Reclassifying historical disasters: From single to multi-hazards

Multi-hazard events, characterized by the simultaneous, cascading, or cumulative occurrence of multiple natural hazards, pose a significant threat to human lives and assets. This is primarily due to the cumulative and cascading effects arising from the interplay of various natural hazards across space and time. However, their identification is challenging, which is attributable to the complex nature of natural hazard interactions and the limited availability of multi-hazard observations. This study presents an approach for identifying multi-hazard events during the past 123 years (1900-2023) using the EM-DAT global disaster database. Leveraging the 'associated hazard' information in EM-DAT, multi-hazard events are detected and assessed in relation to their frequency, impact on human lives and assets, and reporting trends. The interactions between various combinations of natural hazard pairs are explored, reclassifying them into four categories: preconditioned/triggering, multivariate, temporally compounding, and spatially compounding multi-hazard events. The results show, globally, approximately 19 % of the 16,535 disasters recorded in EM-DAT can be classified as multi-hazard events. However, the multi-hazard events recorded in EM-DAT are disproportionately responsible for nearly 59 % of the estimated global economic losses. Conversely, single hazard events resulted in higher fatalities compared to multi-hazard events. The largest proportion of multi-hazard events are associated with floods, storms, and earthquakes. Landslides emerge as the predominant secondary hazards within multi-hazard pairs, primarily triggered by floods, storms, and earthquakes, with the majority of multi-hazard events exhibiting preconditioned/triggering and multivariate characteristics. There is a higher prevalence of multi-hazard events in Asia and North America, whilst temporal overlaps of multiple hazards predominate in Europe. These results can be used to increase the integration of multi-hazard thinking in risk assessments, emergency management response plans and mitigation policies at both national and international levels.

A new method to compile global multi-hazard event sets

This study presents a new method, the MYRIAD-Hazard Event Sets Algorithm (MYRIAD-HESA), that compiles historically-based multi-hazard event sets. MYRIAD-HESA is a fully open-access method that can create multi-hazard event sets from any hazard events that occur on varying time, space, and intensity scales. In the past, multi-hazards have predominately been studied on a local or continental scale, or have been limited to specific hazard combinations, such as the combination between droughts and heatwaves. Therefore, we exemplify our approach by compiling a global multi-hazard event set database, spanning from 2004 to 2017, which includes eleven hazards from varying hazard classes (e.g. meteorological, geophysical, hydrological and climatological). This global database provides new scientific insights on the frequency of different multi-hazard events and their hotspots. Additionally, we explicitly incorporate a temporal dimension in MYRIAD-HESA, the time-lag. The time-lag, or time between the occurrence of hazards, is used to determine potentially impactful events that occurred in close succession. Varying time-lags have been tested in MYRIAD-HESA, and are analysed using North America as a case study. Alongside the MYRIAD-HESA, the multi-hazard event sets, MYRIAD-HES, is openly available to further increase the understanding of multi-hazard events in the disaster risk community. The open-source nature of MYRIAD-HESA provides flexibility to conduct multi-risk assessments by, for example, incorporating higher resolution data for an area of interest.

Toward a framework for systemic multi-hazard and multi-risk assessment and management

In our increasingly interconnected world, natural hazards and their impacts spread across geographical, administrative, and sectoral boundaries. Owing to the interrelationships between multi-hazards and socio-economic dimensions, the impacts of these types of events can surmount those of multiple single hazards. The complexities involved in tackling multi-hazards and multi-risks hinder a more holistic and integrative perspective and make it difficult to identify overarching dimensions important for assessment and management purposes. We contribute to this discussion by building on systemic risk research, especially the focus on interconnectedness, and suggest ways forward for an integrated multi-hazard and multi-risk framework that should be beneficial in real-world applications. In this article, we propose a six-step framework for analyzing and managing risk across a spectrum ranging from single-to multi- and systemic risk.

Consideration of compound drivers and impacts in the disaster risk reduction cycle

Consideration of compound drivers and impacts are often missing from applications within the Disaster Risk Reduction (DRR) cycle, leading to poorer understanding of risk and benefits of actions. The need to include compound considerations is known, but lack of guidance is prohibiting practitioners from including these considerations. This article makes a step toward practitioner guidance by providing examples where consideration of compound drivers, hazards, and impacts may affect different application domains within disaster risk management. We discern five DRR categories and provide illustrative examples of studies that highlight the role of "compound thinking" in early warning, emergency response, infrastructure management, long-term planning, and capacity building. We conclude with a number of common elements that may contribute to the development of practical guidelines to develop appropriate applications for risk management.

The challenge of unprecedented floods and droughts in risk management

Risk management has reduced vulnerability to floods and droughts globally^1,2, yet their impacts are still increasing³. An improved understanding of the causes of changing impacts is therefore needed, but has been hampered by a lack of empirical data^4,5. On the basis of a global dataset of 45 pairs of events that occurred within the same area, we show that risk management generally reduces the impacts of floods and droughts but faces difficulties in reducing the impacts of unprecedented events of a magnitude not previously experienced. If the second event was much more hazardous than the first, its impact was almost always higher. This is because management was not designed to deal with such extreme events: for example, they exceeded the design levels of levees and reservoirs. In two success stories, the impact of the second, more hazardous, event was lower, as a result of improved risk management governance and high investment in integrated management. The observed difficulty of managing unprecedented events is alarming, given that more extreme hydrological events are projected owing to climate change³.

A globally consistent local-scale assessment of future tropical cyclone risk

There is considerable uncertainty surrounding future changes in tropical cyclone (TC) frequency and intensity, particularly at local scales. This uncertainty complicates risk assessments and implementation of risk mitigation strategies. We present a novel approach to overcome this problem, using the statistical model STORM to generate 10,000 years of synthetic TCs under past (1980-2017) and future climate (SSP585; 2015-2050) conditions from an ensemble of four high-resolution climate models. We then derive high-resolution (10-km) wind speed return period maps up to 1000 years to assess local-scale changes in wind speed probabilities. Our results indicate that the probability of intense TCs, on average, more than doubles in all regions except for the Bay of Bengal and the Gulf of Mexico. Our unique and innovative methodology enables globally consistent comparison of TC risk in both time and space and can be easily adapted to accommodate alternative climate scenarios and time periods.

