Prognostic impact of left ventricular thrombus resolution after myocardial infarction on cardiovascular events and mortality

Background

Left ventricular thrombus (LVT) is a rare but dreaded complication during the acute phase of acute coronary syndrome (ACS). Incidence rates differ among the observational studies from 1.6% up to 39.0% indicating that many LVT cases might remain undetected. While the prognosis of patients presenting with LVT after ACS has been controversially discussed, it seems intuitive that individuals in whom the thrombus remains have an increased risk for cardiovascular events and mortality. However, profound data on long-term outcome of this highly vulnerable patient population are not available in current literature. Therefore, we aimed to investigate the impact of LVT resolution on patient's outcome from a long-term perspective.

Methods

We collected data of patients with acute coronary syndrome (n=2011) who underwent treatment between 01/2016 and 09/2019. Patients with a confirmed LVT were included in this analysis. Repeated echocardiographic data, treatment management and clinical outcomes were collected during follow-up. All-cause mortality and major adverse cardiac events (MACE), defined as nonfatal stroke, nonfatal myocardial infarction, nonfatal systemic embolism and cardiovascular death were chosen as primary and secondary endpoint.

Results

Among 2011 patients with ACS, 52 patients (2.6%) developed left ventricular thrombosis (median age: 63±13). 80.5% of LVT patients presented with STEMI. Out of those 52 patients with LVT, 6 died before hospital discharge and 3 did not receive follow-up imaging. In total 13 patients (24%) died. Mean time to thrombus resolution was 23±31 weeks. Mean follow-up time was 98±69.6 weeks. 43 patients received oral anticoagulation including 7 patients (16%) receiving novel oral anticoagulants (NOACs) and 32 patients (84%) Vitamin K antagonists (VKA). All patients developed LVT after anterior wall infarction. From the time of hospital admission all patients were followed prospectively until the primary endpoint was reached. Thrombus resolution was observed in 27 patients (62.8). As expected, thrombus resolution was associated with a significant lower risk of MACE with a crude hazard ratio (HR) of 3.89 (95% CI 1.30–11.65; P=0.015) and mortality with a crude HR of 5.59 (95% CI 1.07–29.07; P=0.041). Notably, the prognostic impact remained stable after comprehensive adjustment for potential confounders with an adjusted HR of 5.38 for MACE and an adjusted HR of 6.10 for overall mortality.

Conclusion

Present data clearly highlighted the prognostic potential of thrombus resolution on both MACE and all-cause mortality in individuals presenting with LVT after ACS. Therefore, thrombus resolution might be considered for risk stratification and an intensified anti-thrombotic approach should be taken into account in this highly vulnerable patient population.

Survival curves

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Vienna

All is not lost: Post-saccadic contributions to the perceptual omission of intra-saccadic streaks

Saccades rapidly jerk the eye into new positions, yet we rarely experience the motion streaks imposed on the retinal image. Here we examined spatial and temporal properties of post-saccadic masking-one potential explanation of this perceptual omission. Observers judged the motion direction of a target stimulus, a Gaussian blob, that moved vertically upwards or downwards and then back to its initial position, just as observers made a saccade. We manipulated the onset and offset of the target and of distractors in various spatial relations to the target, and assessed their effect on performance and subjective confidence. Although the presence of the target after the saccade caused the strongest omission, the offset of spatially distant distractor stimuli upon saccade offset also impaired performance. The temporal properties of these two separate effects suggest that, in addition to masking, an independent effect of attentional distraction further accentuates perceptual omission of intra-saccadic motion streaks.

Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach

Worldwide, one person dies every 40 seconds by suicide, a potentially preventable tragedy. A limiting step in our ability to intervene is the lack of objective, reliable predictors. We have previously provided proof of principle for the use of blood gene expression biomarkers to predict future hospitalizations due to suicidality, in male bipolar disorder participants. We now generalize the discovery, prioritization, validation, and testing of such markers across major psychiatric disorders (bipolar disorder, major depressive disorder, schizoaffective disorder, and schizophrenia) in male participants, to understand commonalities and differences. We used a powerful within-participant discovery approach to identify genes that change in expression between no suicidal ideation and high suicidal ideation states (n=37 participants out of a cohort of 217 psychiatric participants followed longitudinally). We then used a convergent functional genomics (CFG) approach with existing prior evidence in the field to prioritize the candidate biomarkers identified in the discovery step. Next, we validated the top biomarkers from the prioritization step for relevance to suicidal behavior, in a demographically matched cohort of suicide completers from the coroner's office (n=26). The biomarkers for suicidal ideation only are enriched for genes involved in neuronal connectivity and schizophrenia, the biomarkers also validated for suicidal behavior are enriched for genes involved in neuronal activity and mood. The 76 biomarkers that survived Bonferroni correction after validation for suicidal behavior map to biological pathways involved in immune and inflammatory response, mTOR signaling and growth factor regulation. mTOR signaling is necessary for the effects of the rapid-acting antidepressant agent ketamine, providing a novel biological rationale for its possible use in treating acute suicidality. Similarly, MAOB, a target of antidepressant inhibitors, was one of the increased biomarkers for suicidality. We also identified other potential therapeutic targets or biomarkers for drugs known to mitigate suicidality, such as omega-3 fatty acids, lithium and clozapine. Overall, 14% of the top candidate biomarkers also had evidence for involvement in psychological stress response, and 19% for involvement in programmed cell death/cellular suicide (apoptosis). It may be that in the face of adversity (stress), death mechanisms are turned on at a cellular (apoptosis) and organismal level. Finally, we tested the top increased and decreased biomarkers from the discovery for suicidal ideation (CADM1, CLIP4, DTNA, KIF2C), prioritization with CFG for prior evidence (SAT1, SKA2, SLC4A4), and validation for behavior in suicide completers (IL6, MBP, JUN, KLHDC3) steps in a completely independent test cohort of psychiatric participants for prediction of suicidal ideation (n=108), and in a future follow-up cohort of psychiatric participants (n=157) for prediction of psychiatric hospitalizations due to suicidality. The best individual biomarker across psychiatric diagnoses for predicting suicidal ideation was SLC4A4, with a receiver operating characteristic (ROC) area under the curve (AUC) of 72%. For bipolar disorder in particular, SLC4A4 predicted suicidal ideation with an AUC of 93%, and future hospitalizations with an AUC of 70%. SLC4A4 is involved in brain extracellular space pH regulation. Brain pH has been implicated in the pathophysiology of acute panic attacks. We also describe two new clinical information apps, one for affective state (simplified affective state scale, SASS) and one for suicide risk factors (Convergent Functional Information for Suicide, CFI-S), and how well they predict suicidal ideation across psychiatric diagnoses (AUC of 85% for SASS, AUC of 89% for CFI-S). We hypothesized a priori, based on our previous work, that the integration of the top biomarkers and the clinical information into a universal predictive measure (UP-Suicide) would show broad-spectrum predictive ability across psychiatric diagnoses. Indeed, the UP-Suicide was able to predict suicidal ideation across psychiatric diagnoses with an AUC of 92%. For bipolar disorder, it predicted suicidal ideation with an AUC of 98%, and future hospitalizations with an AUC of 94%. Of note, both types of tests we developed (blood biomarkers and clinical information apps) do not require asking the individual assessed if they have thoughts of suicide, as individuals who are truly suicidal often do not share that information with clinicians. We propose that the widespread use of such risk prediction tests as part of routine or targeted healthcare assessments will lead to early disease interception followed by preventive lifestyle modifications and proactive treatment.

Differentiating zones at periodontal ligament-bone and periodontal ligament-cementum entheses

BACKGROUND AND OBJECTIVE

The structural and functional integrity of bone-periodontal ligament (PDL)-cementum complex stems from the load-bearing attachment sites (entheses) between soft (PDL) and hard (bone, cementum) tissues. These attachment sites are responsible for the maintenance of a bone-PDL-cementum complex biomechanical function. The objective was to investigate changes in spatiotemporal expression of key biomolecules in developing and functionally active entheses.

MATERIAL AND METHODS

Multilabeling technique was performed on hemimandibles of 3 wk and 3 mo-old scleraxis-GFP transgenic mice for CD146, CD31, NG2, osterix and bone sialoprotein. Regions of dominant stretch within the PDL were evaluated by identifying directionality of collagen fibrils, PDL fibroblasts and PDL cell cytoskeleton.

RESULTS

CD146+ cells adjacent to CD31+ vasculature were identified at PDL-bone enthesis. NG2+ cells were located at coronal bone-PDL and apical cementum-PDL entheses in the 3-wk-old group, but at 3 mo, NG2 was positive at the entheses of the apical region and alveolar crest. NG2 and osterix were colocalized at the osteoid and cementoid regions of the PDL-bone and PDL-cementum entheses. Bone sialoprotein was prominent at the apical region of 3-wk-old mice. The directionality of collagen fibers, fibroblasts and their cytoskeleton overlapped, except in the apical region of 3 wk.

