Non-invasive ventilation in neuromuscular diseases: should we use higher levels of ventilatory support?

PURPOSE: In patients with COPD, one of the leading indications for domiciliary non-invasive ventilation (NIV), a major paradigm shift has been observed over the past decade in the method for adjusting NIV settings, with the use of sufficient ventilatory support to achieve a significant reduction in PaCO2. Whether this approach may be relevant to other populations, especially slowly progressive neuromuscular diseases (NMD), is unknown. METHODS: This study was conducted as a post hoc analysis from a previously published randomized controlled trial (NCT03458507). Patients with NMD treated with domiciliary NIV were stratified according to the level of ventilatory support: high-level tidal volume (HLVT; mL/kg of predicted body weight [PBW]) or high-level pressure support (HLPS), defined as a value above median value of the whole population (> 6.8 mL/kgPBW or 9.0 cmH2O, respectively). Primary outcome was mean nocturnal transcutaneous CO2 pressure (PtcCO2). Secondary outcomes included adherence to NIV, leaks, and side effects. RESULTS: Of a total of 26 patients, 13 were exposed to HLVT, with significantly lower nocturnal PtcCO2 (respectively 40.5 ± 4.2 vs. 46.3 ± 3.9 mmHg, p = 0.002). A linear correlation between VT (mL/kgPBW) and mean nocturnal PtcCO2 was evidenced (r = - 0.59, 95%CI [- 0.80; - 0.25], p = 0.002). No significant impact of HLVT was found on secondary outcomes. CONCLUSION: Despite the lack of power of this post hoc analysis, our results suggest that higher levels of ventilatory support are correlated with lower PtcCO2 in patients with NMD. Further studies are desirable to assess the extent to which the level of assistance influences PaCO2 evolution in patients with slowly progressive NMD, as well as in restrictive thoracic disorders.

Stalled replication forks within heterochromatin require ATRX for protection.

Expansive growth of neural progenitor cells (NPCs) is a prerequisite to the temporal waves of neuronal differentiation that generate the six-layered neocortex, while also placing a heavy burden on proteins that regulate chromatin packaging and genome integrity. This problem is further reflected by the growing number of developmental disorders caused by mutations in chromatin regulators. ATRX gene mutations cause a severe intellectual disability disorder (α-thalassemia mental retardation X-linked (ATRX) syndrome; OMIM no. 301040), characterized by microcephaly, urogenital abnormalities and α-thalassemia. Although the ATRX protein is required for the maintenance of repetitive DNA within heterochromatin, how this translates to disease pathogenesis remain poorly understood and was a focus of this study. We demonstrate that Atrx(FoxG1Cre) forebrain-specific conditional knockout mice display poly(ADP-ribose) polymerase-1 (Parp-1) hyperactivation during neurogenesis and generate fewer late-born Cux1- and Brn2-positive neurons that accounts for the reduced cortical size. Moreover, DNA damage, induced Parp-1 and Atm activation is elevated in progenitor cells and contributes to their increased level of cell death. ATRX-null HeLa cells are similarly sensitive to hydroxyurea-induced replication stress, accumulate DNA damage and proliferate poorly. Impaired BRCA1-RAD51 colocalization and PARP-1 hyperactivation indicated that stalled replication forks are not efficiently protected. DNA fiber assays confirmed that MRE11 degradation of stalled replication forks was rampant in the absence of ATRX or DAXX. Indeed, fork degradation in ATRX-null cells could be attenuated by treatment with the MRE11 inhibitor mirin, or exacerbated by inhibiting PARP-1 activity. Taken together, these results suggest that ATRX is required to limit replication stress during cellular proliferation, whereas upregulation of PARP-1 activity functions as a compensatory mechanism to protect stalled forks, limiting genomic damage, and facilitating late-born neuron production.

Perfluorooctanoic acid: relationship between repeated inhalation exposures and plasma PFOA concentration in the rat.