Cutting the costs of coastal protection by integrating vegetation in flood defences

Exposure to coastal flooding is increasing due to growing population and economic activity. These developments go hand-in-hand with a loss and deterioration of ecosystems. Ironically, these ecosystems can play a buffering role in reducing flood hazard. The ability of ecosystems to contribute to reducing coastal flooding has been emphasized in multiple studies. However, the role of ecosystems in hybrid coastal protection (i.e. a combination of ecosystems and levees) has been poorly quantified at a global scale. Here, we evaluate the use of coastal vegetation, mangroves, and marshes fronting levees to reduce global coastal protection costs, by accounting for wave-vegetation interaction.The research is carried out by combining earth observation data and hydrodynamic modelling. We show that incooperating vegetation in hybrid coastal protection results in more sustainable and financially attractive coastal protection strategies. If vegetated foreshore levee systems were established along populated coastlines susceptible to flooding, the required levee crest height could be considerably reduced. This would result in a reduction of 320 (range: 107-961) billion USD2005 Power Purchasing Parity (PPP) in investments, of which 67.5 (range: 22.5- 202) billion USD2005 PPP in urban areas for a 1 in 100-year flood protection level.

Economic motivation for raising coastal flood defenses in Europe

Extreme sea levels (ESLs) in Europe could rise by as much as one metre or more by the end of this century due to climate change. This poses significant challenges to safeguard coastal communities. Here we present a comprehensive analysis of economically efficient protection scenarios along Europe's coastlines during the present century. We employ a probabilistic framework that integrates dynamic simulations of all ESL components and flood inundation, impact modelling and a cost-benefit analysis of raising dykes. We find that at least 83% of flood damages in Europe could be avoided by elevating dykes in an economically efficient way along 23.7%-32.1% of Europe's coastline, specifically where high value conurbations exist. The European mean benefit to cost ratio of the investments varies from 8.3 to 14.9 while at country level this ranges between 1.6 and 34.3, with higher efficiencies for a scenario with high-end greenhouse gas emissions and strong socio-economic growth.

Agreement between reconstructed and modeled boreal precipitation of the Last Interglacial

The last extended time period when climate may have been warmer than today was during the Last Interglacial (LIG; ca. 129 to 120 thousand years ago). However, a global view of LIG precipitation is lacking. Here, seven new LIG climate models are compared to the first global database of proxies for LIG precipitation. In this way, models are assessed in their ability to capture important hydroclimatic processes during a different climate. The models can reproduce the proxy-based positive precipitation anomalies from the preindustrial period over much of the boreal continents. Over the Southern Hemisphere, proxy-model agreement is partial. In models, LIG boreal monsoons have 42% wider area than in the preindustrial and produce 55% more precipitation and 50% more extreme precipitation. Austral monsoons are weaker. The mechanisms behind these changes are consistent with stronger summer radiative forcing over boreal high latitudes and with the associated higher temperatures during the LIG.

Spatiotemporal patterns of extreme sea levels along the western North-Atlantic coasts

The western North-Atlantic coast experienced major coastal floods in recent years. Coastal floods are primarily composed of tides and storm surges due to tropical (TCs) and extra-tropical cyclones (ETCs). We present a reanalysis from 1988 to 2015 of extreme sea levels that explicitly include TCs for the western North-Atlantic coastline. Validation shows a good agreement between modeled and observed sea levels and demonstrates that the framework can capture large-scale variability in extreme sea levels. We apply the 28-year reanalysis to analyze spatiotemporal patterns. Along the US Atlantic coasts the contribution of tides can be significant, with the average contribution of tides during the 10 largest events up to 55% in some locations, whereas along the Mexican Southern Gulf coast, the average contribution of tides over the largest 10 events is generally below 25%. At the US Atlantic coast, ETCs are responsible for 8.5 out of the 10 largest extreme events, whereas at the Gulf Coast and Caribbean TCs dominate. During the TC season more TC-driven events exceed a 10-year return period. During winter, there is a peak in ETC-driven events. Future research directions include coupling the framework with synthetic tropical cyclone tracks and extension to the global scale.

Financing agricultural drought risk through ex-ante cash transfers

Despite advances in drought early warning systems, forecast information is rarely used for triggering and financing early actions, such as cash transfer. Scaling up cash transfer pay-outs, and overcoming the barriers to actions based on forecasts, requires an understanding of costs resulting from False Alarms, and the potential benefits associated with appropriate early interventions. On this study, we evaluate the potential cost-effectiveness of cash transfer responses, comparing the relative costs of ex-ante cash transfers during the maize growing season to ex-post cash transfers after harvesting in Kenya. For that, we developed a forecast model using Fast-and Frugal Trees that unravels early warning relationships between climate variability, vegetation coverage, and maize yields at multiple lead times. Results indicate that our models correctly forecast low maize yield events 85% of the time across the districts studied, some already six months before harvesting. The models' performance improves towards the end of the growing season driven by a decrease of 29% in the probability of False Alarms. Overall, we show that timely cash transfers ex-ante to a disaster can often be more cost-effective than investing in ex-post expenditures. Our findings suggest that early response can yield significant cost savings, and can potentially increase the effectiveness of existing cash transfer systems.

Translating large-scale climate variability into crop production forecast in Europe

Studies show that climate variability drives interannual changes in meteorological variables in Europe, which directly or indirectly impacts crop production. However, there is no climate-based decision model that uses indices of atmospheric oscillation to predict agricultural production risks in Europe on multiple time-scales during the growing season. We used Fast-and-Frugal trees to predict sugar beet production, applying five large-scale indices of atmospheric oscillation: El Niño Southern Oscillation, North Atlantic Oscillation, Scandinavian Pattern, East Atlantic Pattern, and East Atlantic/West Russian pattern. We found that Fast-and-Frugal trees predicted high/low sugar beet production events in 77% of the investigated regions, corresponding to 81% of total European sugar beet production. For nearly half of these regions, high/low production could be predicted six or five months before the start of the sugar beet harvesting season, which represents approximately 44% of the mean annual sugar beet produced in all investigated areas. Providing early warning of crop production shortages/excess allows decision makers to prepare in advance. Therefore, the use of the indices of climate variability to forecast crop production is a promising tool to strengthen European agricultural climate resilience.

