Absolute risks of self-harm and interpersonal violence by diagnostic category following first discharge from inpatient psychiatric care

BACKGROUND

Persons discharged from inpatient psychiatric services are at greatly elevated risk of harming themselves or inflicting violence on others, but no studies have reported gender-specific absolute risks for these two outcomes across the spectrum of psychiatric diagnoses. We aimed to estimate absolute risks for self-harm and interpersonal violence post-discharge according to gender and diagnostic category.

METHODS

Danish national registry data were utilized to investigate 62,922 discharged inpatients, born 1967-2000. An age and gender matched cohort study was conducted to examine risks for self-harm and interpersonal violence at 1 year and at 10 years post-discharge. Absolute risks were estimated as cumulative incidence percentage values.

RESULTS

Patients diagnosed with substance misuse disorders were at especially elevated risk, with the absolute risks for either self-harm or interpersonal violence being 15.6% (95% CI 14.9, 16.3%) of males and 16.8% (15.6, 18.1%) of females at 1 year post-discharge, rising to 45.7% (44.5, 46.8%) and 39.0% (37.1, 40.8%), respectively, within 10 years. Diagnoses of personality disorders and early onset behavioral and emotional disorders were also associated with particularly high absolute risks, whilst risks linked with schizophrenia and related disorders, mood disorders, and anxiety/somatoform disorders, were considerably lower.

CONCLUSIONS

Patients diagnosed with substance misuse disorders, personality disorders and early onset behavioral and emotional disorders are at especially high risk for internally and externally directed violence. It is crucial, however, that these already marginalized individuals are not further stigmatized. Enhanced care at discharge and during the challenging transition back to life in the community is needed.

Stability and reproducibility of 6013 deep inspiration breath-holds in left-sided breast cancer

Purpose

Patients with left-sided breast cancer frequently receive deep inspiration breath-hold (DIBH) radiotherapy to reduce the risk of cardiac side effects. The aim of the present study was to analyze intra-breath-hold stability and inter-fraction breath-hold reproducibility in clinical practice.

Material and methods

Overall, we analyzed 103 patients receiving left-sided breast cancer radiotherapy using a surface-guided DIBH technique. During each treatment session the vertical motion of the patient was continuously measured by a surface guided radiation therapy (SGRT) system and automated gating control (beam on/off) was performed using an audio-visual patient feedback system. Dose delivery was automatically triggered when the tracking point was within a predefined gating window. Intra-breath-hold stability and inter-fraction reproducibility across all fractions of the entire treatment course were analyzed per patient.

Results

In the present series, 6013 breath-holds during beam-on time were analyzed. The mean amplitude of the gating window from the baseline breathing curve (maximum expiration during free breathing) was 15.8 mm (95%-confidence interval: [8.5–30.6] mm) and had a width of 3.5 mm (95%-CI: [2–4.3] mm). As a measure of intra-breath-hold stability, the median standard deviation of the breath-hold level during DIBH was 0.3 mm (95%-CI: [0.1–0.9] mm). Similarly, the median absolute intra-breath-hold linear amplitude deviation was 0.4 mm (95%-CI: [0.01–2.1] mm). Reproducibility testing showed good inter-fractional reliability, as the maximum difference in the breathing amplitudes in all patients and all fractions were 1.3 mm on average (95%-CI: [0.5–2.6] mm).

Conclusion

The clinical integration of an optical surface scanner enables a stable and reliable DIBH treatment delivery during SGRT for left-sided breast cancer in clinical routine.

Recent advances of PET imaging in clinical radiation oncology

Radiotherapy and radiation oncology play a key role in the clinical management of patients suffering from oncological diseases. In clinical routine, anatomic imaging such as contrast-enhanced CT and MRI are widely available and are usually used to improve the target volume delineation for subsequent radiotherapy. Moreover, these modalities are also used for treatment monitoring after radiotherapy. However, some diagnostic questions cannot be sufficiently addressed by the mere use standard morphological imaging. Therefore, positron emission tomography (PET) imaging gains increasing clinical significance in the management of oncological patients undergoing radiotherapy, as PET allows the visualization and quantification of tumoral features on a molecular level beyond the mere morphological extent shown by conventional imaging, such as tumor metabolism or receptor expression. The tumor metabolism or receptor expression information derived from PET can be used as tool for visualization of tumor extent, for assessing response during and after therapy, for prediction of patterns of failure and for definition of the volume in need of dose-escalation. This review focuses on recent and current advances of PET imaging within the field of clinical radiotherapy / radiation oncology in several oncological entities (neuro-oncology, head & neck cancer, lung cancer, gastrointestinal tumors and prostate cancer) with particular emphasis on radiotherapy planning, response assessment after radiotherapy and prognostication.

