The Prevention of Musculoskeletal Complaints in Instrumental Musicians: A Systematic Review.

OBJECTIVE: This systematic review synthesizes the evidence of various interventions aiming to prevent muscu¬loskeletal complaints in professional musicians. METHODS: This study comprises a systematic review according to PRISMA guidelines. A database search was performed in Cochrane, Embase, and PubMed on 13 September 2022 without time and language restrictions. The search consisted of the following groups of keywords: preventive measures AND musculoskeletal AND musicians. Risk of bias was assessed with the PEDro and MINORs criteria. Two reviewers independently selected and assessed the quality of the studies. RESULTS: A total of 1,831 articles were screened and 20 articles were included in this review. There is a wide range of interventions aiming to reduce musculoskeletal complaints in musicians. Among the studied programs were interventions focused on strength, cardiovascular and general fitness, flexibility as well as educational interventions and combinations of these. On average, scientific quality was good, moderate, and low for randomized controlled trials (RCTs), comparative studies, and non-comparative studies, respectively. A significant beneficial effect of the evaluated intervention on either playing-related musculoskeletal disorders (PRMD) frequency or severity or (playing-related) pain frequency and intensity was reported in at least 12 of the 20 studies. In particular, interventions with a strength training program reported a beneficial effect on PRMD frequency and severity as well as pain intensity and interference on the short-term. CONCLUSION: This systematic review highlights the heterogeneity in interventions aiming to prevent musculoskeletal complaints in musicians. Strength training might have a positive short-term effect on reducing musculoskeletal complaints. There is a need for further research to improve the quality of evidence as well as long-term outcomes of injury prevention programs.

Essential thrombocytosis: diagnosis, differential diagnosis, complications and treatment considerations of relevance for a cardiologist.

Essential thrombocytosis (ET) is a rare haematological malignancy, with an incidence rate of 1.5-2.5/100,000 per year. For many patients with ET the first manifestation of their underlying disease is a thrombotic or haemorrhagic complication. A recent retrospective study revealed an incidence rate of at least 2.1% in people under 40 years presenting with an acute coronary syndrome, although the diagnosis was initially missed in all cases. Thus, cardiologists face a much higher than average incidence rate of ET in their daily practice, but seem insufficiently aware of the disease. The current review summarises symptoms, (differential) diagnosis, complications and treatment considerations of ET of relevance for a cardiologist. Typical symptoms, besides thrombosis and haemorrhage, include erythromelalgia and aquagenic pruritus, while platelets > 450â€¯× 109/l are a diagnostic for ET once other myeloproliferative neoplasms, secondary and spurious thrombocytosis have been excluded. With regard to treatment, timing of revascularisation depends on the presence of ischaemia and concurrent platelet counts. In the presence of ischaemia, revascularisation should not be delayed and adequate platelet counts can be achieved by platelet apheresis. In the absence of ischaemia, revascularisation can be delayed until adequate platelet counts have been achieved by cytoreductive therapies. Cardiologists should be aware of/screen for possible ET.

Exposure to solar ultraviolet radiation limits diet-induced weight gain, increases liver triglycerides and prevents the early signs of cardiovascular disease in mice.

BACKGROUND AND AIMS: Sunlight exposure is associated with a number of health benefits including protecting us from autoimmunity, cardiovascular disease, obesity and diabetes. Animal studies have confirmed that ultraviolet (UV)-B radiation, independently of vitamin D, can limit diet-induced obesity, metabolic syndrome and atherosclerosis. The aim of this study is to investigate whether exposure to the UV radiation contained in sunlight impacts on these disease parameters. METHODS AND RESULTS: We have trialled an intervention with solar UV in obese and atherosclerosis-prone mice. We have discovered that solar-simulated UV can significantly limit diet-induced obesity and reduce atheroma development in mice fed a diet high in sugar and fat. The optimal regime for this benefit was exposure once a week to solar UV equivalent to approximately 30 min of summer sun. Exposure to this optimal dose of solar UV also led to a significant increase in liver triglycerides which may protect the liver from damage. CONCLUSION: Our results show that the UV contained in sunlight has the potential to prevent and treat chronic disease at sites distant from irradiated skin. A major health challenge going forward will be to harness the power of the sun safely, without risking an increase in skin cancers.