Coastal and river flood risk analyses for guiding economically optimal flood adaptation policies: a country-scale study for Mexico

Many countries around the world face increasing impacts from flooding due to socio-economic development in flood-prone areas, which may be enhanced in intensity and frequency as a result of climate change. With increasing flood risk, it is becoming more important to be able to assess the costs and benefits of adaptation strategies. To guide the design of such strategies, policy makers need tools to prioritize where adaptation is needed and how much adaptation funds are required. In this country-scale study, we show how flood risk analyses can be used in cost-benefit analyses to prioritize investments in flood adaptation strategies in Mexico under future climate scenarios. Moreover, given the often limited availability of detailed local data for such analyses, we show how state-of-the-art global data and flood risk assessment models can be applied for a detailed assessment of optimal flood-protection strategies. Our results show that especially states along the Gulf of Mexico have considerable economic benefits from investments in adaptation that limit risks from both river and coastal floods, and that increased flood-protection standards are economically beneficial for many Mexican states. We discuss the sensitivity of our results to modelling uncertainties, the transferability of our modelling approach and policy implications.This article is part of the theme issue 'Advances in risk assessment for climate change adaptation policy'.

Flood risk and adaptation strategies under climate change and urban expansion: A probabilistic analysis using global data

An accurate understanding of flood risk and its drivers is crucial for effective risk management. Detailed risk projections, including uncertainties, are however rarely available, particularly in developing countries. This paper presents a method that integrates recent advances in global-scale modeling of flood hazard and land change, which enables the probabilistic analysis of future trends in national-scale flood risk. We demonstrate its application to Indonesia. We develop 1000 spatially-explicit projections of urban expansion from 2000 to 2030 that account for uncertainty associated with population and economic growth projections, as well as uncertainty in where urban land change may occur. The projections show that the urban extent increases by 215%-357% (5th and 95th percentiles). Urban expansion is particularly rapid on Java, which accounts for 79% of the national increase. From 2000 to 2030, increases in exposure will elevate flood risk by, on average, 76% and 120% for river and coastal floods. While sea level rise will further increase the exposure-induced trend by 19%-37%, the response of river floods to climate change is highly uncertain. However, as urban expansion is the main driver of future risk, the implementation of adaptation measures is increasingly urgent, regardless of the wide uncertainty in climate projections. Using probabilistic urban projections, we show that spatial planning can be a very effective adaptation strategy. Our study emphasizes that global data can be used successfully for probabilistic risk assessment in data-scarce countries.

Lost food, wasted resources: global food supply chain losses and their impacts on freshwater, cropland, and fertiliser use

Reducing food losses and waste is considered to be one of the most promising measures to improve food security in the coming decades. Food losses also affect our use of resources, such as freshwater, cropland, and fertilisers. In this paper we estimate the global food supply losses due to lost and wasted food crops, and the resources used to produce them. We also quantify the potential food supply and resource savings that could be made by reducing food losses and waste. We used publically available global databases to conduct the study at the country level. We found that around one quarter of the produced food supply (614 kcal/cap/day) is lost within the food supply chain (FSC). The production of these lost and wasted food crops accounts for 24% of total freshwater resources used in food crop production (27 m(3)/cap/yr), 23% of total global cropland area (31 × 10(-3)ha/cap/yr), and 23% of total global fertiliser use (4.3 kg/cap/yr). The per capita use of resources for food losses is largest in North Africa & West-Central Asia (freshwater and cropland) and North America & Oceania (fertilisers). The smallest per capita use of resources for food losses is found in Sub-Saharan Africa (freshwater and fertilisers) and in Industrialised Asia (cropland). Relative to total food production, the smallest food supply and resource losses occur in South & Southeast Asia. If the lowest loss and waste percentages achieved in any region in each step of the FSC could be reached globally, food supply losses could be halved. By doing this, there would be enough food for approximately one billion extra people. Reducing the food losses and waste would thus be an important step towards increased food security, and would also increase the efficiency of resource use in food production.

Modeling growth factor activity during proinflammatory stress: methodological considerations in assessing cytokine modulation of IGF binding proteins released by cultured bovine kidney epithelial cells

The present research was conducted to model potential mechanisms through which IGFBPs might be affected by a key proinflammatory response initiating cytokine tumor necrosis factor (TNF-)-alpha. Madin-Darby bovine kidney epithelial (MDBK) cells, known to release IGFBPs in response to several stimuli, were grown under several conditions and challenged with forskolin (F) or recombinant TNF-alpha for 24h. Forskolin increased IGFBP-3 gene expression and media content of BP-3 protein. TNF-alpha increased basal and augmented F-mediated IGFBP-3 gene expression. However, TNF-alpha effects on the measurable media content of IGFBPs were influenced by culture conditions; in the absence of added protease inhibitors (PIs) or sufficient media albumin concentration (high BSA, 1mg/ml), the effect of TNF-alpha was to decrease (P<0.02) measurable IGFBPs. In the presence of PI and high BSA, media IGFBP-3 levels were shown to be increased by TNF-alpha consistent with the gene expression data. Changes in media IGFBP-3 protease activity were examined further to explain the observed effects of TNF-alpha on production and destruction of IGFBPs in media. When recombinant human IGFBP-3 (500 ng/ml) was added to PI-free, low BSA 100 microg/ml) media from TNF-treated MDBK cells, less than 10% of the BP-3 was recognizable by Western blot in 30 min; conversely, inclusion of High BSA and PI in media resulted in attenuation of the protease effect on the IGFBPs. The data suggest that the MDBK model of cellular response to proinflammatory stimulus is affected by culture conditions and that TNF-alpha affects media content of IGFBPs through effects on IGFBP gene expression coupled with degradation of IGFBPs via enhanced proteolytic enzyme release.