Defining, Measuring and Preventing the Diagnosis of Cancer as an Emergency: A Critical Review of Current Evidence

Background: Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumor, patient and health-care factors, often in combination. Methods: We searched the literature to identify all population-based studies that examined emergency presentation as a diagnosis or independent variable. Results: Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. Conclusion: In this review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this underresearched aspect of cancer diagnosis.

Factors Affecting Diagnostic Timeliness and Safety in Symptomatic Patients Subsequently Diagnosed With Bladder and Kidney Cancer: A Systematic Review

Background: Timely diagnosis of cancer is important for good clinical outcomes and patient experience. Bladder and kidney cancer, being two relatively common cancers, can pose diagnostic challenges. Symptoms such as hematuria and urinary tract infections in some patients have a higher than 3% positive predictive value for cancer, a threshold above which English GPs are advised to consider the referral of patients for, under the 2015 NICE guidelines. However, the majority of patients with these symptoms will end up not having cancer. Therefore, the decision to perform further investigations or refer patients with these common urinary symptoms may differ despite the existence of guidelines. Studying in whom, and why, some patients may experience a longer than average time to diagnosis is important to understanding how avoidable diagnostic delay can be reduced, so that targeted interventions to improve early diagnosis can be developed to improve, ultimately, the outcome of these cancers. Aim: A systematic review was therefore performed to identify the factors that affect the diagnostic timeliness and safety of patients with urological symptoms that may be suggestive of kidney and bladder cancer. Methods: We searched Embase and Medline (Ovid) between 2000 and January 2018, for publications on symptoms/conditions including hematuria and urinary tract infection (UTI). We focused on clinical features that are listed in the English 2015 NICE guidelines for suspected cancer to examine the population that are most likely to have cancer, and in whom a timely diagnosis is the most crucial for outcomes. We also included symptoms that might be suggestive of a UTI (including dysuria, urinary frequency, urgency, incontinence and nocturia) to be overinclusive in our search. Results: Our initial search identified 7787 articles. Following title and abstract screening, 37 full texts were assessed for eligibility. A final 23 relevant studies were included. Our preliminary findings include evidence on patient, clinician and system factors contributing to diagnostic timeliness and safety issues (such as completeness of evaluation/investigations and referrals) in patients with possible urological cancer. These include patient sociodemographic factors (age, gender, ethnicity), clinician type (generalist, urologist vs gynecologist) and experience, and system factors such as delay in specialist appointment scheduling and patient no-shows. Conclusion: Our findings will provide a granular understanding of the factors contributing to avoidable diagnostic delay of patients with possible urological cancers globally. This is particularly important so that targeted interventions can be developed to help clinicians and health systems to better identify and manage at-risk patients with symptoms, so as to improve early diagnosis and outcomes of urological cancers.

Variation in 'Fast-Track' Referrals for Suspected Cancer by Patient Characteristic and Cancer Diagnosis: Evidence From 670,000 Patients With Cancers of 35 Different Sites

Background: In England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups. Methods:  We examined data from 669,220 patients with 35 cancers diagnosed 2006-2010 following either fast-track or nonfast track primary-to-secondary care referrals using a bespoke English dataset, the 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristics and cancer diagnosis and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer. Results:  There were large variations in the odds of fast-track referral by cancer ( P < 0.001). Patients with testicular and breast cancer were most likely to have been diagnosed after a fast-track referral (adjusted odds ratios 2.73 and 2.35 respectively, using rectal cancer as reference); while patients with brain cancer and leukemias least likely (adjusted odds ratios 0.05 and 0.09 respectively for brain cancer and acute myeloid leukemia). There were sex, age and deprivation differences in the odds of fast-track referral ( P < 0.013), which varied in their size and direction for patients with different cancers ( P < 0.001). For example, fast-track referrals were least likely in younger women with endometrial cancer and in older men with testicular cancer. Conclusion: Fast-track referrals are less likely for cancers characterized by nonspecific presenting symptoms and patients belonging to low incidence demographic strata. Interventions beyond clinical guidelines for “alarm” symptoms are needed to improve diagnostic timeliness.