CONCLUSION

Colocalization of biomolecules at zones of the PDL adjacent to attachment sites may be essential for the formation of precementum and osteoid interfaces at a load-bearing bone-PDL-tooth fibrous joint. Biophysical cues resulting from development and function can regulate recruitment and differentiation of stem cells potentially from a vascular origin toward osteo- and cemento-blastic lineages at the PDL-bone and PDL-cementum entheses. Investigating the coupled effect of biophysical and biochemical stimuli leading to cell differentiation at the functional attachment sites is critical for developing regeneration strategies to enable functional reconstruction of the periodontal complex.

Analysis of the tendon cell fate using Scleraxis, a specific marker for tendons and ligaments

Little is known about the genesis and patterning of tendons and other connective tissues, mostly owing to the absence of early markers. We have found that Scleraxis, a bHLH transcription factor, is a highly specific marker for all the connective tissues that mediate attachment of muscle to bone in chick and mouse, including the limb tendons, and show that early scleraxis expression marks the progenitor cell populations for these tissues. In the early limb bud, the tendon progenitor population is found in the superficial proximomedial mesenchyme. Using the scleraxis gene as a marker we show that these progenitors are induced by ectodermal signals and restricted by bone morphogenetic protein (BMP) signaling within the mesenchyme. Application of Noggin protein antagonizes this endogenous BMP activity and induces ectopic scleraxis expression. However, the presence of excess tendon progenitors does not lead to the production of additional or longer tendons, indicating that additional signals are required for the final formation of a tendon. Finally, we show that the endogenous expression of noggin within the condensing digit cartilage contributes to the induction of distal tendons.

Cloning and expression of a novel cysteine-rich secreted protein family member expressed in thyroid and pancreatic mesoderm within the chicken embryo

We have isolated a new chicken gene that is a member of the cysteine-rich secreted protein family (CRISP). The CRISP family is composed of over 70 members that are found in many phyla of organisms, including: vertebrates, plants, fungi, yeast, and insects. Here we describe the cloning of a novel member of this family, SugarCrisp, and its expression pattern throughout chicken embryogenesis. We also describe its utility as a marker of thyroid and pancreatic mesoderm in the developing chicken embryo and its expression within the human and mouse in glandular tissue.

Similar expression and regulation of Gli2 and Gli3 in the chick limb bud

Gli genes encode a family of zinc finger transcription factors that mediate signaling by Hedgehog proteins. We have cloned the chick Gli3 gene and studied its expression in developing chick limbs. Gli3 expression is highly similar to that of chick Gli2. Gli3 mRNA is evenly distributed in the early limb mesenchyme and subsequently downregulated in the posterior mesenchyme by the polarizing activity of Sonic hedgehog. At later stages, Gli3 is expressed in the distal limb mesenchyme.

Decontamination of a Mycoplasma-infected Chlamydia pneumoniae strain by pulmonary passage in SCID mice

We describe a procedure to eliminate contaminating Mycoplasma from Chlamydia pneumoniae (C. pneumoniae) cultures by pulmonary passage in severe combined immunodeficiency mice (SCID). Four weeks after experimental infection only C. pneumoniae could be cultured from the lungs of the infected animals while Mycoplasma could not be detected any longer, as shown by PCR, culture and transmission electron microscopy (TEM).

Digital Imaging as a Detection Method for a Fluorescent Protease Assay in 96-Well and Miniaturized Assay Plate Formats

The demand to increase throughput in HTS programs, without a concomitant addition to costs, has grown significantly during the past few years. One approach to handle this demand is assay miniaturization, which can provide greater throughput, as well as significant cost savings through reduced reagent costs. Currently, one of the major challenges facing assay miniaturization is the ability to detect the assay signal accurately and rapidly in miniaturized formats. Digital imaging is a detection method that can measure fluorescent or luminescent signals in these miniaturized formats. In this study, an imaging system capable of detecting the signal from a fluorescent protease assay in multiple plate formats was used to evaluate this detection method in an HTS environment. A direct comparison was made between the results obtained from the imaging system and a fluorescent plate reader by screening 8,800 compounds in a 96-well plate format. The imaging system generated similar changes in relative signal for each well in the screen, identified the same active compounds, and yielded similar IC(50) values as compared to the plate reader. When a standard protease inhibitor was evaluated in 96-, 384-, 864-, and 1536-well plates using imaging detection, similar IC(50) values were obtained. Furthermore, similar dose-response curves were generated for the compound in 96- and 384-well assay plates read in a plate reader. These results provide support for digital imaging as an accurate and rapid detection method for high-density microtiter plates.