Lipid peroxidation in hepatic steatosis in humans is associated with hepatic fibrosis and occurs predominately in acinar zone 3

BACKGROUND AND AIMS

Hepatic steatosis has been shown to be associated with lipid peroxidation and hepatic fibrosis in a variety of liver diseases including non-alcoholic fatty liver disease. However, the lobular distribution of lipid peroxidation associated with hepatic steatosis, and the influence of hepatic iron stores on this are unknown. The aim of this study was to assess the distribution of lipid peroxidation in association with these factors, and the relationship of this to the fibrogenic cascade.

METHODS

Liver biopsies from 39 patients with varying degrees of hepatic steatosis were assessed for evidence of lipid peroxidation (malondialdehyde adducts), hepatic iron, inflammation, fibrosis, hepatic stellate cell activation (alpha-smooth muscle actin and TGF-beta expression) and collagen type I synthesis (procollagen alpha1 (I) mRNA).

RESULTS

Lipid peroxidation occurred in and adjacent to fat-laden hepatocytes and was maximal in acinar zone 3. Fibrosis was associated with steatosis (P < 0.04), lipid peroxidation (P < 0.05) and hepatic iron stores (P < 0.02). Multivariate logistic regression analysis confirmed the association between steatosis and lipid peroxidation within zone 3 hepatocytes (P < 0.05), while for hepatic iron, lipid peroxidation was seen within sinusoidal cells (P < 0.05), particularly in zone 1 (P < 0.02). Steatosis was also associated with acinar inflammation (P < 0.005). alpha-Smooth muscle actin expression was present in association with both lipid peroxidation and fibrosis. Although the effects of steatosis and iron on lipid peroxidation and fibrosis were additive, there was no evidence of a specific synergistic interaction between them.

CONCLUSIONS

These observations support a model where steatosis exerts an effect on fibrosis through lipid peroxidation, particularly in zone 3 hepatocytes.

FGF5 stimulates expansion of connective tissue fibroblasts and inhibits skeletal muscle development in the limb

FGF5 is expressed in the mesenchyme and skeletal muscle of developing and adult mouse limbs. However, the function of FGF5 during development of the limb and limb musculature is unknown. To elucidate the inherent participation of FGF5 during limb organogenesis, a retroviral delivery system (RCAS) was used to overexpress human FGF5 throughout developing hind limb of chicken embryos. Misexpression of the soluble growth factor severely inhibited the formation of mature myocytes. Limbs infected with RCAS-FGF5 contained smaller presumptive muscle masses as evidenced by a decrease in MyoD and myosin heavy chain expressing cells. In contrast, ectopic expression of FGF5 significantly stimulated proliferation and expansion of the tenascin-expressing, connective-tissue fibroblast lineage throughout the developing limb. Histological analysis demonstrated that the increase in tenascin immunostaining surrounding the femur, ileum, and pubis in the FGF5 infected limbs corresponded to the fibroblasts forming the stacked-cell perichondrium. Furthermore, pulse labeling experiments with the thymidine analog, BrdU, revealed that the increased size of the perichondrium was attributable to enhanced cell proliferation. These results support a model whereby FGF5 acts as a mitogen to stimulate the proliferation of mesenchymal fibroblasts that contribute to the formation of connective tissues such as the perichondrium, and inhibits the development of differentiated skeletal muscle. These results also contend that FGF5 is a candidate mediator of the exclusive spatial patterning of the hind limb connective tissue and skeletal muscle.

Role of alcohol dehydrogenase 3 and cytochrome P-4502E1 genotypes in susceptibility to cancers of the upper aerodigestive tract

Alcohol is a recognized risk factor for upper aerodigestive tract (UAT) cancers, but the mechanism by which alcohol causes cancer remains obscure. Ethanol is oxidized to acetaldehyde (the suspected carcinogenic agent in alcohol) by alcohol dehydrogenases (ADHs) and cytochrome P-4502E1 (CYP2E1), both of which exhibit great inter-individual variability in activity. The hypothesis that these polymorphisms influence susceptibility to alcohol-related cancers remains poorly documented. We investigated whether ADH(3) and CYP2E1 DraI and RsaI genotypes modified the risk of UAT cancers among 121 oral cavity/pharyngeal cancer patients, 129 laryngeal cancer patients, and 172 controls, all French Caucasians. Cancer risks and gene-alcohol interactions were analyzed by unconditional logistic regression, accounting for potential confounders. ADH(3) genotype was not associated with UAT cancer. In contrast, a 2-fold risk of oral cavity/pharyngeal (OR = 2.0, 95% CI 1.0-3.9) and laryngeal (OR = 1.8, 95% CI 1.0-3.5) cancers was observed for carriers of the CYP2E1 DraI C variant allele compared with other individuals. The risk associated with the CYP2E1 RsaI c2 variant allele also increased for oral cavity/pharyngeal cancer (OR = 2.6, 95% CI 1.0-6. 6). The effects of ADH(3) or CYP2E1 genotype and alcohol or tobacco were independent. The highest risk of oral cavity/pharyngeal cancer was observed among the heaviest drinkers (>80 g/day) with the CYP2E1 DraI C allele (OR = 5.8, 95% CI 1.9-18.2) or the CYP2E1 RsaI c2 allele (OR = 7.2, 95% CI 1.4-38.2) compared with lighter drinkers with other genotypes. Our study suggests that CYP2E1 genotype modifies the risk of UAT cancers, but due to the low frequency of CYP2E1 variant alleles, large-scale studies are needed to confirm our findings.

