Screening for abdominal aortic aneurysms does not increase psychological morbidity.

Screening can lead to harmful psychological effects in the screened population--an argument used against abdominal aortic aneurysm (AAA) screening. However, there is no evidence for this in AAA screening. We applied the Hospital Anxiety and Depression Scale (HADS) to a group of men undergoing screening for AAA. The HADS questionnaire was completed by subjects found not to have AAA, subjects with known small aneurysms attending for follow-up scans, subjects with known AAA on waiting lists for surgery, and controls not involved in the screening programme. The groups were well matched for age and the number of additional diseases. There was no significant difference in the distribution of patients for anxiety and depression according to the HADS questionnaire (chi 2 test, P > 0.1). The results from this study suggest that AAA screening does not increase anxiety or depression in the screened subjects--contrary to the argument put forward against screening for this condition.

Do children with autism use the speaker's direction of gaze strategy to crack the code of language?

Normal toddlers infer the referent of a novel word by consulting the speaker's direction of gaze. That is, they use the Speaker's Direction of Gaze (SDG) strategy. This is a far more powerful strategy than the alternative, the Listener's Direction of Gaze (LDG) strategy. In Study 1 we tested if children with autism, who have well-documented impairments in joint attention, used the SDG or the LDG strategy to learn a novel word for a novel object. Results showed that although 70.6% of children with mental handicap passed the test by making the correct mapping between a novel word and a novel object, via the SDG strategy, only 29.4% of children with autism did so. Instead, their reliance on the LDG strategy led to mapping errors. In Study 2 a group of normal children, whose chronological age (24 months old) was equated with the verbal mental age of the 2 clinical groups in Study 1, was tested using a similar procedure. Results showed that 79% of this normal group passed the test by making the correct mapping between a novel word and a novel object using the SDG strategy. Taken together, the results from both studies suggest that children with autism are relatively insensitive to a speaker's gaze direction as an index of the speaker's intention to refer. This result is consistent with previous findings showing that children with autism are relatively "blind" to the mentalistic significance of the eyes. Discussion centers on how the absence of an SDG strategy might disrupt specific aspects of language development in autism.

Joint attention and early social communication: implications for research on intervention with autism.

Highly structured, intensive early intervention may lead to significant developmental gains for many children with autism. However, a clear understanding of early intervention effects may currently be hampered by a lack of precision in outcome measurement. To improve the precision and sensitivity of outcome assessment it may be useful to integrate research on the nature of the social disturbance of autism with research on early intervention. In this regard, it may be that measures of nonverbal social communication skills are especially important in the study of preschool intervention programs. This is because these measures appear to tap into a cardinal component of the early social disturbance of autism, and because these measures have been directly related to neurological, cognitive, and affective processes that may play a role in autism. The research and theory that support the potential utility of these types of measures for early intervention research are reviewed. Examples are provided to illustrate how these types of measures may assist in addressing current issues and hypotheses about early intervention with autism including the "recovery hypothesis," the "pivotal skill hypothesis," and the relative effectiveness of discrete trial versus incidental learning approaches to early intervention. A cybernetic model of autism is also briefly described in an effort to better understand one potential component of early psychoeducational treatment effects with children with autism.

Colour flow duplex in the assessment of recurrent varicose veins.

Recurrent varicose veins represent a common clinical problem. They require accurate assessment of all sites of reflux before surgery to ensure the correct surgical approach and reduce further recurrences. We report our experience of colour flow duplex in 190 legs with recurrent disease with reference to the pattern of reflux seen. We found that multiple sites of reflux were common, and that neovascularity and calf-perforators were most frequently seen. Our observations compare favourably with previously published data. Despite the reported greater accuracy of phlebography for detection of incompetent perforators, its invasive nature and potential contrast reactions have prompted us to use colour flow duplex routinely for the assessment of recurrent varicose veins.

The rat distal colon P-ATPase alpha subunit encodes a ouabain-sensitive H+, K+-ATPase.

The functional properties and the pharmacological profile of the recently cloned cDNA colonic P-ATPase alpha subunit (Crowson, M.S., and Shull, G.E. (1992) J. Biol. Chem. 267, 13740-13748) were investigated by using the Xenopus oocyte expression system. Xenopus oocytes were injected with alpha subunit cRNAs from Bufo marinus bladder or rat distal colon and/or with beta subunit cRNA from B. marinus bladder. Two days after injection, K+ uptake was measured by using 86 Rb+ as a K+ surrogate, and pH measurements were performed by means of ion-selective microelectrodes. Co-injection of alpha and beta subunit cRNAs led to a large increase in 86Rb+ uptake, an intracellular alkalinization, and an extracellular medium acidification, as compared to alpha or beta injection alone. These results indicate that the colonic P-ATPase alpha subunit, like the bladder alpha subunit, acts as a functional H+,K+-ATPase, and that co-expression of alpha and beta subunits is required for the function. External K+ activation of the 86Rb+ uptake had a K1/2 of approximately 440 microM for the bladder isoform (consistent with the previously reported value (Jaisser, F., Horisberger, J.D., Geering, K., and Rossier, B.C. (1993) J. Cell. Biol. 123, 1421-1431) and a K1/2 of approximately 730 microM for the colonic isoform. Sch28080 was ineffective to reduce 86Rb+ uptake whereas ouabain inhibited the activity expressed from rat colon alpha subunit with a Ki of 970 microM when measured at the Vmax of the enzyme. We conclude that, when expressed in Xenopus oocytes, the rat colon P-ATPase alpha subunit encodes a ouabain-sensitive H+,K+-ATPase.

