Sex disparate gut microbiome and metabolome perturbations precede disease progression in a mouse model of Rett syndrome

Rett syndrome (RTT) is a regressive neurodevelopmental disorder in girls, characterized by multisystem complications including gut dysbiosis and altered metabolism. While RTT is known to be caused by mutations in the X-linked gene MECP2, the intermediate molecular pathways of progressive disease phenotypes are unknown. Mecp2 deficient rodents used to model RTT pathophysiology in most prior studies have been male. Thus, we utilized a patient-relevant mouse model of RTT to longitudinally profile the gut microbiome and metabolome across disease progression in both sexes. Fecal metabolites were altered in Mecp2e1 mutant females before onset of neuromotor phenotypes and correlated with lipid deficiencies in brain, results not observed in males. Females also displayed altered gut microbial communities and an inflammatory profile that were more consistent with RTT patients than males. These findings identify new molecular pathways of RTT disease progression and demonstrate the relevance of further study in female Mecp2 animal models.

Behavioural activation therapy for post-stroke depression: the BEADS feasibility RCT

BACKGROUND

There is currently insufficient evidence for the clinical effectiveness and cost-effectiveness of psychological therapies for post-stroke depression.

OBJECTIVE

To evaluate the feasibility of undertaking a definitive trial to evaluate the clinical effectiveness and cost-effectiveness of behavioural activation (BA) compared with usual stroke care for treating post-stroke depression.

DESIGN

Parallel-group, feasibility, multicentre, randomised controlled trial with nested qualitative research and a health economic evaluation.

SETTING

Acute and community stroke services in three sites in England.

PARTICIPANTS

Community-dwelling adults 3 months to 5 years post stroke who are depressed, as determined by the Patient Health Questionnaire-9 (PHQ-9) or the Visual Analogue Mood Scales 'Sad' item. Exclusions: patients who are blind and/or deaf, have dementia, are unable to communicate in English, do not have mental capacity to consent, are receiving treatment for depression at the time of stroke onset or are currently receiving psychological intervention.

RANDOMISATION AND BLINDING

Participants were randomised (1 : 1 ratio) to BA or usual stroke care. Randomisation was conducted using a computer-generated list with random permuted blocks of varying sizes, stratified by site. Participants and therapists were aware of the allocation, but outcome assessors were blind.

INTERVENTIONS

The intervention arm received up to 15 sessions of BA over 4 months. BA aims to improve mood by increasing people's level of enjoyable or valued activities. The control arm received usual care only.

MAIN OUTCOME MEASURES

Primary feasibility outcomes concerned feasibility of recruitment to the main trial, acceptability of research procedures and measures, appropriateness of baseline and outcome measures, retention of participants and potential value of conducting the definitive trial. Secondary feasibility outcomes concerned the delivery of the intervention. The primary clinical outcome 6 months post randomisation was the PHQ-9. Secondary clinical outcomes were Stroke Aphasic Depression Questionnaire - Hospital version, Nottingham Leisure Questionnaire, Nottingham Extended Activities of Daily Living, Carer Strain Index, EuroQol-5 Dimensions, five-level version and health-care resource use questionnaire.

RESULTS

Forty-eight participants were recruited in 27 centre-months of recruitment, at a recruitment rate of 1.8 participants per centre per month. The 25 participants randomised to receive BA attended a mean of 8.5 therapy sessions [standard deviation (SD) 4.4 therapy sessions]; 23 participants were allocated to usual care. Outcome assessments were completed by 39 (81%) participants (BA, n = 18; usual care, n = 21). Mean PHQ-9 scores at 6-month follow-up were 10.1 points (SD 6.9 points) and 14.4 points (SD 5.1 points) in the BA and control groups, respectively, a difference of -3.8 (95% confidence interval -6.9 to -0.6) after adjusting for baseline PHQ-9 score and centre, representing a reduction in depression in the BA arm. Therapy was delivered as intended. BA was acceptable to participants, carers and therapists. Value-of-information analysis indicates that the benefits of conducting a definitive trial would be likely to outweigh the costs. It is estimated that a sample size of between 580 and 623 participants would be needed for a definitive trial.

LIMITATIONS

Target recruitment was not achieved, although we identified methods to improve recruitment.

