Mortality amongst hospitalized COVID-19 cases by acquisition and pandemic wave in Wales, UK, February 2020-March 2022

BACKGROUND

Hospital populations are vulnerable to COVID-19, but the relative severity of hospital acquisition compared to community is unknown. We investigated differences in mortality between hospital and community acquired cases in Wales.

METHODS

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction tests from February 2020 to March 2022 were linked with hospital admissions to identify likely hospital-acquired cases. All-cause mortality within 28 days of a positive SARS-CoV-2 were measured by source of acquisition. Multi-variable logistic regression was used to compare mortality by source of acquisition, adjusting for confounders, computing adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

There were 25,263 hospital-acquired cases of COVID-19 and 5490 (22%) deaths in the study period. Although significant on univariate analysis, adjustment for confounding showed no association with increased mortality for hospital-acquired cases compared with cases admitted with COVID-19 (aOR 0.8, 95% CI 0.7-0.8). Vaccination (aOR 0.6, 95% CI 0.5-0.7) and infection in later pandemic waves (aOR 0.5, 95% CI 0.4-0.6) were associated with lower mortality; older age (≥85 vs <25 years: aOR 76.4, 95% CI 41.8-160.5) and male sex (aOR 1.5, 95% CI 1.4-1.6) were associated with higher mortality.

CONCLUSION

One in five hospitalised COVID-19 cases died within a month of infection. Mortality in nosocomial cases was not worse than those admitted with COVID-19, possibly reflecting early identification of nosocomial cases through screening.

Tunneled island pedicle flap reconstruction for upper lateral cutaneous lip defects

BACKGROUND

Esthetic upper lateral cutaneous lip reconstruction preserves the apical triangle, nasolabial fold symmetry, and free margin position. The tunneled island pedicle flap (IPF) is a novel single-stage reconstruction to achieve these goals.

OBJECTIVES

Describe the technique and patient and surgeon-reported outcomes for the tunneled IPF reconstruction of upper lateral cutaneous lip defects.

METHODS

Retrospective chart review of consecutive tunneled IPF reconstruction following Mohs micrographic surgery (MMS) at a tertiary care center between 2014 and 2020. Patients rated their scars using the validated Patient Scar Assessment Scale (PSAS), and independent surgeons rated scars using the validated Observer Scar Assessment Scale (OSAS). Descriptive statistics were generated for patient demographics and tumor defect characteristics.

RESULTS

Twenty upper lateral cutaneous lip defects were repaired with the tunneled IPF. Surgeons rated scars with a composite OSAS score of 11.83 ± 4.29 (mean, SD) [scale of 5 (normal skin) to 50 (worst scar imaginable)] and an overall scar score of 2.81 ± 1.11 [scale of 1 (normal skin) to 10 (worst scar imaginable)]. Patients rated their scars with a composite PSAS score of 10 ± 5.39 [scale of 6 (best possible score) to 60 (worst)] and with an overall score of 2.2 ± 1.78 [scale of 1 (normal skin) and 10 (very different from normal skin)]. One flap was surgically revised for pincushioning, but none experienced necrosis, hematoma, or infection.

CONCLUSIONS

The tunneled IPF is a single-stage reconstruction for upper lateral cutaneous lip defects with favorable scar ratings by patients and observers.

Diabetes is associated with atrial fibrillation phenotype, cardiac and neurological comorbidities: insights from the Swiss-AF study

Background

Diabetes mellitus is a major risk factor for atrial fibrillation (AF). However, it remains unclear whether individual AF phenotype and related comorbidities differ between AF patients with and without diabetes.

Purpose

To investigate the association of diabetes with AF phenotype, cardiac and neurological comorbidities in patients with documented AF.

Methods

Participants of the multicenter Swiss-AF study with available data on diabetes and AF phenotype were eligible. The primary outcomes were parameters of AF phenotype, including AF type (paroxysmal vs non-paroxysmal), AF symptoms (yes vs no), and quality of life (assessed by EQ-5D score). The secondary outcomes were cardiac (ie, history of hypertension, myocardial infarction, heart failure) and neurological comorbidities (ie, history of stroke, cognitive impairment). The cross-sectional association of diabetes with these outcomes was assessed using logistic and linear regression. Results were adjusted for age, sex, and cardiovascular risk factors.