A large database exists describing the pharmacokinetic behavior of perfluorooctanoic acid (PFOA) following oral exposure. The objective of this study was to examine the concentration- and time-dependence of the pharmacokinetics of inhaled PFOA in rat plasma to determine equivalent inhalation and oral (from literature values) exposure levels. The study was comprised of two separate experiments: a single 6-h inhalation exposure and repeated inhalation exposures for 3 weeks (6h per day, 5 days per week). In both experiments, male and female rats were exposed nose-only to aerosol atmospheres of either 0, 1, 10, or 25mg/m(3) PFOA. In the single exposure experiment, blood was drawn via the tail vein pre-exposure, four times concurrent to exposure, and six times post-exposure up to 24h. In the repeated exposure experiment, blood was collected immediately before and after exposure 3 days per week. Plasma PFOA concentrations were quantitated by liquid chromatography-mass spectrometry (LC-MS). Following the single exposures, plasma PFOA concentrations were directly proportional to airborne concentrations in both male and female rats. Elimination of PFOA from the plasma was sex-dependent, with female rats eliminating PFOA much more rapidly than male rats. Following repeated PFOA exposure, there was little daily PFOA carryover observed in plasma samples from female rats, while males demonstrated an accumulative pattern over the 3-week period. Peak post-exposure PFOA plasma concentrations in female rats averaged 1, 2, and 4 microg/mL when exposed to 1, 10, and 25mg/m(3) PFOA, respectively, and returned to baseline levels by the time of the next pre-exposure sample collection. Male rats reached steady state plasma concentrations of 8, 21, and 36 microg/mL (ppm) after 3 weeks of exposure to 1, 10, and 25mg/m(3) PFOA, respectively. These results demonstrate that the pharmacokinetic properties of inhaled PFOA in male and female rats are similar to those observed in male and female rats following oral dosing with PFOA. It is thus possible to use this internal dose metric (plasma PFOA) for route-to-route dose extrapolation, with inhalation exposures of 1, 10, and 25mg/m(3) PFOA corresponding to oral doses of approximately 0.3, 1.0, and 2.0mg/kg in rats.

A prospective, randomized trial comparing a transparent dressing and a dry gauze on the exit site of long term central venous catheters of hemodialysis patients.

The objective of this study was to assess the risk of bacteremia, estimate the cost and evaluate the quality of life by using a transparent dressing (TD) versus (vs) a dry gauze (DG) on the exit site of long term central I.V. catheters (LTCC) of hemodialysis patients. This 6-months preliminary study was conducted on 58 patients (pts) randomized to receive DG replaced 3 times/week (29 pts) or TD replaced every 7 days (29 pts). Data on patients, conditions of the exit site, local infection, bacteremia, quality of life and cost related to each type of dressing were collected. Two pts in the DG group experienced bacteremia related to their LTCC vs 1 pt in the group TD. A total of 7 (DG) vs 13 (TD) pts experienced skin condition changes at the catheter exit site. Some skin reactions, erythema and pruritus, did occur initially in the group TD and was due in part to insufficient drying time of the skin preparation solution. The estimated individual, weekly costs for using the DG was $7.60 vs $4.72 Canadian dollars for the TD. The SF-36trade mark scores did not show a significant difference between the 2 groups during the study (3.8 (PCS), 6.4 (MCS) at study end). Although this study was statistically underpowered, it suggests that the incidence of bacteremia was not increased with the use of a TD. Moreover, the use of a TD allowed fewer dressing changes, lowered total treatment costs, with no observed unfavorable impact on the quality of life and without significant local complications of the exit site. Based on the positive results observed in this pilot study, further study is warranted to examine the cost effectiveness of long-term use of TD dressings on dialysis catheter exit sites.

Inflammatory cell availability affects ozone-induced lung damage.

