A CRISPR/Cas9-Engineered ARID1A-Deficient Human Gastric Cancer Organoid Model Reveals Essential and Nonessential Modes of Oncogenic Transformation

Mutations in ARID1A rank among the most common molecular aberrations in human cancer. However, oncogenic consequences of ARID1A mutation in human cells remain poorly defined due to lack of forward genetic models. Here, CRISPR/Cas9-mediated ARID1A knockout (KO) in primary TP53-/- human gastric organoids induced morphologic dysplasia, tumorigenicity, and mucinous differentiation. Genetic WNT/β-catenin activation rescued mucinous differentiation, but not hyperproliferation, suggesting alternative pathways of ARID1A KO-mediated transformation. ARID1A mutation induced transcriptional regulatory modules characteristic of microsatellite instability and Epstein-Barr virus-associated subtype human gastric cancer, including FOXM1-associated mitotic genes and BIRC5/survivin. Convergently, high-throughput compound screening indicated selective vulnerability of ARID1A-deficient organoids to inhibition of BIRC5/survivin, functionally implicating this pathway as an essential mediator of ARID1A KO-dependent early-stage gastric tumorigenesis. Overall, we define distinct pathways downstream of oncogenic ARID1A mutation, with nonessential WNT-inhibited mucinous differentiation in parallel with essential transcriptional FOXM1/BIRC5-stimulated proliferation, illustrating the general utility of organoid-based forward genetic cancer analysis in human cells. SIGNIFICANCE: We establish the first human forward genetic modeling of a commonly mutated tumor suppressor gene, ARID1A. Our study integrates diverse modalities including CRISPR/Cas9 genome editing, organoid culture, systems biology, and small-molecule screening to derive novel insights into early transformation mechanisms of ARID1A-deficient gastric cancers.See related commentary by Zafra and Dow, p. 1327.This article is highlighted in the In This Issue feature, p. 1307.

Oncoprotein-specific molecular interaction maps (SigMaps) for cancer network analyses

Tumor-specific elucidation of physical and functional oncoprotein interactions could improve tumorigenic mechanism characterization and therapeutic response prediction. Current interaction models and pathways, however, lack context specificity and are not oncoprotein specific. We introduce SigMaps as context-specific networks, comprising modulators, effectors and cognate binding-partners of a specific oncoprotein. SigMaps are reconstructed de novo by integrating diverse evidence sources-including protein structure, gene expression and mutational profiles-via the OncoSig machine learning framework. We first generated a KRAS-specific SigMap for lung adenocarcinoma, which recapitulated published KRAS biology, identified novel synthetic lethal proteins that were experimentally validated in three-dimensional spheroid models and established uncharacterized crosstalk with RAB/RHO. To show that OncoSig is generalizable, we first inferred SigMaps for the ten most mutated human oncoproteins and then for the full repertoire of 715 proteins in the COSMIC Cancer Gene Census. Taken together, these SigMaps show that the cell's regulatory and signaling architecture is highly tissue specific.

A modular master regulator landscape controls cancer transcriptional identity

Despite considerable efforts, the mechanisms linking genomic alterations to the transcriptional identity of cancer cells remain elusive. Integrative genomic analysis, using a network-based approach, identified 407 master regulator (MR) proteins responsible for canalizing the genetics of individual samples from 20 cohorts in The Cancer Genome Atlas (TCGA) into 112 transcriptionally distinct tumor subtypes. MR proteins could be further organized into 24 pan-cancer, master regulator block modules (MRBs), each regulating key cancer hallmarks and predictive of patient outcome in multiple cohorts. Of all somatic alterations detected in each individual sample, >50% were predicted to induce aberrant MR activity, yielding insight into mechanisms linking tumor genetics and transcriptional identity and establishing non-oncogene dependencies. Genetic and pharmacological validation assays confirmed the predicted effect of upstream mutations and MR activity on downstream cellular identity and phenotype. Thus, co-analysis of mutational and gene expression profiles identified elusive subtypes and provided testable hypothesis for mechanisms mediating the effect of genetic alterations.

A new quinoline-based chemical probe inhibits the autophagy-related cysteine protease ATG4B

The cysteine protease ATG4B is a key component of the autophagy machinery, acting to proteolytically prime and recycle its substrate MAP1LC3B. The roles of ATG4B in cancer and other diseases appear to be context dependent but are still not well understood. To help further explore ATG4B functions and potential therapeutic applications, we employed a chemical biology approach to identify ATG4B inhibitors. Here, we describe the discovery of 4-28, a styrylquinoline identified by a combined computational modeling, in silico screening, high content cell-based screening and biochemical assay approach. A structure-activity relationship study led to the development of a more stable and potent compound LV-320. We demonstrated that LV-320 inhibits ATG4B enzymatic activity, blocks autophagic flux in cells, and is stable, non-toxic and active in vivo. These findings suggest that LV-320 will serve as a relevant chemical tool to study the various roles of ATG4B in cancer and other contexts.

Serum blood metabolite response and evaluation of select organ weight, histology, and cardiac morphology of beef heifers exposed to a dual corticotropin-releasing hormone and vasopressin challenge following supplementation of zilpaterol hydrochloride

The objectives of this study were 1) to determine if supplementation of zilpaterol hydrochloride (ZH) altered select organ weights, histology, and cardiac anatomical features at harvest and 2) to determine if administration of a corticotropin-releasing hormone (CRH) and vasopressin (VP) challenge following 20 d of ZH supplementation altered the blood chemistry profile in cattle. Crossbred heifers ( = 20; 556 ± 7 kg BW) were randomized into 2 treatment groups: 1) control (CON), without ZH, and 2) zilpaterol (ZIL; ZH at 8.33 mg/kg [DM basis] for 20 d). On d 20 of supplementation, heifers were fitted with indwelling jugular catheters. On d 24, starting at 0800 h and continuing until 1600 h, blood samples were collected at 60-min intervals. At 1000 h, heifers received an i.v. bolus of CRH (0.3 µg/kg BW) and VP (1.0 µg/kg BW) to activate the stress axis. Serum was separated and stored at -80°C until analyzed for a large-animal chemistry panel. Following the CRH/VP challenge, heifers were harvested on d 25, 26, and 27 (5, 6, and 7 d after ZH supplementation); BW, HCW, select organ weights, and histology were measured, and a total heart necropsy was performed. A treatment effect ( ≤ 0.02) was observed for Ca, K, creatinine, alkaline phosphatase, and sorbitol dehydrogenase. Zilpaterol-fed heifers had decreased ( ≤ 0.02) concentrations of Ca and K and increased concentrations ( 0.01) of creatinine ( = 0.02) during the CRH/VP challenge when compared to control heifers. Control heifers had greater ( ≤ 0.05) alkaline phosphatase and sorbitol dehydrogenase concentrations when compared with ZIL heifers. A treatment × time interaction ( = 0.02) was observed for P; concentrations were similar between treatments from -2 to 6 h postchallenge, and 7 h postchallenge CON heifers had decreased P. Liver ( = 0.06) and kidney ( = 0.08) weights as a percentage of BW tended ( ≤ 0.08) to be reduced in ZIL heifers. Gross liver weights tended ( = 0.08) to be lower in ZIL heifers. Other organ (heart, lung, adrenals) to BW ratios remained similar ( ≥ 0.41). These data suggest that there are some variations observed between treatments in terms of response to ZH supplementation and the CRH/VP challenge; however, in the environmental conditions of this study, limited variation in blood metabolic responses and organ weights suggests that the supplementation of ZH did not detrimentally alter the physiology of cattle.