CONCLUSIONS

The Behavioural Activation Therapy for Depression after Stroke trial was feasible with regard to the majority of outcomes. The outstanding issue is whether or not a sufficient number of participants could be recruited within a reasonable time frame for a definitive trial. Future work is required to identify whether or not there are sufficient sites that are able to deliver the services required for a definitive trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12715175.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 47. See the NIHR Journals Library website for further project information.

Biomagnetic characterization of spatiotemporal parameters of the gastric slow wave

Certain gastric disorders affect spatiotemporal parameters of the gastric slow wave. Whereas the electrogastrogram (EGG) evaluates electric potentials to determine primarily temporal parameters, fundamental physical limitations imposed by the volume conduction properties of the abdomen suggest the evaluation of gastric magnetic fields. We used a multichannel superconducting quantum interference device magnetometer to study the magnetogastrogram (MGG) in 20 normal human subjects before and after a test meal. We computed the frequency and amplitude parameters of the gastric slow wave from MGG. We identified normal gastric slow wave activity with a frequency of 2.6 +/- 0.5 cycles per minute (cpm) preprandial and 2.8 +/- 0.3 cpm postprandial. In addition to frequency and amplitude, the use of surface current density mapping applied to the multichannel MGG allowed us to visualize the propagating slow wave and compute its propagation velocity (6.6 +/- 1.0 mm s(-1) preprandial and 7.4 +/- 0.4 mm s(-1) postprandial). Whereas MGG and EGG signals exhibited strong correlation, there was very little correlation between the MGG and manometry. The MGG not only records frequency dynamics of the gastric slow wave, but also characterizes gastric propagation. The MGG primarily reflects the underlying gastric electrical activity, but not its mechanical activity.

Simple graphical methods of displaying multiple clinical results

A common challenge in clinical research trials is for applied statistics to manage, analyse, summarize and report an enormous amount of data. Nowadays, due to advances in medical technology, situations frequently arise where it is difficult to display and interpret results. Consequently, a creative approach is required to summarize the main outcomes of the statistical analyses in a form which is easy to grasp, to interpret and possibly to remember. In this paper a number of clinical case studies are provided. Firstly, a topographical map of the brain summarizing P-values obtained from comparisons across different EEG sites; secondly, a bulls eye plot, showing the agreement between observers in different regions of the heart; thirdly, a pictorial table reporting inter- and intra-rater reliability scores of a speech assessment; fourthly a star-plot to deal with numerous questionnaire results and finally a correlogram to illustrate significant correlation values between two diagnostic tools. The intention of this paper is to encourage the effort of visual representations of multiple statistical outcomes. Such representations do not only embellish the report, but aid interpretation by conveying a specific statistical meaning.

Childhood trauma has dose-effect relationship with dropping out from psychotherapeutic treatment for bulimia nervosa: a replication

OBJECTIVE

The primary goal of this study was to replicate the finding that experiences of childhood trauma have a dose-effect relationship with dropping out from psychotherapeutic treatment for bulimia nervosa. It also aimed to replicate logistic regression findings that parental break-up predicts dropping out.

METHOD

The cohort consisted of 114 women consecutively presenting to an outpatient eating disorders clinic with bulimia nervosa or atypical bulimia nervosa. Data were gathered using a retrospective, case-note approach and were analysed using logistic regression (LR). A correlation technique was employed to assess the presence of a dose-effect relationship between experiences of trauma in childhood and dropping out. LR models were double cross-validated between this and an earlier cohort.

RESULTS

The dose-effect relationship between experiences of childhood trauma and dropping out was confirmed. Witnessing parental break-up in childhood again predicted dropping out of treatment in adulthood. Cross-validation of LR equations was unsuccessful.

DISCUSSION

These results strongly suggest that experiences of childhood trauma have a dose-effect relationship with dropping out. Parental break-up is a stable predictor of dropping out. It is possible that these experiences influence attachment style, particularly the ability to make and maintain a trusting relationship with a psychotherapist. Clinical implications are discussed.

Do broken relationships in childhood relate to bulimic women breaking off psychotherapy in adulthood?

