Consensus, controversy, and chaos in the attribution of characteristics to the morally exceptional

OBJECTIVE

What do people see as distinguishing the morally exceptional from others? To handle the problem that people may disagree about who qualifies as morally exceptional, we asked subjects to select and rate their own examples of morally exceptional, morally average, and immoral people.

METHOD

Subjects rated each selected exemplar on several enablers of moral action and several directions of moral action. By applying the logic underlying stimulus sampling in experimental design, we evaluated perceivers' level of agreement about the characteristics of the morally exceptional, even though perceivers rated different targets.

RESULTS

Across three studies, there was strong subjective consensus on who is morally exceptional: those who are empathetic and prone to guilt, those who reflect on moral issues and identify with morality, those who have self-control and actually enact moral behaviors, and those who care about harm, compassion, fairness, and honesty. Deep controversies also existed about the moral directions pursued by those seen as morally exceptional: People evaluated those who pursued similar values and made similar decisions more favorably.

CONCLUSION

Strong consensus suggests characteristics that may push a person to go beyond normal expectations, that the study of moral exceptionality is not overly hindered by disagreement over who is morally exceptional, and that there is some common ground between disagreeing camps.

Gamification of Behavior Change: Mathematical Principle and Proof-of-Concept Study

BACKGROUND

Many people want to build good habits to become healthier, live longer, or become happier but struggle to change their behavior. Gamification can make behavior change easier by awarding points for the desired behavior and deducting points for its omission.

OBJECTIVE

In this study, we introduced a principled mathematical method for determining how many points should be awarded or deducted for the enactment or omission of the desired behavior, depending on when and how often the person has succeeded versus failed to enact it in the past. We called this approach optimized gamification of behavior change.

METHODS

As a proof of concept, we designed a chatbot that applies our optimized gamification method to help people build healthy water-drinking habits. We evaluated the effectiveness of this gamified intervention in a 40-day field experiment with 1 experimental group (n=43) that used the chatbot with optimized gamification and 2 active control groups for which the chatbot's optimized gamification feature was disabled. For the first control group (n=48), all other features were available, including verbal feedback. The second control group (n=51) received no feedback or reminders. We measured the strength of all participants' water-drinking habits before, during, and after the intervention using the Self-Report Habit Index and by asking participants on how many days of the previous week they enacted the desired habit. In addition, all participants provided daily reports on whether they enacted their water-drinking intention that day.

RESULTS

A Poisson regression analysis revealed that, during the intervention, users who received feedback based on optimized gamification enacted the desired behavior more often (mean 14.71, SD 6.57 times) than the active (mean 11.64, SD 6.38 times; P<.001; incidence rate ratio=0.80, 95% CI 0.71-0.91) or passive (mean 11.64, SD 5.43 times; P=.001; incidence rate ratio=0.78, 95% CI 0.69-0.89) control groups. The Self-Report Habit Index score significantly increased in all conditions (P<.001 in all cases) but did not differ between the experimental and control conditions (P>.11 in all cases). After the intervention, the experimental group performed the desired behavior as often as the 2 control groups (P≥.17 in all cases).

CONCLUSIONS

Our findings suggest that optimized gamification can be used to make digital behavior change interventions more effective.

TRIAL REGISTRATION

Open Science Framework (OSF) H7JN8; https://osf.io/h7jn8.

Optimal feedback improves behavioral focus during self-regulated computer-based work

Distractions are omnipresent and can derail our attention, which is a precious and very limited resource. To achieve their goals in the face of distractions, people need to regulate their attention, thoughts, and behavior; this is known as self-regulation. How can self-regulation be supported or strengthened in ways that are relevant for everyday work and learning activities? To address this question, we introduce and evaluate a desktop application that helps people stay focused on their work and train self-regulation at the same time. Our application lets the user set a goal for what they want to do during a defined period of focused work at their computer, then gives negative feedback when they get distracted, and positive feedback when they reorient their attention towards their goal. After this so-called focus session, the user receives overall feedback on how well they focused on their goal relative to previous sessions. While existing approaches to attention training often use artificial tasks, our approach transforms real-life challenges into opportunities for building strong attention control skills. Our results indicate that optimal attentional feedback can generate large increases in behavioral focus, task motivation, and self-control-benefitting users to successfully achieve their long-term goals.

