Finite element model of mechanical imaging of the breast

Purpose: Malignant breast lesions can be distinguished from benign lesions by their mechanical properties. This has been utilized for mechanical imaging in which the stress distribution over the breast is measured. Mechanical imaging has shown the ability to identify benign or normal cases and to reduce the number of false positives from mammography screening. Our aim was to develop a model of mechanical imaging acquisition for simulation purposes. To that end, we simulated mammographic compression of a computer model of breast anatomy and lesions. Approach: The breast compression was modeled using the finite element method. Two finite element breast models of different sizes were used and solved using linear elastic material properties in open-source virtual clinical trial (VCT) software. A spherical lesion (15 mm in diameter) was inserted into the breasts, and both the location and stiffness of the lesion were varied extensively. The average stress over the breast and the average stress at the lesion location, as well as the relative mean pressure over lesion area (RMPA), were calculated. Results: The average stress varied 6.2-6.5 kPa over the breast surface and 7.8-11.4 kPa over the lesion, for different lesion locations and stiffnesses. These stresses correspond to an RMPA of 0.80 to 1.46. The average stress was 20% to 50% higher at the lesion location compared with the average stress over the entire breast surface. Conclusions: The average stress over the breast and the lesion location corresponded well to clinical measurements. The proposed model can be used in VCTs for evaluation and optimization of mechanical imaging screening strategies.

VIRTUAL CLINICAL TRIALS IN MEDICAL IMAGING SYSTEM EVALUATION AND OPTIMISATION

Virtual clinical trials (VCTs) can be used to evaluate and optimise medical imaging systems. VCTs are based on computer simulations of human anatomy, imaging modalities and image interpretation. OpenVCT is an open-source framework for conducting VCTs of medical imaging, with a particular focus on breast imaging. The aim of this paper was to evaluate the OpenVCT framework in two tasks involving digital breast tomosynthesis (DBT). First, VCTs were used to perform a detailed comparison of virtual and clinical reading studies for the detection of lesions in digital mammography and DBT. Then, the framework was expanded to include mechanical imaging (MI) and was used to optimise the novel combination of simultaneous DBT and MI. The first experiments showed close agreement between the clinical and the virtual study, confirming that VCTs can predict changes in performance of DBT accurately. Work in simultaneous DBT and MI system has demonstrated that the system can be optimised in terms of the DBT image quality. We are currently working to expand the OpenVCT software to simulate MI acquisition more accurately and to include models of tumour growth. Based on our experience to date, we envision a future in which VCTs have an important role in medical imaging, including support for more imaging modalities, use with rare diseases and a role in training and testing artificial intelligence (AI) systems.

Strong anti-Epstein Barr virus (EBV) or cytomegalovirus (CMV) cellular immune responses predict survival and a favourable response to anti-tuberculosis therapy

BACKGROUND

Intact immune responses to cytomegalovirus (CMV) and Epstein-Barr virus (EBV) represent a biologically and clinically relevant correlate of 'immunological fitness' in humans. However, there is a lack of knowledge concerning anti-EBV or anti-CMV responses in patients with pulmonary tuberculosis (TB), in whom aberrant immune responses may promote progression of clinical disease.

METHODS

Venous blood samples were obtained at the time of (sputum smear positive) pulmonary TB diagnosis. A whole blood assay was performed by exposing PBMCs (peripheral blood mononuclear cells) to a panel of infectious antigens, including CMV, EBV and mycobacterial proteins. Cell culture supernatants were collected after seven days and interferon gamma (IFN-γ) was measured using a sandwich ELISA. Patients received standard first line anti-tuberculosis rifampicin (R)/isoniazid (H)/ethambutol (E)/pyrazinamide (Z) for two months followed by RH for four months.

RESULTS

PBMCs from cured patients (after treatment completion) exhibited significantly stronger IFN-γ responses to CMV (p=0.035), EBV (p=0.006) or Mycobacterium tuberculosis ESAT-6 (p=0.043) at the time of diagnosis as compared to patients who succumbed to TB during treatment. IFN-γ responses to other viral (H5N1, HSV-1) as well as other mycobacterial (Ag85A, Rv2958c, Rv0447c) antigens were not found to be significantly different among patients who were cured or those who succumbed to TB.

CONCLUSIONS

Increased cellular immune responses to CMV and EBV antigens at the time of diagnosis of pulmonary tuberculosis are associated with increased survival after a standard six months anti-TB therapy. CVM and EBV antigens may represent "intrinsic markers for immune fitness" and guide improved TB therapies including host-directed therapies.

Lymphatic Drainage in the Breast Before and Up to Five Years After a Reduction Mammaplasty

The aim of this study was to investigate lymph circulation before and after breast reduction mammaplasty in different parts of the breast and with two different carriers of the radiopharmaceutical. Nine patients with breast hypertrophy planned for bilateral breast reduction mammaplasty were prospectively included in the study. The breast operation procedure was decided on intraoperatively. The regional lymph circulation in the breast was measured preoperatively by Technetium (99mTc) clearance in 4 different locations in each breast 1, 2 and 3 hours after injection. The procedure was repeated at one month and in six of the nine women also five years postoperatively with injection sites chosen to correspond to the preoperative location of that breast pedicle. Two different types of carriers of the radiopharmaceutical were tested, dextran in the right and nanocoll in the left breast. Dextran had a much more rapid clearance than nanocoll. There was no significant regional difference in lymph drainage up to five years after the mammaplasty, independent of dextran or nanocoll as being the carrier of the radiopharmaceutical.

White blood cell SPECT during active period of cluster headache and in remission

BACKGROUND AND PURPOSE

Cluster headache (CH) is an episodic headache disorder characterized by recurrent, unilateral attacks of excruciating pain in the temporal/orbital region. The pathophysiology of CH is largely unknown although involvement of immunological mechanisms has been suggested. The aim of our study was to investigate whether patients with CH show signs of intracranial inflammation, when using white blood cell single-photon emission computer tomography (WBC-SPECT).

METHODS

We have examined 14 patients with CH, both in active period and in remission, and five control subjects at one occasion, with WBC-SPECT. To be able to precisely define regions of interest (ROI:s) in the brain, all patients with CH and control subjects underwent magnetic resonance imaging (MRI) of the brain.