Results

We included 2411 AF patients (27.4% women; median age, 73.6 years). Diabetes was not associated with non-paroxysmal AF (odds ratio [OR]=1.01; 95% confidence interval [CI]=0.81 to 1.27). Patients with diabetes less often perceived AF symptoms (OR=0.73; CI=0.59 to 0.91), but had worse quality of life (predicted mean difference in EQ-5D score: β=−4.54; CI=−6.40 to −2.68) than those without diabetes. Patients with diabetes were more likely to have cardiac comorbidities [history of hypertension (OR=3.04; CI=2.19 to 4.22), myocardial infarction (OR=1.55; CI=1.18 to 2.03), heart failure (OR=1.99; CI=1.57 to 2.51)] and neurological comorbidities [history of stroke (OR=1.39; CI=1.03 to 1.87), cognitive impairment (OR=1.75; CI=1.39 to 2.21)].

Conclusions

In the Swiss-AF cohort population, patients with diabetes less often perceived AF symptoms, but had worse quality of life, more cardiac and neurological comorbidities than those without diabetes. These findings have significant clinical implications. The reduced perception of AF symptoms in patients with diabetes might result in a delayed AF diagnosis and consequently more adverse events, especially cardioembolic stroke. This raises the question whether patients with diabetes should be systematically screened for silent AF. Moreover, patients with concomitant AF and diabetes have increased likelihood of comorbidities and therefore deserve more attentive care.

Funding Acknowledgement

Type of funding sources: None.

Impaired heart rate variability triangular index to identify clinically silent strokes in patients with atrial fibrillation

Introduction

The identification of clinically silent strokes in patients with atrial fibrillation (AF) is of high clinical relevance as they have been linked to cognitive impairment. Overt strokes have been associated with disturbances of the autonomic nervous system.

Purpose

We therefore hypothesize that impaired heart rate variability (HRV) can identify AF patients with clinically silent strokes.

Methods

We enrolled 1358 patients with AF without a history of stroke or transient ischemic attack from the multicenter SWISS-AF cohort study who were in sinus rhythm (SR-group, n=816) or AF (AF-group, n=542) on a 5 minute resting ECG recording. HRV triangular index (HRVI), the standard deviation of normal-to-normal intervals (SDNN) and the mean heart rate (MHR) were calculated. Brain MRI was performed at baseline to assess the presence of large non-cortical or cortical infarcts, which were considered silent strokes without history of stroke or transient ischemic attack. We constructed binary logistic regression models to analyze the association between HRV parameters and silent strokes.

Results

At baseline, silent strokes were detected in 10.5% in the SR group and 19.9% in the AF group. In the SR-group, HRVI &lt;15 was the only parameter independently associated with the presence of silent strokes (odds ratio (OR) 1.69; 95% confidence interval (CI): 1.04–2.72; p=0.033) after adjustment for various clinical covariates (age, sex, systolic blood pressure, history of hypertension, history of diabetes, history of heart failure, prior myocardial infarction, prior major bleeding, intake of oral anticoagulation, antiarrhythmics or betablockers). Similarly, in the AF-group, HRVI&lt;15 was independently associated with the presence of silent strokes (OR 1.65, 95% CI: 1.05–2.57; p=0.028). SDNN&lt;70ms and MHR&lt;80 were not associated with silent strokes, neither in the SR group, nor in the AF group (Figure).

Conclusions

Reduced HRVI is independently associated with the presence of clinically silent strokes in an AF population, both when assessed during SR and during AF. Our data suggest that a short-term measurement of HRV in routine ECG recordings might contribute to identifying AF patients with clinically silent strokes.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation

Outcomes, Prognostic Factors and Salvage Treatment for Recurrent Chordoma After Pencil Beam Scanning Proton Therapy at the Paul Scherrer Institute

AIMS

The outcome of chordoma patients with local or distant failure after proton therapy is not well established. We assessed the disease-specific (DSS) and overall survival of patients recurring after proton therapy and evaluated the prognostic factors affecting DSS.