Air pollution, deprivation and health: understanding relationships to add value to local air quality management policy and practice in Wales, UK

Background

Air pollution exposure reduces life expectancy. Air pollution, deprivation and poor-health status combinations can create increased and disproportionate disease burdens. Problems and solutions are rarely considered in a broad public health context, but doing so can add value to air quality management efforts by reducing air pollution risks, impacts and inequalities.

Methods

An ecological study assessed small-area associations between air pollution (nitrogen dioxide and particulate matter), deprivation status and health outcomes in Wales, UK.

Results

Air pollution concentrations were highest in 'most' deprived areas. When considered separately, deprivation-health associations were stronger than air pollution-health associations. Considered simultaneously, air pollution added to deprivation-health associations; interactions between air pollution and deprivation modified and strengthened associations with all-cause and respiratory disease mortality, especially in 'most' deprived areas where most-vulnerable people lived and where health needs were greatest.

Conclusion

There is a need to reduce air pollution-related risks for all. However, it is also the case that greater health gains can result from considering local air pollution problems and solutions in the context of wider health-determinants and acting on a better understanding of relationships. Informed and co-ordinated air pollution mitigation and public health action in high deprivation and pollution areas can reduce risks and inequalities. To achieve this, greater public health integration and collaboration in local air quality management policy and practice is needed.

The metabolic, stress axis, and hematology response of zilpaterol hydrochloride supplemented beef heifers when exposed to a dual corticotropin-releasing hormone and vasopressin challenge

The objective of this study was to determine the metabolic, stress, and hematology response of beef heifers supplemented with zilpaterol hydrochloride (ZH) when exposed to an endocrine stress challenge. Heifers ( = 20; 556 ± 7 kg BW) were randomized into 2 treatment groups: 1) control (CON), no ZH supplementation, and 2) zilpaterol (ZIL), supplemented with ZH at 8.33 mg/kg (DM basis). The ZIL group was supplemented ZH for 20 d, with a 3-d withdrawal period. On d 24, heifers received an intravenous bolus of corticotropin-releasing hormone (CRH; 0.3 µg/kg BW) and arginine vasopressin (VP; 1.0 µg/kg BW) to activate the stress axis. Blood samples were collected at 30-min intervals for serum and 60-min intervals for plasma and whole blood, from -2 to 8 h relative to the challenge at 0 h (1000 h). Samples were analyzed for glucose, insulin, NEFA, blood urea nitrogen (BUN), cortisol, epinephrine, norepinephrine, and complete blood cell counts. Following the challenge, cattle were harvested over a 3-d period. Liver, LM, and biceps femoris (BF) samples were collected and analyzed for glucose, lactate, and glycolytic potential (GP). There was a treatment ( ≤ 0.001) effect for vaginal temperature (VT), with ZIL having a 0.1°C decrease in VT when compared with CON. A treatment × time effect ( = 0.002) was observed for NEFA. A treatment effect was observed for BUN; ZIL had decreased BUN concentrations compared with CON ( < 0.001) prior to the challenge; however, no treatment × time effect was observed. There was also a treatment effect for cortisol ( ≤ 0.01) and epinephrine ( = 0.003); ZIL had decreased cortisol and epinephrine during the CRH/VP challenge when compared with CON. There was a time effect for total white blood cells, lymphocytes, and monocytes; each variable increased ( ≤ 0.01) 2 h postchallenge. Additionally, neutrophil counts decreased ( ≤ 0.01) in response to CRH/VP challenge in both treatment groups. Glucose concentrations within the LM were greater ( = 0.03) in CON when compared with ZIL. Lactate concentrations and GP within the BF were greater in CON ( = 0.05) when compared with ZIL. These data suggest there are some variations observed between treatments in terms of response to the CRH/VP challenge; however, in the environmental conditions of this trial, none of the variations observed suggest that the supplementation of ZH detrimentally alters the ability of cattle to effectively respond to stressful stimuli.

Investigating the addition of collagen and its integrin binding sequence (RGD) to glass polyalkenoate: In terms of material and cellular properties to explore a more biocompatible method of root caries restoration

AIMS

Placement of a restoration to treat root caries disrupts many tissues. There is scope for the restorative material to interact with these to augment reductions in micro leakage afforded by an adhesive restorative material.

OBJECTIVES

1) To investigate the effects of incorporating bioactive molecules into a glass polyalkenoate (GPA) 2) To quantify the changes in physical properties of the material.

METHODS

Biocompatibility of the GPA cement (Chemfil Superior, Dentsply De Trey, Konstanz, Germany) in unmodified and modified forms was ascertained using cell culture techniques. The optimum concentration of bioactive components required to promote cell attachment was determined indirectly by quantification and localisation of the fibroblast marker vimentin. The properties of surface hardness, compressive strength and adhesive bond strength were also determined prior to and following addition of the bio-additives: collagen type I and a pentapeptide containing Arg-Gly-Asp (RGD).

RESULTS

Addition of Type I Collagen (100μg/ml) and RGD (5mg/ml) to ChemFil Superior had no statistically significant effect upon the compressive strength and bond strength to bovine enamel but significantly (P<0.05) increased the materials shore hardness. The addition of RGD to ChemFil Superior increased most the expression of vimentin, indicating that the cells had become more fibroblastic. This may be indicative of increased synthesis of extracellular matrix macromolecules with the potential to foster adhesion of the modified glass polyalkenoate to distracted gingival tissues.

CONCLUSIONS

The results suggest that addition of bioactive molecules to GPA cement for subgingival restorations has potential clinical applications.