RESULTS

We found no significant difference in (99m)Tc-labeled WBC uptake between patients with CH in active period and controls. Furthermore, patients with CH in active period were not significantly different in uptake compared with patients with CH in remission.

CONCLUSIONS

These results did not provide conclusive support for a hypothesis of a pathophysiological role of inflammation intracranially. Our conclusions are restricted to the advantages and limitations of the chosen method.

Lack of accuracy for the proposed 'Dubois criteria' in Alzheimer's disease: a validation study from the Swedish brain power initiative

BACKGROUND/AIMS

Our purpose was to investigate whether the new research criteria for Alzheimer's disease proposed in 2007 by Dubois et al. are valid in a naturalistic memory clinic sample.

METHOD

Retrospective diagnostic analyses were carried out to compare the traditional diagnostic criteria for dementia with the new criteria suggested by Dubois et al. No patient had gone through all procedures postulated as additional features in the proposed new Dubois criteria.

MATERIAL

Two independent experienced geriatricians re-examined 150 complete patients' records. The study physicians were blinded to any of the results of the core and additional features suggested by Dubois et al. to avoid circular diagnostic bias.

RESULTS

Among our 96 patients with a clinical diagnosis of subjective cognitive impairment and/or mild cognitive impairment, 2 of the patients with subjective cognitive impairment and 5 patients with mild cognitive impairment would classify as pre-dementia Alzheimer's disease according to the Dubois criteria. In our 23 Alzheimer patients diagnosed clinically, only 12 of the cases fulfilled the criteria for Alzheimer's disease suggested by Dubois et al.

INTERPRETATION

The proposed new criteria for Alzheimer's disease are valid in 55% of our patients clinically diagnosed as having full-blown Alzheimer dementia. Additionally, 7.3% 'true' Alzheimer cases will be identified in a group of 96 clinically non-demented patients. Our results show that there is a large heterogeneity in a clinical naturalistic sample of patients with an Alzheimer phenotype.

CONCLUSION

There is a need to further validate the currently existing biomarkers in large unselected samples and avoid the pitfall of workup bias and circular diagnostic processes. Additionally, valid age-specific cut-off values for the diagnostic markers in question have to be defined.

Bolus compared with continuous infusion of microbubble contrast agent using real-time contrast harmonic imaging ultrasound in breast tumors

BACKGROUND

Contrast-enhanced ultrasound (CEUS) has gained interest because of its ability to gather vascular information in various organs. There is still a matter of debate concerning its value in breast lesions. The method of choice on how to administer the contrast agent varies depending on the organ to be studied. Infusion of microbubbles is used in echocardiography, while bolus administration is the preferred technique for abdominal organs.

PURPOSE

To compare-in equal doses-bolus versus continuous infusion of microbubbles, using real-time contrast harmonic imaging in breast tumors.

MATERIAL AND METHODS

A total of 29 female patients (mean age 54 years) with either clear malignant or benign findings in the breast or axilla were included. Contrast harmonic imaging (CHI US) was performed with a Philips iU22 using an L9-3 MHz linear probe, especially designed for this purpose. A low mechanical index (0.06-0.07) was used to avoid massive destruction of the microbubbles. A dose of 2.4 ml of Sono Vue was first infused intravenously over 1 min with an infusion pump. After 10 min, the same dose was injected as a bolus over 2 s, followed by a flush of 10 ml of saline solution. Contrast uptakes by the tumors were recorded 2 min from the moment of injection, with both methods for each patient.

RESULTS

Bolus administration of contrast agent provided a sharply demarcated enhancement and wash-out pattern for all lesions. The continuous infusion of the same contrast agent failed to show any wash-in/wash-out or time-to-peak/peak intensity phenomena in all cases.

CONCLUSION

CEUS using real-time harmonic imaging in order to evaluate breast tumors should be performed with bolus administration of contrast agent in order to achieve better intensity/time curve outcomes.

Quantitative assessment of 99mTc-depreotide uptake in patients with non-small-cell lung cancer: immunohistochemical correlations

BACKGROUND

Somatostatin receptor (SSTR) scintigraphy with (99m)Tc-depreotide is used for differential diagnosis of solitary pulmonary nodules. The method is based on SSTR expression in cancer tissue.

PURPOSE

To estimate the expression of SSTRs in non-small-cell lung cancer (NSCLC) in vitro, and to determine the correlation between (99m)Tc-depreotide uptake in vivo and different tumor characteristics determined in vitro, such as tumor grade, and presence of SSTR2, MIB-1, and p53.

MATERIAL AND METHODS

A total of 127 patients with lung lesions detected on computed tomography (CT) were investigated with SSTR scintigraphy after injection of 740 MBq (99m)Tc-depreotide. This study includes 19 patients with NSCLC with histologically proven diagnosis. The quantitative evaluation of (99m)Tc-depreotide was performed using region-of-interest analysis and includes tumor counts/cm(3), background counts/cm(3), and the ratio between tumor and background counts.

RESULTS

99mTc-depreotide uptake was found in all NSCLC tumors, which expressed SSTR2 defined in vitro by immunochemical methods. SSTR2 expression was negatively correlated to the degree of the tumor's differentiation (P<0.05). 99mTc-depreotide uptake in tumor cells did not correlate with tumor grade, or SSTR2, MIB-1, or p53 expression.

CONCLUSION

There is an expression of SSTRs in NSCLC. The degree of tumor differentiation correlates negatively with SSTR2 measured in vitro and positively with MIB-1 expression in tumor tissue. No correlation was found between (99m)Tc-depreotide uptake and possible prognostic factors such as MIB-1 and p53 expression in tumor cells in NSCLC. Lastly, no correlation was found between (99m)Tc-depreotide uptake and tumor grade or SSTR2 expression.

Voxel-based correlation between coregistered single-photon emission computed tomography and dynamic susceptibility contrast magnetic resonance imaging in subjects with suspected Alzheimer disease

BACKGROUND

Current diagnosis of Alzheimer disease is made by clinical, neuropsychologic, and neuroimaging assessments. Neuroimaging techniques such as magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) could be valuable in the differential diagnosis of Alzheimer disease, as well as in assessing prognosis.