MATERIALS AND METHODS

A retrospective analysis was carried out of 71 recurring skull base (n = 36) and extracranial (n = 35) chordoma patients who received adjuvant proton therapy at initial presentation (n = 42; 59%) or after post-surgical recurrence (n = 29; 41%). The median proton therapy dose delivered was 74 GyRBE (range 62-76). The mean age was 55 ± 14.2 years and the male/female ratio was about one.

RESULTS

The median time to first failure after proton therapy was 30.8 months (range 3-152). Most patients (n = 59; 83%) presented with locoregional failure only. There were only 12 (17%) distant failures, either with (n = 5) or without (n = 7) synchronous local failure. Eight patients (11%) received no salvage therapy for their treatment failure after proton therapy. Salvage treatments after proton therapy failure included surgery, systemic therapy and additional radiotherapy in 45 (63%), 20 (28%) and eight (11%) patients, respectively. Fifty-three patients (75%) died, most often from disease progression (47 of 53 patients; 89%). The median DSS and overall survival after failure was 3.9 (95% confidence interval 3.1-5.1) and 3.4 (95% confidence interval 2.5-4.4) years, respectively. On multivariate analysis, extracranial location and late failure (≥31 months after proton therapy) were independent favourable prognostic factors for DSS.

CONCLUSION

The survival of chordoma patients after a treatment failure following proton therapy is poor, particularly for patients who relapse early or recur in the skull base. Although salvage treatment is administered to most patients with uncontrolled disease, they will ultimately die as a result of disease progression in most cases.

Learning Effects While Passively Viewing the Necker Cube

Over a 2-wk. period 15 high school students passively viewed a Necker cube for 5 trials (90 sec. per trial). The number of reversals per trial indicates there were practice effects. Measures of tolerance of ambiguity (Tolerance of Ambiguity), anxiety (General Anxiety Scale and Test Anxiety Scale), and rigidity (Breskin's Rigidity) were administered. Pearson correlations indicate that tolerance of ambiguity was not associated with viewing an ambiguous figure, the Necker cube. Analysis also suggests the more rigid the person's outlook, the fewer reversals were reported, and exposure to viewing the figure lowers anxiety.

The STRokE DOC Trial Technique: ‘Video Clip, Drip, and/or Ship’

Rationale

To describe the clinical trial methods of a site-independent telemedicine system used in stroke.

Aims

A lack of readily available stroke expertise may partly explain the low rate of rt-PA use in acute stroke. Although telemedicine systems can reliably augment expertise available to rural settings, and may increase rt-PA use, point-to-point systems do require fixed base stations. Site-independent systems may minimize delay. The STRokE DOC trial assesses whether site-independent telemedicine effectively and efficiently brings rt-PA to a remote population.

Design

STRokE DOC is a 5–year, 400–participant, noninvasive trial, comparing two consultative techniques at four remote sites. Participants are randomized to acute ‘STRokE DOC telemedicine’ or ‘telephone’ consultations. Treatment decision accuracy is adjudicated at two time points, using three levels of data availability and an independent auditor.

Study outcomes

The primary outcome measure is whether there was a ‘correct decision to treat or not to treat using rt-PA’ at each of three adjudication levels (primarily at Level #2). Secondary outcomes include the number of thrombolytic recommendations, intracerebral hemorrhage, and 90–day outcomes. Using the STRokE DOC system (or telephone evaluation), medical history, neurologic scales, CT interpretations, and recommendations have been completed on over 200 participants to date. Of the initial 11, nonrandomized, ‘run-in’ patients, six (65%) were evaluated wirelessly, and five (45%) were evaluated with a site-independent LAN or cable modem. Three (27%) received rt-PA. The adjudication methodology was able to show both agreements and disagreements in these 11 cases. It is feasible to perform site-independent stroke consultations, and adjudicate those cases, using the STRokE DOC system and trial design. Telemedicine efficacy remains to be proven.