CLINICAL SIGNIFICANCE

It is possible to envisage that the additions, as described in this paper, could foster the attachment of displaced gingival tissues to GPA restorative materials placed subgingivally where root caries has been treated. This would offer potential to form a seal around the restoration by the attached gingival tissues avoiding a periodontal pocket and depriving residual cariogenic bacteria of a nutrient supply. Further investigation of the effects upon other similar materials of such additions is warranted.

Focal therapy for prostate cancer: current status and future perspectives

Focal therapy is a relatively new and extremely attractive option of treatment for prostate cancer. It has been described as the "middle approach" between active surveillance and radical treatment, aiming to destroy the tumor itself or the region containing the tumor in order to preserve surrounding non-cancerous tissue. The goal is to maintain disease control at acceptable levels, while preserving erectile, urinary, and rectal function. While a lot of technologies have been described for delivering targeted therapy to the prostate, such as cryoablation, high intensity focused ultrasound, photodynamic therapy, irreversible electroporation and laser, the key point is the patient selection. Recent advances in mpMRI and the introduction of new biopsy techniques that use MR images as a guidance, have significantly improved localization of the tumor lesions and the detection rate, evolving prostate biopsy toward targeted rather than systematic biopsies. The future challenge to clinicians is to precisely risk-stratify patients to differentiate between those who would profit from focal treatment and who would not. Forthcoming research efforts should pursue to identify molecular, genetic, and imaging characteristics that distinguish aggressive prostate tumors from indolent lesions.

Conformational dynamics of calcium-triggered activation of fusion by synaptotagmin

Synaptotagmin triggers rapid exocytosis of neurotransmitters from synaptic vesicles in response to Calcium (Ca(2+)) ions. Here, we use a novel Nanodisc-based system, designed to be a soluble mimetic of the clamped synaptic vesicle-bilayer junction, combined with fluorescence resonance energy transfer (FRET) spectroscopy to monitor the structural relationships among SNAREs (soluble N-ethylmaleimide-sensitive factor attachment protein receptor), Synaptotagmin C2 domains, and the lipid bilayer in real time during the Ca(2+)-activation process. We report that Synaptotagmin remains rigidly fixed on the partially assembled SNARE complex with no detectable internal rearrangement of its C2 domains, even as it rapidly inserts into the bilayer. We hypothesize that this straightforward, one-step physical mechanism could explain how this Ca(2+)- sensor rapidly activates neurotransmitter release from the clamped state.

Double-antibody ELISA for detection of trace amounts of pig meat in raw meat mixtures

A modification of double-antibody sandwich ELISA (enzyme-linked immunosorbent assay) has been applied successfully to the problem of the detection of very low amounts of pig meat (1-3%) in beef and manufactured beef products made with rusk and other additives. The assay uses a monospec fic antiserum bound to the solid plastic support to sequester the porcine serum albumin (PSA) from amongst the many proteins co-extracted from the complex sample extracts. Further immuno-recognition was made with a second antibody, also specific for PSA, which was detected by a conjugated enzyme anti-IgG that interacted only with the second anti-PSA antibodies. Subsequent enzymic conversion of substrate gave clear visual differences between beef and beef containing 0·5% of pig meat and beef products with 1% of the lean replaced by lean pork compared with reference samples.

First Report of Boeremia Blight Caused by Boeremia exigua var. exigua on Pyrethrum in Australia

Pyrethrum (Tanacetum cinerariifolium) is produced for extraction of insecticidal compounds from the flower achenes. In 2004 and 2006, isolations from necrotic lesions on stems and leaves in three fields in northern Tasmania, Australia yielded four unidentified fungal isolates. Leaf lesions were medium brown and circular (2 to 4 mm in diameter) or irregular in shape (2 to 5 mm long). Stem lesions were irregular, necrotic spots, 5 to 15 mm below the flower peduncle, medium brown, 2 to 4 mm long, and 1 to 2 mm wide. Isolations were conducted on water agar following surface sterilization. Isolates were identified by colony characteristics and the presence of metabolite 'E' (1). On oatmeal agar (OA), colonies had irregular margins, were greenish olivaceous-to-olivaceous gray with sparse, white, floccose, aerial mycelia. On malt extract agar (MEA), cultures were variable in color with olivaceous black centers with soft, dense, aerial mycelia. Conidia were hyaline, ellipsoidal to oblong, mainly aseptate, but occasionally 1-septate with dimensions ranging from 2.5 to 7.5 × 1.8 to 3.8 μm (length/width ratio = 1.7 to 2.1). All isolates had moderate reactions to the NaOH test for metabolite 'E'. DNA was extracted from all four isolates with a DNeasy Plant Mini Kit (QIAGEN Inc., Valencia, CA). For identification, the internal transcribed spacer region (ITS1, 5.8s, and ITS2) and part of the translation elongation factor (TEF) region were amplified and sequenced. Primers ITS1 and ITS4 (2) were used for the ITS region and primers EFCF1 (5'-AGTGCGGTGGTATCGACAAG) and EFCF6 (3'-CATGTCACGGACGGCGAAAC) were used for the TEF. Amplicons were sequenced in both directions and consensus sequences assembled. The ITS sequence was 100% identical to Boeremia exigua var. exigua (GenBank Accession No. GU237715). Base pairs 413 to 1,214 of the TEF sequence from the pyrethrum isolates matched base pairs 1 to 802 (799 of 802 identities) of B. exigua var. exigua (GenBank Accession No. GU349080). All isolates were confirmed as B. exigua var. exigua using morphology and sequencing. Pathogenicity tests were conducted three times in separate glasshouse trials for two of the four isolates. For each isolate, conidial suspensions in water (3 ml/plant) from MEA, adjusted to 5 × 10⁵/ml were applied with Tween 20 (1 drop per 100 ml of water) to 8-week-old pyrethrum plants (five pots per isolate with four plants per pot) using a hand-held spray bottle. Twenty plants were sprayed with water and Tween 20 as nontreated controls. Plants were covered with plastic bags for 48 h after inoculation and examined for symptoms after 15 days at 20°C. Disease incidence (number of symptomatic leaves affected per total number of leaves) of the inoculated plants varied from 7.5 to 9.4%. Noninoculated plants did not develop symptoms. Isolations resulted in cultures morphologically identical on MEA and OA to those inoculated. To our knowledge, this is the first report of B. exigua var. exigua causing disease in pyrethrum. Cultures were deposited in the New South Wales Department of Agriculture collection (DAR79101 to 79104) and TEF and ITS sequences for DAR79101 in GenBank (Accession Nos. JF925328 and JF925329, respectively). Boeremia blight is likely to contribute to the fungal disease complex causing reductions in green leaf area in Australian pyrethrum production. References: (1) M. M. Aveskamp et al. Stud. Mycol. 65:1, 2010. (2) T. J. White et al. PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, 1990.