Identifying whether or not neutrophils have a role to play in the early stages of acute lung epithelial injury brought about by inhalation of reactive substances continues to be a major area of investigation. In this study, the availability of circulating neutrophils was manipulated by treatment with either cyclophosphamide or rabbit antiserum against rat neutrophils, prior to exposures to air, a single high ozone exposure of 1 or 2 ppm for 3 h, or a continuous exposure to 0.8-1.0 ppm for up to 48 h. Although cyclophosphamide treatment resulted in undetectable levels of neutrophils in the blood, the recovery of tissue marginated-interstitial neutrophils of 1 x 10(6) cells by collagenase tissue digestion was not significantly diminished at the onset of air and ozone exposures. Cyclophosphamide treatment alone did not cause any permeability damage to air-exposed rat lungs, but did ameliorate ozone-induced increases in bronchoalveolar lavage (BAL) neutrophil and albumin recoveries after both short-term and 1 d of continuous ozone exposure. In contrast to cyclophosphamide, antiserum treatment resulted in greater than a 90% decrease in neutrophil recoveries from both blood and lung tissue at the onset of air and ozone exposures. Antiserum treatment also abrogated ozone-induced neutrophil accumulations in lung lavageable spaces following both single and continuous ozone exposures, but did not significantly affect ozone-associated lung permeability damage indicated by unaltered BAL fluid albumin recoveries. These data demonstrated that under experimental conditions when neutrophils remain within lung tissue marginated and interstitial pools, reduction in circulating blood neutrophil availability is associated with a concomitant decrease in ozone-induced lung damage.

Comparative analysis of the digestive efficiency and nitrogen and energy requirements of the phyllostomid fruit-bat (Artibeus jamaicensis) and the pteropodid fruit-bat (Rousettus aegyptiacus).

Nitrogen (N) and energy (E) requirements of the phyllostomid fruit bat, Artibeus jamaicensis, and the pteropodid fruit bat Rousettus aegyptiacus, were measured in adults that were fed on four experimental diets. Mean daily food intake by A. jamaicensis and R. aegyptiacus ranged from 1.1-1.6 times body mass and 0.8-1.0 times body mass, respectively. Dry matter digestibility and metabolizable E coefficient were high (81.1% and 82.4%, respectively) for A. jamaicensis and (77.5% and 78.0%, respectively) for R. aegyptiacus. Across the four diets, bats maintained constant body mass with mean metabolizable E intakes ranging from 1357.3 kJ.kg-0.75.day-1 to 1767.3 kJ.kg-0.75.day-1 for A. jamaicensis and 1282.6-1545.2 kJ.kg-0.75.day-1 for R. aegyptiacus. Maintenance E costs were high, in the order of 3.6-5.4 times the basal metabolic rate (BMR). It is unlikely that the E intakes that we observed represent a true measure of maintenance E requirements. All evidence seems to indicate that fruit bats are E maximizers, ingesting more E than required and regulating storage by adjusting metabolic output. We suggest that true maintenance E requirements are substantially lower than what we observed. If it follows the eutherian norm of two times the BMR, fruit bats must necessarily over-ingest E on low-N fruit diet. Dietary E content did affect N metabolism of A. jamaicensis. On respective low- and high-E diets, metabolic fecal N were 0.492 mg N.g-1 and 0.756 mg N.g-1 dry matter intake and endogenous urinary N losses were 163.31 mg N.kg-0.75.day-1 and 71.54 mg N.kg-0.75.day-1. A. jamaicensis required 332.3 mg.kg-0.75.day-1 and 885.3 mg.kg-0.75.day-1 of total N on high- and low-E diets, respectively, and 213.7 mg.kg-0.75.day-1 of truly digestible N to achieve N balance. True N digestibilities were low (29% and 49%) for low- and high-E diets, respectively. For R. aegyptiacus, metabolic fecal N and endogenous urinary N losses were 1.27 mg N.g-1 dry matter intake and 96.0 mg N.kg-0.75.day-1, respectively, and bats required 529.8 mg.kg-0.75.day-1 (total N) or 284.0 mg.kg-0.75.day-1 (truly digestible N). True N digestibility was relatively low (50%). Based on direct comparison, we found no evidence that R. aegyptiacus exhibits a greater degree of specialization in digestive function and N retention than A. jamaicensis. When combined with results from previous studies, our results indicate that all fruit bats appear to be specialized in their ability to retain N when faced with low N diet.

A cluster of bloodstream infections and pyrogenic reactions among hemodialysis patients traced to dialysis machine waste-handling option units.