Hazmat Emergency Preparedness in Hong Kong: What are the Dangerous Goods in Kowloon?

Introduction

Hazmat emergency preparedness is critical, especially as Hong Kong prepares for major international events, such as the 2008 Olympic Equestrian Games. No published medical study has described the identities and quantities of dangerous goods (DG) in the Kowloon area and listed what antidotes are needed for these DG. This study describes what hazardous materials are most common in Kowloon to prioritise emergency preparedness and training.

Materials & methods

Design A descriptive, cross-sectional study. Setting The Hong Kong Special Administrative Region, specifically Kowloon. Sample The Hong Kong Fire Services Department (HKFSD) Dangerous Goods Database (DGD). Interventions Descriptive statistical analyses with Stata 9.2. Chief outcome Identifying and quantifying dangerous goods in the HKFSD DGD.

Results

Most DG do not have antidotes. The most common DG with recognised antidotes are carbon monoxide, methylene chloride, fluorine, fluorides, fluoroboric acid, cyanides, nitriles, methanol, nitrobenzene, nitrites, and nitrates. The most common categories of DG are substances giving off inflammable vapours, compressed gases, and corrosive and poisonous substances.

Conclusions

Hazmat emergency preparedness and training should emphasize these most common categories of DG. Disaster planning should ensure adequate antidotes for DG with recognised antidotes, i.e., oxygen for carbon monoxide and methylene chloride; calcium gluconate or calcium chloride for fluorine, fluorides, and fluoroboric acid; hydroxocobalamin for cyanides and nitriles; ethanol for methanol; and methylene blue for methaemoglobinaemia produced by nitrobenzene, nitrites, and nitrates. Supportive care is essential for patients exposed to hazardous materials because most dangerous goods do not have antidotes.

Large turbulent reservoirs of cold molecular gas around high-redshift starburst galaxies

Starburst galaxies at the peak of cosmic star formation are among the most extreme star-forming engines in the Universe, producing stars over about 100 million years (ref. 2). The star-formation rates of these galaxies, which exceed 100 solar masses per year, require large reservoirs of cold molecular gas to be delivered to their cores, despite strong feedback from stars or active galactic nuclei. Consequently, starburst galaxies are ideal for studying the interplay between this feedback and the growth of a galaxy. The methylidyne cation, CH⁺, is a most useful molecule for such studies because it cannot form in cold gas without suprathermal energy input, so its presence indicates dissipation of mechanical energy or strong ultraviolet irradiation. Here we report the detection of CH⁺ (J = 1-0) emission and absorption lines in the spectra of six lensed starburst galaxies at redshifts near 2.5. This line has such a high critical density for excitation that it is emitted only in very dense gas, and is absorbed in low-density gas. We find that the CH⁺ emission lines, which are broader than 1,000 kilometres per second, originate in dense shock waves powered by hot galactic winds. The CH⁺ absorption lines reveal highly turbulent reservoirs of cool (about 100 kelvin), low-density gas, extending far (more than 10 kiloparsecs) outside the starburst galaxies (which have radii of less than 1 kiloparsec). We show that the galactic winds sustain turbulence in the 10-kiloparsec-scale environments of the galaxies, processing these environments into multiphase, gravitationally bound reservoirs. However, the mass outflow rates are found to be insufficient to balance the star-formation rates. Another mass input is therefore required for these reservoirs, which could be provided by ongoing mergers or cold-stream accretion. Our results suggest that galactic feedback, coupled jointly to turbulence and gravity, extends the starburst phase of a galaxy instead of quenching it.