Potential diagnostic implications of breakpoints in the long arm of chromosome 8 in lipoblastoma.

We report a case of lipoblastoma in a 17-month-old male patient with a pseudodiploid karyotype of 46,XY,der(14)t(8;14)(q11.2;q24). The tumor cells show two normal chromosome 8 homologs in addition to the extra 8q11.2-->qter segment, making it trisomic for the region 8q11.2-->qter, and monosomic for 14q24-->qter. Reports of chromosome studies in lipoblastoma are rare; however, a breakpoint in the long arm of chromosome 8q11-13 appears to be emerging as a consistent finding.

A case-control family history study of autism.

Family history data on 99 autistic and 36 Down's syndrome probands are reported. They confirmed a raised familial loading for both autism and more broadly defined pervasive developmental disorders in siblings (2.9% and 2.9%, respectively, vs 0% in the Down's group) and also evidence for the familial aggregation of a lesser variant of autism, comprising more subtle communication/social impairments or stereotypic behaviours, but not mental retardation alone. Between 12.4 and 20.4% of the autism siblings and 1.6% and 3.2% of the Down's siblings exhibited this lesser variant, depending on the stringency of its definition. Amongst autistic probands with speech, various features of their disorder (increased number of autistic symptoms; reduced verbal and performance ability) as well as a history of obstetric complications, indexed an elevation in familial loading. No such association was seen in the probands without speech, even though familial loading for the lesser variant in this subgroup, was significantly higher than in the Down's controls. The findings suggest that the autism phenotype extends beyond autism as traditionally diagnosed; that aetiology involves several genes; that autism is genetically heterogeneous; and that obstetric abnormalities in autistic subjects may derive from abnormality in the foetus.

Can children with Gilles de la Tourette syndrome edit their intentions?

In this paper we describe a cognitive mechanism, the Intention Editor, which is triggered whenever there are several intentions competing in parallel with each other. This mechanism is hypothesized to be a subcomponent of a larger mechanism, the Supervisory Attentional System (SAS: Shallice, 1988) which serves inhibition in general. The Intention Editor interrupts one of several simultaneously activated intentions, preventing it from executing its action, utterance, or thought. This mechanism appears to develop during the first five to six years of life. We propose that an impairment in the development of this mechanism may account for the triad of symptoms in children with Gilles de la Tourette Syndrome (GTS): involuntary movements, involuntary utterances, and obsessive thoughts. This mechanism is tested with normal children aged 3-6 years old, and with children with GTS, in two experiments. In Experiment 1, subjects were required to make one hand movement while inhibiting making a (different) hand movement that the other hand was simultaneously making. In Experiment 2, they were asked to say one thing while inhibiting saying something else. On both tasks, normal 6-year-olds were significantly better than normal 4-year-olds, but children with GTS performed worse than normal 6-year-olds, despite having a mean age of 12 years. These results constitute preliminary evidence for the theory that the Intention Editor is dysfunctional in GTS.

Isolation and characterization of a cDNA encoding the putative distal colon H+,K(+)-ATPase. Similarity of deduced amino acid sequence to gastric H+,K(+)-ATPase and Na+,K(+)-ATPase and mRNA expression in distal colon, kidney, and uterus.

A series of Northern blot hybridization experiments using probes derived from the rat gastric H+,K(+)-ATPase cDNA and the human ATP1AL1 gene revealed the presence of a 4.3-kilobase mRNA in colon that seemed likely to encode the distal colon H+,K(+)-ATPase, the enzyme responsible for K+ absorption in mammalian colon. A rat colon library was then screened using a probe from the ATP1AL1 gene, and cDNAs containing the entire coding sequence of a new P-type ATPase were isolated and characterized. The deduced polypeptide is 1036 amino acids in length and has an Mr of 114,842. The protein exhibits 63% amino acid identity to the gastric H+,K(+)-ATPase alpha-subunit and 63% identity to the three Na+,K(+)-ATPase alpha-subunit isoforms, consistent with the possibility that it is a K(+)-transporting ATPase. Northern blot analyses show that the 4.3-kilobase mRNA is expressed at high levels in distal colon; at much lower levels in proximal colon, kidney, and uterus; and at trace levels in heart and forestomach. The high mRNA levels in distal colon and the similarity of the colon pump to both gastric H+,K(+)- and Na+,K(+)-ATPases suggest that it is the distal colon H+,K(+)-ATPase. Furthermore, expression of its mRNA in kidney raises the possibility that the enzyme also corresponds to the H+,K(+)-ATPase that seems to play a role in K+ absorption and H+ secretion in the distal nephron.