PURPOSE

To compare SPECT and MRI in a cohort of patients examined for suspected dementia, including patients with no objective cognitive impairment (control group), mild cognitive impairment (MCI), and Alzheimer disease (AD).

MATERIAL AND METHODS

24 patients, eight with AD, 10 with MCI, and six controls, were investigated with SPECT using (99m)Tc-hexamethylpropyleneamine oxime (HMPAO, Ceretec; GE Healthcare Ltd., Little Chalsont UK) and dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) with a contrast-enhancing gadobutrol formula (Gadovist; Bayer Schering Pharma, Berlin, Germany). Voxel-based correlation between coregistered SPECT and DSC-MR images was calculated. Region-of-interest (ROI) analyses were then performed in 24 different brain areas using brain registration and analysis of SPECT studies (BRASS; Nuclear Diagnostics AB, Stockholm, Sweden) on both SPECT and DSC-MRI.

RESULTS

Voxel-based correlation between coregistered SPECT and DSC-MR showed a high correlation, with a mean correlation coefficient of 0.94. ROI analyses of 24 regions showed significant differences between the control group and AD patients in 10 regions using SPECT and five regions in DSC-MR.

CONCLUSION

SPECT remains superior to DSC-MRI in differentiating normal from pathological perfusion, and DSC-MRI could not replace SPECT in the diagnosis of patients with Alzheimer disease.

Familial and environmental aetiologic factors in paranoid psychosis quantified by a new statistical method

A new mathematical model for quantification of familial factors was used in this study of psychiatric morbidity among the first-degree relatives of 25 patients with paranoid psychosis. The method provides a measure, a familial score of psychiatric morbidity of practical value in correlation analysis since it is applicable at different numbers of relatives per proband, excludes the influence of systematical errors, and allows the inclusion of background factors. A total of 159 first-degree relatives above the age of 15 were traced, 44 (28%) of whom were found to have a history of psychiatric disorder. The familial score of psychiatric morbidity, which varied between 2.0 and 23.0 in the 25 patients, was not significantly correlated to neurophysiological findings or clinical picture. A highly significant negative correlation between the familial score and parental age suggested that the relative influence of nonfamilial factors on the development of psychiatric disorder may be increased with increasing parental age.

Familial score of psychiatric morbidity and age at onset of psychiatric disorder

A group of 182 male psychotic patients with varying DSM-III diagnoses were studied concerning age at onset and psychiatric morbidity among relatives. The age at onset was defined as the age when symptoms first appeared and necessitated medical contact. The psychiatric morbidity among parents and siblings was studied and formed the basis for calculation of a familial score. A highly negative correlation between this familial score and age at onset was demonstrated. The results indicate that an increased familial loading of psychiatric illness involves an increased risk of early onset of psychotic illness.

Role of scintigraphy with technetium-99m depreotide in the diagnosis and management of patients with suspected lung cancer

BACKGROUND

In Sweden, there are over 3000 new lung cancer cases every year. There are still numerous patients with undetermined lesions after routine diagnostic evaluation by clinical examination, chest radiography, computed tomography (CT) of the thorax, and bronchoscopy. An appropriate method for further diagnostic workup is therefore needed.

PURPOSE

To evaluate the diagnostic value of the somatostatin analogue depreotide in patients with suspected lung cancer, and to determine in which clinical settings it would be beneficial to use 99mTc-depreotide scintigraphy.

MATERIAL AND METHODS

We included 99 consecutive patients referred to our hospital with suspected lung cancer. A clinical examination, bronchoscopy, chest radiography, CT of the thorax and upper abdomen, and scintigraphy were done. Scintigraphy was performed after injection of 740 MBq (99m)Tc depreotide with tomographical imaging of the thorax and whole-body scanning. The diagnostic outcome of the scintigrams was compared to CT, using morphology or clinical outcome as the endpoint.

RESULTS

99mTc-depreotide uptake was found in 62 out of 66 malignancies, including 57 of 58 primary lung cancer cases. Two cases of lung metastasis (one from a colon cancer and one from an adenoid cystic carcinoma originating in the palate) and one rib chondrosarcoma did not show depreotide uptake. There were 33 patients with benign lesions, of whom 16 displayed false-positive 99mTc-depreotide uptake, whereof 11 were pneumonias. Tc-99m-depreotide uptake was absent in 17 patients with benign lesions, including all 10 hamartomas. The sensitivity in detecting malignancy was 94%, and in detecting lung cancer 98%. The specificity was calculated based on two sets of data. When all cases were used, the specificity was 52%. If the 12 pneumonias are excluded, the specificity was 77%.

CONCLUSION

99mTc-depreotide scintigraphy has a high sensitivity in detecting lung cancer. The method is useful in decision-making with respect to surgery.

Parameters obtained by hepatobiliary scintigraphy have significant correlation with biochemical factors early after liver transplantation

BACKGROUND

Early postoperative hepatobiliary scintigraphy after liver transplantation is performed worldwide, but data on its significance for graft function are currently limited.

PURPOSE

To examine the correlation between the result of early postoperative hepatobiliary scintigraphy and pre- and postoperative biochemical parameters in liver transplantation (LTx) patients.

MATERIAL AND METHODS

Six parameters of hepatobiliary scintigraphy using (99m)Tc mebrofenin were statistically analyzed in 108 LTx patients: 1) half-life of the activity of elimination of mebrofenin from the blood; 2) total clearance of mebrofenin from the blood due to all possible routes; 3) half-life of the activity due to liver uptake; 4) clearance of mebrofenin from the blood due to liver uptake; 5) time to maximal uptake in the liver; and 6) the hepatic extraction fraction (HEF) and biochemical data. Analysis between patients with preoperative normal liver function, familial amyloid polyneuropathy (FAP), and end-stage liver disease (non-FAP) was also performed.