Rapidly star-forming galaxies adjacent to quasars at redshifts exceeding 6

The existence of massive (10¹¹ solar masses) elliptical galaxies by redshift z ≈ 4 (refs 1, 2, 3; when the Universe was 1.5 billion years old) necessitates the presence of galaxies with star-formation rates exceeding 100 solar masses per year at z > 6 (corresponding to an age of the Universe of less than 1 billion years). Surveys have discovered hundreds of galaxies at these early cosmic epochs, but their star-formation rates are more than an order of magnitude lower. The only known galaxies with very high star-formation rates at z > 6 are, with one exception, the host galaxies of quasars, but these galaxies also host accreting supermassive (more than 10⁹ solar masses) black holes, which probably affect the properties of the galaxies. Here we report observations of an emission line of singly ionized carbon ([C ii] at a wavelength of 158 micrometres) in four galaxies at z > 6 that are companions of quasars, with velocity offsets of less than 600 kilometres per second and linear offsets of less than 100 kiloparsecs. The discovery of these four galaxies was serendipitous; they are close to their companion quasars and appear bright in the far-infrared. On the basis of the [C ii] measurements, we estimate star-formation rates in the companions of more than 100 solar masses per year. These sources are similar to the host galaxies of the quasars in [C ii] brightness, linewidth and implied dynamical mass, but do not show evidence for accreting supermassive black holes. Similar systems have previously been found at lower redshift. We find such close companions in four out of the twenty-five z > 6 quasars surveyed, a fraction that needs to be accounted for in simulations. If they are representative of the bright end of the [C ii] luminosity function, then they can account for the population of massive elliptical galaxies at z ≈ 4 in terms of the density of cosmic space.

[Use of the Symptom Validation Test BEVA in Social Medical Assessment]

The present study investigates whether the BEVA is suitable to detect negative response bias by claimants with psychosomatic symptoms in the social medical assessment. 107 claimants for disability pension to a psychosomatic disorder fulfilled the BEVA, SIMS and a sociodemographic questionnaire. The social medical examiners assess the credibility of the complaints representation. A Known-Group-Design and a Bootstrapping-Design was used to estimate the validity of the BEVA. For the external criterion SFSS the following psychometric characteristics for the BEVA could be determined: specificity=0.86, sensitivity=0.42, positive predictive value=0.81, negative predictive value=0.51. The interrater reliability estimates with Cohen κ=0.253. If the expert's assessments are chosen as external criterion following psychometric characteristics were estimated: specificity=0.71, sensitivity=0.32, positive predictive value=0.38, negative predictive value=0.66. The rater agreement is Cohen κ=0.031. The results show that the BEVA has an excellent specificity in the detection of negative response bias. This is highly desirable in terms of an ethically moral discussion. Furthermore, the study shows that - in addition to the expert estimates - further screenings can improve the assessment of negative response bias.

Evaluation of daily patient positioning for radiotherapy with a commercial 3D surface-imaging system (Catalyst™)

Background

To report our initial clinical experience with the novel surface imaging system Catalyst™ (C-RAD AB, Sweden) in connection with an Elekta Synergy linear accelerator for daily patient positioning in patients undergoing radiation therapy.

Methods

We retrospectively analyzed the patient positioning of 154 fractions in 25 patients applied to thoracic, abdominal, and pelvic body regions. Patients were routinely positioned based on skin marks, shifted to the calculated isocenter position and treated after correction via cone beam CT which served as gold standard. Prior to CBCT an additional surface scan by the Catalyst™ system was performed and compared to a reference surface image cropped from the planning CT to obtain shift vectors for an optimal surface match. These shift vectors were subtracted from the vectors obtained by CBCT correction to assess the theoretical setup error that would have occurred if the patients had been positioned using solely the Catalyst™ system. The mean theoretical set up-error and its standard deviation were calculated for all measured fractions and the results were compared to patient positioning based on skin marks only.

Results

Integration of the surface scan into the clinical workflow did not result in a significant time delay. Regarding the entire group, the mean setup error by using skin marks only was 0.0 ± 2.1 mm in lateral, −0.4 ± 2.4 mm in longitudinal, and 1.1 ± 2.6 mm vertical direction. The mean theoretical setup error that would have occurred using solely the Catalyst™ was −0.1 ± 2.1 mm laterally, −1.8 ± 5.4 mm longitudinally, and 1.4 ± 3.2 mm vertically. No significant difference was found in any direction. For thoracic targets the mean setup error based on the Catalyst™ was 0.6 ± 2.6 mm laterally, −5.0 ± 7.9 mm longitudinally, and 0.5 ± 3.2 mm vertically. For abdominal targets, the mean setup error was 0.3 ± 2.2 mm laterally, 2.6 ± 1.8 mm longitudinally, and 2.1 ± 5.5 mm vertically. For pelvic targets, the setup error was −0.9 ± 1.5 mm laterally, −1.7 ± 2.8 mm longitudinally, and 1.6 ± 2.2 mm vertically. A significant difference between Catalyst™ and skin mark based positioning was only observed in longitudinal direction of pelvic targets.