The role of personality in the development and perpetuation of chronic fatigue syndrome

OBJECTIVES

Qualitative evidence suggests that personality may have special relevance to the predisposition, precipitation and perpetuation of chronic fatigue syndrome (CFS). This study compares three dimensions of personality - perfectionism, self-esteem, and emotional control in the personality profiles of CFS patients (N=44) and a control group (N=44) without a history of CFS, matched for age and gender.

METHODS

Participants were assessed on the MPS [Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism. Cognit Ther Res 1990;14:449-468.]; the Rosenberg Self-Esteem Scale [Rosenberg M. Society and the Adolescent Self-image. Princeton, NJ: Princeton Univ Press, 1965.]; the Courtauld Emotional Scale [Watson M, Greer S. Development of a questionnaire measure of emotional control. J Psychosom Res 1983;27:299-305.] and the Marlowe-Crowne Social Desirability Scale [Crowne DP, Marlowe D. A new scale of social desirability independent of psychopathology. J Consult Psychol 1960;24:349-354.].

RESULTS

Analyses revealed that the CFS group reported higher levels than the control group on the Total Perfectionism score and Doubts about Actions and the Concern over Mistakes subscales. Furthermore, the CFS group also reported lower self-esteem than the control group. No difference between the two groups was found on the dimensions of emotional control and social desirability response bias.

CONCLUSION

A developmental model of CFS, which considers the predisposing, precipitating, and perpetuating factors that may account for the course of the disorder irrespective of etiology, is proposed. In the context of the results, recommendations for practice and future research are discussed.

Neutralization of disease associated autoantibodies by an immunoglobulin M- and immunoglobulin A-enriched human intravenous immunoglobulin preparation

Immunoglobulin preparations enriched with IgM and IgA are used in the therapy of severe bacterial infections and for the treatment of acute graft-versus-host disease, but not as yet, in the treatment of autoimmune diseases. We investigated the potential of an IgM- and IgA-enriched immunoglobulin preparation to neutralize activity autoantibodies from patients with autoimmune diseases. We demonstrate that Pentaglobin(R) was at least as effective as intravenous immunoglobulin (Sandoglobulin(R)) in inhibiting autoantibody activity. Each of the immunoglobulin isotypes present in Pentaglobin(R) may be responsible for the inhibitory effect. Pentaglobin(R) immobilized on an affinity matrix retained the disease associated autoantibodies and interacted with F(ab')2 fragments of IgG autoantibodies. Suppression of autoantibody activity is dependent, at least in part, on idiotypic interactions. The present findings provide a rationale for considering these preparations for the immunomodulation of autoimmune disease.

p63 is essential for regenerative proliferation in limb, craniofacial and epithelial development

The p63 gene, a homologue of the tumour-suppressor p53, is highly expressed in the basal or progenitor layers of many epithelial tissues. Here we report that mice homozygous for a disrupted p63 gene have major defects in their limb, craniofacial and epithelial development. p63 is expressed in the ectodermal surfaces of the limb buds, branchial arches and epidermal appendages, which are all sites of reciprocal signalling that direct morphogenetic patterning of the underlying mesoderm. The limb truncations are due to a failure to maintain the apical ectodermal ridge, a stratified epithelium, essential for limb development. The embryonic epidermis of p63-/- mice undergoes an unusual process of non-regenerative differentiation, culminating in a striking absence of all squamous epithelia and their derivatives, including mammary, lacrymal and salivary glands. Taken together, our results indicate that p63 is critical for maintaining the progenitor-cell populations that are necessary to sustain epithelial development and morphogenesis.

EGF domain swap converts a drosophila EGF receptor activator into an inhibitor

In Drosophila the function of the epidermal growth factor (EGF) receptor is modulated zygotically by three EGF-like proteins: Spitz (Spi), which is a potent activator; Vein (Vn), which is a moderate activator; and Argos (Aos), which is an inhibitor. Chimeric molecules were constructed in which the EGF domain of Vn was swapped with the EGF domain from each factor. The modified Vn proteins behaved both in vitro and in vivo with properties characteristic of the factor from which the EGF domain was derived. These results demonstrate that the EGF domain is the key determinant that gives DER inhibitors and activators their distinct properties.