Seroprevalence study of SARS-CoV-2 antibodies in healthcare workers following the first wave of the COVID-19 pandemic in a tertiary-level hospital in the south of Ireland

OBJECTIVE

This study investigated seroprevalence of SARS-CoV-2-specific IgG antibodies, using the Abbott antinucleocapsid IgG chemiluminescent microparticle immunoassay (CMIA) assay, in five prespecified healthcare worker (HCW) subgroups following the first wave of the COVID-19 pandemic.

SETTING

An 800-bed tertiary-level teaching hospital in the south of Ireland.

PARTICIPANTS

Serum was collected for anti-SARS-CoV-2 nucleocapsid IgG using the Abbott ARCHITECT SARS-CoV-2 IgG CMIA qualitative assay, as per the manufacturer's specifications.The groups were as follows: (1) HCWs who had real-time PCR (RT-PCR) confirmed COVID-19 infection (>1-month postpositive RT-PCR); (2) HCWs identified as close contacts of persons with COVID-19 infection and who subsequently developed symptoms (virus not detected by RT-PCR on oropharyngeal/nasopharyngeal swab); (3) HCWs identified as close contacts of COVID-19 cases and who remained asymptomatic (not screened by RT-PCR); (4) HCWs not included in the aforementioned groups working in areas determined as high-risk clinical areas; and (5) HCWs not included in the aforementioned groups working in areas determined as low-risk clinical areas.

RESULTS

Six of 404 (1.49%) HCWs not previously diagnosed with SARS-CoV-2 infection (groups 2-5) were seropositive for SARS-CoV-2 at the time of recruitment into the study.Out of the 99 participants in group 1, 72 had detectable IgG to SARS-CoV-2 on laboratory testing (73%). Antibody positivity correlated with shorter length of time between RT-PCR positivity and antibody testing.Quantification cycle value on RT-PCR was not found to be correlated with antibody positivity.

CONCLUSIONS

Seroprevalence of SARS-CoV-2 antibodies in HCWs who had not previously tested RT-PCR positive for COVID-19 was low compared with similar studies.

OPTN/SRTR 2019 Annual Data Report: Kidney

Despite the ongoing severe shortage of available kidney grafts relative to candidates in need, data from 2019 reveal some promising trends. After remaining relatively stagnant for many years, the number of kidney transplants has increased each year since 2015, reaching the highest annual count to date of 24,273 in 2019. The number of patients waiting for a kidney transplant in the United States was relatively stable, despite an increase in the number of new candidates added in 2019 and a decrease in patients removed from the waiting list owing to death or deteriorating medical condition. However, these encouraging trends are tempered by ongoing challenges. Nationwide, only a quarter of waitlisted patients receive a deceased-donor kidney transplant within 5 years, and this proportion varies dramatically by donation service area, from 15.5% to 67.8%. The non-utilization (discard) rate of recovered organs remains at 20.1%, despite adramatic decline in the discard of organs from hepatitis C-positive donors. Non-utilization rates remain particularly high for Kidney Donor Profile Index ≥85% kidneys and kidneys from which a biopsy specimen was obtained. While the number of living-donor transplants increased again in 2019, only a small proportion of the waiting list receives living-donor transplants each year, and racial disparities in living-donor transplant access persist. As both graft and patient survival continue to improve incrementally, the total number of living kidney transplant recipients with a functioning graft is anticipated to exceed 250,000 in the next 1-2 years. Over the past decade, the total number of pediatric kidney transplants performed has remained stable. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients with continued racial disparities among recipients. Congenital anomalies of the kidney and urinary tract remain the leading cause of kidney disease. While most deceased donor recipients receive a kidney from a donor with KDPI less than 35%, the majority of pediatric recipients had four or more HLA mismatches. Graft survival continues to improve with superior outcomes for living donor recipients.

The Presentation and Diagnosis of the First Known Community-Transmitted Case of SARS-CoV-2 in the Republic of Ireland

Introduction This case series describes the diagnosis of the first case of community transmission of SARS-CoV-2 in the Republic of Ireland. Cases Case 1: A 25 year old male presented with dyspnoea, cough and high fevers for 4 days. He was commenced on broad-spectrum antimicrobials and oxygen therapy. His respiratory function deteriorated in spite of these measures and he required mechanical ventilation. CT showed left upper lobe consolidation as well as multifocal ground-glass opacification. Case 2: A 43 year-old male presented with headache and was found incidentally to have pneumonia. He was recently diagnosed with pituitary apoplexy secondary to an adenoma with resultant pituitary insufficiency but MRI brain was stable. His respiratory function deteriorated in spite of antibiotics and he required mechanical ventilation. CT showed likely atypical infection with resultant ARDS. Outcome Both underwent nasopharyngeal RT-PCR testing for SARS-CoV-2. Patient 2 was positive. Patient 1 was extubated and made a good recovery. Patient 2 was transferred to another centre for ECMO therapy. He died 27 days after transfer. Conclusion Given the atypical presentations in generally otherwise young and healthy individuals, the decision was made outside of national guidance to perform testing for SARS-CoV-2. This diagnosis had far-reaching implications for the SARS-CoV-2 pandemic within Ireland.

