Representative survey of german people concerning enlightenment and patient directive in a case of terminal illness

The basic principles dealing with euthanasia (1998) as expressed by the German Association of Doctors states that in advance written directives are of "substantial help for the doctor in his or her actions". This requires, however, wide proliferation of patient directives. Hence it was important to ascertain the prevalence of such directives in the German population, as well as the relationship to the wish for enlightenment in terminal illness and diseases in their final stages. This was accomplished in December 1998 using 2050 people obtained with the Random-Route-Procedure (1024 from the new German states, 1013 from the old German states). The sample was obtained from the opinion research institute USUMA with ages ranging between 14 - 92. The main results from this representative survey represent an important record of the status quo with respect to opinion shaping of patient autonomy. 16 % of this survey expressed the wish not to be fully enlightened in the case of a terminal illness or they wished for a clarification to be given to the family only. This result shows that part of the population still holds on to their right of no knowledge. 59.1 % expressed the wish for a complete and immediate enlightenment. The other 24.9 % desired a careful step-by-step presentation of information. The high percentage of those who desired information and enlightenment is in contradiction to the small 2.5 % of patients who have actually written advance directives. These empirical results are consistent with the clinical experience of many doctors and represents the decision of the "representational" doctors for the current ethical regulation of patient directives as an ideal idea. Since 71.9 % of those surveyed had never before thought about this issue conclusions are drawn regarding patient consultations. Gender and East/West differences are also shown.     

Environmental conditions influence hippocampus-dependent behaviours and brain levels of amyloid precursor protein in rats

Sprague-Dawley rats were reared in enriched (EC; group housing, exposure to stimulating objects, frequent handling) or restricted (RC; individual housing, no exposure to stimulating objects, minimal handling) environments starting on day 23 of life. At six months of age, they underwent behavioural tests to assess 'cognitive' and 'stimulus-response' memory, selective attention, and inflammatory pain processing. Alterations in synapses and cell survival may occur as a result of environment differences; therefore we assessed the brain levels of several proteins implicated in neurite outgrowth, synaptogenesis, and cell survival. Brains were dissected and analysed for amyloid precursor protein (APP) and other synaptic and cytoskeletal proteins using Western blotting. The performance of EC animals in a hidden platform water maze task, and in a test of selective attention (both of which are thought to involve the hippocampus) was superior to that of RC animals. In contrast, performance of RC animals on two stimulus-response tasks, the visible platform water maze test and simple visual discrimination (both of which are thought to be hippocampal independent) was indistinguishable from that of EC animals. Male EC rats displayed a different behavioural response to formalin during the inflammatory phase of nociception--the phase affected by hippocampal processing; a similar trend was observed in females. Female but not male RC rats exhibited elevated plasma corticosterone levels; adrenal weights were unaffected by environmental conditions. Region-specific increases in brain levels of APP, neurofilament-70 (NF-70), and platelet-activating factor receptor (PAF-R) were found in EC rats. These data suggest that enriched animals manifest enhanced functioning of certain hippocampus-mediated behaviours when compared with that of their restricted counterparts; and that brain levels of various synaptic and structural proteins involved in neurite outgrowth, cell survival, and synaptogenesis, are affected by environmental factors.     

Hippocampal expression of the calcium sensor protein visinin-like protein-1 in schizophrenia

Hippocampal cytoarchitectural abnormalities may be part of the cerebral substrate of schizophrenia. Amongst the chemical components being abnormal in brains of schizophrenics are altered calcium concentrations and reduced expression of the neurotrophin receptor, trkB. We studied by immunohistochemical methods the distribution of visinin-like protein-1 (VILIP-1), which is a calcium sensor protein and at the same time a trkB mRNA binding protein, in hippocampi of nine schizophrenic patients and nine matched control subjects. In normal hippocampi VILIP-1 immunoreactivity was found in multiple pyramidal cells and interneurons. A portion of VILIP-1 immunoreactive interneurons co-express calretinin (60%) and parvalbumin (<10%). In schizophrenics fewer pyramidal cells but more interneurons were immunostained. Our data point to an involvement of the protein in the altered hippocampal circuitry in schizophrenia.     