First Report of Verticillium Wilt of Ailanthus altissima in Virginia Caused by Verticillium nonalfalfae.

Ailanthus altissima (Mill.) Swingle, commonly known as tree-of-heaven, is an invasive tree species that has spread throughout the United States since its introduction in 1784 (2). During a survey in July 2009, approximately 1,100 A. altissima trees were observed at two locations in western Virginia (a roadside in Montgomery Co. and a wooded area adjacent to a railroad in Bedford Co.) exhibiting foliar wilt symptoms, defoliation, yellowish vascular discoloration, or death at an incidence of ~77%. Similar symptoms on A. altissima were reported in Roanoke, VA in the early 1930s and after 2005 in Pennsylvania, attributed to a Verticillium sp. (1,2). To identify the causal agent, discolored xylem tissue samples were excised from 10 symptomatic A. altissima trees at both locations, soaked in 1% NaOCl for 2 min, rinsed with sterilized distilled water for 5 min, and placed onto plum extract agar. Cultures were incubated in the dark at 22°C for 7 to 14 days. The resultant colonies (three to four per location) were subcultured and identified putatively as a Verticillium sp. closely related to Verticillium albo-atrum Reinke and Berthold (3), based on melanized, thick-walled, resting mycelia and phialides arranged in verticillate whorls that amassed round, oval-shaped conidia (5.1 ± 1.2 µm × 2.8 ± 0.4 µm, n = 100). Molecular identification of two fungal isolates (one per location) was determined by amplification of the protein coding genes elongation factor 1-alpha (EF), glyceraldehyde-3-phosphate dehydrogenase (GPD), and tryptophan synthase (TS), using PCR primers developed recently for Verticillium (3). A BLAST search on the edited contigs revealed 100% sequence similarity for all three protein coding genes among the two isolates and reference sequences of isolates PD592 (GenBank Accessions JN188227, JN188163, and JN188035 for EF, GPD, and TS, respectively) and VnAaPA140 (KC307764, KC307766, and KC307768 for EF, GPD, and TS, respectively) of the newly-proposed species, V. nonalfalfae (formerly V. albo-atrum). Aligned sequences from one representative isolate, VnAaVA2 (Bedford Co.), were deposited into GenBank as KC307758 (EF), KC307759 (GPD), and KC307760 (TS). To confirm pathogenicity to A. altissima, the two molecularly characterized isolates (one per location) were inoculated into 18 10-week old A. altissima stems that were grown in an environmental chamber at 24°C, 60% RH, and a 12-h photoperiod from seeds collected in Blacksburg, VA. A conidial suspension of each isolate was injected into each stem (0.1 ml of 1 × 108 CFU/ml/stem). All 36 seedlings inoculated with the proposed V. nonalfalfae isolates developed wilting of leaflets within 2 weeks post-inoculation (WPI), defoliation of leaflets by 6 WPI, and were dead by 9 WPI. Eighteen control seedlings were inoculated similarly with distilled water, and remained asymptomatic. Fungi resembling the proposed species V. nonalfalfae were reisolated from all inoculated stems except the control plants, and the species confirmed morphologically as described above. V. nonalfalfae is a recently proposed species that can infect a variety of plant species (3). To our knowledge, this is the first report of this proposed species on A. altissima in Virginia. New state reports of this pathogen on A. altissima are important for regulatory issues associated with using this pathogen as a potential biological control agent. References: (1) G. F. Gravatt and R. B. Clapper. Plant Dis. Rep. 16:96, 1932. (2) M. J. Schall and D. D. Davis. Plant Dis. 93:747, 2009. (3) P. Inderbitzin et al. PLoS ONE, 6, e28341, 2011.

Histone deacetylase inhibitors increase human arylamine N-acetyltransferase-1 expression in human tumor cells.