Self-determination theory as a foundation for personality researchers

In this introductory article, we first describe the impetus for this special issue. What made us think that self-determination theory (SDT) might provide a sort of foundation for the rest of personality psychology? For readers unfamiliar with SDT, we then provide a historical overview that covers the evolution of the six "mini-theories" that currently compose SDT: cognitive evaluation theory, causality orientations theory, organismic integration theory, basic psychological needs theory, goal contents theory, and relational motivation theory. Following each section are preliminary suggestions about how each mini-theory might be useful or informative in other branches of personality. This special issue contains nine articles, each of which makes its own attempt to newly link its area of personality research to SDT. Even if SDT is not the appropriate seed for greater consilience in personality psychology, we urge the field not to neglect the search for unifying principles (Sheldon, Cheng, & Hilpert, 2011); it may finally be time to renew the search for a "grand theory" in personality.

Refugees in the media: Exploring a vicious cycle of frustrated psychological needs, selective exposure, and hostile intergroup attitudes

Two research objectives underlay the present research. First, we tested how frustrated psychological needs caused by the refugee-influx influence the endorsement and selection of refugee-relevant information. Second, we tested how information selection processes contribute to the development of exclusionary attitudes that counteract the integration of refugees into host countries. In a laboratory study (n = 181), frustrated psychological needs decreased participants' endorsement of a refugee-friendly essay (vs. a control essay). Additionally, frustrated needs led to a biased selection of refugee-hostile over refugee-friendly information and such selection biases, in turn, predicted higher levels of ingroup defense and prejudice toward refugees. The findings imply that host societies' receptiveness to refugees is influenced by the maintenance of basic psychological needs.

Strangers in a Strange Land: Relations Between Perceptions of Others' Values and Both Civic Engagement and Cultural Estrangement

Healthy democracies require civic engagement (e.g., voting) from their citizens. Past research has suggested that civic engagement is positively associated with self-transcendence values of care and concern for the welfare of others, and negatively associated with self-enhancement values of self-interest, dominance, and personal success. However, research has yet to address whether people's perceptions of others' values are related to civic engagement. Across three studies with nationally representative samples in the UK and US (Ns ≥ 1,000), we explored how civic engagement relates to (a) perceptions of national values, (b) perceptions of the values of one's typical compatriot, and (c) perceptions of the values encouraged by social and cultural institutions. Study 1 showed that the tendency for British citizens to perceive British culture as valuing self-transcendence was associated with an increased likelihood of voting in the 2015 general election. These findings were replicated for “a typical British person” (Study 2) and “a typical American person” (Study 3); Studies 2 and 3 also found that perceived self-enhancement values of typical compatriots were negatively correlated with reported voting. We also examined how perceptions of others' values relate to cultural estrangement—the feeling of not fitting in one's culture or of being atypical. Like civic engagement, those who perceived less self-transcendence and more self-enhancement in their culture felt more culturally estranged. Mediation analyses in Studies 2 and 3 revealed that estrangement helped to explain the relationship between perceptions of others' values and voting. In sum, the extent to which Brits and Americans perceive that self-transcendence values are strongly held by other citizens is associated with feeling less estranged and with reports of being more civically engaged. In contrast, the perception that these targets hold or promote self-enhancement values is positively associated with feelings of estrangement, to the detriment of civic engagement. Implications for future research and democratic processes are discussed.