Phase diffusion in graphene-based Josephson junctions

We report on graphene-based Josephson junctions with contacts made from lead. The high transition temperature of this superconductor allows us to observe the supercurrent branch at temperatures up to ∼2 K, at which point we can detect a small, but nonzero, resistance. We attribute this resistance to the phase diffusion mechanism, which has not been yet identified in graphene. By measuring the resistance as a function of temperature and gate voltage, we can further characterize the nature of the electromagnetic environment and dissipation in our samples.

Do parents of children with caries choose to opt out of positive consent dental surveys in Wales?

BACKGROUND

Recently, positive consent has been required for dental surveys in some parts of the UK. Concerns have been raised that when positive consent is used participation is reduced in deprived areas and reported caries levels are biased as a consequence. This paper analyses caries data collected under positive and negative consent arrangements to explore this issue further.

METHOD

Retrospective analysis of response rates by deprivation fifth and by caries experience of participating children in NHS coordinated dental surveys in Wales undertaken from 2001/2 until 2005/6 using negative consent and in 2007/8 using positive consent.

RESULTS

Across Wales, the change from negative to positive consent was associated with greatly decreased participation. In comparison with previous surveys there was a large increase in children sampled but not examined. The decrease in the proportion of children sampled, who were examined and found to have no decay was similar across all deprivation fifths, with no obvious deprivation-related trend. There was a much larger reduction in the number of children with decay who participated across all quintiles of deprivation.

CONCLUSION

Caries status could be a more important factor than deprivation regarding opting out of the survey. It appears that children with caries are more likely to be opted out of the survey than similarly deprived peers without caries. Parents appear to be more likely to opt children with caries out of dental surveys when positive consent is used. These findings have significant implications for targets aimed at improving oral health which were set before the change in consent procedures, but reported upon after.

The impact of deprivation on youth violence: a comparison of cities and their feeder towns

BACKGROUND AND AIMS

66,000 children and adolescents are treated at emergency departments (EDs) in England and Wales each year for assault injury. The aim of this study was to compare adolescent assault injury rates in cities and towns and determine how assault injury varies with deprivation and gender.

METHODS

The study was set in three cities in Wales, UK, and their surrounding towns. Subjects were 11-17 year olds treated for assault injury at one of seven EDs from 1 October 2005 to 30 September 2006. Area of residence (electoral divisions, EDivs) was identified from patient postcode. EDivs were aggregated into deprivation fifths for males and females and cities and towns. Assault injury rates, rate ratios and 95% CIs were calculated.

RESULTS

1472 children and adolescents of 11-17 years old were treated for assault injury. Male city assault injury rates were 14.2/1000 11-17 year olds; and 13.1 in towns. Female city assault injury rates were 6.0; and 5.6 in towns. In the most deprived city areas males had assault injury rates 2.6 times (95% CI 1.85 to 3.59) that of the most affluent, compared with 2.0 times in towns (95% CI 1.39 to 2.86). For females, the most deprived city areas had assault injury rates 5.3 times that of the most affluent (95% CI 2.93 to 9.41), compared with 2.8 times in towns (95% CI 1.47 to 5.28).

CONCLUSIONS

Injury in youth violence increased with increasing deprivation in cities and their feeder towns. This was true for boys and girls, though rates for boys were consistently higher. This link between assault injury and deprivation was stronger for girls in cities than in feeder towns. Strategies to prevent youth violence need to include improved safeguarding arrangements for girls living in the most deprived city areas.

Parecoxib for analgesia after craniotomy

BACKGROUND

Pain after craniotomy is often under-treated. Opiates carry distinct disadvantages. Non-steroidal anti-inflammatory drugs have an anti-platelet action and carry a bleeding risk. Cyclo-oxygenase 2 inhibitors such as parecoxib are not associated with a bleeding risk and would be welcome analgesics if shown to be effective.

METHODS

In a prospective double-blind, randomized, placebo-controlled study, we investigated the analgesic effect of a single dose of parecoxib 40 mg given at dural closure in 82 patients undergoing elective craniotomies. Remifentanil was used intraoperatively, and i.v. morphine was titrated to the requirement in the post-anaesthetic unit. On the ward, i.m. morphine 5 mg as required and regular acetaminophen was prescribed. Morphine use and visual analogue pain scores were recorded at 1, 6, 12, and 24 h after surgery.

RESULTS

Parecoxib reduced pain scores at 6 h and morphine use at 6 and 12 h after operation. However, overall, it had only minimal impact on postoperative analgesia. We found a wide variability in analgesic requirements where 11% of patients required no opioids and 16% required more than 15 mg i.v. morphine 1 h after the surgery.

CONCLUSIONS

We found only limited evidence to support parecoxib as an analgesic after craniotomy.

The influence of local politicians on pedestrian safety

AIM

To determine whether local politicians influence the distribution of traffic calming measures.

METHODS

Longitudinal ecological study in two UK cities. Local political constituencies were categorized by representation by members of the cabinet structure as a marker of influence. The density of traffic calming features per political area, adjusted for the historical pattern of road injuries, was compared between cabinet represented and non-represented areas.

RESULTS

Traffic calming density was significantly associated with cabinet representation status, adjusted for historical collision risk (risk ratio 2.77, 95% confidence interval 1.37 to 5.61).

CONCLUSION

These results support the hypothesis that senior local politicians are effective advocates for enhancing safety in their areas.

Optic nerve magnetization transfer imaging and measures of axonal loss and demyelination in optic neuritis

Magnetization transfer imaging is an MRI technique that provides quantitative information about in vivo tissue integrity, including myelin and axonal content, and is expressed as the magnetization transfer ratio (MTR). The optic neuritis lesion can model the MS lesion in vivo and permits use of non-invasive markers of optic nerve myelination (visual evoked potential [VEP] latency) and retinal neuroaxonal loss (optical coherence tomography [OCT]) to provide further information about the in vivo substrates of optic nerve MTR. Twenty-five patients with optic neuritis were studied using an optic nerve MTR sequence, quantitative visual function testing, VEPs and OCT, along with 15 controls. MTR was reduced in affected nerves compared to both clinically unaffected nerves from patients and control nerves (P < 0.001). Whole-nerve MTR correlated modestly with central-field VEP latency but more strongly when lesion-only MTR was measured, when a modest correlation with whole-field VEP latency emerged. OCT-quantified retinal neuroaxonal loss also correlated with MTR. In conclusion, markers of optic nerve myelination and axonal loss both correlate with optic nerve MTR. Because axonal loss following optic neuritis also results in myelin loss, the relative contributions of the two pathological conditions to the MTR measures cannot be estimated from this study.

