muscle fibres from O. andersonii which is also expressed in hybrid genotypes.

How fish power predation fast-starts

Short-horned sculpin (Myoxocephalus scorpius L.) were acclimated for 6&shy;8 weeks to either 5 &deg;C or 15 &deg;C (12 h dark: 12 h light). Fast-starts elicited by prey capture were filmed from above in silhouette using a high-speed video camera (200 frames s-1). Outlines of the body in successive frames were digitised and changes in strain for the dorsal fast muscle calculated from a knowledge of backbone curvature and the geometrical arrangement of fibres. For 15 &deg;C-acclimated fish at 15 &deg;C, muscle strain amplitude (peak-to-peak) during the first tail-beat was approximately 0.16 at 0.32L, 0.19 at 0.52L and 0.15 at 0.77L, where L is the total length of the fish. Fast muscle fibres were isolated and subjected to the strains calculated for the first tail-beat of the fast-start (abstracted cycle). Preparations were electrically stimulated at various times after the initiation of the fast-start using an in vivo value of duty cycle (27 %). Prior to shortening, muscle fibres at 0.52L and 0.77L were subjected to a pre-stretch of 0.055l0 and 0.085l0 respectively (where l0 is resting muscle length). The net work per cycle was calculated from plots of fibre length and tensile stress. For realistic values of stimulus onset, the average power output per abstracted cycle was similar at different points along the body and was in the range 24&shy;31 W kg-1 wet muscle mass. During shortening, the instantaneous power output reached 175&shy;265 W kg-1 wet muscle mass in middle and caudal myotomes. At the most posterior position examined, the muscle fibres produced significant tensile stresses whilst being stretched, resulting in an initially negative power output. The fibres half-way down the trunk produced their maximum power at around the same time that caudal muscle fibres generated significant tensile stress. Fast muscle fibres at 0.37&shy;0.66L produced 76 % of the total work done during the first tail-beat compared with only 14 % for fibres at 0.67&shy;0.86L, largely reflecting differences in muscle mass. The effect of temperature acclimation on muscle power was determined using the strain fluctuations calculated for 0.52L. For 5 &deg;C-acclimated fish, the average power per cycle (&plusmn; s.e.m.; W kg-1 wet muscle mass) was 21.8&plusmn;3.4 at 5 &deg;C, falling to 6.3&plusmn;1.8 at 15 &deg;C. Following acclimation to 15 &deg;C, average power per cycle increased to 23.8&plusmn;2.8 W kg-1 wet muscle mass at 15 &deg;C. The results indicate near-perfect compensation of muscle performance with temperature acclimation.