SOCIETY FOR ENDOCRINOLOGY CLINICAL GUIDANCE: Inpatient management of cranial diabetes insipidus

Cranial diabetes insipidus (CDI) is a treatable chronic condition that can potentially develop into a life-threatening medical emergency. CDI is due to the relative or absolute lack of the posterior pituitary hormone vasopressin (AVP), also known as anti-diuretic hormone. AVP deficiency results in uncontrolled diuresis. Complete deficiency can lead to polyuria exceeding 10 L/24 h. Given a functioning thirst mechanism and free access to water, patients with CDI can normally maintain adequate fluid balance through increased drinking. Desmopressin (DDAVP, a synthetic AVP analogue) reduces uncontrolled water excretion in CDI and is commonly used in treatment. Critically, loss of thirst perception (through primary pathology or reduced consciousness) or limited access to water (through non-availability, disability or inter-current illness) in a patient with CDI can lead to life-threatening dehydration. This position can be further exacerbated through the omission of DDAVP. Recent data have highlighted serious adverse events (including deaths) in patients with CDI. These adverse outcomes and deaths have occurred through a combination of lack of knowledge and treatment failures by health professionals. Here, with our guideline, we recommend treatment pathways for patients with known CDI admitted to hospital. Following these guidelines is essential for the safe management of patients with CDI.

Morality as a Basic Psychological Need

We investigate the long-standing yet understudied assumption that feeling moral is a basic psychological need, perhaps like the needs to feel autonomous, competent, and related (ACR). We report an empirical “entrance exam” on whether morality should be considered a need. Specifically, we applied to morality a pioneering method from which Sheldon and colleagues provided evidence that ACR are basic psychological needs. In two studies and four samples, participants recalled events in which they felt un/satisfied, meaningful, pleasurable, at their best, and at their worst. They rated how much candidate psychological needs were satisfied during them. Morality was frequently as or more satisfied than ACR during peak events. Further, it was positively related to indices of positive functioning. These findings suggest feelings of being moral may help people identify times when life is going well. Further, they suggest that morality may be a fundamental psychological need and warrants further investigation.

Openness to experience predicts intrinsic value shifts after deliberating one's own death

Individual differences that might moderate processes of value shifting during and after deliberating one's own death remain largely unexplored. Two studies measured participants' openness and relative intrinsic-to-extrinsic value orientation (RIEVO) before randomly assigning them to conditions in which they wrote about their own death or dental pain for 6 days, after which RIEVO was assessed again up to 12 days later. When participants confronted thoughts about their own death over a sustained period, high openness to experience helped them shift toward intrinsic values. Implications for understanding openness' role in value reorientation from existential deliberation processes are discussed.

Inhibition Underlies the Effect of High Need for Closure on Cultural Closed-Mindedness under Mortality Salience

The hypothesis that people respond to reminders of mortality with closed-minded, ethnocentric attitudes has received extensive empirical support, largely from research in the Terror Management Theory (TMT) tradition. However, the basic motivational and neural processes that underlie this effect remain largely hypothetical. According to recent neuropsychological theorizing, mortality salience (MS) effects on cultural closed-mindedness may be mediated by activity in the behavioral inhibition system (BIS), which leads to passive avoidance and decreased approach motivation. This should be especially true for people motivated to avoid unfamiliar and potentially threatening stimuli as reflected in a high need for closure (NFC). In two studies involving moderated mediation analyses, people high on trait NFC responded to MS with increased BIS activity (as indicated by EEG and the line bisection task), which is characteristic of inhibited approach motivation. BIS activity, in turn, predicted a reluctance to explore foreign cultures (Study 1) and generalized ethnocentric attitudes (Study 2). In a third study, inhibition was induced directly and caused an increase in ethnocentrism for people high on NFC. Moreover, the effect of the inhibition manipulation × NFC interaction on ethnocentrism was explained by increases in BIS-related affect (i.e., anxious inhibition) at high NFC. To our knowledge, this research is the first to establish an empirical link between very basic, neurally-instantiated inhibitory processes and rather complex, higher-order manifestations of intergroup negativity in response to MS. Our findings contribute to a fuller understanding of the cultural worldview defense phenomenon by illuminating the motivational underpinnings of cultural closed-mindedness in the wake of existential threat.

Motivation for aggressive religious radicalization: goal regulation theory and a personality × threat × affordance hypothesis

A new set of hypotheses is presented regarding the cause of aggressive religious radicalization (ARR). It is grounded in classic and contemporary theory of human motivation and goal regulation, together with recent empirical advances in personality, social, and neurophysiological psychology. We specify personality traits, threats, and group affordances that combine to divert normal motivational processes toward ARR. Conducive personality traits are oppositional, anxiety-prone, and identity-weak (i.e., morally bewildered). Conducive threats are those that arise from seemingly insurmountable external forces and frustrate effective goal regulation. Conducive affordances include opportunity for immediate and concrete engagement in active groups that are powered by conspiracy narratives, infused with cosmic significance, encouraging of moral violence, and sealed with religious unfalsifiability. We propose that ARR is rewarding because it can spur approach motivated states that mask vulnerability for people whose dispositions and circumstances would otherwise leave them mired in anxious distress.