RESULTS

Univariate and multivariate analysis revealed that total bilirubin postoperative day 3 correlated with all three scintigraphic parameters, and peak aspartate aminotransferase and alanine aminotransferase correlated with HEF. The analysis between patients with FAP and non-FAP revealed no significant difference of scintigraphic data between the two groups.

CONCLUSION

A significant correlation between early postoperative scintigraphic results and biochemical parameters was demonstrated.

How does iron-sulfur cluster coordination regulate the activity of human glutaredoxin 2?

Human mitochondrial glutaredoxin (Grx2) was described as the first iron-sulfur protein from the thioredoxin superfamily of proteins. The [2Fe-2S] cluster was proposed to serve as redox sensor for the activation of Grx2 during oxidative stress. The authors have demonstrated that the iron-sulfur cluster is complexed by the two N-terminal active site thiols of two Grx2 monomers and two molecules of glutathione that are bound noncovalently to the proteins and in equilibrium with glutathione in solution. When reduced glutathione becomes the limiting factor for cluster coordination, the holo-Grx2 complex dissociates, yielding enzymatically active Grx2.

Financial incentives in health care. The impact of performance-based reimbursement

The key question addressed in this study is whether performance-based reimbursement (PBR) is a useful way to create the right incentive for efficiency improvements in health care. In this 4-year prospective cohort study, physicians in one council with PBR and in ten councils without such a system were studied. The results of this study indicate that PBR, compared to an annual budget system, creates a different incentive, an 'inner incentive' which may be stronger than the external incentive of financial pressures. PBR may result in a greater cost awareness and shorter average length of stay, but it may also lead to negative effects on the quality of care. A strong cost awareness was found to be a negative predictor of quality of care indicating that it is a difficult balancing act to maintain cost considerations at a 'good' level in order to retain the benefits of cost awareness without adversely impacting quality of care. There is a need for further studies of the impact of PBR on financial performance and quality of care issues.

Effects of performance-based reimbursement on the professional autonomy and power of physicians and the quality of care

The key question addressed in this study is whether performance-based reimbursement in health care affects the professional power and autonomy of physicians, and if so, whether this has any consequences for the quality of care. This cohort study examines the period 1994-98 in 11 Swedish county councils. Four hundred and eighteen physicians were studied in Stockholm County Council, which has a performance-based reimbursement system, and in ten councils without such a system. The results show that professional power and autonomy are considered to be very limited in all councils, and that they have decreased during the period studied. Professional autonomy is, however, more limited in Stockholm. The limitations in Stockholm are more related to financial considerations, whereas the limitations in the other councils are more due to guidelines and lists of recommended drugs. Professional autonomy and power were found to be important determinants for quality of care, and the physicians in Stockholm estimated the quality of care lower than their colleagues in the ten other councils. Thus, our study suggests that the performance-based reimbursement system might fail to reach the desired results due to its negative impact on professional power and autonomy.

Cloning and characterisation of a hyp gene cluster in the filamentous cyanobacterium Nostoc sp. strain PCC 73102

Maturation of [NiFe]-hydrogenases requires the action of several groups of accessory genes. Homologues of one group of these genes, the so-called hyp genes, putatively encoding proteins participating in the formation of an active uptake hydrogenase in the filamentous, heterocyst-forming cyanobacterium Nostoc PCC 73102, were cloned. The cluster, consisting of hypF, hypC, hypD, hypE, hypA, and hypB, is located 3.8 kb upstream from the uptake hydrogenase-encoding hupSL. Gene expression analyses show that these hyp genes are, like hupL, transcribed under N(2)-fixing but not under non-N(2)-fixing growth conditions. Furthermore, the six hyp genes are transcribed together with an open reading frame upstream of hypF, as a single mRNA. Analysis of the DNA region upstream of the experimentally determined transcriptional start site revealed putative -10 and -35 sequence elements and putative binding sites for the global nitrogen regulator NtcA.

Effects of performance-based reimbursement in healthcare

The aim of this study was to assess changes in attitudes and behaviour related to efficiency and quality of care after introduction of performance-based reimbursement. The study consisted of two parts. Part One was performed in 1992-94 as a repeated cross-sectional study of physicians in Stockholm County Council working with a newly introduced performance-based reimbursement system. Part Two was a similar study conducted in 1994 in 11 Swedish councils without performance-based reimbursement. The results show a significant difference between the two groups of physicians in attitudes concerning changes in quality of care and premature discharge from hospital. Despite concern about quality and premature discharge, physicians in Stockholm were found to have changed their behaviour in that the average length of stay in 1994 was about one day shorter in Stockholm than in the other 11 county councils. This indicates that the performance-based reimbursement system may strengthen the incentive to increase efficiency.

The organizational pendulum--healthcare management in Sweden 1865-1998

In recent years, there have been a number of large-scale changes in the organization of healthcare in Sweden, as in many other countries. From a longer time perspective, however, there has been a more or less permanent oscillation between centralization and decentralization, and also between competition and co-operation, in Swedish healthcare organizations. In fact, there seems to be something like a pendulum moving all the time between opposite forms of organization. The frequency of these changes has been increasing during the last fifteen years, as different organizational models have replaced each other at shorter and shorter intervals. This development is partly due to the increasing rate of change in modern society, but partly also due to an element of fashion in the area of management. There is, however, a growing change fatigue in many healthcare organizations, and also increasing demands for empirical evidence on the efficiency and effectiveness of different organizational models before they are introduced into the healthcare system.

Characterization of MK-801-induced behavior as a putative rat model of psychosis

The objective of this study was to characterize the behavior induced by the N-methyl-D-aspartate receptor antagonist MK-801 (dizocilpine maleate) in rats as a model of psychosis. The temporal profile, dose dependence, age, and sex differences of the behavior are described. A gas chromatographic method for the analysis of MK-801 in plasma and brain was developed. Female rats showed 4 to 10 times more MK-801-induced behavior and displayed around 25 times higher serum and brain concentrations of MK-801 than male rats. Twenty-one neuroactive compounds, including a number of excitatory amino acid-active substances, were tested for the effect on MK-801-induced behavior. Neuroleptics blocked MK-801-induced behavior in a dose-dependent manner that correlated to their antipsychotic potency in humans. Adenosine receptor agonists and an N-methyl-D-aspartate receptor-associated glycine site antagonist showed putative antipsychotic effects. In conclusion, MK-801-induced behavior represents a rat excitatory amino acid hypofunction model of psychosis that appears to be of clinical relevance and may be of value in the search for new antipsychotic agents.