Arylamine N-acetyltransferase-1 (NAT1) has been associated with disorders involving folate metabolism, such as spina bifida, as well as numerous human cancers. As a result, the transcriptional and post-transcriptional regulation of NAT1 activity has been extensively studied. However, little work has been reported on the epigenetic control of NAT1 expression. Here, we demonstrate that the histone deacetylase inhibitor trichostatin A (TSA) increases NAT1 activity in human cancer cells by increasing transcription from the proximal promoter NATb. A specific Sp1 binding site was identified as essential for optimal induction of NAT1 by TSA. However, TSA did not increase the expression of Sp1 in HeLa cells. Instead, TSA increased the acetylation of histones associated with the NATb promoter. This allowed recruitment of Sp1 to the promoter along with acetylated histones. We propose that NAT1 transcription is partially repressed by the local chromatin condensation in the vicinity of NATb and that histone deacetylase inhibition leads to up-regulation of NAT1 expression via a direct change in chromatin conformation.

Visual ability and searching behavior of adult Laricobius nigrinus, a hemlock woolly adelgid predator.

Very little is known about the searching behavior and sensory cues that Laricobius spp. (Coleoptera: Derodontidae) predators use to locate suitable habitats and prey, which limits our ability to collect and monitor them for classical biological control of adelgids (Hemiptera: Adelgidae). The aim of this study was to examine the visual ability and the searching behavior of newly emerged L. nigrinus Fender, a host-specific predator of the hemlock woolly adelgid, Adelges tsugae Annand (Hemiptera: Phylloxeroidea: Adelgidae). In a laboratory bioassay, individual adults attempting to locate an uninfested eastern hemlock seedling under either light or dark conditions were observed in an arena. In another bioassay, individual adults searching for prey on hemlock seedlings (infested or uninfested) were continuously video-recorded. Beetles located and began climbing the seedling stem in light significantly more than in dark, indicating that vision is an important sensory modality. Our primary finding was that searching behavior of L. nigrinus, as in most species, was related to food abundance. Beetles did not fly in the presence of high A. tsugae densities and flew when A. tsugae was absent, which agrees with observed aggregations of beetles on heavily infested trees in the field. At close range of prey, slow crawling and frequent turning suggest the use of non-visual cues such as olfaction and contact chemoreception. Based on the beetles' visual ability to locate tree stems and their climbing behavior, a bole trap may be an effective collection and monitoring tool.

Impaired endoplasmic reticulum-mitochondrial signaling in ataxia-telangiectasia.

There is evidence that ATM mutated in ataxia-telangiectasia (A-T) plays a key role in protecting against mitochondrial dysfunction, the mechanism for which remains unresolved. We demonstrate here that ATM-deficient cells are exquisitely sensitive to nutrient deprivation, which can be explained by defective cross talk between the endoplasmic reticulum (ER) and the mitochondrion. Tethering between these two organelles in response to stress was reduced in cells lacking ATM, and consistent with this, Ca2+ release and transfer between ER and mitochondria was reduced dramatically when compared with control cells. The impact of this on mitochondrial function was evident from an increase in oxygen consumption rates and a defect in mitophagy in ATM-deficient cells. Our findings reveal that ER-mitochondrial connectivity through IP3R1-GRP75-VDAC1, to maintain Ca2+ homeostasis, as well as an abnormality in mitochondrial fusion defective in response to nutrient stress, can account for at least part of the mitochondrial dysfunction observed in A-T cells.

Molybdate toxicity in Chinese cabbage is not the direct consequence of changes in sulphur metabolism.