Oxidised mannan-listeriolysin O conjugates induce Th1/Th2 cytokine responses after intranasal immunisation

Clearance of infectious organisms does not always require polarised Th1 or Th2 responses and it may be advantageous for both Th1 and Th2 responses to be elicited for effective protection against an invading pathogen. It was the aim of this study to investigate oxidised mannan as a possible Th1/Th2 adjuvant. Oxidised mannan was conjugated to two candidate antigens and delivered intranasally to mice. Immunisation with the oxidised conjugate resulted in significant antigen specific proliferative responses, IL-2, IFN-gamma and IL-4 production when compared to unconjugated controls.     

Helping tomorrow's doctors to gain a population health perspective - good news for community stakeholders

INTRODUCTION: The modernising agenda of the NHS and recommendations of professional bodies demand that all doctors achieve a basic understanding of a population health perspective. The principle of integrated learning and the logistics of provision make it inappropriate for such learning to be delivered solely by public health specialists, and community-based learning has been promoted as the best setting in which to assist this objective. However, there is little evidence from practice as to whether non-specialist staff are willing or able to play a role in orienting tomorrow's doctors to the needs of communities. METHODS: Semi-structured interviews, questionnaires and focus groups iterated the opinion of key stakeholders on their preferred contributions to community-oriented undergraduate medical education. Framework analysis was used to elicit key outcomes and process factors. RESULTS: There was consensus that community-based learning should be a core element of the medical curriculum as it can demonstrate the socioenvironmental context of care and the doctor's role in interagency working and preventive care. Effective academic/NHS partnerships were called for, with higher education leading the agenda on aims and objectives, creating collaborative structures, and reallocating resources to support new learning. Community-based stakeholders would offer the translation of theory into practice by demonstrating clinical and social diversity, models of teamworking, and a context for the application of prior learning. They also promoted recurrent contact with communities, and suggested an enhanced role in mentoring students through longer term relationships. CONCLUSION: Community-based personnel and NHS users are an under-used resource for medical education. Their proposed contributions strongly accord with the agenda for a population health perspective in basic training. Curriculum planners need to make long-term partnerships with community-based agencies, rather than using them as an intermittent provider of limited learning sessions with narrowly defined objectives.     

Ten-year outcome including patterns of failure and toxicity for adjuvant whole abdominopelvic irradiation in high-risk and poor histologic feature patients with endometrial carcinoma