Conclusion

Optical surface scanning using Catalyst™ seems potentially useful for daily positioning at least to complement usual imaging modalities in most patients with acceptable accuracy, although a significant improvement compared to skin mark based positioning could not be derived from the evaluated data. However, this effect seemed to be rather caused by the unexpected high accuracy of skin mark based positioning than by inaccuracy using the Catalyst™. Further on, surface registration in longitudinal axis seemed less reliable especially in pelvic localization. Therefore further prospective evaluation based on strictly predefined protocols is needed to determine the optimal scanning approaches and parameters.

Treatment planning and evaluation of gated radiotherapy in left-sided breast cancer patients using the CatalystTM/SentinelTM system for deep inspiration breath-hold (DIBH)

BACKGROUND

There is a potential for adverse cardiovascular effects in long-term breast cancer survivors following adjuvant radiotherapy (RT). For this purpose, the deep inspiration breath-hold technique (DIBH) has been introduced into clinical practice, to maximally reduce the radiation dose to the heart. However, there are a variety of DIBH delivery techniques, patient positioning and visual patient feedback mechanisms. The aim of the present study was to evaluate the application of radiotherapy in DIBH using the Catalyst^TM/Sentinel^TM system, with a special emphasis on treatment planning and dosimetric plan comparison in free breathing (FB) and DIBH.

PATIENTS AND METHODS

A total of 13 patients with left-sided breast cancer following breast conserving surgery were included in this prospective clinical trial. For treatment application the Catalyst^TM/Sentinel^TM system (C-RAD AB, Uppsala, Sweden) was used and gating control was performed by an audio-visual patient feedback system. CT and surface data were acquired in FB and DIBH and dual treatment plans were created using Pencil Beam and Collapsed Cone Convolution. Dosimetric output parameters of organs at risk were compared using Wilcoxon signed-rank test. Central lung distance (CLD) was retrieved from iView^TM portal images during treatment delivery.

RESULTS

The system contains a laser surface scanner (Sentinel^TM) and an optical surface scanner (Catalyst^TM) interconnected to the LINAC systems via a gating interface and allows for a continuous and touchless surface scanning. Overall, 225 treatment fractions with audio-visual guidance were completed without any substantial difficulties. Following initial patient training and treatment setup, radiotherapy in DIBH with the Catalyst^TM/Sentinel^TM system was time-efficient and reliable. Following dual treatment planning for all patients, nine of 13 patients were treated in DIBH. In these patients, the reduction of the mean heart dose for DIBH compared to FB was 52 % (2.73 to 1.31 Gy; p = 0.011). The maximum doses to the heart and LAD were reduced by 59 % (47.90 to 19.74 Gy; p = 0.008) and 75 % (38.55 to 9.66 Gy; p = 0.008), respectively. In six of the nine patients the heart completely moved out of the treatment field by DIBH. The standard deviation of the CLD varied between 0.12 and 0.29 cm (mean: 0.16 cm).

CONCLUSION

The Catalyst^TM/Sentinel^TM system enabled a fast and reliable application and surveillance of DIBH in daily clinical routine. Furthermore, the present data show that using the DIBH technique during RT could significantly reduce high dose areas and mean doses to the heart.

TRIAL REGISTRATION

DRKS: DRKS00010929 registered on 5. August 2016.

Pull-out strength of cemented solid versus fenestrated pedicle screws in osteoporotic vertebrae

Objectives

Cement augmentation of pedicle screws could be used to improve screw stability, especially in osteoporotic vertebrae. However, little is known concerning the influence of different screw types and amount of cement applied. Therefore, the aim of this biomechanical in vitro study was to evaluate the effect of cement augmentation on the screw pull-out force in osteoporotic vertebrae, comparing different pedicle screws (solid and fenestrated) and cement volumes (0 mL, 1 mL or 3 mL).