Sequential activation of the EGF receptor pathway during Drosophila oogenesis establishes the dorsoventral axis

Previous work has demonstrated a role for the Drosophila EGF receptor (Torpedo/DER) and its ligand, Gurken, in the determination of anterioposterior and dorsoventral axes of the follicle cells and oocyte. The roles of DER in establishing the polarity of the follicle cells were examined further, by following the expression of DER-target genes. One class of genes (e.g. kekon) is induced by the DER pathway at all stages. Broad expression of kekon at the stage in which the follicle cells migrate posteriorly over the oocyte, demonstrates the capacity of the pathway to pattern all follicle cells except the ventral-most rows. This may provide the spatial coordinates for the ventral-most follicle cell fates. A second group of target genes (e.g. rhomboid (rho)) is induced only at later stages of oogenesis, and may require additional inputs by signals emanating from the anterior, stretch follicle cells. The function of Rho was analyzed by ectopic expression in the stretch follicle cells, and shown to induce a non-autonomous dorsalizing activity that is independent of Gurken. Rho thus appears to be involved in processing a DER ligand in the follicle cells, to pattern the egg chamber and allow persistent activation of the DER pathway during formation of the dorsal appendages.

A comparison of masticatory function in patients with or without reconstruction of the mandible

BACKGROUND

The functional benefits of mandibular reconstruction following a composite resection remain unclear. Although microvascular surgical techniques have dramatically increased the predictability of bone and soft-tissue reconstruction towards presurgical anatomic norms, the specific factors responsible for improved function remain controversial. Objective measures of masticatory function need to be more clearly determined before the predictability and efficacy of reconstructive approaches is established.

METHODS

We evaluated objective measures of oral function and patient reports of function in 10 reconstructed mandibulectomy patients, 10 without reconstruction, and 10 controls. Measures of oral function included bite force assessed at the first molar and incisal edge, a measure of tongue and cheek function, and patient reports of food they could eat.

RESULTS

Both reconstructed and nonreconstructed patients presented decreased biting force, a more restricted diet, and compromised cheek and tongue function as compared with normals. However, reconstructed patients had significantly better measures of tongue function and ability to eat a varied diet than did nonreconstructed patients. Of the objective measures used to measure masticatory performance, bite force was poorly correlated, whereas measures of tongue function strongly correlated with successful mastication.

CONCLUSION

Both reconstructed and nonreconstructed patients presented with a significant functional deficit when compared with normals, with reconstructed patients having better overall function than nonreconstructed patients.

A thousand and one roles for the Drosophila EGF receptor

In the Drosophila genome there is a single member of the EGF receptor tyrosine kinase family. This receptor fulfills multiple roles during development, as reflected by the many designations given to mutant alleles in the locus (Egfr, DER, faint little ball, torpedo and Ellipse). The full scope of EGFR functions became apparent only in recent years: receptor activation was shown to have an instructive role in successive cell fate determination events during oogenesis, embryogenesis, and the proliferation and differentiation of imaginal discs. To ensure the fidelity of these processes, the precise place and time of receptor activation are tightly regulated by the localized presentation of activating ligands, in conjunction with a negative-feedback loop generated by an inhibitory secreted factor. The cellular mechanisms that translate EGFR activation to discrete cell fates are now the focus of intense studies.

Plasma carotenoids in German children and adolescents

Carotenoids are important antioxidants and precursors of vitamin A, but only few studies have been carried out on plasma carotenoid levels in paediatric age groups. Using high-performance liquid chromatography we analysed concentrations of four important carotenoids (alpha-carotene, beta-carotene, cryptoxanthin, lycopene) in 129 healthy German children and adolescents (81 boys, 48 girls; age 1-18 years). For all carotenoids analysed, no significant differences between girls and boys were found. alpha-Carotene values ranged from 0 mumol/l (below detection limits) to 0.73 mumol/l (0-395 micrograms/l), beta-carotene from 0.09 mumol/l to 2.68 mumol/l (48-1443 micrograms/l), lycopene from 0 mumol/l to 1.51 mumol/l (0-815 micrograms/l), and cryptoxanthin from 0 mumol/l to 0.30 mumol/l (0-164 micrograms/l), respectively. Data analyses according to age groups showed a tendency towards higher levels of alpha- and beta-carotene, and lower levels of lycopene in young children. These differences were significant when children younger than 4 years were compared with those above 8 and 12 years, respectively. The data presented may serve as reference values for studies on children with nutritional disorders and diseases associated with a risk of vitamin deficiencies.

CONCLUSION

Carotenoids are important antioxidants and singlet oxygen scavengers. Plasma levels of alpha-carotene, beta-carotene, lycopene and cryptoxanthin were determined in 129 healthy German children and adolescents. Highest values were found for beta-carotene and lycopene.