OBJECTIVE/METHOD

The case notes of 111 women presenting consecutively to an outpatient eating disorders clinic with bulimia nervosa or atypical bulimia nervosa were reviewed for pretreatment factors that predicted dropout in a retrospective study. Dropping out was conceptualized as not just a patient characteristic but as a transaction between patient and therapist. Factors believed to influence this transaction included experiences of childhood trauma, severity of eating disorder characteristics and comorbid psychiatric symptoms, demographic characteristics, waiting times for assessment and therapy, distance traveled to the clinic, previous experience of psychiatric treatment, and Eating Disorder Inventory (EDI) and Rosenberg Self-Esteem questionnaire results.

RESULTS

Witnessing parental breakup, being younger, being employed outside the home, and having previous experience of psychiatric treatment predicted dropping out in logistic regression models. Experiences of childhood trauma had a dose-effect relationship with dropping out. Having lower overall severity of eating disorder characteristics may also relate to dropping out.

DISCUSSION

An impaired ability to trust resulting from disturbed attachments may link childhood trauma and dropping out.

Prevalence of thiamin deficiency in anorexia nervosa

OBJECTIVE

Deficiency of thiamin (vitamin B1) causes a range of neuropsychiatric symptoms that resemble those reported in patients with anorexia nervosa (AN) but the prevalence of thiamin deficiency in AN has not been reliably established. This study was designed to investigate the prevalence of thiamin deficiency in AN.

METHOD

Thirty-seven patients attending a specialist eating disorders unit and meeting all or some of the DSM-IV criteria for AN were compared with 50 blood donor controls. All subjects underwent measurement of erythrocyte transketolase activation following the addition of thiamin pyrophosphate, the standard biochemical test for thiamin deficiency. Deficiency was defined as a result more than 2 SD above the mean of the control population.

RESULTS

Fourteen patients (38%) had results in the deficient range; 7 (19%) met the most stringent published criterion for deficiency. Deficiency was not related to duration of eating restraint, frequency of vomiting, or alcohol consumption.

DISCUSSION

Thiamin deficiency may account for some of the neuropsychiatric symptoms of AN and routine screening or supplementation may be indicated.

The childhood and family background of women with clinical eating disorders: a comparison with women with major depression and women without psychiatric disorder

BACKGROUND

Childhood antecedents are often put forward as being of possible aetiological significance for both anorexia nervosa and bulimia nervosa.

METHOD

Comparisons were made of groups of women with eating disorders with groups of women with major depression or without current psychiatric disorder, using the Childhood Experience of Care and Abuse interview (CECA).

RESULTS

Women with bulimia nervosa (or mixed bulimia and anorexia nervosa) tended to report more troubled childhood experiences than did women from the non-morbid comparison group. In this respect, they resembled those with major depression. In contrast, those with anorexia nervosa resembled the non-morbid women rather than the other psychiatric groups.

CONCLUSIONS

Adversity in childhood as measured by the CECA may play a part in the causation of bulimia nervosa but not of anorexia nervosa. It remains possible that more specific or subtle family influences may be relevant.

The prevalence and correlates of binge eating in a British community sample of women with a history of obesity

OBJECTIVE

To estimate the frequency of binge eating and binge eating disorder and their correlates in a sample of women with a history of obesity.

METHOD

A group of women who had been found in a previous community study to have a body mass index > or = 30 were studied using self-report measures (n = 74) and interview (n = 62).

RESULTS

One subject met criteria for binge eating disorder, while 24% reported binging. Subjects who reported binging were significantly more likely to have a past history of depressive illness.

DISCUSSION

Prevalence of binge eating, binge eating disorder, and psychopathology was broadly in keeping with that found in North America. In addition, there were nonsignificant trends towards a positive family history of obesity, of childhood obesity, of early onset of dieting, of excessive concern about weight and shape, and a recent history of weight reduction. Further study is required to elucidate the causes of binge eating in the obese.

Anorexia nervosa and bulimia nervosa: sibling sex ratio and birth rank--a catchment area study

OBJECTIVES

These were to determine (1) whether there is a birth rank effect in eating disorders, and (2) whether all-female sibships are overrepresented in the families of those with eating disorders.

METHOD

The study sample consisted of 293 female patients referred from a defined catchment area, the County of Leicester, United Kingdom, to an eating disorders clinic. Diagnoses were made using DSM-III and DSM-III-R. To discern birth rank effect, this core sample was expanded to one of 673 by adding published data sets to our own.