In polluted areas, plants may be exposed to supra-optimal levels of the micronutrient molybdenum. The physiological basis of molybdenum phytotoxicity is poorly understood. Plants take up molybdenum as molybdate, which is a structural analogue of sulphate. Therefore, it is presumed that elevated molybdate concentrations may hamper the uptake and subsequent metabolism of sulphate, which may induce sulphur deficiency. In the current research, Chinese cabbage (Brassica pekinensis) seedlings were exposed to 50, 100, 150 and 200 µm Na2 MoO4 for 9 days. Leaf chlorosis and a decreased plant growth occurred at concentrations ≥100 µm. Root growth was more affected than shoot growth. At ≥100 µm Na2 MoO4 , the sulphate uptake rate and capacity were increased, although only when expressed on a root fresh weight basis. When expressed on a whole plant fresh weight basis, which corrects for the impact of molybdate on the shoot-to-root ratio, the sulphate uptake rate and capacity remained unaffected. Molybdate concentrations ≥100 µm altered the mineral nutrient composition of plant tissues, although the levels of sulphur metabolites (sulphate, water-soluble non-protein thiols and total sulphur) were not altered. Moreover, the levels of nitrogen metabolites (nitrate, amino acids, proteins and total nitrogen), which are generally strongly affected by sulphate deprivation, were not affected. The root water-soluble non-protein thiol content was increased, and the tissue nitrate levels decreased, only at 200 µm Na2 MoO4 . Evidently, molybdenum toxicity in Chinese cabbage was not due to the direct interference of molybdate with the uptake and subsequent metabolism of sulphate.

Propagation, synchrony, and impact of introduced and native Laricobius spp. (Coleoptera: Derodontidae) on hemlock woolly adelgid in Virginia.

Synchrony and impact of the predators Laricobius nigrinus Fender and Laricobius rubidus LeConte, on hemlock woolly adelgid, Adelges tsugae Annand, were studied in an eastern hemlock field insectary in Virginia. First, a field insectary for propagation of the introduced L. nigrinus was established by planting hemlocks in 2001, infesting them with hemlock woolly adelgid in 2002 and 2003, followed by releasing 258 L. nigrinus in 2003. Initial sampling showed that the native L. rubidus was present in the area. Hemlock woolly adelgid and both Laricobius species populations increased annually, from which 305 F3 L. nigrinus adults were collected and redistributed to forests in 2007. Second, the phenology of hemlock woolly adelgid and Laricobius spp. life cycles were monitored in 2005 and 2006. Adult L. nigrinus (F2) and L. rubidus were active on hemlock from fall through mid-spring and overlapped with second-instar sistentes nymphs through progredientes eggs. The predators' eggs were oviposited and larvae developed (i.e., F3 L. nigrinus) from late winter to mid-spring on progredientes eggs, indicating synchrony with suitable prey life stages. Third, a predator exclusion experiment was used to examine the relationships between the predators and prey in 2005 and 2006. When exposed to L. nigrinus (F2 adults and F3 larvae) and L. rubidus, hemlock woolly adelgid survival and ovisac density were lower and ovisac disturbance was higher than hemlock woolly adelgid protected in cages. The establishment and production of L. nigrinus at a field insectary, synchronization with, and impacts on hemlock woolly adelgid after a small release 2 yr earlier makes it an important potential biological control agent of hemlock woolly adelgid.

The characteristic high sulfate content in Brassica oleracea is controlled by the expression and activity of sulfate transporters.

The uptake and distribution of sulfate in BRASSICA OLERACEA, a species characterised by its high sulfate content in root and shoot, are coordinated and adjusted to the sulfur requirement for growth, even at external sulfate concentrations close to the K (m) value of the high-affinity sulfate transporters. Plants were able to grow normally and maintain a high sulfur content when grown at 5 or 10 microM sulfate in the root environment. Abundance of mRNAs for the high affinity sulfate transporters, BolSultr1;1 and BolSultr1;2, were enhanced at

Behavior and daily activity patterns of specialist and generalist predators of the hemlock woolly adelgid, Adelges tsugae.