Argos transcription is induced by the Drosophila EGF receptor pathway to form an inhibitory feedback loop

Argos is a secreted molecule with an atypical EGF motif. It was recently shown to function as an inhibitor of the signaling triggered by the Drosophila EGF receptor (DER). In this work, we determine the contribution of Argos to the establishment of cell fates in the embryonic ventral ectoderm. Graded activation of DER is essential for patterning the ventral ectoderm. argos mutant embryos show expansion of ventral cell fates suggesting hyperactivation of the DER pathway. In the embryonic ventral ectoderm, argos is expressed in the ventralmost row of cells. We show that argos expression in the ventral ectoderm is induced by the DER pathway: argos is not expressed in DER mutant embryos, while it is ectopically expressed in the entire ventral ectoderm following ubiquitous activation of the DER pathway. argos expression appears to be triggered directly by the DER pathway, since induction can also be observed in cell culture, following activation of DER by its ligand, Spitz. Argos therefore functions in a sequential manner, to restrict the duration and level of DER signaling. This type of inhibitory feedback loop may represent a general paradigm for signaling pathways inducing diverse cell fates within a population of non-committed cells.

Quality of life in chronic fatigue syndrome

Whilst the debilitating fatigue experienced in patients suffering from Chronic Fatigue Syndrome (CFS) results in a subjective marked impairment in functioning, little research has investigated the impact of this disorder on quality of life. Forty-seven subjects with a confirmed diagnosis of CFS and 30 healthy controls were compared using the Sickness Impact Profile (SIP). A subgroup of subjects were interviewed regarding the impact CFS has had on their social and family relationships, work and recreational activities. Results from both the SIP and the interview revealed that CFS subjects had significantly impaired quality of life, especially in areas of social functioning. These findings highlight the importance of addressing the social isolation and loss of role functioning experienced by CFS sufferers.

Suicidal ideation and behaviours among university students in Australia

OBJECTIVE

The aim of the study was to investigate the prevalence and demographic correlates of suicidal ideation and behaviours among university students in Australia and the utilisation of mental health services by this population.

METHOD

Suicidal ideation and behaviours and demographic variables were assessed in a population of 1,678 undergraduate students by use of a modified Suicide Ideation Scale (SIS) and questionnaire.

RESULTS

Sixty two percent of students surveyed showed some suicidal ideation and 6.6% reported one or more suicide attempts. Over half of the group who reported suicide attempts did not use any type of mental health services. Suicidal ideation was found to be highly correlated with previous use of mental health services. In examining the relationship between suicidal ideation (SI) and demographic variables, SI was not significantly different for gender or parental marital status but was related to living arrangements, racial groups, religious affiliation and father's education.

CONCLUSIONS

The results suggest that a higher proportion of students reported suicidal ideation and behaviours than that documented in related studies undertaken in the USA. While these findings draw attention to a higher level of suicidal ideation in students who utilise mental health assistance, more than half of those who reported suicide attempts did not use any kind of mental health service. The study has particular implications for detecting and assisting young people with a high suicide risk within the university environment.

Inhibition of Drosophila EGF receptor activation by the secreted protein Argos

The Drosophila homologue of the mammalian epidermal growth factor (EGF) receptor (DER) is a receptor tyrosine kinase involved in many stages of fly development, including photoreceptor determination, and wing-vein formation. Its primary activating ligand is the Spitz protein, which is similar to mammalian TGF-alpha. Argos is a secreted protein that, like Spitz, contains a single EGF motif. It is a repressor of cell determination in the eye, and acts in other tissues, including the wing. Because Argos has the opposite effects to DER in the eye (the former blocks photoreceptor determination, the latter promotes it) we have tested whether it acts by blocking the DER pathway. We show that Argos does indeed repress this pathway in vivo and find that, in vitro, Argos protein can inhibit the activation of DER by Spitz. Thus the determination of cells by the DER pathway is regulated by a balance between extracellular activating and inhibiting signals. This is the first in vivo example of an extracellular inhibitor of a receptor tyrosine kinase.