RESULTS

No evidence for either effect was found.

DISCUSSION

Biases which may have obscured genuine effects are discussed. A comment is made on the implication for family theories of causation of these negative findings.

Childhood sexual experiences with adults: adult male psychiatric patients and general practice attenders

BACKGROUND

Sexual abuse of male children is now believed to be common, and there may be links to adult psychiatric disorders.

METHOD

Recollections of sexual experiences with adults in childhood were studied systematically in 115 men attending general practice surgeries and 100 male psychiatric patients.

RESULTS

The latter reported more frequent and more serious events before the age of 13 than the general practice attenders. No significant difference was detected for events between the ages of 13 and 15.

CONCLUSIONS

Childhood sexual abuse before the age of 13 may be associated with later psychiatric disorders, although the nature of the association remains uncertain. The possible significance of such experiences should be considered when assessing men with mental disorders.

Attention deficit disorder in children: three clinical variants

A clinic-referred population of 116 children with attentional problems was classified by DSM-III [attention deficit disorder (ADD)] with respect to inattention, impulsivity, and hyperactivity. The sample proved to subdivide into three groups: inattentive, impulsive, and hyperactive (HII), n = 60; inattentive and impulsive (II), n = 26; and inattentive (I), n = 30. The distinction between II and I resolves the confounding of impulsivity and inattention in previous studies of children who have ADD but are not hyperactive. The three groups were found to be similar in mean age, gender ratio, prevalence, and pattern of associated learning disabilities, family history of psychopathology, and probability of favorable response to methylphenidate. Group I differed from Groups HII and II in the frequency of externalizing relative to internalizing comorbid psychopathology. A group that is hyperactive and impulsive but not inattentive was not found. The preponderance of similarities in associated characteristics suggests that the three groups are differing clinical presentations of an ADD spectrum.

Weight concern should not be a necessary criterion for the eating disorders: a polemic

Problems associated with the inclusion of weight concern as a necessary and defining criterion for the diagnosis of the eating disorders are reviewed. It is proposed that the substitution of the criterion of eating restraint that is overinvested by the subject might have advantages for both clinical classification and for research.

Childhood sexual experiences with adults. A comparison of reports by women psychiatric patients and general-practice attenders

Reports of childhood sexual experiences with adults were collected from 120 women attending general-practice surgeries and 115 women psychiatric patients. The method of study, research team and county of residence were the same for the two groups. The psychiatric patients tended to report rates of events higher than the general-practice attenders by a factor of 2-3. The results suggest an association between such experiences and later psychiatric patienthood and are compatible with a causal role for them in some cases.

Who benefits from electroconvulsive therapy? Combined results of the Leicester and Northwick Park trials

This paper describes the results obtained by combining data from the Northwick Park and Leicester randomised controlled trials of ECT. Patients who suffered from depression in which retardation and delusions were features and who received real ECT had a significantly improved outcome at the end of four weeks of treatment (as measured by improvement in the HRSD) in comparison with those who received simulated ECT. However, this treatment effect was not detectable at six-month follow-up. Patients who were neither retarded nor deluded did not benefit significantly from real as opposed to simulated ECT.

Childhood sexual experiences with adults reported by female psychiatric patients

A group of 115 female psychiatric in-patients and out-patients were studied, using a self-report questionnaire followed by interview, for evidence of childhood sexual activity with adults. About half of the sample reported some childhood sexual experience, ranging from full sexual intercourse to sexual suggestions. Future research should study the possible role of such experience in the genesis of subsequent psychiatric disorder.