Transcriptional regulation of Nostoc uptake hydrogenase

Filamentous, heterocystous cyanobacteria may contain both an uptake hydrogenase (encoded by hupSL) and a bidirectional enzyme (encoded by hoxFUYH). The present study identifies three strains (Anabaena variabilis, Nostoc muscorum and Nostoc sp. strain PCC 73102) with a contiguous hupL in both vegetative cells and heterocysts. The two Nostoc strains differ in either containing a bidirectional enzyme (N. muscorum) or lacking this enzyme (N. PCC 73102). Transcriptional studies, using reverse transcriptase-polymerase chain reaction, demonstrated an induction of a hupL transcript approximately 24 h after a shift from non-nitrogen-fixing to nitrogen-fixing conditions (in parallel with the induction of an in vivo light-dependent H2-uptake activity) in N. muscorum. However, the level of hoxH transcripts did not change significantly during the induction of the H2-uptake activity.

Towards an evidence based health care management

Inspired by the development of Evidence Based Medicine, this article introduces a new approach for health care management called Evidence Based Management. This approach promises to improve the practice of health care management, at the same time as it may stimulate research on the organization and management of health care. Evidence Based Management means that health care managers should learn to search for and critically appraise evidence from management research as a basis for their practice. This will require some new managerial skills that should be included in the education and training of health care managers. It will also require a new orientation for research on health care management. There will be a demand for more applied research, and also for research with a more positivist orientation.

A panel study of migration, self-selection and household real income

"The impact of migration on income for Swedish multi-adult households is examined using panel data pertaining to a sample of stable household constellations during the period 1980-1990. In contrast to previous studies, data on household disposable income is employed in estimating the income function. The empirical results indicate no significant effect on real disposable income from migration. In addition, the hypothesis of no self-selection, or zero correlation between the errors in the decision function and the income function, cannot be rejected."

The effect of anosmia on MK-801-induced behaviour in mice

Systemic administration of N-methyl-D-aspartate (NMDA) receptor antagonists induces a well defined behaviour in rodents characterized by, for example increased locomotion and ataxia. It is not clear in what brain region(s) NMDA antagonists induce this behaviour. We have studied the possible involvement of olfactory pathways by making adult mice anosmic via intranasal injection of zinc sulphate, a procedure that is known to destroy the olfactory epithelium. The NMDA antagonist MK-801 was given intraperitoneally (0.1-1.0 mg/kg) and the animals were scored for locomotion and ataxia 60-90 min later. Before MK-801 administration, olfactory-lesioned mice did not differ from non-lesioned controls with regard to locomotion or ataxia. MK-801 caused locomotor activation (> or = 0.2 mg/kg) and ataxia (> or = 0.5 mg/kg) in both groups. In general, olfactory-lesioned animals showed more locomotion and less ataxia after MK-801 administration than non-lesioned animals. Lesioned animals displayed 2.0- (P < 0.05) and 3.7-fold (P < 0.05) more extensive locomotor activation than non-lesioned animals after 0.5 and 1.0 mg/kg of MK-801, respectively. No difference in the degree of ataxia was seen between the two groups at 0.5 mg/kg, whereas non-lesioned animals showed a 2.1-fold higher degree of ataxia after 1.0 mg/kg of MK-801, indicating that the enhanced MK-801-induced locomotor activation in olfactory-lesioned mice was not simply due to less ataxia. These results suggest that olfactory input is involved in NMDA antagonist-induced behaviour.

Demonstration of immunoglobulin G with affinity for dopamine in cerebrospinal fluid from psychotic patients

Using an enzyme-linked immunosorbent assay, significantly raised concentrations of immunoglobulin G with affinity for the neurotransmitter dopamine were demonstrated in cerebrospinal fluid from psychotic patients. We have varied the antigen presentation in order to find a conjugate with low unspecific binding. The conjugation of dopamine to carbodiimide-activated poly-L-glutamic acid and that to activated succinimide ester of biotin are described. The use of glutaraldehyde conjugation is not recommended because of the risk of formation of tetrahydroisoquinolines. A strong correlation (r = 0.94, P < 0.001) between the results obtained with dopamine conjugated to poly-L-glutamic acid and dopamine conjugated to biotin was observed. Forty-two human cerebrospinal fluid samples from 20 psychotic patients, (12 with a bipolar disorder and 8 with schizophrenia) and 22 control patients, with various neurological diseases but no apparent psychiatric diseases were investigated. A significantly higher incidence (P < 0.001) of antibodies with affinity for dopamine were found in the group of psychotic patients compared with the neurological control group.

Incidence of cycloid psychosis. A clinical study of first-admission psychotic patients

The concept of cycloid psychosis has gained increasing acceptance during recent decades. Using the diagnostic criteria of Perris and Brockington, an intelligible delineation of a group of patients has been obtained. Few epidemiological data on cycloid psychosis have been reported so far. The objective of the present study was to describe the one-year incidence of cycloid psychosis in a clinical sample. The diagnostic registers of all patients hospitalized for a functional or an organic psychosis and discharged in the year 1983, in Lund, Sweden were investigated. 514 patients were identified of whom 83 were admitted to hospital for the first time. 29 of these patients had a functional psychosis and were below the age of 50. In this age group 7 cases (4 women, 3 men) fulfilled the diagnostic criteria of cycloid psychosis and thus constituted almost one fourth of all first admissions of functional psychoses that year. The one-year incidence for first admission in cycloid psychosis was 5.0 per 100,000 inhabitants in women and 3.6 per 100,000 inhabitants in men within the age group 15-50 years in the catchment area of 163,175 persons. We conclude that cycloid psychosis constitutes a considerable proportion of functional psychoses in both sexes.