Steering, entanglement, nonlocality, and the Einstein-Podolsky-Rosen paradox

The concept of steering was introduced by Schrödinger in 1935 as a generalization of the Einstein-Podolsky-Rosen paradox for arbitrary pure bipartite entangled states and arbitrary measurements by one party. Until now, it has never been rigorously defined, so it has not been known (for example) what mixed states are steerable (that is, can be used to exhibit steering). We provide an operational definition, from which we prove (by considering Werner states and isotropic states) that steerable states are a strict subset of the entangled states, and a strict superset of the states that can exhibit Bell nonlocality. For arbitrary bipartite Gaussian states we derive a linear matrix inequality that decides the question of steerability via Gaussian measurements, and we relate this to the original Einstein-Podolsky-Rosen paradox.

Cortical processing of quasi-periodic versus random noise sounds

The first objective was to confirm using auditory evoked potentials (AEPs) the findings of magnetoencephalographic studies, that quasi-periodic iterated rippled noise (IRN) elicits a population response in the human auditory cortex which is topographically distinct from that elicited by random noise with a similar overall frequency spectrum. AEPs were recorded at the onset of random noise from silence, at the transition from random noise to IRN with a period of 5 ms, and in the two complementary conditions, IRN onset from silence and the transition from IRN to random noise. An N1/P2 complex was recorded to all four stimuli, that to the transition to IRN being significantly the most anteriorly distributed on the scalp. The second objective was to determine whether the response to the transition to IRN was due to detection of its quasi-periodicity, rather than its spectral "ripples". Virtually no effect was found of applying a 2 kHz low- or high-pass filter, above which it is unlikely that the spectral ripples at intervals of 200 Hz would have been resolved on the cochlear partition. It is concluded that a substantial neuronal population in the auditory cortex is influenced by temporal regularity in sounds, and that this population is equally responsive to spectral frequencies below and above 2 kHz.

Modification of the home environment for the reduction of injuries

BACKGROUND

Injury in the home is extremely common, accounting for around a third of all injuries. The majority of injuries of children under five and people aged 75 and over, occur at home. Multifactorial injury prevention interventions have been shown to reduce injuries in the home. However, few studies have focused specifically on the impact of physical adaptations to the home environment and the effectiveness of such interventions needs to be ascertained.

OBJECTIVES

To review the evidence for the effect on injuries of modification of the home environment with a primary focus on interventions to reduce physical hazards.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, National Research Register and other specialised databases. We also scanned conference proceedings and reference lists. In addition, we contacted experts and trialists in the field. The searches were not restricted by language or publication status. The searches were last updated in December 2004.

SELECTION CRITERIA

Randomised controlled trials.

DATA COLLECTION AND ANALYSIS

All abstracts were screened by two authors for relevance, outcome and design. Two authors independently assessed methodological quality and extracted data from each eligible study.

MAIN RESULTS

We found 18 published and one unpublished trials. Trials were not sufficiently similar to allow pooling of data by statistical analyses, so this review takes a narrative form. Studies were divided into three groups based on the primary population sample; children (five studies), older people (14 studies) and the general population/mixed age group (no studies). None of the studies focusing on children demonstrated a reduction in injuries that might have been due to environmental adaptation in the home; one study reported a reduction in injuries and in hazards but the two could not be linked. Of the 14 included studies in older people, none demonstrated a reduction in injuries due to hazard reduction, although two demonstrated a reduction in falls that could be due to hazard reduction.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effects of interventions to modify environmental home hazards. Further interventions to reduce hazards in the home should be evaluated by adequately designed randomised controlled trials measuring injury outcomes. Recruitment of large study samples to measure effect must be a major consideration for future trials.

Detection of signals in modulated and unmodulated noise observed using auditory evoked potentials

OBJECTIVE

To investigate a neurophysiological correlate of the perceptual enhancement of noise-masked sounds when the masking frequencies have a wide spectral bandwidth and are coherently amplitude-modulated.

METHODS

Auditory evoked potentials were recorded to 1 kHz tones (200 ms, 61 dBSPL, SOA 3s) occurring in silence or with 80 dB masking noise, which was either wide-band or narrow-band and either unmodulated or 100% amplitude-modulated by a 17.5 Hz square-wave. In a second study, the tones were timed to coincide alternately with the rise and fall of the masker envelope.

RESULTS

N1 and P2 potentials recorded to the unmasked tones were abolished in the presence of the unmodulated masker, but were elicited again with lower amplitude and longer latency when the masker was modulated. No significant effect of the masker bandwidth was observed. Latencies were strongly determined by whether the tones coincided with the rise or fall of the masker envelope, indicating that the responses were only evoked when the instantaneous noise level was low.

CONCLUSIONS

The findings demonstrate partial correspondence to the threshold reduction to similar stimuli seen in comodulation masking release (CMR). The dependence of latencies on the phase of the masker envelope is consistent with the 'dip-listening' model of CMR.

SIGNIFICANCE

Under these conditions the N1/P2 complex can be viewed as a possible neurophysiological correlate of perceptual CMR.

Quantification of optic nerve head topography in optic neuritis: a pilot study

AIMS

To investigate optic nerve head topography in patients with optic neuritis compared to controls using the Heidelberg retina tomograph-II (HRT-II) and to determine if detected changes are related to visual function and electrophysiology.

METHODS

25 patients with a previous single episode of unilateral optic neuritis and 15 controls were studied with HRT-II, visual evoked potentials, and pattern electroretinogram. Patients also had testing of visual acuity, visual field, and colour vision.

RESULTS

In affected eyes compared to fellow eyes, there was reduction of both the mean retinal nerve fibre layer (RNFL) thickness at the disc edge (p = 0.009) and the neuroretinal rim volume (p = 0.04). In affected eyes compared to control eyes, the three dimensional optic cup shape measure was increased (p = 0.01), indicative of an abnormal cup shape. There were no other significant differences in HRT-II measures. Within patient interocular difference correlation was used to investigate the functional relevance of these changes and demonstrated associations between RNFL thickness change and changes in visual acuity, visual field, and colour vision. Colour vision change was also associated with change in neuroretinal rim volume.