Changes in beta-1,3-Glucan Synthase Activity in Developing Lima Bean Plants

A plasma membrane-enriched fraction was isolated from various tissues of developing lima bean seedlings, Phaseolus lunatus var Cangreen, to study beta-1,3-glucan synthase activity changes. All tissues contained an active beta-glucan synthase, including the cotyledons that will be senescent in mature lima bean plants. Young primary leaves exhibited a very active beta-glucan synthase; but this activity dropped markedly, about fivefold, as the leaves gained weight and became photosynthetic. Some tissues, such as the hypocotyl and young stem, exhibited an increase in beta-glucan synthase activity as the tissues were growing and a decrease as the growth rate slowed. Roots exhibited a high activity early in development that only decreased slightly, about 30%, as root growth increased. Surprisingly the senescent cotyledons contained an activity equivalent to some other tissues that was maintained over our measurement time of 21 days. Perhaps this callose synthesis activity is related to translocation processes as the cotyledons transfer their reserves to the growing seedling. We concluded that beta-glucan synthase was not a good indicator of sink strength in these lima bean tissues. The plasma membrane fractions also were tested for other enzymes that might be present because an electron microscope study revealed a low contamination by other types of membranes. The membrane fractions had low but detectable activities of sucrose synthase, UDPglucose pyrophosphorylase, UDPase, alkaline invertase, and a general phosphatase; but these enzymes exhibited no consistent pattern(s) of activity change with plant development.

Neuropsychological deficits in adults with dyslexia

Adults with severe dyslexia were compared with age-, sex-, IQ- and SES-matched controls on a neuropsychological and neuromotor test battery, and a contrast group who had recovered from dyslexia was also included. The severely dyslexic group was substantially impaired on tests of verbal fluency and learning, as well as on non-verbal temporal order judgements. These test scores were strong predictors of the degree of reading impairment, as was the rate of repetitive movement of the right hand and foot. The results suggest that adult dyslexia is not 'isolated', but is one expression of a widespread left-hemisphere dysfunction.

Childhood sexual experiences reported by male psychiatric patients

One hundred adult male psychiatric patients were investigated concerning their recollections of defined sexual activities occurring with adults before the age of sixteen. Twenty-three subjects reported such events. The events were remembered as having been mostly distressing at the time but their later significance is unclear.

Childhood sexual experiences with adults reported by women with eating disorders: an extended series

A total of 158 women presenting with clinical eating disorders have been investigated using a self-report questionnaire and subsequent interview concerning their recollections of sexual experiences with adults before the age of 16 and later adverse sexual experiences. About a third reported events in childhood and over half described some adverse experiences. It may be that these experiences are relevant to the subsequent illness in some cases, but greater certainty must await further research. In the meantime, inquiring about such matters would seem to be advisable in the assessment and therapy of eating-disordered patients.

Automatic-effortful processing and cognitive inertia in persons with mental retardation

A modified Stroop Color-Word Interference Test (Stroop, 1935) was used to assess automatic-effortful processing in persons with mental retardation and college students in three experiments. In Experiment 1, retarded persons experienced greater Stroop interference than did college students. This was attributed to a failure of control (effortful) processing needed to suppress the automatic reading responses of retarded subjects. In Experiments 2 and 3, all subjects practiced the Stroop color-naming task over three or four daily sessions. Changes in Stroop interference over practice were viewed as reflecting automatization of the suppression of the reading response. Both groups automatized the suppression response at about the same rate, but the automatized responses had far greater and more durable suppression effects for retarded subjects. This persistence of automatized responses, which were no longer adaptive, was described as cognitive inertia, a phenomenon similar to cognitive rigidity as defined by Kounin (1948).

Pseudomonas aeruginosa cytotoxin stimulates secretion of amylase and protease zymogens with a concomitant decrease of mRNA levels in isolated rat pancreatic acini

The action of Pseudomonas aeruginosa cytotoxin on isolated pancreatic acini was investigated. The release of amylase and serine protease zymogens from the isolated rat pancreatic acini was induced with increasing amounts of cytotoxin in vitro. The stimulated release of amylase reached 30% of total cellular content with 100 micrograms/mL of the purified cytotoxin. The induced release of amylase, trypsinogen, proelastase, and chymotrypsinogen reached the maximum after 75 minutes of incubation while lactate dehydrogenase began to appear after 15 minutes of incubation with a secondary biphasic increase at 75 min of incubation. The concentrations of acinar mRNAs of amylase, trypsinogen, proelastase, and chymotrypsinogen, as measured by dot-blot hybridization with the cloned cDNAs of amylase, trypsinogen I, proelastase II, and chymotrypsinogen B of the rat, decreased with time and were significantly lower than in the untreated acini. It is concluded that cytotoxin stimulates the release of amylase and protease zymogens with a concomitant increase in membrane permeability and a decrease of cellular mRNA levels. The inhibition of gene expression is attributable merely to a generalized toxic effect upon cellular metabolism.