Materials and Methods

A total of 54 osteoporotic human cadaver thoracic and lumbar vertebrae were instrumented with pedicle screws (uncemented, solid cemented or fenestrated cemented) and augmented with high-viscosity PMMA cement (0 mL, 1 mL or 3 mL). The insertion torque and bone mineral density were determined. Radiographs and CT scans were undertaken to evaluate cement distribution and cement leakage. Pull-out testing was performed with a material testing machine to measure failure load and stiffness. The paired t-test was used to compare the two screws within each vertebra.

Results

Mean failure load was significantly greater for fenestrated cemented screws (+622 N; p ⩽ 0.001) and solid cemented screws (+460 N; p ⩽ 0.001) than for uncemented screws. There was no significant difference between the solid and fenestrated cemented screws (p = 0.5). In the lower thoracic vertebrae, 1 mL cement was enough to significantly increase failure load, while 3 mL led to further significant improvement in the upper thoracic, lower thoracic and lumbar regions.

Conclusion

Conventional, solid pedicle screws augmented with high-viscosity cement provided comparable screw stability in pull-out testing to that of sophisticated and more expensive fenestrated screws. In terms of cement volume, we recommend the use of at least 1 mL in the thoracic and 3 mL in the lumbar spine.

Cite this article: C. I. Leichtle, A. Lorenz, S. Rothstock, J. Happel, F. Walter, T. Shiozawa, U. G. Leichtle. Pull-out strength of cemented solid versus fenestrated pedicle screws in osteoporotic vertebrae. Bone Joint Res 2016;5:419–426.

Cancer beliefs in ethnic minority populations: a review and meta-synthesis of qualitative studies

People from ethnic minorities often experience poorer cancer outcomes, possibly due to later presentation to healthcare and later diagnosis. We aimed to identify common cancer beliefs in minority populations in developed countries, which can affect symptom appraisal and help seeking for symptomatic cancer. Our systematic review found 15 relevant qualitative studies, located in the United Kingdom (six), United States (five), Australia (two) and Canada (two) of African, African-American, Asian, Arabic, Hispanic and Latino minority groups. We conducted a meta-synthesis that found specific emotional reactions to cancer, knowledge and beliefs and interactions with healthcare services as contributing factors in help seeking for a cancer diagnosis. These findings may be useful to inform the development of interventions to facilitate cancer diagnosis in minority populations.

Imaging of single cell responses to ER stress indicates that the relative dynamics of IRE1/XBP1 and PERK/ATF4 signalling rather than a switch between signalling branches determine cell survival

An accumulation of misfolded proteins in the endoplasmic reticulum (ER) triggers the unfolded protein response (UPR) mediated via the activation of three transmembrane proteins IRE1, PERK and ATF6. Signalling through these proteins is aimed at enhancing the ER folding capacity and reducing the folding load. If these processes fail to re-establish protein homeostasis within the ER, then cell death prevails via apoptosis. How the shift from pro-survival to pro-apoptotic signalling is regulated remains unclear with both IRE1 and PERK signalling associated with pro-survival as well as pro-apoptotic signalling. To investigate the temporal activation of IRE1 and PERK in live cells and their relationship to cellular fate, we devised single cell reporters for both ER stress signalling branches. SH-SY5Y neural cells stably expressing these fluorescent protein reporter constructs to monitor IRE1-splicing activity and PERK-mediated ATF4-translation were imaged using single cell and high content time lapse live cell microscopy. We could correlate an early onset and attenuation of XBP1 splicing in the IRE1-reporter cells as cytoprotective. Indeed, silencing of IRE1 expression using shRNA inhibited splicing of XBP1 resulting in an early onset of cell death. In contrast, in the PERK-reporter cells, we observed that a slow rate of ATF4-translation and late re-initiation of general translation coincided with cells which were resistant to ER stress-induced cell death. Interestingly, whereas silencing of PERK did not affect overall levels of cell death in response to ER stress, it did increase sensitivity to ER stressors at early time points following treatment. Our results suggest that apoptosis activation in response to ER stress is not caused by a preferential activation of a single UPR branch, or by a switch from one branch to the other. Rather, our data indicated that the relative timing of IRE1 and PERK signalling determines the shift from cell survival to apoptosis.