CONCLUSIONS

HRT detects functionally relevant changes in RNFL thickness and neuroretinal rim volume between eyes affected by optic neuritis and unaffected fellow eyes.

Traffic calming policy can reduce inequalities in child pedestrian injuries: database study

OBJECTIVES

To determine whether area wide traffic calming distribution reflects known inequalities in child pedestrian injury rates. To determine whether traffic calming is associated with changes in childhood pedestrian injury rates.

DESIGN

Small area ecological study, longitudinal analysis of injury rates with cross sectional analysis of traffic calming and method of travel to school.

SETTINGS

Two cities in the United Kingdom.

PARTICIPANTS

4-16 year old children between 1992 and 2000.

MAIN OUTCOME MEASURES

Area wide traffic calming distribution by area deprivation status and changes in injury rate/1000.

RESULTS

The most deprived fourth of city A had 4.8 times (95% CI 3.71 to 6.22) the number of traffic calming features per 1000 population compared with the most affluent fourth. Injury rates among the most deprived dropped from 9.42 to 5.07 from 1992-94 to 1998-2000 (95% CI for change 2.82 to 5.91). In city B, the traffic calming ratio of the most to least deprived fourth was 1.88 (95% CI 1.46 to 2.42); injury rates in the deprived areas dropped from 8.92 to 7.46 (95% CI for change -0.84 to 3.77). Similar proportions of 9-12 year olds walked to school in both cities.

CONCLUSIONS

Area wide traffic calming is associated with absolute reductions in child pedestrian injury rates and reductions in relative inequalities in child pedestrian injury rates.

Effectiveness of rugby headgear in preventing soft tissue injuries to the head: a case-control and video cohort study

OBJECTIVE

To determine if headgear use by rugby players was associated with a reduced risk of head or facial laceration, abrasion, or fracture.

METHODS

An emergency department based case-control study in South Wales, UK, with cases being rugby players treated for superficial head and facial injuries and controls being their matched opponents during the game. A review of videos of the 41 games in the 1999 Rugby World Cup was also carried out to compare with the case-control study. Odds ratios (OR) and 95% confidence intervals (95% CI) were used to measure association between exposure (headgear wearing) and outcome (head and facial injuries).

RESULTS

In the case-control study, 164 pairs were analysed, with headgear worn by 12.8% of cases and 21.3% of controls. Headgear use was associated with substantial but non-significant reductions in superficial head (OR = 0.43, 95% CI 0.13 to 1.19) and facial (OR = 0.57, 95% CI 0.21 to 1.46) injuries. The video study followed 547 players over 41 games, during which there were 47 bleeding injuries to the head. Headgear use significantly reduced the risk of bleeding head injury in forwards (OR = 0.14, 95% CI 0.01 to 0.99, p = 0.02), but not in backs. There was also a higher risk of facial injury among forwards, but this was not significant.

CONCLUSIONS

The combined results suggest that headgear can prevent certain types of superficial head injuries in players at all levels of the game, but the evidence is strongest for superficial head injury in elite forwards. A randomised controlled trial would be the best way to study this further.

Are mobile speed cameras effective? A controlled before and after study

OBJECTIVE

To identify the most appropriate metric to determine the effectiveness of mobile speed cameras in reducing road traffic related injuries.

DESIGN

Controlled before and after study which compares two methods for examining the local effectiveness of mobile speed cameras-a circular zone around the camera and a route based method to define exposure at various distances from sites.

SETTING

South Wales, UK.

SUBJECTS

Persons injured by road traffic before and after intervention.

INTERVENTION

Use of mobile speed cameras at 101 sites.

MAIN OUTCOME MEASURES

Rate ratio of injurious crashes at intervention and control sites.

RESULTS

Camera sites had lower than expected numbers of injurious crashes up to 300 metres using circles and up to 500 metres using routes. Routes methods indicated a larger effect than the circles method except in the 100 metres nearest sites. A 500 metre route method was used to investigate the effect within strata of time after intervention, time of day, speed limit, and type of road user injured. The number of injurious crashes after intervention was substantially reduced (rate ratio 0.49, 95% confidence interval 0.42 to 0.57) and sustained throughout two years after intervention. Significant decreases occurred in daytime and night time, on roads with speed limits of 30 and 60-70 miles/hour and for crashes that injured pedestrians, motorcycle users, and car occupants.

CONCLUSIONS

The route based method is the better method of measure effectiveness at distances up to 500 metres. This method demonstrates a 51% reduction in injurious crashes.

Serial magnetization transfer imaging in acute optic neuritis

In serial studies of multiple sclerosis lesions, reductions in magnetization transfer ratio (MTR) are thought to be due to demyelination and axonal loss, with later rises due to remyelination. This study followed serial changes in MTR in acute optic neuritis in combination with clinical and electrophysiological measurements to determine if the MTR changes over time mirror the picture in multiple sclerosis lesions, further validating MTR as a marker of tissue integrity. Twenty-nine patients were recruited who had acute optic neuritis for a median of 13 days (range 7-24 days) since the onset of visual symptoms. A clinical examination and measurement of visual evoked potentials (VEP) was performed on each patient. Their optic nerves were imaged with a fat-saturated fast spin echo (FSE) sequence and a magnetization transfer sequence. Twenty-one had multiple subsequent examinations over the course of 1 year. In addition, 27 control subjects had their optic nerves imaged up to three times over 1 year. A blinded observer segmented the optic nerves from the MTR maps. Lesions were defined on the acute FSE images and, from the coordinates, the ratio of mean lesion MTR : healthy nerve MTR (lesion ratio) was calculated for each dataset. The time-averaged mean MTR in control optic nerves was 47.7 per cent units (pu). In diseased optic nerves, baseline mean MTR was 47.3 pu, with a mean lesion ratio of 0.98. The diseased optic nerve MTR and lesion ratio declined over time with a nadir at about 240 days at a mean MTR value of 44.2 pu and mean lesion ratio of 0.91. Subsequently, diseased optic nerve MTR appeared to rise; after 1 year the diseased optic nerve mean MTR was 45.1 pu (mean lesion ratio 0.93), although the difference was not significant compared with the nadir value. For each 0.01 increase in time-averaged lesion ratio logMAR visual acuity recovery improved by 0.03 (95% CI, 0.002, 0.08, P = 0.02). Time-averaged VEP central field latency was shorter by 6.1 ms (95% CI 1.5, 10.7, P = 0.012) per 1 pu rise in time-averaged diseased optic nerve MTR. The early fall in diseased optic nerve MTR is consistent with demyelination and Wallerian degeneration of transected axons. The late nadir compared with studies of multiple sclerosis lesions may have been due to slow clearance of myelin debris. Remyelination may have influenced subsequent MTR changes. The observations support using MTR to monitor symptomatic demyelinating lesions.