Changes in the C-Labeled Cell Wall Components with Chase Time after Incorporation of UDP[C]Glucose by Intact Cotton Fibers

Intact, in vitro-grown cotton fibers will incorporate [(14)C]glucose from externally supplied UDP[(14)C]glucose into a variety of cell wall components including cellulose; this labeled fraction will continue to increase up to 4 hours chase time. In the fraction soluble in hot water there was no significant change in total label; however, the largest fraction after the 30 minute pulse with UDP[(14)C]glucose was chloroform-methanol soluble (70%) and showed a significant decrease with chase. The lipids that make up about 85% of this fraction were identified by TLC as steryl glucosides, acylated steryl glucosides, and glucosyl-phosphoryl-polyprenol. Following the pulse, the loss of label from acylated steryl glucosides and glucosylphophoryl-polyprenol was almost complete within 2 hours of chase; steryl glucosides made up about 85% of the fraction at that chase time. The total loss in the lipid fraction (about 100 picomoles per milligram dry weight of fiber) with chase times of 4 hours approximates the total gain in the total glucans.

Incorporation of UDPGlucose into Cell Wall Glucans and Lipids by Intact Cotton Fibers

The [(14)C] moiety from [(3)H]UDP[(14)C]glucose was incorporated by intact cotton fibers into hot water soluble, acetic-nitric reagent soluble and insoluble components, and chloroform-methanol soluble lipids; the [(3)H] UDP moiety was not incorporated. The (3)H-label can be exchanged rapidly with unlabeled substrate in a chase experiment. The cell wall apparent free space of cotton fibers was in the order of 30 picomoles per milligram of dry fibers; 25 picomoles per milligram easily exchanged and about 5 picomoles per milligram more tightly adsorbed. At 50 micromolar UDPglucose, 70% of the [(14)C]glucose was found in the lipid fraction after both a short labeling period and chase. The percent of [(14)C]glucose incorporated into total glucan increased slightly with chase, but the fraction of total glucans incorporated into insoluble acetic-nitric reagent (cellulose) did increase within a 30-minute chase period. The data supports the concept that glucan synthesis, including cellulose, as well as the synthesis of steryl glucosides, acetylated steryl glucosides, and glucosyl-phosphoryl-polyprenol from externally supplied UDPglucose occurs at the plasma membrane-cell wall interface. The synthase enzymes for such synthesis must be part of this interfacial membrane system.

Eating attitudes and disorder in young women: a general practice based survey

A postal survey with selected follow-up interviews was conducted on a complete population of females aged 18-22 registered with two group general practices in Leicestershire. The mailing included the Eating Attitudes Test (EAT) and the Crown-Crisp Experiential Index (CCEI). There was a 70% response rate and 411 usable questionnaires were returned. Twenty-eight respondents (6.8%) produced EAT scores of 30 or more. One case of anorexia nervosa and one of bulimia were identified. Interviews of high EAT scoring subjects revealed several subjects with partial syndromes which failed to fulfil diagnostic criteria for either clinical eating disorder.

The TRH test in bulimia and anorexia nervosa: a controlled study

TSH responsiveness to 500 micrograms TRH given intravenously was examined in ten bulimic outpatients, nine anorexic in-patients and a group of age matched healthy subjects. Serum TSH levels were measured by means of a sensitive radioimmune assay. There were no group differences between bulimic subjects and the healthy comparison group. Anorexic subjects at low weight showed a delayed response to TRH, which tended to normalize with weight gain. Bulimic subjects showed varied patterns of response and it remains possible that a sub-group of bulimic patients may have an abnormality of response to TRH.

Adverse sexual experience in childhood and clinical eating disorders: a preliminary description

Seventy-eight eating disordered patients were asked systematically about any history of adverse sexual experience. About two thirds gave such a history. The events reported were often distressing and significant to the subject. It is unclear what role such events play in the causation of later eating disorder.