Covariate effects on linkage and association using a general pair method

The "general pair method" (GPM) is a nonparametric, identity-by-state (IBS) method of assessing linkage between a chromosomal marker and a binary phenotype. It is applicable to any pedigree structure, and uses marker information from affected as well as unaffected individuals. Results obtained here from nuclear families (Problem 2A) are contrasted with those from extended pedigrees (Problem 2B). Test statistics for chromosomal linkage between each marker and disease status are contrasted with tests for "direct association" which test the hypothesis that a particular allele is associated disease status across all pedigrees. A novel extension of the GPM is presented here for testing whether the strength of linkage (and/or association) depends on the levels of a covariate (i.e., dependency on gender, age, the levels of the "environmental factor," or the levels of the "quantitative phenotypes" supplied). The GPM is seen to have some power to detect major gene 1 on chromosome 5, and major gene 3 on chromosome 4. The gender interaction effects proved too small to detect. No direct associations are found.

The progression of an infundibulum to aneurysm formation and rupture: case report and literature review

OBJECTIVE AND IMPORTANCE

Infundibula (IFs) are funnel-shaped symmetrical enlargements that occur at the origins of cerebral arteries and are apparent on 7 to 25% of otherwise normal angiograms. They are frequently considered as normal anatomic variants of no pathogenic significance.

CLINICAL PRESENTATION

We report the case of a ruptured posterior communicating artery aneurysm that had developed at the site of a previously known IF in a 49-year-old hypertensive woman. She had a poor conscious level at admission, with widespread subarachnoid hemorrhage and obstructive hydrocephalus.

INTERVENTION

The patient was immediately ventilated, and an external ventricular drain was inserted. The aneurysm was successfully clipped; however, secondary hemorrhage occurred both before and during craniotomy. She developed marked hypernatremia and subsequently died.

CONCLUSION

This is the 11th case of IF-to-aneurysm progression reported. It suggests that in certain cases, serial investigations may be indicated with IFs to detect aneurysm formation and preempt rupture.

The use of the supracondylar nail in the management of femoral fractures in the presence of other femoral implants in the very elderly

In a retrospective study we review the use of the supracondylar nail for the treatment of distal femoral fractures above existing knee prostheses or below upper femoral implants in a very elderly population of mean age 85. Over a 2 year period we have used the Smith and Nephew supracondylar nail to stabilise seven distal third femoral fractures either distal to a femoral implant (six cases) or proximal to a total knee replacement. One patient died soon after surgery, one patient had an extension of the fracture proximal to the nail but the others made an excellent functional recovery with early mobilisation of the knee. We recommend the use of the supracondylar nail in the management of these difficult cases. The very elderly patient benefits from the early and stable fixation of these fractures.

Overtaking road-accidents: differences in manoeuvre as a function of driver age

Nine-hundred and seventy-three police road-accident files describing overtaking accidents were sampled from the headquarters of Nottinghamshire Constabulary, England, for the years 1989-1993. Salient facts were extracted from each case, including the exact manoeuvre involved, the principle explanatory factors, the driver(s) most at fault, and the drivers' ages. Two kinds of reliability measure for case interpretations. indicated high levels of consistency. Two induced exposure measures were used, comparing driver involvement in a given type of overtaking accident with involvement in overtaking accidents in general, and comparing the age profiles of the drivers most at fault with those of the other drivers involved. Ten types of overtaking accident were distinguished, and three are discussed in detail: collision with a right-turning vehicle (the most common injury-accident for overtakers), which tends to occur either because a young driver makes a faulty overtaking decision, or an older driver makes a faulty right turn; head-on collision, which affects all age groups roughly in proportion to exposure; and the 'return-and-lose-control' accident, which is associated particularly with young drivers. The study illustrates the 'structured judgement method' of accident causation research, in which human interpreters are used to ascribe causes and processes to individual cases, but orthodox research techniques are used to standardise procedures, and to assess and ensure reliability.

The role of magnetic resonance imaging in the investigation of spinal dysraphism in the child with lower limb abnormality

A review of magnetic resonance imaging (MRI) performed to exclude the presence of spinal dysraphism in children presenting with lower limb pathology is unrewarding in the absence of abnormal neurology. Over a 5-year period, 29 children ages 2 weeks to 15 years with a mean age of 6 years presenting with lower limb abnormalities were referred for MRI of the spine to exclude an occult neurologic cause for the deformities. More than one limb abnormality, for example pes cavus and limb length discrepancy, was present in 93% of the children, and 11 children had severe or recurrent talipes equinovarus deformity. Only two children (7%), both of whom had abnormal limb neurology, had abnormal MRI scans. In the absence of a demonstrable neurologic deficit in the lower limb, there appears to be no advantage in requesting MRI of the spine in children presenting with lower limb abnormality.

Population distribution of alcohol dehydrogenase class I in France: comparison with other populations, and distribution with respect to gender and age. The French Group for Research on Alcohol and Liver

In Caucasians, a genetic polymorphism is known for some alcohol dehydrogenase (ADH) systems (beta and gamma). Knowledge of population frequencies of the beta and gamma hepatic isozyme variants in France is a prerequisite to understanding any role this genetic variation might play in determining the risk of alcohol-related diseases. For the present study, the ADH phenotypes of 115 French Caucasian control subjects, consisting of 64 men and 51 women, were studied. The beta2 subunit was found to have a very low frequency. The relative frequencies of ADH gamma subunits observed in French Caucasians were found to be in good agreement with those already observed in other Caucasian populations. When gender and age were taken into account, a particular group corresponding to young men (age <50 years) was characterized by a manifest discordance with the comparable female population.

Increased hepatic iron concentration in nonalcoholic steatohepatitis is associated with increased fibrosis

BACKGROUND & AIMS

Nonalcoholic steatohepatitis (NASH) is a chronic liver disease that occasionally progresses to cirrhosis but usually has a benign course. The aim of this study was to investigate the role of the hemochromatosis mutation Cys282Tyr in development of the mild hepatic iron overload found in some patients with NASH and its association with hepatic damage in these patients.

METHODS

Fifty-one patients with NASH were studied. The presence of the Cys282Tyr mutation was tested in all patients, and the data were analyzed with respect to the histological grade of steatosis, inflammation, Perls' staining, hepatic iron concentration (HIC), and serum iron indices.