Secreted Spitz triggers the DER signaling pathway and is a limiting component in embryonic ventral ectoderm determination

The spitz gene encoding a TGF-alpha homolog, has been shown to affect a subset of developmental processes that are similar to those regulated by DER, the Drosophila EGF receptor homolog. This work demonstrates that Spitz triggers the DER signaling cascade. Addition of a secreted, but not the membrane-associated form of Spitz to S2 Drosophila cells expressing DER gives rise to a rapid tyrosine autophosphorylation of DER. Following autophosphorylation, DER associates with the Drk adapter protein. Consequently, activation of MAP kinase is observed. The profile of MAP kinase activation provides a quantitative assay for DER activation. A dose response between the levels of Spitz and MAP kinase activity was observed. The secreted Spitz protein was expressed in embryos to assess its biological activity. An alteration in cell fates was observed in the ventral ectoderm, such that lateral cells acquired the ventral-most fates. The result indicates that graded activation of the DER pathway may normally give rise to a repertoire of discrete cell fates in the ventral ectoderm. Spatially restricted processing of Spitz may be responsible for this graded activation. The Rhomboid (Rho) and Star proteins were suggested, on the basis of genetic interactions, to act as modulators of DER signaling. No alteration in DER autophosphorylation or the pattern of MAP kinase activation by secreted Spitz was observed when the Rho and Star proteins were coexpressed with DER in S2 cells. In embryos mutant for rho or Star the ventralizing effect of secreted Spitz is epistatic, suggesting that Rho and Star may normally facilitate processing of the Spitz precursor.

Tachycardia and panic attacks

This case taught me the importance of listening closely to the patient's history, and not just jumping in and accepting an old diagnosis. It also showed me how patients can effect change in their lives, that even when patients are seemingly crippled by panic, anxiety, stress, and with a history of sexual abuse as a child, that person can effect meaningful change in their life and reclaim their life from the effects of these problems.

Scattered-site crisis beds: an alternative to hospitalization for children and adolescents

This paper describes the rationale, development, and implementation of a countywide scattered-site crisis bed program for seriously emotional disturbed youngsters. The program was developed by an interagency coalition consisting of representatives of the county's mental health, social service, and juvenile justice systems and was implemented with no new funding using available beds in facilities administered by the participating agencies. Referrals are screened by an interagency crisis consultation team responsible for the program's operation. A computerized registry significantly reduces the amount of time needed to make placements and helps agencies meet the goal of placing youngsters on the day of referral. Evaluation of the first 100 placements indicated that the program is a cost-effective alternative to more restrictive, longer-term placements and has resulted in positive clinical outcomes.

Illness behaviour of patients with chronic fatigue syndrome

The study examines the illness behaviour of patients with Chronic Fatigue Syndrome (CFS). The Illness Behaviour Questionnaire (IBQ), the twenty-eight version of the General Health Questionnaire (GHQ-28), and the Beck Depression Inventory (BDI) were administered to forty patients with a diagnosis of CFS. The results revealed that CFS patients in comparison with general practice patients, scored significantly higher on the IBQ sub-scales of General Hypochonriasis, t(188) = 5.2, p < 0.001 and Disease Conviction, t(188) = 13.28, p < 0.001 but lower on the Psychological/Somatic sub-scale, t(188) = -5.88, p < 0.001. The CFS and psychiatric patients did not differ significantly on the general hypochondriasis sub-scale. Results of the GHQ-28 revealed 66.7% of the CFS patients scored above the cut-off for psychiatric morbidity. In comparison to a previous study of CFS patients [1], the current findings indicate a significantly higher score on general hypochondriasis. The implications of these findings are discussed.

Difficulties in treating one's family

Thinking of treating your family?--think again! There are risks involved as objectivity is in danger of being clouded by emotions. Guidelines for the 'family' doctor are drawn from the author's experience.

Report on the American Cancer Society Workshop on Community Cancer Detection, Education, and Prevention Demonstration Projects for Underserved Populations

The American Cancer Society has been funding six pilot projects organized with the stated purpose of demonstrating how to implement cancer prevention and control projects for socioeconomically disadvantaged and underserved populations. This article reports on the results of a workshop held to evaluate project experiences and develop recommendations for the future.

Parent and adolescent perceptions of family functioning: a comparison of clinic and non-clinic families

In this paper two studies are reported which compare (a) the perceptions of family functioning held by clinic and non-clinic adolescents, and (b) the perceptions of family functioning held by adolescents and their mothers in clinic and non-clinic families. In Study 1, matched group of clinic and non-clinic adolescents were compared on their responses to a 30-item scale (ICPS) designed to measure three factors of family functioning: Intimacy (high vs. low), Parenting Style (democratic vs. controlled) and Conflict (high vs. low). Clinic and non-clinic adolescents were also compared on their responses to a multi-dimensional measure of adolescent self-concept. Although there was little difference between the two groups of adolescents in terms of their perceptions of family functioning, there were strong relationships between the self-concept variables and the family functioning variables. In Study 2, comparisons were made between the perceptions of family functioning held by mothers and adolescents for both clinical and non-clinic families. There were no differences between the two groups of adolescents in terms of their perceptions of family functioning, although there were clear differences between the two groups of mothers. In addition, clinic adolescents and their mothers did not differ in their perceptions of the family, whereas adolescents in the non-clinic group saw their families significantly as less intimate and more conflicted than did their mothers.