Factors predicting suicide in psychotic patients

Death rate and causes of death during a mean period of 5.8 years were investigated in 250 male inpatients with psychotic disorders (DSM-III). Fifty patients died during the observation period. Suicide was confirmed in 11 of these patients and could not be excluded in 7 cases, where the cause of death was reported as uncertain. Clinical and neurobiological characteristics (DST-non-suppression, CSF proteins, and monoamine metabolites) were compared in patients who committed suicide and non-suicide patients of the same age, with or without suicidal behaviour. A highly increased mortality rate was seen among the patients and the rate of suicide was more than 20 times higher than that expected in a normal population of the same age. The estimated annual incidence of suicide was 2.5%, 1.3%, 1.0% and 0.4% for patients with bipolar disorder, paranoid psychosis, major depression and schizophrenic disorder, respectively. The following factors were significantly positively correlated with completed suicide: depressive mood, elated mood, paranoid ideas, and paternal age. All suicides had previously shown suicidal behaviour and the suicide occurred during or shortly after a period of hospitalisation. No correlations were found with age at onset of illness, duration of illness, substance abuse or neurobiological parameters.

Lithium discontinuers. II. Therapeutic outcome

Eleven patients from a lithium-treated cohort of 64 patients with major affective disorder (DSM-III) were investigated after a mean of 6.7 years on lithium prophylaxis and reinvestigated 7 years later, at which point they had discontinued lithium for a mean of 2.3 years. Therapeutic outcome was compared in the 11 discontinuers and 20 continuers on lithium from the same cohort, matched for sex, age, and mental status on admission to the study. Ratings of psychopathology (CPRS) at the end of the 7-year follow-up period showed that the only significant difference between the patient categories was a higher frequency of reported autonomic disturbances and worry over trifles in the discontinuers. Daily doses of neuroleptic drugs were significantly higher in discontinuers than in controls by the end of the study. Alternative concomitant treatment outside conventional medicine was sought by 45% of the discontinuers, whereas no lithium-treated control reported the need for such additional therapeutic measures.

Effects of amperozide in schizophrenia. An open study of a potent 5-HT2 receptor antagonist

Ten male inpatients (aged 29 +/- 6 years) with a DSM-III diagnosis of schizophrenia participated in a 4-week open dose escalation study of amperozide, a novel 5-HT2 receptor antagonist. The maximum daily dose of amperozide was 20 mg. A close dose-plasma concentration relationship showed considerable interindividual variation in the steady-state plasma levels at a given dose. Approximately equal concentrations of amperozide and its metabolite, N-deethylated amperozide, were seen in plasma. The prolactin levels were not increased during amperozide treatment. No changes occurred in hematological or other laboratory parameters. ECG showed changes in T-wave morphology and a prolongation of the QTc time. One patient was withdrawn from the trial due to aggravation of psychotic symptoms, and two patients had a brief, temporary discontinuation of the drug due to somatic illness. Six patients were improved during amperozide treatment, as assessed by the Clinical Global Improvement Scale. Among the responders the total CPRS was reduced by a mean of 64% and total BPRS score by a mean of 46%. Mild tremor was a frequent side effect, but other extrapyramidal symptoms were rare. Nausea was seen in six patients and of a more pronounced character in one patient. In general, the severity of the side effects increased with increasing doses of amperozide.

On the pathogenesis of abnormal involuntary movements in lithium-treated patients with major affective disorder

Abnormal involuntary movements during long-term lithium treatment were investigated on two occasions, 7 years apart, in 37 outpatients with major affective disorder according to DSM-III. The patients had been on continuous lithium treatment for an average of 8.2 years when entering the study, and all had been exposed to neuroleptics. Psychiatric status and side effects were evaluated, and abnormal involuntary movements were assessed using the Abnormal Involuntary Movement Scale (AIMS). Signs of abnormal involuntary movements were age-dependent and seen in 8% of the patients at the initial investigation in 1980, and the proportion of affected individuals had increased by 16% by the end of the study in 1987. Women above the age of 50 (in which category the frequency of abnormal involuntary movements was 38%) were selected for further analysis. Severe abnormal involuntary movements in this category were associated with the early onset of affective illness, low body weight, the occurrence of dementia among first-degree relatives, and with high 12-h lithium levels.

Lithium discontinuers. I. Clinical characteristics and outcome

Eleven patients with major affective disorder (DSM-III) were investigated after a mean of 6.7 years on lithium prophylaxis and reinvestigated 7 years later, at which time they had discontinued lithium for a mean 2.3 years. Outcome was assessed by the Comprehensive Psychopathological Rating Scale, by relapse frequencies, by need for psychotropic medication and for inpatient treatment. The study period was associated with an increase in the rated score for depression, as previously observed also in lithium discontinuers. Although the relapse frequencies remained largely unchanged, a significantly increased number of inpatient treatment days indicated considerably more severe episodes after the discontinuation of lithium. Long periods without lithium were associated with higher doses of neuroleptic drugs.

Factors associated with discontinuation of long-term lithium treatment

Sixty-four outpatients with major affective disorder according to DSM-III and on continuous lithium treatment for an average duration of 7.8 years were first investigated in 1980 and then followed for 7 years. The predictive value of patients' attitudes to their lithium, the prognostic influence of psychiatric status, side effects, and anamnestic and laboratory data including lithium parameters were studied. At the end of the 7-year follow-up, 61% of the patients were still on lithium maintenance treatment, 25% had discontinued lithium for clinical reasons, and 14% of the patients had died. Side effects of lithium were the major clinical reason for discontinuing treatment, while attitudes towards medication were of minor importance. Approximately one fourth of the patients who discontinued lithium were differentiated from those who continued treatment by showing a high frequency of the neurologic side effects incoordination, paresthesia, and disturbed sensibility in addition to having more severe tremor. In yet another fourth of those who discontinued for clinical reasons, lithium was stopped by the treating psychiatrist as maximal urine osmolality values were considered to be too low. These patients did not show any signs of clinically significant impairment of renal functions. Their psychiatric status was excellent in terms of extremely low CPRS scores. The patients who died during the follow-up period were differentiated from those who continued treatment by a much higher frequency of alcohol and drug abuse prior to the initiation of lithium therapy. The total number of side effects and the number of severe side effects were significantly larger than in continuers on lithium. The most common causes of death were cardiovascular disease and suicide. In no case was the cause of death attributed to lithium therapy.