The behavior and daily activity patterns of two specialist predators, Laricobius nigrinus Fender (Coleoptera: Derodontidae) and Sasajiscymnus tsugae, Sasaji and McClure (Coleoptera: Coccinellidae), and a generalist predator, Harmonia axyridis Pallas (Coleoptera: Coccinellidae), of hemlock woolly adelgid, Adelges tsugae (Hemiptera: Adelgidae), were examined using digital video recording in the laboratory. The two specialists are part of a biological control program for A. tsugae, and it is not known if competitive interactions with previously established generalist predators will negatively impact their effectiveness. The behavior and daily activity patterns of adult females of each species were documented in single- and paired-predator assays under simulated spring and summer conditions. Behavior varied qualitatively and quantitatively by species, and did not appear to be highly coordinated temporally or spatially. All species exhibited continuous activity patterns that were punctuated by longer periods of rest. Extensive and intensive searching behavior occurred in all species, with intensive searching being highly variable. Specialist predators appeared to be more selective of feeding and oviposition sites, and rested at more concealed locations than the generalist species. In spring conditions, L. nigrinus had greater activity and a more even behavior distribution than S. tsugae or H. axyridis, which were skewed towards resting. In summer, the latter two species showed increased activity at higher temperatures. Conspecifics significantly altered the time allocated to specific behaviors for L. nigrinus and H. axyridis, resulting in reduced predator effectiveness by reducing time and energy expenditure on activities that directly impact the adelgids. In contrast, S. tsugae conspecifics and all heterospecific combinations showed non-interference. The activity of each species varied with time of day; L. nigrinus was more active at night, while S. tsugae and H. axyridis were more active during the day. All predator groupings maintained a high degree of spatial separation relative to assay size. The use of multiple-predator species combinations that include the specialist predators, is recommended over single-species for biological control of A. tsugae, as temporal and spatial patterns were not highly coordinated. Low-density releases may reduce the potential negative effects of intraspecific competition.

Numerical Response and Impact of Laricobius nigrinus (Coleoptera: Derodontidae) on Adelges tsugae (Hemiptera: Adelgidae) in Their Native Range.

To determine if key attributes for a successful biological control agent are possessed by the predator, Laricobius nigrinus Fender, field studies were conducted in its native range of Seattle, WA. The relationship between adult and immature L. nigrinus abundance to different densities of its prey, Adelges tsugae Annand, were determined. In a second study, predator and prey densities, and survivorship of each sistens A. tsugae stage were determined to gauge the impact of predation. The predator strongly aggregated and increased its reproduction when prey density increased, the two mechanisms of a numerical response. Immature predator-prey ratios were high and average prey density was low in comparison with invaded areas of the eastern United States. Survivorship of aestivating first-instar sistens A. tsugae was low and survivorship of each instar (second, third, and fourth) and adults was high and increased with each stage. When pooled, however, the survivorship of sistens second instar-ovisac stages was low primarily owing to L. nigrinus larval consumption of ovisacs. In its native range, L. nigrinus has key attributes of a successful biological control agent, such as a strong numerical response, high predator-prey ratios, and an important larval impact on A. tsugae populations. Demographic data could serve as important benchmarks for future studies to determine if L. nigrinus and other predators can regulate densities of A. tsugae below eastern hemlock's physiological damage threshold in the eastern United States.

[Costs and benefits of smoking]. / De rekening van roken.

- Two recent societal cost-benefit analyses have documented the costs of smoking and the cost-effectiveness of preventing smoking.- Smoking costs the Netherlands society EUR 33 billion per year.- The majority of this is the monetary value of health loss; these are "soft" euros that cannot be re-spent.- There is not a great deal of difference between costs and benefits when expressed in "hard" euros, which means that there is no clear business case for anti-smoking policy.- The greatest benefit of discouraging smoking is improved health for the individual and increased productivity for the business sector; however, the benefits cannot be easily realised, because even in the most favourable scenario the number of smokers will decrease slowly.- Excise duties seem to offer the most promising avenue for combating smoking. The benefits of anti-smoking policy, therefore, consist mainly of tax revenues for the government.- Stringent policy is required to transform tax revenues into health gains.

Temperature determines size and direction of effects of elevated CO2 and nitrogen form on yield quantity and quality of Chinese cabbage.

Rising atmospheric CO2 concentrations (e[CO2 ]) are presumed to have a significant impact on plant growth and yield and also on mineral nutrient composition, and therefore, on nutritional quality of crops and vegetables. To assess the relevance of these effects in future agroecosystems it is important to understand how e[CO2 ] interacts with other environmental factors. In the present study, we examined the interactive effects of e[CO2 ] with temperature and the form in which nitrogen is supplied (nitrate or ammonium nitrate) on growth, amino acid content and mineral nutrient composition of Chinese cabbage (Brassica pekinensis Rupr.), a crop characterised by its high nutritional value and increasing relevance for human nutrition in many developing countries. Higher temperature, ammonium nitrate and e[CO2 ] had a positive impact on net photosynthesis and growth. A stimulating effect of e[CO2 ] on growth was only observed if the temperature was high (21/18 °C, day/night), and an interaction of e[CO2 ] with N form was only observed if the temperature was ambient (15/12 °C, day/night). Mineral nutrient composition was affected in a complex manner by all three factors and their interaction. These results demonstrate how much the effect of e[CO2 ] on mineral quality of crops depends on other environmental factors. Changes in temperature, adapting N fertilisation and the oxidation state of N have the potential to counteract the mineral depletion caused by e[CO2 ].