Blood transfusion: an overused resource in colorectal cancer surgery.

The use of blood transfusion was examined in 476 patients who underwent curative surgery for large bowel cancer. Of these patients, 128 were not transfused while 348 received a total of 1174 units of blood. A patient was considered over-transfused if the predischarge haemoglobin was more than 12 g/dl. Using this criteria and accepting that single unit transfusions should be avoided, transfusion could have been avoided in 30% of the patients and a total of 377 units were given unnecessarily. Major under-transfusion did not occur; no patient being discharged with a haemoglobin of less than 9 g/dl. This study shows that blood transfusion is overused and the reasons for its use rarely recorded. In view of the morbidity related to transfusion, it is suggested that surgeons and anaesthetists reappraise their transfusion policy and the first step in this must be to record the reason for transfusion.

Failed femorocrural reconstruction does not prejudice amputation level.

From January 1985 to December 1989, 500 consecutive patients presented to a single vascular unit with limb-threatening acute or critical ischaemia. Vascular reconstruction was attempted unless the patient had insufficient viable tissue to permit weight bearing or complete absence of run-off vessels in the calf. Fifty patients underwent a primary amputation and 450 patients underwent vascular reconstruction, of whom 265 had a femorocrural bypass. Sixty secondary amputations were performed following femorocrural bypass failure. The below-knee amputation to above-knee amputation ratio (BKA:AKA) was 2.0 in the primary amputation group and 1.1 in the secondary amputation group. Direct comparison between the two groups is not valid as they are clinically different. The combined BKA:AKA ratio was 1.4. This compares favourably with the BKA:AKA ratio of recent published series and figures from the National Amputation and Limb Fitting Services. It suggests that an unselective policy of vascular reconstruction for critical ischaemia does not lead to a higher proportion of above-knee amputations.

Haemoccult testing as an indicator of recurrent colorectal cancer: a 5-year prospective study.

A prospective study was conducted to assess the value of routine haemoccult testing as an indicator of early luminal recurrence of colorectal cancer. One hundred patients (mean age 72 years) undergoing radical resection (70% Dukes' B and 30% Dukes' C) for colorectal carcinoma were asked to provide 3-monthly haemoccult tests to a special follow-up clinic for a minimum of 5 years. Positive tests underwent further investigation with barium enema and colonoscopy. Patient compliance was 84%. Positive tests were obtained in 14 asymptomatic individuals, five of whom proved to have anastomotic recurrence. Recurrence was also identified in a further patient despite a negative haemoccult test. Three patients with anastomotic recurrence were able to undergo further radical surgery; two were still alive over 5 years after detection of recurrent disease. Haemoccult screening appears to detect increased numbers of patients with luminal recurrence (7.2%) when compared to historical controls (2.1%). Larger studies will be needed to determine if this increased detection rate results in improved long-term survival.

Iloprost improves femoro-distal graft flow after a single bolus injection.

A double-blind, randomised, placebo-controlled trial was conducted to study the effect of the stable prostacyclin analogue iloprost on femoro-distal graft blood flow. After completing femoro-distal reconstruction, 3000 ng of iloprost or placebo was injected into the graft over 2 min. Graft blood flow, measured by electromagnetic flowmetry, increased by a mean (range) of 94% (12 to 192%) in patients receiving iloprost (n = 15) compared to 6% (-34 to 53%) in controls (n = 16; p less than 0.0001, t-test). Increased graft flow, measured by duplex ultrasound, was maintained in the iloprost group over a 7 day period postoperatively (F = 5.2, p = 0.03; analysis of variance) and remained higher at 7 days (p = 0.007, t-test). Iloprost produces an immediate, sustained increase in graft blood flow after femoro-distal reconstruction and may therefore be of benefit in reducing the incidence of early graft failure.

Vertical Silastic ring gastroplasty: a 6-year experience.

Vertical Silastic ring gastroplasty was carried out in 71 patients as treatment for morbid obesity. The mean excess weight loss at 6 months (59 patients) and 2 years (43 patients) was 48 per cent and 65 per cent respectively. Subsequently the weight stabilized around this level with 58 per cent of the excess weight lost at 5 years (14 patients) postgastroplasty. Five patients (7 per cent) failed to lose weight. Sixteen patients (23 per cent) required revision for technical complications but continued to lose weight or to maintain a satisfactory weight. Vertical Silastic ring gastroplasty is an effective surgical method of achieving sustained weight loss.