RESULTS

Thirty-one percent of patients with NASH were either homozygous or heterozygous for the Cys282Tyr mutation. This mutation was significantly associated with Perls' stain grade (P < 0.005), HIC (P < 0.005), and transferrin saturation percentage (P < 0.005) but not with serum ferritin levels. Linear regression analysis showed that increased hepatic iron (Perls' stain or HIC) had the greatest association with the severity of fibrosis (P < 0.0001).

CONCLUSIONS

The Cys282Tyr mutation is responsible for most of the mild iron overload found in NASH and thus has a significant association with hepatic damage in these patients. Heterozygosity for the hemochromatosis gene mutation therefore cannot always be considered benign.

Tarsal tunnel syndrome: a study of the clinical and neurophysiological results of decompression

The neurophysiological and clinical outcomes of surgical decompression of 22 cases of tarsal tunnel syndrome are analysed. Recent work by Pfeiffer & Cracchiolo has suggested a successful outcome in only 44% of cases. We have reviewed the outcome of surgery both clinically and with the use of nerve conduction studies. Pre- and post-operative motor conduction delays in the plantar nerves are compared with clinical results found both in the clinic and later by a postal questionnaire. Despite careful clinical and neurophysiological assessment prior to a full surgical release, only 42% of patients had a satisfactory outcome. A larger reduction in plantar nerve conduction delay post-operatively corresponded well to an improvement in symptoms. However, we were unable to predict which cases would respond to decompression using clinical or electrophysiological methods. We question the use of nerve conduction studies in the diagnosis of tarsal tunnel syndrome, and also the role of surgery in the management of this condition.

Biochemistry and pharmacology of 7alpha-substituted androstenediones as aromatase inhibitors

The inhibition of aromatase, the enzyme responsible for converting androgens to estrogens, is therapeutically useful for the endocrine treatment of hormone-dependent breast cancer. Research by our laboratory has focused on developing competitive and irreversible steroidal aromatase inhibitors, with an emphasis on synthesis and biochemistry of 7alpha-substituted androstenediones. Numerous 7alpha-thiosubstituted androst-4-ene-3,17-diones are potent competitive inhibitors, and several 1,4-diene analogs, such as 7alpha-(4'-aminophenylthio)-androsta-1,4-diene-3,17-di one (7alpha-APTADD), have demonstrated effective enzyme-activated irreversible inhibition of aromatase in microsomal enzyme assays. One focus of current research is to examine the effectiveness and biochemical pharmacology of 7alpha-APTADD in vivo. In the hormone-dependent 7,12-dimethylbenz(a)anthracene (DMBA)-induced rat mammary carcinoma model system, 7alpha-APTADD at a 50 mg/kg/day dose caused an initial decrease in mean tumor volume during the first week, and tumor volume remained unchanged throughout the remaining 5-week treatment period. This agent lowers serum estradiol levels and inhibits ovarian aromatase activity. A second research area has focused on the synthesis of more metabolically stable inhibitors by replacing the thioether linkage at the 7alpha position with a carbon-carbon linkage. Several 7alpha-arylaliphatic androst-4-ene-3,17-diones were synthesized by 1,6-conjugate additions of appropriate organocuprates to a protected androst-4,6-diene or by 1,4-conjugate additions to a seco-A-ring steroid intermediate. These compounds were all potent inhibitors of aromatase with apparent Kis ranging between 13 and 19 nM. Extension of the research on these 7alpha-arylaliphatic androgens includes the introduction of a C1-C2 double bond in the A-ring to provide enzyme-activated irreversible inhibitors. The desired 7alpha-arylaliphatic androsta-1,4-diene-3,17-diones were obtained from their corresponding 7alpha-arylaliphatic androst-4-ene-3,17-diones by oxidation with 2,3-dichloro-5,6-dicyano-1,4-benzoquinone (DDQ). These inhibitors demonstrated enzyme-mediated inactivation of aromatase with apparent k(inact)s ranging from 4.4 x 10(-4) to 1.90 x 10(-3) s(-1). The best inactivator of the series was 7alpha-phenpropylandrosta-1,4-diene-3,17-dione, which exhibited a T(1/2) of 6.08 min. Aromatase inhibition was also observed in MCF-7 human mammary carcinoma cell cultures and in JAr human choriocarcinoma cell cultures, exhibiting IC50 values of 64-328 nM. The 7alpha-arylaliphatic androgens thus demonstrate potent inhibition of aromatase in both microsomal incubations and in choriocarcinoma cell lines expressing aromatase enzymatic activity. Additionally, the results from these studies provide further evidence for the presence of a hydrophobic binding pocket existing near the 7alpha-position of the steroid in the active site of aromatase. The size of the 7alpha-substituent influences optimal binding of steroidal inhibitors to the active site and affects the extent of enzyme-mediated inactivation observed with androsta-1,4-diene-3,17-dione analogs.

Laryngeal and oropharyngeal cancer, and alcohol dehydrogenase 3 and glutathione S-transferase M1 polymorphisms

In this study the GSTmu phenotype and ADH genotype at the ADH3 locus were investigated in a group of 39 alcoholic men with upper respiratory/digestive tract cancer: 21 with oropharyngeal cancer and 18 with laryngeal cancer. The results are compared with those of a control group of 37 alcoholic men without alcohol-related medical complications. Of the control subjects, 48% were found to be GSTmu deficient [GSTmu(-)] and 19% carried the ADH(3)1/ADH(3)1 genotype. In the laryngeal cancer patients, a significantly elevated frequency of both the GSTmu(-) (78%) and ADH(3)1/ADH(3)1 genotype (56%) was observed, relative to the control group. On the basis of this result, the risk of laryngeal cancer associated with the GSTmu(-) and ADH(3)1/ADH(3)1 genotypic combination within the population of alcoholics was estimated to be 12.9 with a 95% confidence interval of 1.8-92 (P < 0.01) relative to alcoholic individuals who have GSTmu [GSTmu(+)] and are not ADH(3)1/ADH(3)1. Thus, alcoholics who are GSTmu(-) and ADH(3)1/ADH(3)1 have at least an 80% greater risk of developing laryngeal cancer than alcoholics who are GSTmu(+) and who are not ADH(3)1/ADH(3)1. In addition, the oropharyngeal cancer patients had excess frequencies of both GSTmu(-) (62%) and ADH(3)1/ADH(3)1 (43%) relative to the control group, but these excess frequencies were not statistically significant. The GSTmu(-) and ADH(3)1/ADH(3)1 genotypic combination may be a constitutional risk factor for laryngeal cancer among alcoholics.