[Symptom validation: an overview]

When assessing mental disorders, there may appear different distortions of symptoms. Often patients exaggerate their complaints in order to achieve certain aims (e. g. retirement). Special symptom validity tests are therefore demanded as standard methods. These tests aim to verify the plausibility of the patient's symptoms, described at the assessment. This paper will give an overview of international and national research on symptom validation, manipulation of the test results, and coaching of patients.

Pharmacological pre- and post-conditioning with the sphingosine-1-phosphate receptor modulator FTY720 after myocardial ischaemia-reperfusion

BACKGROUND AND PURPOSE

Our recent experiments demonstrated that the Sphingosine-1-phosphate (S1P) receptor agonist FTY720 (2-amino-2-[2-(4-octylphenyl)ethyl]-1,3-propanediol hydrochloride) improves recovery of function after myocardial ischaemia-reperfusion ex vivo. Therefore, we tested the hypothesis that pharmacological post-conditioning with FTY720 reduces infarct size after myocardial ischaemia-reperfusion in vivo.

EXPERIMENTAL APPROACH

Myocardial ischaemia was induced in Wistar rats by ligation of the left coronary artery for 45 min. FTY720 (0.5 mg kg(-1)) was applied i.p. either once, before reperfusion, or twice, 24 h before myocardial ischaemia and before reperfusion. After 24 h reperfusion, we determined infarct size by triphenyltetrazolium chloride staining and granulocyte infiltration by immunohistochemistry. Tumour necrosis factor-alpha (TNF)-alpha concentration was determined by elisa. S1P receptor expression was studied by Western blot. Calcium transients were evaluated in Indo-1-loaded cardiomyocytes.

KEY RESULTS

In both groups, FTY720 significantly reduced lymphocyte count in peripheral blood. FTY720 treatment attenuated granulocyte infiltration and TNF-alpha protein expression in reperfused myocardium. However, both treatment regimens were not able to reduce infarct size. FTY720 increased mortality due to induction of fatal ventricular tachyarrhythmias when administered once before reperfusion, but protected against reperfusion arrhythmias when given 24 h prior to ischaemia. Pretreatment selectively down-regulated S1P(1) receptor expression within the myocardium. S1P receptor agonists did not induce calcium deregulation in cardiomyocytes.

CONCLUSIONS AND IMPLICATIONS

FTY720 applied during reperfusion did not reduce infarct size but increased mortality during myocardial ischaemia-reperfusion due to induction of arrhythmias. Pretreatment with FTY720 before ischaemia abrogated the deleterious pro-arrhythmic effects without reducing infarct size.

ORGAN WORK AND ORGAN WEIGHT

1. The ratios between the rates of growth of the body and of the heart, kidneys, and liver are approximately uniform between 40 gm. body weight and the body weight at maturity in the albino rat. The male and female hearts grow at 0.75 times the rate of growth of the body, the male kidneys at 0.717 times, the female kidneys at 0.648 times, and the liver at 0.838 times the rate of growth of the body as a whole. 2. Formulas for the prediction of organ weight from body weight were derived from the data on 1591 albino rats kept under constant conditions. 3. A series of experiments in which dietetic and metabolic variables were introduced into otherwise constant conditions showed that the heart weight was not affected by diet, and that both kidney weight and weight of liver protein (used as a measure of effective liver size) varied in the direction of change in the protein content of the diet. Decrease in rate of metabolism induced by thyroidectomy and increase in metabolism following the administration of thyroxin led to a corresponding fall and rise of heart, kidney, and liver protein weight. These results were confirmed in experiments on fasted rats with the exception that under these conditions thyroidectomy did not appreciably decrease liver protein weight relatively to fasted controls. Increase in organ metabolism due to dinitrophenol had no effect on organ weight. 4. When experimental changes alter the composition of the body with respect to fat or water, the comparison of experimental and control organ weights in terms of any one function of body weight is fallacious. 5. Conditions that change kidney weight usually change liver protein weight in the same direction and roughly to the same degree. The possible meaning of two exceptions to this rule is discussed. 6. The observations made are regarded as supporting the hypothesis that, after weaning, change in the weight of the heart, kidney, and liver protein is determined mainly by change in the amount of work done by these organs.