Psychopathology during long-term lithium treatment of patients with major affective disorders. A prospective study

Thirty-seven patients with major affective disorders according to DSM-III and on continuous lithium treatment were followed during a 7-year period. Outcome was assessed by use of the Comprehensive Psychopathological Rating Scale and by the need for additional psychotropic medication and for hospital and outpatient care. Anamnestic variables and patient's attitudes to their lithium medication were also included in the analysis of outcome, as were laboratory data, including lithium parameters. An increase in psychopathology was demonstrated in a significant number of patients and was attributed mainly to an increase in the depressive symptoms, with a significant increase in the rated scores for fatiguability, pessimistic thoughts, reduced sleep, and inner tension. Suicidal thoughts were common, but no suicide attempts were made. A significant number of patients complained of failing memory, but no significant progression was demonstrated during the 7-year study period. The increase in the depressive symptoms was closely correlated with the number of hospital admissions for depressive recurrence and with the number of days in hospital. The following factors showed a significant relationship with the increase in depressive symptoms: serum lithium levels, large increase in the elimination half-life of lithium, low level of social functioning, low TSH values, and need of concomitant administration of antidepressants and benzodiazepines.

Factors associated with discontinuation of long-term lithium treatment

Sixty-four outpatients with major affective disorder according to DSM-III and on continuous lithium treatment for an average duration of 7.8 years were first investigated in 1980 and then followed for 7 years. The predictive value of patients' attitudes to their lithium, the prognostic influence of psychiatric status, side effects, and anamnestic and laboratory data including lithium parameters were studied. At the end of the 7-year follow-up, 61% of the patients were still on lithium maintenance treatment, 25% had discontinued lithium for clinical reasons, and 14% of the patients had died. Side effects of lithium were the major clinical reason for discontinuing treatment, while attitudes towards medication were of minor importance. Approximately one fourth of the patients who discontinued lithium were differentiated from those who continued treatment by showing a high frequency of the neurologic side effects incoordination, paresthesia, and disturbed sensibility in addition to having more severe tremor. In yet another fourth of those who discontinued for clinical reasons, lithium was stopped by the treating psychiatrist as maximal urine osmolality values were considered to be too low. These patients did not show any signs of clinically significant impairment of renal functions. Their psychiatric status was excellent in terms of extremely low CPRS scores. The patients who died during the follow-up period were differentiated from those who continued treatment by a much higher frequency of alcohol and drug abuse prior to the initiation of lithium therapy. The total number of side effects and the number of severe side effects were significantly larger than in continuers on lithium. The most common causes of death were cardiovascular disease and suicide. In no case was the cause of death attributed to lithium therapy.

Soft-tissue-anchored percutaneous device for long-term intracorporeal access

A percutaneous device system for long-term intracorporeal access is presented. A technical description of the device is given as well as results from healing in of device dummies and everyday functioning devices both in the short- and long-term perspectives in experimental animals and in human volunteers and patients. Major complications have not been observed by clinical inspection. Histological analyses of the animal experiments indicated that the downgrowth of the epidermal cells was arrested at the most superficial borderline of a preformed cavity region. An increased subepithelial cell density was observed lateral to a moderate sinus tract, but there were no heavy inflammatory cell infiltrations. The clinical success of the implants evaluated appears to be based on the following design factors: (1) selection of titanium as the tissue interfacing surface, (2) surface geometry factors applied, (3) a system of preformed cavities promoting connective-tissue interdigitation, (4) stress relief design of the subcutaneous flange, (5) high-precision surgical instrumentation and method. It is concluded that the results obtained so far are sufficiently promising to justify further controlled clinical trials and extended observation periods.

Total plasma concentrations, red blood cell concentrations, and radioreceptor assay values compared with unbound plasma concentrations of thioridazine and thioridazine metabolites in psychiatric patients

Neuroleptic drug concentrations at the receptor sites are likely to be reflected more closely by the unbound than by the total plasma concentrations. The aim of this study was to establish whether or not the unbound plasma concentrations of thioridazine and its main nonconjugated metabolites show a stronger correlation to the red blood cell (RBC) concentration than to the total plasma concentration of the drug. The total and unbound plasma concentrations and the RBC concentrations of thioridazine and its metabolites were therefore determined in thioridazine-treated patients. "Calculated unbound concentration values" were derived from the determined total concentrations of the drug, the concentrations of drug-binding proteins, and previously determined kappa values. Since the RBC concentrations showed the best correlation to the unbound plasma values, they may be a more accurate tool than the total plasma concentrations for monitoring thioridazine treatment. The determined unbound plasma concentrations were better correlated to the calculated unbound concentrations than to the total plasma concentrations. The total plasma concentrations, but neither the unbound plasma nor the RBC concentrations, were significantly correlated to the concentrations of the drug-binding protein alpha 1-acid glycoprotein. Radioreceptor assay values were strongly correlated to the weighted sum of the total and unbound plasma concentrations of thioridazine and its metabolites.

Patterns of response to neuroleptic treatment: factors influencing the amelioration of individual symptoms in psychotic patients

Fifty-three patients with acute psychotic disorders (diagnosed according to DSM-III) were treated with thioridazine alone and observed during periods of up to 2 months. The amelioration of paranoid ideas and hallucinations (target symptoms) and of concentration difficulties, disorientation, reduced appetite, and reduced sleep (additional symptoms) was studied by repeated psychopathology ratings (CPRS). The patients were classified as "fast, slow or partial responders" according to the therapeutic effect registered on each target symptom. Paranoid ideas disappeared completely after less than 3 weeks of treatment in 28% of the patients (fast responders) and after more than 3 weeks in 32% (slow responders). Hallucinations disappeared significantly faster than paranoid ideas; 47% of the patients were completely free from hallucinations after less than 2 weeks of treatment (fast responders) and 38% after more than 2 weeks (slow responders). The following factors were significantly correlated to positive treatment effects of thioridazine: 1) diagnosis involving a brief history of psychotic symptoms before admission; 2) a low CPRS score for paranoid ideas on admission; 3) presence of disorientation on admission; 4) normal appetite on admission, and 5) rapidly reached optimal serum concentration of the drug.