From June 17 through November 15, 1995, ten episodes of Enterobacter cloacae bloodstream infection and three pyrogenic reactions occurred in patients at a hospital-based hemodialysis center. In a case-control study limited to events occurring during October 1-31, 1995, seven dialysis sessions resulting in E. cloacae bacteremia or pyrogenic reaction without bacteremia were compared with 241 randomly selected control sessions. Dialysis machines were examined, dialysis fluid and equipment were cultured, and E. cloacae isolates were genotyped by pulsed-field gel electrophoresis. Each dialysis machine had a waste-handling option (WHO) through which dialyzer-priming fluid was discarded before each dialysis session; in 7 of 11 machines, one-way check valves designed to prevent backflow from the WHO into patient bloodlines were dysfunctional. In the case-control study, case sessions were more frequent when machines with >/=1 dysfunctional check valves were used. E. cloacae with identical pulsed-field gel electrophoresis patterns were isolated from case patients, dialysis fluid, station drains, and WHO units. Our investigation shows that bloodstream infections and pyrogenic reactions were caused by backflow from contaminated dialysis machine WHO units into patient bloodlines. The outbreak was terminated when WHO use was discontinued, check valves were replaced, and dialysis machine disinfection was enhanced.

Anticoagulant dermatan sulfate proteoglycan (decorin) in the term human placenta.

Normal pregnancy is characterized by increased in vivo thrombin generation. A greater proportion of endogenously generated thrombin is complexed to heparin cofactor II in plasma from pregnant women compared to plasma from nonpregnant ones. The increase in thrombin-heparin cofactor II complexes suggests that the site of the additional thrombin generation is relatively rich in dermatan sulfate. We postulated that the site of thrombin generation may be the placenta since endogenous thrombin generation returns rapidly to normal after delivery. This report describes the isolation and characterization of placental dermatan sulfate proteoglycan from villous tissue of the term human placenta. Placental dermatan sulfate was isolated by guanidine HCI extraction and anion exchange chromatography. The isolated material was found to have anticoagulant activity with a relative activity of approximately 40% of that of a porcine mucosal dermatan sulfate which is undergoing clinical trial as an antithrombotic agent. The dermatan sulfate was present as a proteoglycan with a molecular mass of 90-150 kD. Upon degradation with chondroitin ABC lyase, the core protein was demonstrated to be a doublet with molecular masses of 42 and 44 kD. This core protein reacted with antiserum against the core protein of decorin on Western analysis. The role of this placental dermatan sulfate in local regulation of thrombin in the placenta warrants further study.

Detection of significant patterns by compression algorithms: the case of approximate tandem repeats in DNA sequences.

MOTIVATION: Compression algorithms can be used to analyse genetic sequences. A compression algorithm tests a given property on the sequence and uses it to encode the sequence: if the property is true, it reveals some structure of the sequence which can be described briefly, this yields a description of the sequence which is shorter than the sequence of nucleotides given in extenso. The more a sequence is compressed by the algorithm, the more significant is the property for that sequence. RESULTS: We present a compression algorithm that tests the presence of a particular type of dosDNA (defined ordered sequence-DNA): approximate tandem repeats of small motifs (i.e. of lengths < 4). This algorithm has been experimented with on four yeast chromosomes. The presence of approximate tandem repeats seems to be a uniform structural property of yeast chromosomes.

The effects of dermatan sulfate at submicrogram/ml concentrations on in vitro thrombin generation.