Laboratory diagnosis of bleeding disorders. Basic screening tests

Five studies are important to the diagnosis of bleeding disorders: bleeding time (BT) (Simplate), platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), and thrombin time (TT). If the platelet count alone is low, the cause is usually peripheral destruction of platelets, immunothrombocytopenia, or an abnormality of bone marrow production. An abnormal bleeding time alone suggests a platelet aggregation defect that is most likely due to medication. When the aPTT is the only abnormal test and the patient has a definite history of bleeding, one of the hemophiliac states is present. An abnormal PT, with or without an abnormal aPTT but with normal results in the other three tests, indicates an abnormal reduction in the vitamin K-dependent clotting factors (II, VII, IX, X) or factor V. When the TT is abnormal, disseminated intravascular coagulation, the presence of plasma heparin, or a hepatopathy should be suspected.

Institutional care for the elderly: the impact and implications of the ageing population

Two cross-sectional studies three years apart assessed functional capacity in everyone aged 65 years and over in any ward, hospital, home or hostel in a defined geographical area. Comparison of the proportion of patients aged 65-74 years, 75-84 years and 85 years and over within these institutions showed that a higher proportion of the very elderly were in homes for the elderly and a lower proportion in National Health Service (NHS) geriatric hospital beds in the later time period. Greater proportions of all age groups of the elderly were in NHS acute hospital beds. Levels of incapacity in these people had increased between 1976 and 1979. In continuously resident people the proportion remaining unchanged fell and the extent of deterioration increased with greater age: among recent admissions significant increases in incapacity were only seen in patients in NHS geriatric hospitals. At present the demands of the ageing population are such that old people will be admitted where places are available even if the setting is not entirely appropriate to their needs. Restrictive admission policies on the part of residential homes will not reduce levels of incapacity if they continue to admit older residents.

Eating attitudes and neurotic symptoms in university students

A postal survey of male and female university students is reported, using the Eating Attitude Test (EAT) and the Crown Crisp Experiential Index (CCEI). Eleven per cent of the 156 female respondents but none of 120 males scored above 30 on the EAT, thereby declaring eating attitudes comparable to anorexic subjects. Of those interviewed, none fulfilled diagnostic criteria for anorexia nervosa, but half showed eating disorder of clinical severity. There was a clear association between high EAT scores and higher scores on all the subscales of the CCEI except the phobic scale. The results are discussed in relation to ideas about the possible origins of clinical eating disorders.

Patterns of self-reported symptoms in chronic psychiatric patients

The patterns of self-reported symptoms in 103 chronic psychiatric patients were examined using the Delusions-Symptoms-Sign Inventory (DSSI). The subjects were all those able to co-operate drawn from the total population of psychiatric patients in Leicestershire who had been in continuous in-patient or day-patient care for over one year. A majority reported dysthymic symptoms and some sort of delusions. Three-quarters produced patterns of response predicted by the hierarchy hypothesis of Foulds.

Pyrimidine Pathway in Boron-deficient Cotton Fiber

Cotton ovules cultured in an insufficiency of boron (10 micromolar), showed inhibition of fiber growth by the ninth day in culture. Averaging data from eight to eleven days of culture under these conditions, total incorporation of [6-(14)C]orotic acid into fiber was inhibited by 59%. Inhibition was evident in all radioactively labeled pools, indicating that the effect may be at the membrane transport level or at an early stage of orotic acid metabolism. On a per cent basis, incorporation into RNA under boron deficiency was higher than under sufficiency. The effect is greater on the eighth day of culture, with a decreasing difference from controls up to the eleventh day. Conversely, the per cent incorporation into UDP-glucose was lower under boron deficiency than in controls, having a more or less constant value from 8 to 11 days of culture. Thus, a primary event of boron deficiency in cotton fiber culture is an alteration in the flow of metabolites through the pyrimidine synthesis pathway.