[Of Caipirinhas and two ham steaks - variations of the "White Hat Syndrome" of farewell]

Three case studies exemplify the role of smell and its associations with memories, paramount life episodes and critical decisions. Specific food and drinks resp. their fragrances may be of particular importance in multimorbid and terminally ill patients. A "white hat round" by a particularly trained hospital cook is proposed.

[Platelet inhibitors in clinical practice]

Despite improvements in the treatment of acute coronary syndromes, cardiovascular disease remains the leading cause of death in Europe and the United States. Antiplatelet agents, such as aspirin and clopidogrel, play an important role in the treatment of those patients. Several new alternatives have been tested in clinical trails and some of them have been approved for routine treatment of patients with ACS in Switzerland and the European Union. The latter include Prasugrel (Efient®) and Ticagrelor (Brilique®). Those substances provide more rapid and consistent platelet inhibition but increase the risk of bleeding in some patient subgroups. Thus, the main challenge is to tailor treatment for each patient by taking into consideration patient characteristics, comorbidities, underlying short- and long-term risk factors, ischemic and bleeding risks, and expected individual responses to different medications. This ambitious new approach will be a challenge for in daily clinical work and may ultimately require prioritization among several treatment alternatives. In this article, we review the new antiplatelet agents being developed as well as their pharmacological characteristics, key interactions and side effects and potential clinical indications in subpopulations.

First- and second-line anti-tuberculosis drug resistance in Northwest Ethiopia

SETTING

Gondar Hospital, Gondar Health Centre, Metemma Hospital, Bahir Dar Hospital and Debre Markos Hospital in Northwest Ethiopia.

OBJECTIVE

To assess the level of and risk factors for first- and second-line drug resistance among tuberculosis (TB) patients.

DESIGN

Drug susceptibility testing (DST) against first-line drugs, including isoniazid (INH), rifampicin (RMP), streptomycin (SM), ethambutol (EMB) and pyrazinamide (PZA), was performed using the BacT/ALERT 3D system. DST against second-line drugs, including fluoroquinolones and aminoglycocides/cyclic peptides, was performed using GenoType MTBDRsl.

RESULTS

Of 260 Mycobacterium tuberculosis isolates, 41 (15.8%) were resistant to at least one first-line drug, 13 (5.0%) were multidrug-resistant (MDR) and 9 (3.5%) were resistant to all first-line drugs. Any resistance to INH, RMP, SM, EMB and PZA was respectively 36 (13.8%), 15 (5.8%), 26 (10.0%), 19 (7.3%) and 12 (4.6%). Of 214 new and 46 previously treated cases, respectively 8 (3.7%) and 5 (10.9%) were MDR. All isolates were susceptible to all second-line drugs.

CONCLUSION

A substantial number of new and previously treated cases harbour MDR-TB. We recommend DST at least for previously treated cases, patients who remain smear-positive at the end of the second month of treatment and patients in close contact with MDR-TB cases. Improved infection control measures need to be implemented in Ethiopia.

On the origin of129I in rain water near Zürich

129I concentrations in precipitation at Dübendorf/Zürich, Switzerland, have been determined with monthly resolution for almost three years in the mid 1990s. The results confirm that annual mean129I concentrations in precipitation in central Europe have remained about constant since the late 1980s. Liquid and gaseous emissions from the nuclear fuel reprocessing plants at Sellafield and La Hague are discussed as the only possible sources of129I in precipitation in central Europe. Based on an upper limit estimate for iodine transferred from the sea to the atmosphere, the gaseous discharges constitute the potentially bigger129I reservoir for precipitation. Moreover, the time dependence of the annual gaseous129I releases from Sellafield and La Hague correlates much better with the129I concentrations in precipitation in central Europe since the late 1980s than does the time dependence of the liquid emissions from these sites. At monthly resolution, the129I concentrations in the precipitation samples close to Zürich exhibit a large variability. A meteorological transport analysis was carried out for four selected months with particularly low or high observed129I concentrations. It was found that meteorological transport alone, based upon assimilated wind fields and observed precipitation values, can not directly account for the large month-to-month variability.