A randomized controlled study of modified cobratoxin in adrenomyeloneuropathy

Adrenomyeloneuropathy is a peroxisomal disorder that causes demyelination, with no proven therapy. Oral modified cobratoxin was assessed in a double-blind, randomized, crossover study of eight patients. Treatment was well tolerated. There were no significant improvements with therapy. The authors do not confirm previous anecdotal reports of dramatic improvement with modified cobratoxin.

Sensitivity of human auditory evoked potentials to the harmonicity of complex tones: evidence for dissociated cortical processes of spectral and periodicity analysis

A strong subjective tendency exists for simultaneous sound frequencies forming an harmonic series (integer multiples of the fundamental) to "group" together into a unified auditory percept whose pitch is similar to that of the fundamental. The aim of the study was to determine whether cortical auditory evoked potentials (AEPs) to complex tones differ according to whether the component frequencies of the stimuli are harmonically related or not. AEPs were recorded to continuous complex tones comprising four or more sinusoids. The vertex-maximal "change-potentials" (CP1, CN1, CP2), recorded to a stimulus cycle comprising one harmonic and five inharmonic complexes changing every second, showed no sensitivity to harmonicity, although an additional mismatch negativity was possibly present to the harmonic complex. In a second study the CP2 was significantly attenuated when an harmonic complex changed to a new one in the presence of an unchanging sinusoidal background tone, harmonically related to the first complex but not to the second, and thus becoming perceptually distinct. This, however, might be caused by lateral inhibitory effects not related to harmonicity. In a third experiment, when four concurrent sinusoidal tones came to rest on steady frequencies after a 5-s period of 16/s pseudo-random frequency changes, fronto-centrally maximal "mismatch-potentials" (MN1, MP2), were recorded. Both the MN1 and the MP2 were significantly shorter in latency when the steady frequencies formed an harmonic complex. Since the harmonic complex had a short overall periodicity, equal to that of the fundamental, while that of the inharmonic complex was much longer, the effect might be explained if the latencies of the mismatch-potential are related to periodicity. The perceptual grouping of harmonically related frequencies appears not to be a function of spectral domain analysis, reflected in the change-potentials, but of periodicity analysis, reflected in the mismatch-potentials

Routine narrative analysis as a screening tool to improve data quality

AIM

To determine whether narrative information in emergency department surveillance systems can be systematically interrogated to improve our understanding of the causes of injury.

METHODS

Screening algorithms for location, intent, and activity were developed from structured analysis of narrative data from 98999 records. The algorithms were then tested on a 50000 record database containing entries in both of the two narrative fields. A proxy gold standard was defined as the total extract using both code and narrative. Sensitivity and specificity of the emergency department coding and narrative algorithms was calculated.

RESULTS

The proportion of records carrying an informative emergency department code was higher in records containing narrative-the percentage of causes coded "not know" dropped by 28.3%. The sensitivity of coded data varied from 42% to 98 % and from 33% to 99% for narrative data. Narrative analysis increased the percentage of home injuries identified by 19%, assaults by 26%, and rugby injuries by 137%.

CONCLUSIONS

Using a small amount of narrative is a practical and effective means of developing more informative injury causation data in an emergency department based surveillance system. It allows for internal validation of the codes and for the identification of emerging hazards without adding more "tick boxes" or further burdening data entry clerks.

Socioeconomic variation in injury in children and older people: a population based study

OBJECTIVES

To compare hospital admission rates for all causes and specific causes of injury in children and the elderly by a measure of economic deprivation.

STUDY DESIGN

All emergency admissions for Welsh residents from 1997-99 were located to one of 865 electoral tracts, which were grouped into fifths using a measure of socioeconomic deprivation. Standardised admission rates for all ages and 0-14, 15-75, and 75+ year groups for each quintile were calculated with 95% confidence intervals.

RESULTS

There were 90 935 admissions in a population of 2.84 million yielding a crude admission rate of 1601/100 000/year and a standardised rate of 1493/100 000. The ratio of admissions in deprived and affluent areas varied with category of injury and age group. In general, socioeconomic variations in injury rates were much smaller in older people than in children with the exception of pedestrian related injuries where the rates were similar. The largest variations were for injuries sustained in assaults or self inflicted.

CONCLUSIONS

The relationship between socioeconomic position and injury varies by cause and age group. This should be considered when developing area based preventive interventions or monitoring the effectiveness of policies to reduce inequalities in injury occurrence.

Two cases of quadriparesis following anterior cervical discectomy, with normal perioperative somatosensory evoked potentials

Two cases illustrate an uncommon failure of perioperative somatosensory evoked potential (SEP) monitoring to detect iatrogenic lesions causing temporary quadriparesis during straightforward cervical surgery. In both cases, anterior cervical discectomy at one or two levels was undertaken with bone graft and titanium implants, and cortical SEP were monitored to alternate stimulation of the left and right median or ulnar nerves. The SEP showed only minor changes during surgery, not considered pathologically significant, and were normal when recorded postoperatively. Both patients, however, experienced marked postoperative limb weakness or paralysis. Motor evoked potentials (MEP) recorded postoperatively to transcranial magnetic stimulation were absent. The clinical motor deficits resolved over the ensuing months. In spite of the normally low incidence of "false negatives," in these two cases SEP monitoring failed to detect a iatrogenic lesion causing moderate to severe, though temporary, motor impairment. Monitoring of MEP may be considered as an alternative to SEP during anterior cervical procedures, while combined monitoring of SEP and MEP may be the ideal.

Comparison of measured and estimated angles of table tilt at Caesarean section

BACKGROUND

Lateral maternal tilt reduces aortocaval compression and the consequent cardiovascular instability.

METHODS

We measured the angle of table tilt used by 16 anaesthetists during uncomplicated, elective Caesarean section. After initiating anaesthesia, they were asked to position the patient and estimate the angle of tilt, which was then measured.

RESULTS

Almost every anaesthetist positioned the patient less than 15 degrees because they overestimated the angle of tilt. When questioned on their knowledge of the current advice for lateral tilt, 11 of the 16 anaesthetists were aware of the 15 degrees recommendation.

CONCLUSION

Estimation of the angle of table tilt is unreliable.