Priming effects on cooperative behavior in social dilemmas: considering the prime and the person

ABSTRACT. We test whether people with a relatively more intrinsic vs. extrinsic value orientation (RIEVO) are particularly likely to enact cooperative behavior in resource dilemmas when they are primed with relatedness goals. In Study 1, high RIEVO participants primed with relatedness exhibited more restrained fishing behavior in a resource dilemma than their unprimed counterparts or participants low in RIEVO. Study 2 replicated this effect and further showed that the prime must signal the possibility of satisfying a valued goal (relatedness satisfaction) in order to elicit the value-consistent behavior. We discuss these results in the context of recent process models of goal priming, and also discuss how these findings contribute to our understanding of cooperative behavior and the predictive power of value constructs more broadly.

Do Some People Need Autonomy More Than Others? Implicit Dispositions Toward Autonomy Moderate the Effects of Felt Autonomy on Well-Being

The present studies examined whether implicit or explicit autonomy dispositions moderate the relationship between felt autonomy and well-being. Study 1 (N = 187 undergraduate students) presents an initial test of the moderator hypothesis by predicting flow experience from the interaction of autonomy need satisfaction and autonomy dispositions. Study 2 (N = 127 physically inactive persons) used vignettes involving an autonomy (un)supportive coach to test a moderated mediation model in which perceived coach autonomy support leads to well-being through basic need satisfaction. Again, the effects of need satisfaction on well-being were hypothesized to be moderated by an implicit autonomy disposition. Study 1 showed that individuals with a strong implicit autonomy (but not power or achievement) motive disposition derived more flow experience from felt autonomy than individuals with a weak implicit autonomy disposition. Study 2 revealed that perceived autonomy support from sports coaches, which we experimentally induced with a vignette method, leads to autonomy satisfaction, leading in turn to positive effects on well-being. This indirect effect held at high and average but not low implicit autonomy disposition. The results indicate that the degree to which people benefit from autonomy need satisfaction depends on their implicit disposition toward autonomy.

The Experiential Incompatibility of Mindfulness and Flow Absorption

Mindfulness and flow are both beneficial states of mind, but are they difficult to experience simultaneously? After all, flow involves losing self-awareness within an activity, and mindfulness involves maintaining self-awareness throughout or even despite an activity. In three studies, we examine this potential antagonism, finding negative associations between mindfulness and flow as assessed in a variety of ways and contexts. These associations emerged within Global trait data and diary data concerning daily goal behavior (Study 1), experience-sampling data concerning behavior at the time of signaling (Study 2), and experimental data concerning the experience of playing the flow-conducive computer game, Tetris, after undergoing a mindfulness induction (Study 3). However, these associations only apply to the “absorption” aspect of flow, not the “sense of control” aspect.

Muted neural response to distress among securely attached people

Neural processes that support individual differences in attachment security and affect regulation are currently unclear. Using electroencephalography, we examined whether securely attached individuals, compared with insecure individuals, would show a muted neural response to experimentally manipulated distress. Participants completed a reaction time task that elicits error commission and the error-related negativity (ERN)-a neural signal sensitive to error-related distress-both before and after a distressing insecurity threat. Despite similar pre-threat levels, secure participants showed a stable ERN, whereas insecure participants showed a post-threat increase in ERN amplitude. These results suggest a neural mechanism that allows securely attached people to regulate distress.

An unusual case of Legionellosis

Legionella species is a common cause of community-acquired pneumonia. However disease due to L. pneumophila serogroup 13 is rare and has not previously been reported in Ireland. It may not be detected by routine Legionella antigen and antibody kits. Due to these limitations, early culture should be considered when legionellosis is suspected. The potential therapeutic benefit of quinolones in the management of this disease is also illustrated.

Patellar height measurement in trochlear dysplasia

A number of measurements of patellar height are in clinical use all of which reference from the tibia. The patellotrochlear index (PTI) has been proposed recently as a more accurate reflection of the functional height of the patella and described in normal knees. We compared patellar height measurements in patients with patellofemoral dysplasia. In a retrospective analysis of the MRI scans of 33 knees in 29 patients with patellofemoral dysplasia we assessed the inter- and intraobserver reliability of four patellar height measurements: the recently described PTI, Insall-Salvati (IS), Blackburne-Peel (BP) and Caton-Deschamps (CD) ratios. We also assessed the correlation between the different measurements in predicting patella alta. Three blinded observers on two separate occasions performed the measurements. There were 21 females and 8 males with a median age of 21 years (range 13-33). Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75 and 0.78, respectively). There was weak correlation between the PTI and the other ratios for patella alta. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539, respectively). We propose the PTI as a more clinically relevant measure than the IS, CD and BP ratios.