Measuring gene-disease association using a general pair method

The general-pair-method (GPM) was applied to the analysis of the Problem 1 data set. GPM is a nonparametric, identity-by-state method for associating variation at a chromosomal locus with disease status. It can accommodate information from all pairs of individuals across any degree of genetic relatedness, including genetically unrelated individuals, within a single test statistic. Pairwise contrasts between members of different pedigrees, including "control" pedigrees containing no affected individuals, can therefore be exploited in order to increase the power of the test statistic. Such a strategy makes sense within the context of a candidate gene (direct association) study, where the alleles or genotypes of high disease risk are assumed to be the same ones within all families. Applied to the Problem 1 data set in this way, the GPM successfully identified the effect on disease status of locus 31 on chromosome 1, and of locus 23 on chromosome 5. The observed strength of gene-disease association at the other chromosomal loci was compatible with the null hypothesis.

The freckle plot (daily turnaround time chart): a technique for timely and effective quality improvement of test turnaround times

Test turnaround times are often monitored on a monthly basis. However, such an interval usually means that not all causes for delay in test reporting can be unequivocally identified for institution of remedial action. We have devised a daily chart--the freckle plot--that graphically displays the test turnaround times by laboratory receipt time. Different symbols are used to designate specimens reported within the test's turnaround time limit, those within 10 min beyond that limit, and those well outside the limit. These categories are adjustable to suit different limits of stringency. Freckle plots are produced on a daily basis and can be used to track down causes for test delays. Using the 1-h turnaround time "stat" potassium test as a model, we found 16 causes for test delay, of which 9 were potentially remediable. By applying these remedies, we were able to increase test compliance, in the day shift, from 91.5% (95% confidence interval 88.8%-93.7%) to 97.6% (95% confidence interval 96.4-98.55%), which is significant at P < 10(-7). This daily plot is a useful quality assurance tool, supplementing the more conventional tests used to ensure laboratory quality improvement.

The freckle plot (daily turnaround time chart): a technique for timely and effective quality improvement of test turnaround times

Test turnaround times are often monitored on a monthly basis. However, such an interval usually means that not all causes for delay in test reporting can be unequivocally identified for institution of remedial action. We have devised a daily chart--the freckle plot--that graphically displays the test turnaround times by laboratory receipt time. Different symbols are used to designate specimens reported within the test's turnaround time limit, those within 10 min beyond that limit, and those well outside the limit. These categories are adjustable to suit different limits of stringency. Freckle plots are produced on a daily basis and can be used to track down causes for test delays. Using the 1-h turnaround time "stat" potassium test as a model, we found 16 causes for test delay, of which 9 were potentially remediable. By applying these remedies, we were able to increase test compliance, in the day shift, from 91.5% (95% confidence interval 88.8%-93.7%) to 97.6% (95% confidence interval 96.4-98.55%), which is significant at P &lt; 10(-7). This daily plot is a useful quality assurance tool, supplementing the more conventional tests used to ensure laboratory quality improvement.

Some developments on the affected-pedigree-member method of linkage analysis

Some improvements are presented for the affected-pedigree-member method of linkage analysis, which is a generalization of the sib-pair method. The test statistic is extended to include contrasts between affected and unaffected pedigree members, so that it now utilizes marker information from all typed pedigree members rather than just the typed affected members. Computer simulation using a sample pedigree of 14 individuals shows that this modification can substantially increase statistical power where there is a direct association between marker variation and disease and where disease risk is elevated in carriers of the disease allele. Data on Huntington disease in 16 British families, which were analyzed previously using only the affected individuals, are reanalyzed with the unaffected individuals included. Strong rejection of the null hypothesis of no association between Huntington disease and the HindIII polymorphism is confirmed, but the particular families in which the association is significant differs from that obtained through an analysis based only on affected individuals and reflects more closely the results obtained from a lod-score analysis. The test statistic is also modified here to incorporate contrasts between individuals of zero kinship, if needed. This enables contrasts between individuals from different pedigrees, as well as contrasts involving individuals sampled from the general population, to be incorporated into the test of association. For population data, the methodology reduces to a type of contingency-table analysis, in which the rows of the table correspond to different marker-locus genotypes and in which the two columns categorize subjects into an "affected" group versus an "unaffected," or control, group. This aspect of the methodology is illustrated using two population data sets, the first relating APO-E genotype to the frequency of individuals undergoing maintenance hemodialysis and the second relating APO-B genotype to the frequency of coronary artery disease. The present methodology confirms the lack of association between marker and disease in the former data set and confirms the presence of association in the latter. Finally, the methodology is formulated here in terms of ordinary, multiperson kinship coefficients rather than in terms of the generalized kinship coefficients originally proposed. This greatly reduces the number of coefficients to be calculated, thereby enhancing the computational efficiency of the computer program.

The inheritance of metabolic flux: expressions for the within-sibship mean and variance given the parental genotypes

Recent developments have related quantitative trait expression to metabolic flux. The present paper investigates some implications of this for statistical aspects of polygenic inheritance. Expressions are derived for the within-sibship genetic mean and genetic variance of metabolic flux given a pair of parental, diploid, n-locus genotypes. These are exact and hold for arbitrary numbers of gene loci, arbitrary allelic values at each locus, and for arbitrary recombination fractions between adjacent gene loci. The within-sibship, genetic variance is seen to be simply a measure of parental heterozygosity plus a measure of the degree of linkage coupling within the parental genotypes. Approximations are given for the within-sibship phenotypic mean and variance of metabolic flux. These results are applied to the problem of attaining adequate statistical power in a test of association between allozymic variation and inter-individual variation in metabolic flux. Simulations indicate that statistical power can be greatly increased by augmenting the data with predictions and observations on progeny statistics in relation to parental allozyme genotypes. Adequate power may thus be attainable at small sample sizes, and when allozymic variation is scored at a only small fraction of the total set of loci whose catalytic products determine the flux.