Prospective reliability of the STRokE DOC wireless/site independent telemedicine system

The authors evaluated a site-independent telemedicine system. Telemedicine may be limited by the need for fixed connectivity. Wireless and site-independent technologies eliminate this limitation. Twenty-five stroke patients underwent evaluations by remote and bedside examiners. Ten of 15 (67%) NIH Stroke Scale and 9 of 11 (82%) Modified NIH Stroke Scale items showed excellent interrater reliability. Spearman correlations were > or =0.93. This Internet system is reliable and valid. Further studies should assess its use in acute stroke.

Unusual activity of the Sun during recent decades compared to the previous 11,000 years

Direct observations of sunspot numbers are available for the past four centuries, but longer time series are required, for example, for the identification of a possible solar influence on climate and for testing models of the solar dynamo. Here we report a reconstruction of the sunspot number covering the past 11,400 years, based on dendrochronologically dated radiocarbon concentrations. We combine physics-based models for each of the processes connecting the radiocarbon concentration with sunspot number. According to our reconstruction, the level of solar activity during the past 70 years is exceptional, and the previous period of equally high activity occurred more than 8,000 years ago. We find that during the past 11,400 years the Sun spent only of the order of 10% of the time at a similarly high level of magnetic activity and almost all of the earlier high-activity periods were shorter than the present episode. Although the rarity of the current episode of high average sunspot numbers may indicate that the Sun has contributed to the unusual climate change during the twentieth century, we point out that solar variability is unlikely to have been the dominant cause of the strong warming during the past three decades.

Persistent solar influence on North Atlantic climate during the Holocene

Surface winds and surface ocean hydrography in the subpolar North Atlantic appear to have been influenced by variations in solar output through the entire Holocene. The evidence comes from a close correlation between inferred changes in production rates of the cosmogenic nuclides carbon-14 and beryllium-10 and centennial to millennial time scale changes in proxies of drift ice measured in deep-sea sediment cores. A solar forcing mechanism therefore may underlie at least the Holocene segment of the North Atlantic's "1500-year" cycle. The surface hydrographic changes may have affected production of North Atlantic Deep Water, potentially providing an additional mechanism for amplifying the solar signals and transmitting them globally.

The relationship between interview characteristics and accuracy of recall in young children: do individual differences matter?

The relationship between interview characteristics and accuracy of recall in young children, as mediated by child characteristics, was examined. The interview characteristics included preinterview instructions and level of questioning. Fifty-six children ranging from ages 3 to 6 years participated in a Circus Day event and were interviewed 10 days later. Following either instructions or filler questions, children were questioned about the event. Results indicated that based on several individual difference factors, young children varied significantly in the accuracy of their interviews and their ability to resist misleading questions. However, individual differences did not mediate children's ability to benefit from different question types or preinterview instructions. As a whole, children provided limited information to the most open-ended questions and more correct information to highly structured questions. In contrast to the research with older children, younger children did not benefit from preinterview instructions. Suggestions for future research and implications for investigative interviews in the field of child abuse are discussed.

Changes in deep-water formation during the Younger Dryas event inferred from 10Be and 14C records

Variations in atmospheric radiocarbon (14C) concentrations can be attributed either to changes in the carbon cycle--through the rate of radiocarbon removal from the atmosphere--or to variations in the production rate of 14C due to changes in solar activity or the Earth's magnetic field. The production rates of 10Be and 14C vary in the same way, but whereas atmospheric radiocarbon concentrations are additionally affected by the carbon cycle, 10Be concentrations reflect production rates more directly. A record of the 10Be production-rate variations can therefore be used to separate the two influences--production rates and the carbon cycle--on radiocarbon concentrations. Here we present such an analysis of the large fluctuations in atmospheric 14C concentrations, of unclear origin, that occurred during the Younger Dryas cold period. We use the 10Be record from the GISP2 ice core to model past production rates of radionuclides, and find that the largest part of the fluctuations in atmospheric radiocarbon concentrations can be attributed to variations in production rate. The residual difference between measured 14C concentrations and those modelled using the 10Be record can be explained with an additional change in the carbon cycle, most probably in the amount of deep-water formation.