PURPOSE: To evaluate the long-term results of treatment using adjuvant whole abdominal irradiation (WAPI) with a pelvic/vaginal boost in patients with Stage I-III endometrial carcinoma at high risk of intra-abdominopelvic recurrence, including clear cell (CC) and serous-papillary (SP) histologic features. METHODS AND MATERIALS: In a prospective nonrandomized trial, 119 patients were treated with adjuvant WAPI between November 1981 and April 2000. All patients were analyzed, including those who did not complete therapy. The mean age at diagnosis was 66 years (range 39-88). Thirty-eight patients (32%) had 1989 FIGO Stage I-II disease and 81 (68%) had Stage III. The pathologic features included the following: 64 (54%) with deep myometrial invasion, 48 (40%) with positive peritoneal cytologic findings, 69 (58%) with high-grade lesions, 21 (18%) with positive pelvic/para-aortic lymph nodes, and 44 (37%) with SP or CC histologic findings. RESULTS: The mean follow-up was 5.8 years (range 0.2-14.7). For the entire group, the 5- and 10-year cause-specific survival (CSS) rate was 75% and 69% and the disease-free survival (DFS) rate was 58% and 48%, respectively. When stratified by histologic features, the 5- and 10-year CSS rate for adenocarcinoma was 76% and 71%, and for serous papillary/CC subtypes, it was 74% and 63%, respectively (p = 0.917). The 5- and 10-year DFS rate for adenocarcinoma was 60% and 50% and was 54% and 37% serous papillary/CC subtypes, respectively (p = 0.498). For surgical Stage I-II, the 5-year CSS rate was 82% for adenocarcinoma and 87% for SP/CC features (p = 0.480). For Stage III, it was 75% and 57%, respectively (p = 0.129). Thirty-seven patients had a relapse, with the first site of failure the abdomen/pelvis in 14 (38%), lung in 8 (22%), extraabdominal lymph nodes in 7 (19%), vagina in 6 (16%), and other in 2 (5%). When stratified by histologic variant, 32% of patients with adenocarcinoma and 30% with the SP/CC subtype developed recurrent disease. Most failures for either histologic group occurred within the abdominopelvic region. However, one-third of the adenocarcinoma recurrences were in the lung. Multivariate regression analysis (age, surgical stage, grade, myometrial invasion, histologic type, lymph node status, and peritoneal cytology) demonstrated age (p = 0.019) and surgical stage (p = 0.036) to be of prognostic significance for CSS; age (p = 0.036) was the only significant prognostic factor for DFS. Grade 1-2 gastrointestinal and hematologic acute toxicities were common. Asymptomatic bibasilar scarring on chest X-ray and mild elevation of liver enzymes were seen in almost 50% of the patients. Even though chronic toxicities were less frequent, 12% developed Grade 3-4 gastrointestinal and 2% Grade 3 renal toxicities. CONCLUSION: Adjuvant WAPI is very effective treatment with excellent 10-year results for Stage I-III endometrial carcinoma with risk factors for intra-abdominopelvic recurrence, including SP or CC histologic variants, deep myometrial invasion, high grade, nodal involvement, and positive peritoneal cytology. The low long-term complication rate with high CSS rate makes WAPI the treatment of choice for these patients with significant comorbidities.     

Complementary and layered expression of Ephs and ephrins in developing mouse inner ear

The distributions of the Eph-class receptors EphA4 and EphB1, and their ligands ephrin-A2, ephrin-B1, and ephrin-B2, were analysed by immunostaining in the mouse inner ear. Complementary patterns of EphA4 and its potential ligand ephrin-A2 were found, with ephrin-A2 in many of the structures lining the cochlear duct and within the cochlear nerve cells, and EphA4 in the deeper structures underlying the cochlear duct and in the cells lining the nerve pathway. EphB1 and its potential ligands ephrin-B1 and ephrin-B2 showed a segregated layered expression in the lateral wall of the cochlear duct (the external sulcus), which together with EphA4 expressed in the area, form a four-layered structure with an alternating pattern of receptors and ligands in the different layers. This arrangement gives the potential for different bidirectional Eph-mediated interactions between each of the layers. The results suggest that the Eph system in the cochlea may have a role in maintaining cell segregation during phases of cochlear development.     

Watching where you look: modulation of visual processing of foveal stimuli by spatial attention

Two experiments investigated the effect of sustained selective spatial attention upon the perceptual analysis of stimuli within the center of gaze. Spatial attention has typically been studied in relation to peripheral stimuli, and its relevance to the processing of central stimuli has remained relatively ignored. Here, behavioral measures in normal human volunteer participants showed that focused spatial attention can also influence responses to central stimuli, over and beyond the advantage conferred by their foveation. Event-related potentials (ERPs) showed that the action of attention upon foveal stimuli included the modulation of perceptual processing in extrastriate visual areas. Surprisingly, the visual modulation revealed an intriguing and consistent pattern of hemispheric asymmetry, in both experiments. These findings show that in addition to the established right hemisphere dominance of the brain areas that direct attention, the consequences of directed attention may also be asymmetrical.