The protease inhibitory properties of the Alzheimer's beta-amyloid precursor protein

We have expressed the 57-amino acid Kunitz domain of the Alzheimer's beta-amyloid precursor protein (APP751) as a bacterial fusion protein. The protease inhibitory properties of the purified fusion protein, BX9, were virtually identical in all respects tested to those of purified secreted APP751. Both proteins strongly inhibited pancreatic trypsin (Kis = 0.2 and 0.3 nM) and less well epidermal growth factor-binding protein (Kis = 1 and 3.5 nM), alpha-chymotrypsin (Kis = 3 and 6 nM), and the gamma-subunit of nerve growth factor (Kis = 8 and 9 M). Neither protein appreciably inhibited plasma and pancreatic kallikreins, thrombin, lung tryptase, neutrophil elastase, or cathepsin G. The remarkable similarity of the protease inhibitory profile of BX9 to that of secreted APP751 suggests that proper intramolecular disulfide bond formation has occurred in the bacterial fusion protein and leads to the conclusion that the amyloid precursor protein Kunitz domain is a relatively specific inhibitor of only a few trypsin-like arginine esterases.

Cleavage of amyloid beta peptide during constitutive processing of its precursor

The amyloid beta peptide (A beta P) is a small fragment of the much larger, broadly distributed amyloid precursor protein (APP). Abundant A beta P deposition in the brains of patients with Alzheimer's disease suggests that altered APP processing may represent a key pathogenic event. Direct protein structural analyses showed that constitutive processing in human embryonic kidney 293 cells cleaves APP in the interior of the A beta P, thus preventing A beta P deposition. A deficiency of this processing event may ultimately prove to be the etiological event in Alzheimer's disease that gives rise to senile plaque formation.

The Alzheimer amyloid precursor protein. Identification of a stable intermediate in the biosynthetic/degradative pathway

The amyloid forming beta-peptide of Alzheimer's disease is synthesized as part of a larger integral membrane precursor protein (beta APP) of which three alternatively spliced versions of 695, 751, and 770 amino acids have been described. A fourth beta APP form of 563 amino acids does not contain the beta-peptide region. Recent experiments using transient expression in HeLa cells (Weidemann, A., Konig, G., Bunke, D., Fischer, P., Salbaum, J.M., Masters, C.L., and Beyreuther, K. (1989) Cell 57, 115-126) indicate that the beta APP undergoes several posttranslational modifications including the cleavage and secretion of a large portion of its extracellular domain. The nature and fate of the fragment that remains cell-associated following this cleavage has not heretofore been described. The metabolism of this fragment may have particular significance in Alzheimer's disease since it must contain at least part of the beta-peptide. To study the metabolic fate of this fragment, we have established cell lines overexpressing the 695- and 751-amino acid versions of beta APP. Pulse-chase studies show that this system is similar to the HeLa cell system in that both proteins are synthesized first as membrane-bound proteins of approximately 98 and 108 kDa carrying asparagine-linked sugar side chains and are subsequently processed into higher molecular mass forms by the attachment of sulfate, phosphate, and further sugar groups including sialic acid, adding approximately 20 kDa in apparent molecular mass. The mature form of beta APP is cleaved and rapidly secreted, leaving an 11.5-kDa fragment with the transmembrane region and the cytoplasmic domain behind in the cell. This fragment is stable with a half-life of at least 4 h.

The secreted form of the Alzheimer's amyloid precursor protein with the Kunitz domain is protease nexin-II

The A4 protein (or beta-protein) is a 42- or 43-amino-acid peptide present in the extracellular neuritic plaques in Alzheimer's disease and is derived from a membrane-bound amyloid protein precursor (APP). Three forms of APP have been described and are referred to as APP695, APP751 and APP770, reflecting the number of amino acids encoded for by their respective complementary DNAs. The two larger APPs contain a 57-amino-acid insert with striking homology to the Kunitz family of protease inhibitors. Here we report that the deduced amino-terminal sequence of APP is identical to the sequence of a cell-secreted protease inhibitor, protease nexin-II (PN-II). To confirm this finding, APP751 and APP695 cDNAs were over-expressed in the human 293 cell line, and the secreted N-terminal extracellular domains of these APPs were purified to near homogeneity from the tissue-culture medium. The relative molecular mass and high-affinity binding to dextran sulphate of secreted APP751 were consistent with that of PN-II. Functionally, secreted APP751 formed stable, non-covalent, inhibitory complexes with trypsin. Secreted APP695 did not form complexes with trypsin. We conclude that the secreted form of APP with the Kunitz protease inhibitor domain is PN-II.

Iatrogenic lumbar meningocoel after excision of a neurofibroma

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Verapamil SR and propranolol LA: a comparison of efficacy and side effects in the treatment of mild to moderate hypertension

The efficacy, safety and toleration of sustained release verapamil (Securon SR, Knoll) and long acting propranolol (Inderal LA, ICI) in the treatment of mild to moderate hypertension were compared in a randomized, double-blind, parallel group study. Both drugs were of similar efficacy and were well tolerated in the majority of patients. However, in the verapamil SR treated group side-effects resulted in significantly fewer drug-related withdrawals.

Total intravenous anaesthesia for military surgery. A technique using ketamine, midazolam and vecuronium

Ketamine and midazolam were used for induction of anaesthesia and by continuous intravenous infusion for maintenance to assess their suitability for use in a total intravenous anaesthetic technique in the management of battle casualties. Muscular relaxation was provided by vecuronium and the patients' lungs ventilated with air. Ketamine was infused at a rate of 2 mg/kg/hour. This was achieved by mixing ketamine 200 mg, midazolam 5 mg and vecuronium 12 mg in 50 ml normal saline. The rate of infusion of the mixture (ml/hour) was then equal to 50% of the body weight in kg. The technique proved to be simple, effective and versatile and should be adaptable for use in the management of battle casualties.