Conservative treatment as an option in the management of pancreatic pseudocyst

BACKGROUND

Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience.

PATIENTS AND METHODS

A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10).

RESULTS

All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass.

CONCLUSIONS

These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.

Portopulmonary hypertension in decompensated cirrhosis with refractory ascites

BACKGROUND

The prevalence of portopulmonary hypertension (PPHTN) in patients with cirrhosis and refractory ascites is unknown. Its presence may preclude patients from receiving a transjugular intrahepatic portosystemic shunt or liver transplantation as a definitive treatment for their end stage cirrhosis.

PURPOSE

To determine the prevalence, possible aetiological factors, and predictive factors for the development of PPHTN in these patients.

METHODS

Sixty two patients (53 males, nine females; mean age 54.5 (1.4) years) with biopsy proven cirrhosis and refractory ascites underwent angiographic measurements of pulmonary and splanchnic haemodynamics. Endothelin 1 levels were measured from the pulmonary artery. Forty nine patients underwent radionuclide angiography for measurements of central blood volume, pulmonary vascular, and cardiac chamber volumes. Forty seven patients also underwent two dimensional echocardiography for measurements of cardiac structural and functional parameters. Cardiac output, and systemic and pulmonary vascular resistance were calculated.

RESULTS

Ten patients (16.1%) fulfilled the criteria for PPHTN (mean pulmonary artery pressure >/= 25 mm Hg and pulmonary vascular resistance >/= 120 dynxs/cm(5)), with significantly higher mean right atrial (15.4 (1.2) v 7.9 (0.5) mm Hg; p<0.001), and right ventricular pressures (24.7 (1.5) v 14.7 (0.6) mm Hg; p<0.001), and endothelin 1 levels (3.04 (0.40) v 1.98 (0.12) pg/ml; p=0.02). No significant differences in any of the other parameters measured were detected between the two groups. A right atrial pressure of >/= 14 mm Hg had a 83% positive predictive value for the presence of PPHTN.

CONCLUSIONS

Portopulmonary hypertension is common in cirrhosis with refractory ascites, possibly due to excess endothelin 1 in the pulmonary circulation. An elevated right atrial pressure >/= 14 mm Hg predicts the presence of PPHTN, which may be helpful in deciding management options in these patients.

Endocervical cancer is associated with an increase in the ligands and receptors for transforming growth factor-beta and a contrasting decrease in p27(Kip1)

OBJECTIVE

The aim of this study was to investigate the relationship between the expression of the TGF-beta ligands and TGF-beta receptors to the expression of p27(Kip1), a TGF-beta-regulated gene, in endocervical cancer.

METHODS

To examine the expression of TGF-beta and p27(Kip1) in malignant transformation of the uterine endocervix, a panel of 23 formalin-fixed and paraffin-embedded human cervical specimens, including 8 with benign endocervical glands, 8 with cervical adenocarcinoma in situ, and 7 with cervical adenocarcinomas, was used. Tissues were immunostained with polyclonal antibodies that react specifically with TGF-beta 1, TGF-beta 2, TGF-beta 3, TGF-beta RI, TGF-beta RII, and p27(Kip1).

RESULTS

Immunostaining for TGF-beta 1, TGF-beta 2, TGF-beta 3, TGF-beta RI, TGF-beta RII, and p27(Kip1) was detected in normal endocervix, with the TGF-betas showing weak cytoplasmic staining, while p27(Kip1) showed strong nuclear staining. Expression of TGF-beta increased significantly upon neoplastic transformation with the TGF-beta ligands and receptors showing strong cytoplasmic staining in adenocarcinoma in situ compared to normal endocervix. Interestingly, expression of TGF-beta was lower in adenocarcinoma than in adenocarcinoma in situ, but still significantly higher than in normal endocervix. TGF-beta 2 and TGF-beta 3 showed higher levels of immunostaining than TGF-beta 1 in adenocarcinomas. In contrast, p27(Kip1) protein expression decreased with progressive malignancy, with lower p27(Kip1) protein levels detected in adenocarcinoma than in adenocarcinoma in situ, while normal endocervix showed the highest level of p27(Kip1) protein expression.