Dermatan sulfate is an antithrombotic glycosaminoglycan which has been shown to be effective in preventing deep venous thrombosis in general surgery patients when present at concentrations less than 1 microgram/ml. It has also been found to circulate physiologically in similar concentrations in pregnant women at term and in cord blood. We investigated the ability of dermatan sulfate added to plasma at 0.2, 0.5 and 1.0 microgram/ml to inhibit thrombin generation initiated by low concentrations of recombinant human tissue factor in defibrinated plasma. A dose dependent decrease in thrombin potential was demonstrated at therapeutically relevant concentrations of dermatan sulfate (0.5 and 1.0 microgram/ml) but there was no induction of a lag phase in thrombin generation. We were unable to demonstrate a significant effect on thrombin potential of dermatan sulfate at a concentration similar to that found in pregnancy plasma (0.2 microgram/ml). This indicates that either the dermatan sulfate concentration found in pregnancy plasma is not physiologically relevant or that our experimental system (which lacks platelets and fibrin) does not accurately reflect physiologic conditions. The effect on the thrombin potential was somewhat greater at the lowest concentration of tissue factor and amounted to a maximum inhibition of approximately 50% at 1 microgram/ml dermatan sulfate. A dose dependent increase in formation of thrombin-heparin cofactor II complexes and a decrease in thrombin-antithrombin complex formation with increasing dermatan sulfate concentration were observed at all dermatan sulfate concentrations. Prothrombin consumption was not changed by any dose of dermatan sulfate. We conclude that dermatan sulfate, at the concentrations tested, catalyses inhibition of free thrombin by heparin cofactor II but not efficiently enough to inhibit prothrombinase formation.

Nitrogen and energy requirements of the short-tailed fruit bat (Carollia perspicillata): fruit bats are not nitrogen constrained.

Nitrogen (N) and energy (E) requirements were measured in adult Carollia perspicillata which were fed on four experimental diets. Bats ate 1.3-1.8 times their body mass.day-1 and ingested 1339.5-1941.4 kJ.kg-0.75.day-1. Despite a rapid transit time, dry matter digestibility and metabolizable E coefficient were high (83.3% and 82.4%, respectively), but true N digestibility was low (67.0%). Mass change was not correlated with E intake, indicating that bats adjusted their metabolic rate to maintain constant mass. Bats were able to maintain constant mass with digestible E intake as low as 1168.7 kJ.kg-0.75.day-1 or 58.6 kJ.. Metabolic fecal N and endogenous urinary N losses were 0.87 mg N.g-1 dry matter intake and 172.5 mg N.kg-0.75.day-1, respectively, and bats required 442 mg N.kg-0.75.day-1 (total nitrogen) or 292.8 mg N.kg-0.75.day-1 (truly digestible nitrogen) for N balance. Based on E and N requirements and digestibilities, it was calculated that non-reproductive fruit bats were able to meet their N requirements without resorting to folivory and without over-ingesting energy. It was demonstrated that low metabolic fecal requirements allowed bats to survive on low-N diets.

Circulating dermatan sulfate and heparan sulfate/heparin proteoglycans in children undergoing liver transplantation.

The liver produces dermatan sulfate (DS), heparan sulfate (HS) and heparin glycosaminoglycans (GAG) and in the presence of hepatic disease, tissue levels of the DS GAG increase dramatically. We hypothesized that in children undergoing liver transplantation plasma levels of DS would be increased. Plasma from children undergoing liver transplantation were tested preoperative, intra operative and post operative at 24-48 h, and 1-3 weeks. Fluctuating levels of DS, HS and heparin anticoagulant activity were detected at all timepoints. The anticoagulant activity was purified and gel chromatography of the material displayed a mean Mr 110,000 D. Reductive elimination decreased the mean Mr 24,000 D indicating the activity resides on a proteoglycan (PG). The purified material was subjected to further chromatography and two peaks of anticoagulant activity resolved, compatible with at least two separate PGs, one with DS GAG chains and the additional PG(s) with HS and heparin GAG chains.

Behavioral reactions of the bat Carollia perspicillata to abrupt changes in gravity.

As part of an ongoing survey of the behavioral responses of vertebrates to abrupt changes in gravity, we report here on the reactions of bats (Carollia perspicillata) exposed to altered gravity during parabolic aircraft flight. In microgravity, mammals typically behave as if they were upside-down and exhibit repetitive righting reflexes, which often lead to long axis rolling. Since bats, however, normally rest upside-down, we hypothesized that they would not roll in microgravity. Only one of three specimens attempted to fly during microgravity. None rolled or performed any righting maneuvers. During periods of microgravity the bats partially extended their forearms but kept their wings folded and parallel to the body. Between parabolas and occasionally during microgravity the bats groomed themselves. Both the extended limbs and autogrooming may be stress responses to the novel stimulus of altered gravity. This is the first behavioral record of Chiroptera in microgravity.