Breast cancer incidence in women with abnormal cytology in nipple aspirates of breast fluid

This is a prospective study of breast cancer risk in relation to nipple aspirate fluid cytology in 2,701 volunteer white women from the San Francisco Bay Area first enrolled between 1973 and 1980. The women were not pregnant or lactating and were free of breast cancer within 6 months of entry into the study. The breast cancer status of this cohort was determined between June 1988 and April 1991. Follow-up was complete for 87% (n = 2,343) of the cohort, representing 29,961 person-years and an average of 12.7 years of follow-up. The overall breast cancer incidence was 4.4% (104 of 2,343) and rose with fluid cytology findings as follows: no fluid obtained, 2.6% (9 of 352); unsatisfactory specimen, 4.8% (15 of 315); normal cytology, 4.3% (56 of 1,291); epithelial hyperplasia, 5.5% (18 of 327); and atypical hyperplasia, 10.3% (6 of 58). Relative risks for breast cancer and their 95% confidence intervals were estimated by Cox regression, adjusting for age and year of entry. Compared with the relative risk for women who yielded no fluid, relative risks were: unsatisfactory specimen, relative risk (RR) = 1.4 (95% confidence interval (CI) 0.6-3.3); normal cytology, RR = 1.8 (95% CI 0.9-3.6); epithelial hyperplasia, RR = 2.5 (95% CI 1.1-5.5); and atypical hyperplasia, RR = 4.9 (95% CI 1.7-13.9). These findings were strongest for and were mainly confined to women aged 25-54 years. Women with atypical hyperplasia and a first-degree family history of breast cancer were six times more likely to develop breast cancer than were women with atypical hyperplasia but without a family history of breast cancer (95% CI 1.0-30.2). These findings provide strong support for our hypothesis that hyperplasia and atypical hyperplasia diagnosed in nipple aspirates of breast fluid are associated with an increased risk of breast cancer.

Alcoholism and family interaction

In 16 families, half of which had an alcoholic parent, both parents and an adolescent were videotaped interacting with each other. Mothers, fathers and the adolescent in each family viewed the videotaped interaction and completed ratings of themselves and the other two family members on levels of anxiety, involvement, dominance and friendliness. In families with an alcoholic parent, adolescents and their mothers rated family members as less anxious than did adolescents and mothers in families without a drinking problem. Also mothers in the alcoholic families rated family members as being more involved, and their ratings were higher than mothers in other families. Alcoholic families rated parent-adolescent interactions as more dominant and friendlier. At least in these videotaped interactions where alcohol was not being consumed, mothers in alcoholic families adopted a more positive view of family members than mothers in other families. In addition, possibly due to the efforts of fathers not to drink and memories of interactions when he was drunk, alcoholic families perceived their family interactions as more dominant and friendlier than families without an alcohol-related problem.

The impact of chronic childhood illness on family stress: a comparison between autism and cystic fibrosis

The study compared the different patterns of stress reported by mothers of children with either a chronic physical illness (cystic fibrosis), a chronic psychological disorder (autism), and children without a physical or psychological disorder. Twenty-four mothers from each of these three groups completed the Questionnaire on Resources and Stress Short Form (Holroyd & Guthrie, 1986). Each clinical group exhibited different patterns of stressful response consistent with the nature of the disorder and the requirements of care imposed on the families. Autism was found to contribute significantly more to family stress than did cystic fibrosis. The number of children in the family was not a significant variable. Implications for the development of family intervention programs are discussed.

Papular acrodermatitis of childhood and hepatitis B infection

A case of papular acrodermatitis (PAC) associated with acute anicteric type B hepatitis occurred in a 2-year-old child. Immunocytochemical studies failed to detect the presence of viral antigens in the involved skin lesion. Current knowledge of the hepatitis B viral antigens and of their possible role in PAC is discussed.

Melanoma in a patient treated for psoriasis

Psoriasis, ultraviolet light, and coal tar have been associated with the development of cutaneous malignancy. We have described a 32-year-old psoriatic man who developed a melanoma after 16 years of treatment with ultraviolet light and coal tar. This is the only case of melanoma occurring in a patient treated for psoriasis reported in the world literature.