CONCLUSION

Elevated expression of the TGF-beta ligands and receptors is found in both cervical adenocarcinoma in situ and adenocarcinoma compared to normal endocervix. In contrast, a progressive decrease in p27(Kip1) occurs upon neoplastic transformation of the normal endocervix to cervical adenocarcinoma. These results suggest that neoplastic transformation of the endocervix may be related to dysregulation of TGF-beta and p27(Kip1) seen as an elevation of TGF-beta and a reduction of p27(Kip1) expression that may lead to loss of cell cycle control.

The high-pathogenicity island of Yersinia enterocolitica Ye8081 undergoes low-frequency deletion but not precise excision, suggesting recent stabilization in the genome

Highly pathogenic strains of Yersinia pestis, Y. pseudotuberculosis, and Y. enterocolitica are characterized by the possession of a pathogenicity island designated the high-pathogenicity island (HPI). This 35- to 45-kb island carries an iron uptake system named the yersiniabactin locus. While the HPIs of Y. pestis and Y. pseudotuberculosis are subject to high-frequency spontaneous deletion from the chromosome, we were initially unable to obtain HPI-deleted Y. enterocolitica 1B isolates. In the present study, using a positive selection strategy, we identified three HPI-deleted mutants of Y. enterocolitica strain Ye8081. In these three independent clones, the chromosomal deletion was not limited to the HPI but encompassed a larger DNA fragment of approximately 140 kb. Loss of this fragment, which occurred at a frequency of approximately 5 x 10(-7), resulted in the disappearance of several phenotypic traits, such as growth in a minimal medium, hydrolysis of o-nitrophenyl-beta-D-thiogalactopyranoside, Tween esterase activity, and motility, and in a decreased virulence for mice. However, no precise excision of the Ye8081 HPI was observed. To gain more insight into the molecular basis for this phenomenon, the putative machinery of HPI excision in Y. enterocolitica was analyzed and compared to that in Y. pseudotuberculosis. We show that the probable reasons for failure of precise excision of the HPI of Y. enterocolitica Ye8081 are (i) the interruption of the P4-like integrase gene located close to its right-hand boundary by a premature stop codon and (ii) lack of conservation of 17-bp att-like sequences at both extremities of the HPI. These mutations may represent a process of HPI stabilization in the species Y. enterocolitica.

The 102-kilobase unstable region of Yersinia pestis comprises a high-pathogenicity island linked to a pigmentation segment which undergoes internal rearrangement

Several pathogenicity islands have recently been identified in different bacterial species, including a high-pathogenicity island (HPI) in Yersinia enterocolitica 1B. In Y. pestis, a 102-kb chromosomal fragment (pgm locus) that carries genes involved in iron acquisition and colony pigmentation can be deleted en bloc. In this study, characterization and mapping of the 102-kb region of Y. pestis 6/69 were performed to determine if this unstable region is a pathogenicity island. We found that the 102-kb region of Y. pestis is composed of two clearly distinct regions: an approximately 35-kb iron acquisition segment, which is an HPI per se, linked to an approximately 68-kb pigmentation segment. This linkage was preserved in all of the Y. pestis strains studied. However, several nonpigmented Y. pestis strains harboring an irp2 gene have been previously identified, suggesting that the pigmentation segment is independently mobile. Comparison of the physical map of the 102-kb region of these strains with that of strain 6/69 and complementation experiments were carried out to determine the genetic basis of this phenomenon. We demonstrate that several different mechanisms involving mutations and various-size deletions are responsible for the nonpigmented phenotype in the nine strains studied. However, no deletion corresponded exactly to the pigmentation segment. The 102-kb region of Y. pestis is an evolutionarily stable linkage of an HPI with a pigmentation segment in a region of the chromosome prone to rearrangement in vitro.

The leg ulcer resource team: a standard of care

A leg ulcer resource team was formed to introduce and implement a standard of care for patients with leg ulcers. An audit of the standard following implementation showed that 82% of ulcers had been classified correctly, diagnostic tools had been used in 78% of cases and a clear rationale for care given in 86%. However, accurate identification of patient needs in the care plan occurred in only 39% of cases, and only 60% of care plans had ulcer size and site recorded. Patient education was also a problem--25% of patients did not know what type of ulcer they had and only 43% could describe care of their ulcer or identify risk factors associated with leg ulceration.