Comparison of Mycobacterium tuberculosis susceptibility testing performed with BACTEC 460TB (Becton Dickinson) and MB/BacT (Organon Teknika) systems

The recently introduced automated culture systems MB/BacT (Organon Teknika, Belgium) was compared with radiometric BACTEC 460TB (Becton Dickinson, USA) to test antimicrobial susceptibility of Mycobacterium tuberculosis to first line drugs. On 113 strains 97.5% agreement was obtained, with the difference being not significant. Concordance was practically complete for the most important drugs, isoniazid and rifampin. The two methods however significantly differed for the time needed to complete the test; in fact MB/BacT required on the average five days more than BACTEC 460TB. Despite the delay in the completion of the test, the excellent reliability along with the elimination of radioactivity and full automation make MB/BacT an attractive alternative for susceptibility testing of M. tuberculosis.

Functional imaging of brain areas involved in the processing of coherent and incoherent wide field-of-view visual motion

The brain areas involved in processing wide field-of-view (FOV) coherent and incoherent visual stimuli were studied using positron emission tomography (PET). The brains of nine subjects were scanned as they viewed texture patterns moving in the roll plane. Five visual conditions were used: (1) coherent clockwise (CW) wide-FOV (>100 degrees) roll motion; (2) coherent counter-clockwise (CCW) wide-FOV roll motion; (3) wide-FOV incoherent motion; (4) CCW motion confined to the central visual field (approximately 55 degrees); and (5) a stationary control texture. The region most activated by the coherent-motion stimulus relative to the static one was the medial-occipital cortex, whereas both the medial- and lateral-occipital cortices were activated by incoherent motion relative to a static texture. Portions of the retroinsular parietal-temporal cortex, superior insula, putamen, and vestibulocerebellum responded specifically to the coherence of the stimulus, whereas a widespread lateralized activation was observed upon subtracting the CW scans from the CCW scans. The results indicate separate neural regions for processing wide-FOV motion versus stimulus coherence.

Child characteristics which impact accuracy of recall and suggestibility in preschoolers: is age the best predictor?

OBJECTIVE

The purpose of the present study was to determine whether individual difference factors of metamemory, intelligence, and temperament can improve the ability to predict accuracy of recall and suggestibility in preschoolers.

METHOD

Fifty-six children ranging in age from 43 months to 83 months (M = 61, SD = 9) were recruited from 13 child care centers in a rural southeastern town. Children participated in a "Circus Day" event conducted by two female undergraduate psychology students dressed as clowns. Approximately 10 days (M = 10; SD = 2) after the event, children were interviewed regarding their experiences.

RESULTS AND CONCLUSIONS

Bivariate correlations and multiple regression analyses were performed in order to determine which factors were related and unique contributors to accuracy of recall and suggestibility. Of principal importance is the finding that child characteristics such as metamemory ability, intellectual functioning, and temperament may indeed be helpful in determining a child's capacity to accurately recall information in an interview, although for the most part age is the best predictor. Findings also underscore the importance of considering a child's SES and race when planning and conducting interviews with young children. Possible explanations for these findings as well as implications for future research and clinical application are discussed.

Is "ambient vision" distributed in the brain? Effects of wide-field-view visual yaw motion on PET activation

Ambient vision comprises the visual functions that are associated with the maintenance of spatial orientation and that depend on peripheral, preconscious visual inputs. Although a limited number of brain areas appear to be activated by coherent wide-field-of-view (WFOV) motion in more than one axis, a diffuse pattern of lateralized brain activity occurs in response to clockwise or counterclockwise ambient visual roll motion. In the present study involving positron emission tomography (PET), a similar finding was shown for rightward versus leftward yaw stimulation. A total of 18 PET scans were obtained from six subjects in response to either leftward or rightward WFOV motion in a collimated display subtending > 100 degrees horizontally. Rightward stimulation elicited mainly activation throughout the right hemisphere, whereas leftward stimulation elicited mainly activation throughout the left hemisphere. These findings provide further evidence that the ambient vision signal is either processed or transmitted throughout the entire brain, as befits a visual function that is fundamental to all other perceptual systems.