Stress and Depression: a Crucial Role of the Mineralocorticoid Receptor.

Cortisol and corticosterone act on the appraisal process, which comprises the selection of an appropriate coping style and the encoding of the experience for storage in the memory. This action exerted by the stress hormones is mediated by mineralocorticoid receptors (MRs), which are expressed abundantly in the limbic circuitry, particularly in the hippocampus. Limbic MR is down-regulated by chronic stress and during depression but induced by antidepressants. Increased MR activity inhibits hypothalamic-pituitary-adrenal axis activity, promotes slow wave sleep, reduces anxiety and switches circuit connectivity to support coping. Cortisol and emotion-cognition are affected by MR gene haplotypes based on rs5522 and rs2070951. Haplotype 1 (GA) moderates the effects of (early) life stressors, reproductive cycle and oral contraceptives. MR haplotype 2 (CA) is a gain of function variant that protects females against depression by association with an optimistic, resilient phenotype. Activation of MR therefore may offer a target for alleviating depression and cognitive dysfunction. Accordingly, the MR agonist fludrocortisone was found to enhance the efficacy of antidepressants and to improve memory and executive functions in young depressed patients. In conclusion, CORT coordinates via MR the networks underlying how an individual copes with stress, and this action is complemented by the widely distributed lower affinity glucocorticoid receptor (GR) involved in the subsequent management of stress adaptation. In this MR:GR regulation, the MR is an important target for promoting resilience.

Assessment of global atrial fibrillation organization to optimize timing of atrial defibrillation.

BACKGROUND: We hypothesized that frequency domain analysis of a wide bipolar interatrial electrogram describes the global organization of atrial fibrillation (AF) and should vary over time. By timing shocks to periods of high organization of AF, cardioversion efficacy should improve. METHODS AND RESULTS: A total of 15 dogs (weight, 28.2+/-3.4 kg) were rapidly paced for 48 to 72 hours to induce AF. Coil electrodes with a surface area of 1.80 cm(2) were then placed in the left and right atria to form a wide bipole. Wide bipolar electrograms were digitally filtered, and a fast Fourier transform was performed over a sliding 2-s window every 0.5 s. The organization index (OI) was calculated as the ratio of the area of the dominant peak and its harmonics to the total area of the magnitude spectrum. The atrial defibrillation threshold (ADFT(50)) was determined using a 3-ms/3-ms biphasic shock and an up-down-up protocol. Additional shocks with higher and lower energies were delivered in a random sequence to develop a distribution curve. The OI varied over time, with a mean of 0.42+/-0.03, a maximum of 0.65+/-0.07, and a minimum of 0.20+/-0.06. The OI changed rapidly, with durations of high organization (OI>0.5) ranging from 1 to 5 s. The ADFT(50) for QRS complex-synchronized shocks was 183+/-56 V, versus 142+/-49 V for shocks synchronized to an OI>0.5 (P<0.001). The distribution curve shifted leftward when shocks were synchronized to an OI>0.5. CONCLUSIONS: AF signals show a high degree of variability. Shock efficacy is increased when shocks are delivered during periods of high AF organization as determined by the OI method.

Coexistence of type I atrial flutter and intra-atrial re-entrant tachycardia in patients with surgically corrected congenital heart disease.