Characterization of a large chromosomal "high-pathogenicity island" in biotype 1B Yersinia enterocolitica

Pathogenic Yersinia spp. can be subdivided into highly pathogenic (high-pathogenicity) and low-pathogenicity strains. Several genes specific for the high-pathogenicity strains are clustered on a chromosomal fragment designated a "high-pathogenicity island" (HPI). In the present work, the HPI of biotype 1B strain Ye 8081 of Y. enterocolitica was characterized. We demonstrate important differences from the HPI of Y. pestis. The HPI of Y. enterocolitica is smaller (45 kb) and is not flanked by insertion sequences. A copy of the gene coding for the tRNA-Asn is present at one extremity of the HPI and may, as in uropathogenic Escherichia coli, participate in the excision of the island. In addition to the genes encoding the yersiniabactin-pesticin receptor and the high-molecular-weight protein 2, four repeated sequences are present on the HPI of Y. enterocolitica. At least two of them are insertion elements: previously described IS1328 and newly characterized IS1400. Comparison of the HPI of strain Ye 8081 with that of other Y. enterocolitica strains of biotype 1B indicates that most of the island is conserved, apart from 15 kb at the left-hand end which is variable, especially in the region where three repeated sequences are clustered.

Osteopenia as a feature of the androgen insensitivity syndrome

OBJECTIVE

The syndrome of androgen insensitivity, a paradigm of a hormone resistance syndrome, manifests as failure of masculinization despite normal or high concentrations of serum testosterone. The defect in these 46 XY patients resides in the androgen receptor gene, with consequent defective androgen action and abnormal sexual differentiation. We sought to evaluate whether the adverse sequelae of androgen resistance may extend to skeletal tissue by measuring bone mineral density in six patients with androgen insensitivity.

DESIGN

A cross-sectional retrospective study.

MEASUREMENTS

Bone mineral density was measured by means of a Dexa (Hologic QDR 1000 scanner). The diagnosis of androgen insensitivity was confirmed in each patient by karyotype and assay of sex hormones.

RESULTS

The five adult patients with androgen insensitivity had been exposed to both defective androgen action and variable periods of oestrogen deficiency. The latter resulted from the low circulating oestrogen concentrations (for premenopausal females) before gonadectomy and inadequate oestrogen replacement after gonadectomy. All five adults with androgen insensitivity had osteopenia in both the lumbar spine (T-score -1.52 to -3.85) and femoral neck (T-score -1.34 to -4.91).

CONCLUSIONS

Osteopenia in patients with androgen insensitivity may relate to defective androgen action, oestrogen deficiency or a combination of the two. These observations have implications for the management of patients with androgen insensitivity and may provide insight into the effects of androgens on the female as well as the male skeleton.

Seroepidemiology and serodiagnosis of schistosomiasis in Kenya using crude and purified egg antigens of Schistosoma mansoni in ELISA

The performance of antibody detection for the diagnosis of schistosomiasis has been evaluated in Kenya. Approximately 1500 blood samples from 3 areas with endemic schistosomiasis (Schistosoma mansoni only, S. haematobium only, and a mixed infection area), and from a non-endemic control area, were tested for their antibody reactivity in an enzyme-linked immunosorbent assay (ELISA). The results were compared with infection status determined by parasitological examination. Two test antigens were used: unfractionated S. mansoni egg homogenate (SEA), and CEF6, a previously described, partially purified fraction of SEA containing 2 cationic antigens. The antigens prepared from eggs of Kenya and Puerto Rico S. mansoni isolates gave very similar results. Bloods from patients with S. haematobium infection cross-reacted significantly with the two S. mansoni antigen preparations, but reactivity against CEF6 appeared more specifically indicative of S. mansoni infection. Of 254 blood samples from schoolchildren in the non-endemic area, 100% gave ELISA optical density readings at 492 nm (OD492) < 0.20 against SEA, and 98% were < 0.20 against CEF6. With 887 blood samples from subjects of all ages in the area endemic for S. mansoni alone, using an ELISA OD492 cut-off point of 0.20, SEA and CEF6 had sensitivities of 94% and 97% respectively, and specificities of 64% and 59% respectively. Increasing the OD492 cut-off value reduced the sensitivity and increased the specificity of both test antigens. Specificity of both antigens was poor with samples from 234 children in an area endemic for both S. mansoni and S. haematobium (< 20% for both antigens at an OD492 cut-off value of 0.20).(ABSTRACT TRUNCATED AT 250 WORDS)