DosDNA occurs along yeast chromosomes, regardless of functional significance of the sequence.

Complex genomes contain numerous simple sequence repeats, the biological significance of which remains obscure. Recently it has been shown that several human diseases are the result of changes in such sequences. Thus it has become urgent to undertake a systematic study of their properties. We have set the task of describing as completely as possible the set of sequences which contain bases organized according to symmetrical elements, the dosDNA: defined ordered sequence. Examination of local anomalies in dinucleotide composition serves to identify dosDNA zones in the genome. The study of chromosomes II, III, VIII and XI of Saccharomyces cerevisiae reveals these dosDNA zones comprise about 2% of the genome. They are regularly distributed along the chromosomes, regardless of the functional significance of the sequence. A more detailed analysis of dosDNA segments seems to indicate that simple repeats are the consequence of local properties of the chromosome, and not due to any motif in particular.

Inhibition of thrombin by antithrombin III and heparin cofactor II in vivo.

The critical role of thrombin in the pathogenesis of venous and arterial thrombosis, and the effectiveness of glycosaminoglycans as antithrombotic drugs are well known. Antithrombin III is a major inhibitor of thrombin and augmentation of its inhibitory actions by heparin is the basis for the clinical uses of heparin. Recent clinical and experimental studies have demonstrated that another glycosaminoglycan, dermatan sulfate, is an effective antithrombotic drug. Dermatan sulfate catalyses the inhibition of thrombin by heparin cofactor II. The concentrations of heparin cofactor II are higher in the plasmas of individuals with congenital antithrombin III deficiency and pregnant women than controls. The role of heparin cofactor II as a physiologic thrombin inhibitor is unknown. Enzyme-linked immunosorbent assays were used to quantify thrombin-heparin cofactor II and thrombin-antithrombin III endogenous to the plasmas of adult antithrombin III-Hamilton deficient subjects, their siblings with normal antithrombin III levels, pregnant women at term and 3 to 5 days after delivery. Both thrombin-antithrombin III and thrombin-heparin cofactor II complexed with vitronectin were detected in all the plasmas. Significantly, the concentrations of thrombin-heparin cofactor II-vitronectin were higher in the plasmas of congenital antithrombin III deficient subjects and in pre- and post-delivery plasmas than those of normal subjects. In addition, the concentrations of thrombin-heparin cofactor II decreased 3 to 5 days after delivery, reflecting the disappearance of the catalytically active dermatan sulfate elaborated by the placenta. Thus, heparin cofactor II normally inactivates thrombin in vivo, with its role increasing in conditions associated with high levels of heparin cofactor II and/or dermatan sulfate.

alpha 2-Macroglobulin remains as important as antithrombin III for thrombin regulation in cord plasma in the presence of endothelial cell surfaces.

Infants and children rarely develop thrombotic complications compared with adults, suggesting that there are protective mechanisms in place for the young. Because endothelial cell surfaces regulate thrombin formation and inhibition, we compared thrombin regulation by human umbilical vein endothelial cell surfaces exposed to defibrinated cord and adult plasmas. After activation by either 10% activated partial thromboplastin reagent (strong activator) or coagulant phospholipids (weak activator) the following were measured: free thrombin, thrombin bound to antithrombin III (ATIII), heparin cofactor II, alpha 2-macroglobulin (alpha 2M), and prothrombin concentration. Free thrombin activity was expressed as remaining activity, after subtraction of thrombin-alpha 2M activity. After 10% activated partial thromboplastin reagent, 100% of prothrombin was consumed and significant amounts of thrombin generated by 2 min. Cord plasma generated significantly less thrombin than adult plasma, reflecting the lower initial plasma concentration of prothrombin. correspondingly, concentrations of thrombin inhibitor complexes were significantly greater in adult plasma than in cord plasma. After coagulant phospholipids, 50% of prothrombin was consumed and negligible thrombin activity measured for both adult and cord plasma. Similar amounts of thrombin inhibitor complexes were formed. ATIII was the predominant inhibitor of thrombin in adult plasma, whereas alpha 2M was as important as ATIII in cord plasma for both activators. When cord plasma concentrations of ATIII were increased to adult values, the proportion complexed to alpha 2M decreased. We conclude that on human umbilical vein endothelial cells, the capacity to generate thrombin is decreased in adult and cord plasmas.(ABSTRACT TRUNCATED AT 250 WORDS)

[Latex hypersensitivity: a foreseeable accident?]. / Hypersensibilité au latex: un accident prévisible?