Expression of c-jun, junB, c-fos, fra-1 and fra-2 mRNA in the rat brain following seizure activity and axotomy

The present study has investigated the congruence of mRNA induction and protein expression of inducible transcription factors (ITFs). The patterns of c-jun, junB, c-fos, fra-1 and fra-2 mRNAs were studied by radioactive and non-radioactive in situ hybridization in the adult rat brain following kainate-induced seizure activity and axotomy. In the same animals, the expression of c-Jun, JunB and c-Fos proteins was compared with the respective mRNA signals. Using radioactive labeled probes all investigated mRNAs showed an onset within 1 h after systemic kainate application and the maximal levels were generally reached after 3 h. Each mRNA displayed a specific temporo-spatial expression pattern. Whereas fra-1 and fra-2 were restricted to the hippocampus, c-jun, junB and c-fos were additionally induced in the cortex, amygdala and thalamus. The areas with maximal labeling were the dentate gyrus and the hippocampal CA1 and CA3 subfields. The expression patterns between c-jun, junB and c-fos mRNA were virtually congruent with the respective protein. Labeling of the junB and fra-2 probes with digoxigenin yielded similar results. Twenty-four hours, 3 and 10 days following transection of the medial forebrain bundle and the mamillo-thalamic tract, high levels of c-jun mRNA (either digoxigenin or radioactive labeled probes) and protein were seen in the axotomized neurons of the substantia nigra pars compacta and mamillary body whereas the other mRNAs studied and the JunB or c-Fos proteins could not be detected. These findings demonstrate that mRNAs encoding for ITFs are translated into the respective proteins following excitotoxic seizures and axotomy, and that the antisera used for immunocytochemistry yield specific expression patterns of homologous proteins.

Geomagnetic modulation of the 36Cl flux in the GRIP ice core, greenland

Geomagnetic field strength is expected to affect the production rate of cosmogenic isotopes such as beryllium-10, carbon-14, or chlorine-36. Chlorine-36 data from the Greenland Ice Core Project (GRIP) ice core agree well with a production rate calculation based on a paleomagnetic reconstruction for the past 100,000 years over both long- and short-term variations. A chlorine-36 peak at 38,000 years ago previously found in the beryllium-10 record from the Vostok ice core can be explained by a period of low geomagnetic field intensity.

Reduced calcium dialysate in CAPD patients: efficacy and limitations

BACKGROUND

The increasing use of 'reduced calcium' dialysate in CAPD patients treated with calcium-based phosphate binders has raised concerns that this could lead to negative calcium balance, worsening hyperparathyroidism, and osteopenia.

METHODS

The present study was conducted to examine the possibilities (a) that 1.25 mM calcium dialysate leads to negative calcium balance and worsening hyperparathyroidism, and (b) that conversely 1.25 mM calcium dialysate is still too high for some patients. We studied 22 patients who, after a 2-month run in using 1.75 mM calcium dialysate and aluminium hydroxide binders, entered a 3-month phase of 1.25 mM calcium dialysate with continuation of aluminium hydroxide as the sole phosphate binder. The patients then entered a final 9-month phase in which dialysate calcium remained at 1.25 mM and calcium carbonate was substituted for aluminium hydroxide and progressively titrated to achieve optimum phosphate control.

RESULTS

During the initial 3-month period, parathyroid hormone increased from 259, range 11-1149 to 405, range 16-1318 pg/ml (P = 0.0001) and ionized calcium decreased from 1.17 +/- 0.06 to 1.11 +/- 0.08 mM (P = 0.0004). The subsequent 9-month phase was associated with return of parathyroid hormone to baseline levels. Further dialysate calcium reduction to 0.6 mM was implemented in the four patients who became hypercalcaemic.

CONCLUSION

This study has clearly shown that reduction of dialysate calcium to 1.25 mM can be harmful to CAPD patients if oral calcium availability is inadequate. It has also shown that dialysate calcium at 1.25 mM is a compromise, with increased risk of hyperparathyroidism if calcium intake is too low and, conversely, risk of hypercalcaemia and unacceptable increases of the Ca x Pi product in a minority of patients. At these extremes there is a need for a high-calcium dialysate (1.75 mM) and a very low-calcium dialysate (0.6 mM or less), to optimize management.