Effect of Boron on the Incorporation of Glucose from UDP-Glucose into Cotton Fibers Grown in Vitro

Boron is required for fiber growth and development in cotton ovules cultured in vitro. Incorporation of [(14)C]glucose by such fiber from supplied UDP-[(14)C]glucose into the hot alkali-insoluble fraction is rapid and linear for about 30 minutes. Incorporation of [(14)C]glucose from such substrate by fibers grown in boron-deficient ovule cultures is much less than in the case with fibers from ovules cultured with boron in the medium. Total products (alkali-soluble plus alkali-insoluble fractions) were also greater in fibers from ovules cultured with boron. The fraction insoluble in acetic-nitric reagent was a small part of the total glucans; however, in the boron-sufficient fibers, there was significantly more of this fraction than in fibers from boron-deficient ovule cultures. The hot water-soluble glucose polymers from the labeled fibers had a significant fraction of the total [(14)C]glucose incorporated from UDP-[(14)C]glucose. Both beta-1,4- and beta-1,3- water-soluble polymers were formed in the boron-sufficient fibers, whereas the same water-soluble fraction from the boron-deficient fibers was predominantly beta-1,3-polymers. The incorporation of [(14)C]glucose from GDP-[(14)C]glucose by the fibers attached to the ovules was insignificant.

The dietary chaos syndrome: a useful new term?

Following typical primary anorexia nervosa some subjects enter a state characterized by disordered eating behaviour and emotional instability whilst remaining at or above a normal weight. Other subjects may reach a similar position without having been in a state of anorexia nervosa. Surprisingly the state seems to lack a satisfactory name. The term 'Dietary chaos syndrome' is proposed.

Adriamycin in combination for the treatment of breast cancer: a Southwest Oncology Group study

Patients with advanced breast cancer who had not previously received chemotherapy were treated on a three-arm prospective study: adriamycin day 1 plus 5-FU on day 1 and 8 (AF), adriamycin day 1, plus 5-FU day 1 and 8, and cyclophosphamide day 1 (AFC), and adriamycin day 1 plus 5-FU day 1 and 8, cyclophosphamide day 1 and methotrexate day 1 (AFCM). These courses were repeated every 21 days. The response rate was 44/105 (42%) AF, 44/103 (43%) AFC and 52/105 (49%) AFCM. The length of response was 22, 33 and 35 weeks, respectively, for AF, AFC and AFCM (P = 0.21). The median survival, 64 weeks, was equal in all three limbs. The major toxicity was leukopenia. Twenty-eight percent developed a WBC of less than 2,000/microliter, which resulted in seven deaths (2.2%).

Comparative trial of combination chemotherapy in extensive squamous carcinoma of the lung: a Southwest Oncology Group Study

The Southwest Oncology Group carried out a comparative study of two combination chemotherapy regimens in 231 patients with extensive squamous carcinoma of the lung. One regimen consisted of bleomycin, adriamycin, CCNU, vincristine, and mechlorethamine (BACON). The other involved mechlorethamine, adriamycin, and CCNU (NAC) in the same dose and schedule but with the deletion of vincristine and bleomycin. The response rate was 21% for BACON and 16% for NAC. The median survival time (MST) was 16 weeks for all patients receiving each regimen. Pretreatment performance statues (PS) was significantly related to the response rates: these were 28% for BACON and 23% for NAC among fully ambulatory patients (PS, 8-10) versus 15% for BACON and 10% for NAC among those with a lesser PS (P less than 0.05). Survival was also influenced by PS; the MST was 28 weeks for PSs 8-10 with either regimen compared to an overall MST of 11.5 weeks for patients with PSs 5-7 and 2.8 weeks for PSs 1-4. The toxicity of the two regimens was comparable with a 4% incidence of treatment-related deaths. An additional 10% of the patients were hospitalized because of life-threatening but reversible toxic effects. The only patients for whom there may be an improvement in MST over that expected from supportive care alone are those with PSs 8-10. Patients who demonstrated response or improvement, regardless of PS, had a significantly longer MST: 39.5 versus 11.2 weeks for those who did not respond (P = 0.001).

Intravascular coagulation and fibrinolysis

Intravascular coagulation occurs as a sequela of many diverse conditions and may vary greatly in clinical and laboratory manifestations. The essence of the problem is that plasma is converted to serum in the circulation. As a result, both hemorrhagic and thrombotic events may occur. Platelet count and fibrinogen determination are the most important diagnostic tests. If values are abnormal, tests for fibrin (fibrinogen) degradation products are indicated. The first step in management is to identify and attempt to eliminate the underlying cause. Heparin therapy should be considered, particularly when clotting and severe fibrinolysis are both present. Replacement of clotting factors may be considered, but its value is a matter of debate.