Concentrations of thioridazine and thioridazine metabolites in erythrocytes

The concentrations of thioridazine and its main metabolites in erythrocytes from 61 thioridazine-treated patients were determined by gas-liquid chromatography. The mean and range of the erythrocyte concentrations, expressed as percentage of the corresponding plasma concentrations, were: thioridazine, 5.1% (2.0-10.6); side-chain sulfoxide, 5.6% (1.6-10.4); side-chain sulfone, 3.3% (1.1-6.8); ring sulfoxide 2.7% (0.8-4.9). The erythrocyte and plasma concentrations were significantly correlated. The erythrocyte/plasma concentration ratios, all the erythrocyte concentrations, but none of the plasma concentrations except ring sulfoxide were significantly positively correlated to the dose of thioridazine. The erythrocyte/plasma concentration ratio was not correlated to age. In vitro experiments indicated no clinically relevant erythrocyte-mediated oxidation of thioridazine.

Mental illness and sex chromosome aberration: renewed interest in light of a current survey

Chromosome determination in 134 men with psychotic disorder revealed sex chromosome aberrations in three patients; one with karyotype 47, XXY, one with 47, XXY/46, XY, and one with 46, XY/45, XO. The frequency of sex chromosome changes in our population (2%) was significantly increased compared to that in newborns. Since sex chromosome aberrations may play an important role in the etiology of psychiatric disorders, chromosome determination should be included among the routine investigations of patients with psychotic symptoms.

Hereditary diffuse leucoencephalopathy with spheroids

The clinical, genetic, and morphological features of a previously unknown progressive neuropsychiatric disease are presented. By genealogical investigation of the background of an uncharacteristic case of presumed organic psychosis, we traced 71 relatives from four generations. The anamnestic data showed various combinations of psychiatric symptoms (depression, anxiety, aggressiveness, and severe dementia), neurological symptoms (impaired balance with retropulsion, hyperkinesia, and epilepsy), and somatic symptoms (gastrointestinal disorders, arthritis, and gynaecological problems) in 17 (11 dead and 6 living) members of the family. Age at onset varied between 8 and 60 years. Some patients rapidly developed severe dementia and died a few months after the onset of symptoms, while in others the course was prolonged with dementia over several decades. The genetic interpretation indicated an autosomal dominant inheritance with possible full penetrance but widely variable expressivity. Morphological studies were performed on the central nervous system of four decreased family members (three siblings and their maternal uncle). The same type of widespread leucoencephalopathy was seen in the four autopsy cases. It was characterised by degeneration and loss of myelin sheaths and axons, occurrence of numerous neuroaxonal spheroids in the affected white matter, accumulation of lipid-laden macrophages, and gliosis. The bilateral, frontal, fronto-parietal, and temporal locations of the most pronounced, diffusely demarcated lesions corresponded fairly well to the symptoms of an organic psychosyndrome with its main substrate in the forebrain. For this new clinico-pathological entity, the name "hereditary diffuse leucoencephalopathy with spheroids" (HDLS) is proposed. As a working hypothesis, it is suggested that not only genetic, but also immunological and possible endocrine factors may contribute to the development of the disease.

Neurofibromatosis in monozygotic twins: a case report

A case report is given of a pair of monozygotic twin girls with neurofibromatosis caused by a new mutation. The symptomatology was dominated by a neurofibrosarcoma on the leg of one twin and by a large plexiform neurofibroma on the neck of the other twin. Otherwise, the disease showed similar, although not identical or mirror-image distribution of subcutaneous neurofibromas and café-au-lait spots. The twins had identical HLA and blood group antigens and the same chromosome aberration. These case reports indicate that nonhereditary factors may influence the manifestations of neurofibromatosis. A review of the literature on monozygotic twins with neurofibromatosis is given.

Serum concentration and protein binding of thioridazine and its metabolites in patients with chronic alcoholism

The blood chemistry and clinical pharmacokinetics of thioridazine and its metabolites, side-chain sulphoxide, side-chain sulphone and ring sulphoxide, were studied in 31 alcoholics and were compared with values in 17 thioridazine-treated controls without alcoholism. Pathological blood chemistry values, including abnormal liver function and protein concentrations, were common among the alcoholics. In relation to dosage, the majority had a low serum concentration of thioridazine and at a given concentration of thioridazine they had high serum concentrations of its metabolites. Positive intercorrelations were found between pathological liver function tests, prolonged serum half-life and increased serum concentration of thioridazine. The free fractions of thioridazine, side-chain sulphoxide and ring sulphoxide were significantly higher and those of the side-chain sulphone lower in the alcoholics than in the controls. The free fractions of side-chain and ring sulphoxide were significantly increased in patients with a low concentration of alpha 1-acid glycoprotein.

Impairment of the blood-brain barrier as an aetiological factor in paranoid psychosis

Possible psychiatric implications of impairment of the blood-brain barrier were studied in 25 patients with paranoid psychosis. Determination of the ratio between the albumin concentrations in cerebrospinal fluid and serum showed increased, indicating impairment of the blood-brain barrier, in seven patients and normal values in 18. The two groups were compared for clinical, pharmacokinetic, neurophysiological and anamnestic variables. The highly significant finding that onset of psychosis had occurred, on average, 20 years earlier in the patients with impairment of the blood-brain barrier than in those without suggests that such impairment might influence the development of psychosis in predisposed individuals.

Electrocardiographic changes and serum concentrations in thioridazine-treated patients

Electrocardiograms and serum concentrations of thioridazine and its metabolites were studied in 43 patients with paranoid psychosis. Two types of T-wave changes were distinguished: Type I with rounded, leveled, or notched T-waves, and Types II with diphasic waves. Significant positive correlations were found between serum drug concentrations and the Type I changes, while the Type II changes showed no concentration dependence. The two types of T-wave changes also differed in respect of prevalence, time of onset, duration, and variation with sex. The ECG response to thioridazine provides useful information about the serum drug concentrations.