N-acetylcysteine and Unverricht-Lundborg disease: variable response and possible side effects

Serum glutathione levels were assessed in a patient with genetically proven Unverricht-Lundborg disease (ULD) before and during treatment with the antioxidant N-acetylcysteine (NAC). Glutathione levels were low before treatment, and increased during treatment. This increase was mirrored by an improvement in seizures, but not in myoclonus or ataxia. Three other patients with clinically determined ULD showed a variable response and some notable side effects during treatment with NAC.

Effect of diclofenac on cerebral blood flow velocity in patients with supratentorial tumours

BACKGROUND

The aim of this investigation was to determine the effects of diclofenac on cerebral blood flow. Middle cerebral artery blood flow velocity was measured in nine patients with supratentorial tumours.

METHODS

Using a transcranial Doppler ultrasound, we measured the baseline mean and systolic cerebral blood flow velocity. Measurements were repeated following administration of diclofenac 75 mg i.v.

RESULTS

There was no significant change in cerebral blood flow velocity. All other physiological variables remained constant.

CONCLUSION

Diclofenac does not cause a significant change in cerebral blood flow velocity in patients with supratentorial tumours.

Electrophysiological evidence for a defect in the processing of temporal sound patterns in multiple sclerosis

OBJECTIVES

To assess the processing of spectrotemporal sound patterns in multiple sclerosis by using auditory evoked potentials (AEPs) to complex harmonic tones.

METHODS

22 patients with definite multiple sclerosis but mild disability and no auditory complaints were compared with 15 normal controls. Short latency AEPs were recorded using standard methods. Long latency AEPs were recorded to synthesised musical instrument tones, at onset every two seconds, at abrupt frequency changes every two seconds, and at the end of a two second period of 16/s frequency changes. The subjects were inattentive but awake, reading irrelevant material.

RESULTS

Short latency AEPs were abnormal in only 4 of 22 patients, whereas long latency AEPs were abnormal to one or more stimuli in 17 of 22. No significant latency prolongation was seen in response to onset and infrequent frequency changes (P1, N1, P2) but the potentials at the end of 16/s frequency modulations, particularly the P2 peaking approximately 200 ms after the next expected change, were significantly delayed.

CONCLUSION

The delayed responses appear to be a mild disorder in the processing of change in temporal sound patterns. The delay may be conceived of as extra time taken to compare the incoming sound with the contents of a temporally ordered sensory memory store (the long auditory store or echoic memory), which generates a response when the next expected frequency change fails to occur. The defect cannot be ascribed to lesions of the afferent pathways and so may be due to disseminated brain lesions visible or invisible on magnetic resonance imaging.

The auditory C-process of spectral profile analysis

OBJECTIVES

We here review the findings of several experiments, aimed at clarifying the functional role of the human auditory cortex in the processing of complex sound mixtures.

METHODS

Long-latency auditory evoked potentials were recorded to abrupt changes in the pitch or timbre of continuous complex tones (synthesized musical instrument sounds). Changes were made at intervals of 0.5-4.5 s while the subjects read a magazine.

RESULTS

The main response was a P1/N1/P2 complex which was maximal at the vertex and symmetrically distributed, consistent with origin in the supratemporal cortices of both hemispheres. To distinguish them from the conventional responses to brief pure tones, the potentials were named CP1 (c. 55 ms), CN1 (90 ms) and CP2 (165 ms). Responses to changes of pitch, where all the spectral components changed frequency, and to changes of timbre, where the frequencies remained the same but their energy levels changed, were very similar to one another. The response amplitudes were little affected by the magnitude of frequency changes in the range 6-100%, but were strongly influenced by the rate at which changes occurred (requiring at least 4 s for full recovery) and by the breadth of the changing frequency spectrum (the upper partials of the tone in sum contributing more than the fundamental). When the C-potentials were made refractory by a high rate of pitch changes (16/s) within a narrow frequency range, responses could still be elicited by infrequently interspersed changes of timbre. When the tones were split into their high and low partials, the responses to change in the two frequency bands combined roughly algebraically.

CONCLUSIONS

The responses appear to represent a cortical process concerned with analysing the distribution of sound energy across the frequency spectrum ('spectral profile analysis'). This may be an important stage in the analysis of complex sound mixtures and in the perception of sound quality.

The internal auditory clock: what can evoked potentials reveal about the analysis of temporal sound patterns, and abnormal states of consciousness?

Whereas in vision a large amount of information may in theory be extracted from instantaneous images, sound exists only in its temporal extent, and most of its information is contained in the pattern of changes over time. The "echoic memory" is a pre-attentive auditory sensory store in which sounds are apparently retained in full temporal detail for a period of a few seconds. From the long-latency auditory evoked potentials to spectro-temporal modulation of complex harmonic tones, at least two automatic sound analysis processes can be identified whose time constants suggest participation of the echoic memory. When a steady tone changes its pitch or timbre, "change-type" CP1, CN1 and CP2 potentials are maximally recorded near the vertex. These potentials appear to reflect a process concerned with the distribution of sound energy across the frequency spectrum. When, on the other hand, changes occur in the temporal pattern of tones (in which individual pitch changes are occurring at a rate sufficiently rapid for the C-potentials to be refractory), a large mismatch negativity (or MN1) and following positivity (MP2) are generated. The amplitude of these potentials is influenced by the degree of regularity of the pattern, larger responses being generated to a "deviant" tone when the pitch and time of occurrence of the "standards" are fully specified by the preceding pattern. At the sudden cessation of changes, on resumption of a steady pitch, a mismatch response is generated whose latency is determined with high precision (in the order of a few milliseconds) by the anticipated time of the next change, which did not in fact occur. The mismatch process, therefore, functions as spectro-temporal auditory pattern analyser, whose consequences are manifested each time the pattern changes. Since calibration of the passage of time is essential for all conscious and subconscious behaviour, is it possible that some states of unconsciousness may be directly due to disruption of internal "clocks"? Abnormal mismatch potentials may provide a manifestation of a disordered auditory time-sense, sometimes being abolished in comatose patients while the C-potentials and similar responses to the onset of tones are preserved. Both C- and M-potentials were usually found to be preserved, however, in patients who had emerged from coma and were capable of discriminating sounds. Substantially intact responses were also recorded from three patients who were functionally in a "vegetative" state. The C- and M-potentials were once again dissociated in a group of patients with multiple sclerosis, only the mismatch potentials being found to be significantly delayed. This subclinical impairment of a memory-based process responsible for the detection of change in temporal sound patterns may be related to defects in other memory domains such as working memory.