OBJECTIVES: This study assessed the coexistence of intra-atrial re-entrant tachycardia (IART) and isthmus-dependent atrial flutter (IDAF) in patients presenting with supraventricular tachyarrhythmias after surgical correction of congenital heart disease (CHD). BACKGROUND: In patients with CHD, atrial tachyarrhythmias may result from IART or IDAF. The frequency with which IART and IDAF coexist is not well defined. METHODS: Both IDAF and IART were diagnosed in 16 consecutive patients using standard criteria and entrainment mapping. Seven patients had classic atrial flutter morphology on surface electrocardiogram (ECG), whereas nine had atypical morphology. RESULTS: A total of 24 circuits were identified. Three patients had IDAF only, five had IART only, seven had both, and one had a low right atrial wall tachycardia that could not be entrained. Twenty-two different reentry circuits were ablated. Successful ablation was accomplished in 13 of 14 (93%) IART and 9 of 10 (90%) IDAF circuits. There was one IART recurrence. The slow conduction zone involved the region of the right atriotomy scar in 12 of 14 (86%) IART circuits. No procedural complications and no further recurrences were seen after a mean follow-up of 24 months. CONCLUSIONS: Both IDAF and IART are the most common mechanisms of atrial re-entrant tachyarrhythmias in patients with surgically corrected CHD, and they frequently coexist. The surface ECG is a poor tool for identifying patients with coexistent arrhythmias. The majority of IART circuits involve the lateral right atrium and may be successfully ablated by creating a lesion extending to the inferior vena cava.

Koilocytosis and squamous (pre)neoplasia as detected in population-based cervical screening: practice and theory.

INTRODUCTION: Koilocytosis (cavitation of the cytoplasm due to active HPV infection) can be detected in the screening process for cervical carcinoma. OBJECTIVE: To report the practice of detection of koilocytosis and (pre)neoplasia in population screening and to exploit the collected data to propose an explanation for the relationship between HPV infection and nuclear precancerous changes. STUDY DESIGN: Centrally collected and stored (SBBW, Leiden, the Netherlands) data from all smears of six regional pathology laboratories (1995-2002), coded according to KOPAC (the national cervical smear coding system; S1: normal thru S9: invasive carcinoma) were accessed. Prevalences per 100,000 smears were calculated for koilocytosis and for squamous abnormalities after stratification for country of origin of screenees. The relative risk (RR) for the ethnic (age) groups was computed by dividing the prevalence of the relevant ethnic (age) group by the prevalence of all women. RESULTS: Surinamese women featured the highest prevalence of koilocytosis and of all squamous abnormalities. Moroccan women the lowest. The RR for koilocytosis was highest at 30 years (1.84) and lowest at 60 (0.26). RR dependence on age of S5-S9 lesions was similar. Compared to nonkoilocytotic smears, koilocytosis was 104 times more frequent in the 1,500 S4 smears, 36x more frequent in the 6,700 S2-S3 smears, and 24x more frequent in the 1,740 S5-S9 smears. In all three categories this difference is statistically significant. CONCLUSION: High prevalences for both koilocytosis and for preneoplasia were detected in Surinamese immigrants, however, it still does not exclude HPV infection as a confounder linked to sexual lifestyle. The presence of koilocytosis in cervical smears may serve to identify patients with an increased risk for cervical cancer and perhaps warrant more intensive surveillance than what is provided through five-yearly screening.

Legal issues in the treatment of a violent manic patient in a non-gazetted setting: a case report.

INTRODUCTION: Psychiatrists in non-gazetted treatment settings, like psychiatric wards in restructured general hospitals and private hospitals, face a major problem when psychiatric patients who require admission are either not competent or refuse to consent to admission and treatment, although they are clearly in need of such inpatient management. Admission to the state mental hospital is often refused by their relatives for a number of reasons, like the stigma attached to admission to such a hospital, and the fear that future employment prospects might be affected. CLINICAL PICTURE: Mr X, a manic, violent patient, had no insight into his disorder and refused admission and treatment for his manic episode. He was the head of a large corporation, and his relatives were apprehensive he would make decisions that could jeopardize the company. TREATMENT: He refused oral medication, could not tolerate parenteral haloperidol and had lithium nephrotoxicity. Inpatient electroconvulsive therapy had to be administered, after which he responded satisfactorily. CONCLUSION: The legal implications in this case, like consent for treatment and admission, and ethical issues, are discussed.