This paper describes another case of severe anaphylactic reaction due to allergy to natural rubber during anaesthesia in a child without known risk factors. The day after surgery the child reported that he experienced a few months ago an impressive skin reaction of both face and lips after inflating a latex balloon. It is suggested to try to detect latex allergy during the preoperative visit in all patients by including questions about latex sensitivity such as previous skin reactions or respiratory symptoms after wearing latex gloves or after inflating toy balloons. Patients in whom latex sensitivity is suspected should be tested appropriately in order to perform the planned surgery in a latex-free environment.

[The impact of suicide on the caregiver]. / L'impact du suicide sur l'aidant.

Suicide ("the killing of one's self") raises one crucial question: what does the manifest desire of death bring out in oneself and in others? For those providing care and support who are confronted with the voluntary death of a client or patient, the question is particularly difficult to address. Using the story of a suicide in an institution, the authors reveal the nature of defense mechanisms at play within the group of caregivers. Whether it be a traumatic daze, denial, guilt or depression, these individual and collective reactions to the event hinder the mourning process and threaten cohesion within the institution. Members of an "institution in crisis" must try to relieve their tensions by refraining from withdrawal, banalities, being haunted by suicide and implementing pseudo-solutions. The purpose of such an exercise is especially to avoid the cancellation or displacement of necessary thought process about the origins, implications and consequences of a suicide taking place within an institution. The authors discuss the founding principles and guidelines for group exploration of these phenomena. Without this coming-to-terms with the crisis, the authors point out that the institution could find itself in a rut where discussion focuses only on when and where things went wrong, and how it turned its back on a suffering patient.

Plasma dermatan sulfate proteoglycan in a patient on chronic hemodialysis.

A 68-year-old man on chronic hemodialysis for 6 years, presented with a spontaneous psoas muscle hemorrhage. Investigations showed intermittently elevated activated partial-thromboplastin time and thrombin time. Preliminary investigations suggested a heparin-like inhibitor in the patient's plasma, but no anti-Xa activity could be detected. Investigation of the ability of patient plasma to inhibit exogenous thrombin showed that most thrombin was inhibited by heparin cofactor II, in contrast to normal plasma in which most thrombin was inhibited by antithrombin III. Treatment of plasma with glycosaminoglycan-degrading enzymes suggested the presence of dermatan sulfate (DS) in patient plasma. This was confirmed in a heparin cofactor II-dependent antithrombin assay for DS that showed anticoagulant equivalent to 2.2 +/- 0.3 micrograms/mL (mean +/- SD) of porcine mucosal DS. Of this activity, approximately 90% was sensitive to enzymes that degrade DS. The glycosaminoglycan containing fraction of plasma was isolated and subjected to gel chromatography. Anticoagulant activity eluted from Sephadex G-100 (Pharmacia, Montreal, Quebec, Canada) as two peaks with Kav of 0.10 and 0.45. After treatment with base, the Kav of the higher molecular weight species was increased to 0.55. This activity was completely sensitive to enzymes that degrade DS. Thus, the active DS was present as a proteoglycan. The lower molecular weight material was not sensitive to enzymes that degrade DS or heparan sulfate and it was active in the heparin cofactor II-dependent antithrombin assay but not in an antithrombin III-dependent antithrombin assay. This activity was not degraded by heating. Subsequently, measurement of DS activity was performed in plasmas obtained from eight other patients on hemodialysis before administration of heparin that showed that all patients had DS activity present that varied from 0.05 to 0.4 microgram/mL. No enzyme-resistant activity could be shown in these patients. In summary, a circulating anticoagulant with properties of DS is present in patients requiring hemodialysis.