A collaborative approach to improving representation in viral genomic surveillance

The lack of routine viral genomic surveillance delayed the initial detection of SARS-CoV-2, allowing the virus to spread unfettered at the outset of the U.S. epidemic. Over subsequent months, poor surveillance enabled variants to emerge unnoticed. Against this backdrop, long-standing social and racial inequities have contributed to a greater burden of cases and deaths among minority groups. To begin to address these problems, we developed a new variant surveillance model geared toward building microbial genome sequencing capacity at universities in or near rural areas and engaging the participation of their local communities. The resulting genomic surveillance network has generated more than 1,000 SARS-CoV-2 genomes to date, including the first confirmed case in northeast Louisiana of Omicron, and the first and sixth confirmed cases in Georgia of the emergent BA.2.75 and BQ.1.1 variants, respectively. In agreement with other studies, significantly higher viral gene copy numbers were observed in Delta variant samples compared to those from Omicron BA.1 variant infections, and lower copy numbers were seen in asymptomatic infections relative to symptomatic ones. Collectively, the results and outcomes from our collaborative work demonstrate that establishing genomic surveillance capacity at smaller academic institutions in rural areas and fostering relationships between academic teams and local health clinics represent a robust pathway to improve pandemic readiness. Author summaryGenomic surveillance involves decoding a pathogens genetic code to track its spread and evolution. During the pandemic, genomic surveillance programs around the world provided valuable data to scientists, doctors, and public health officials. Knowing the complete SARS-CoV-2 genome has helped detect the emergence of new variants, including ones that are more transmissible or cause more severe disease, and has supported the development of diagnostics, vaccines, and therapeutics. The impact of genomic surveillance on public health depends on representative sampling that accurately reflects the diversity and distribution of populations, as well as rapid turnaround time from sampling to data sharing. After a slow start, SARS-CoV-2 genomic surveillance in the United States grew exponentially. Despite this, many rural regions and ethnic minorities remain poorly represented, leaving significant gaps in the data that informs public health responses. To address this problem, we formed a network of universities and clinics in Louisiana, Georgia, and Mississippi with the goal of increasing SARS-CoV-2 sequencing volume, representation, and equity. Our results demonstrate the advantages of rapidly sequencing pathogens in the same communities where the cases occur and present a model that leverages existing academic and clinical infrastructure for a powerful decentralized genomic surveillance system.

Wastewater surveillance in smaller college communities may aid future public health initiatives

Since its declaration, the COVID-19 pandemic has resulted in over 530 million cases and over 6 million deaths worldwide. Predominant clinical testing methods, though invaluable, may create an inaccurate depiction of COVID-19 prevalence due to inadequate access, testing, or most recently under-reporting because of at-home testing. These concerns have created a need for unbiased, community-level surveillance. Wastewater-based epidemiology has been used for previous public health threats, and more recently has been established as a complementary method of SARS-CoV-2 surveillance. Here we describe the application of wastewater surveillance for SARS-CoV-2 in two university campus communities located in rural Lincoln Parish, Louisiana. This cost-effective approach is especially well suited to rural areas where limited access to testing may worsen the spread of COVID-19 and quickly exhaust the capacity of local healthcare systems. Our work demonstrates that local universities can leverage scientific resources to advance public health equity in rural areas and enhance their community involvement.

Liminality: A major category of the experience of cancer illness.

Narrative analysis is well established as a means of examining the subjective experience of those who suffer chronic illness and cancer. In a study of perceptions of the outcomes of treatment of cancer of the colon, we have been struck by the consistency with which patients record three particular observations of their subjective experience: (1) the immediate impact of the cancer diagnosis and a persisting identification as a cancer patient, regardless of the time since treatment and of the presence or absence of persistent or recurrent disease; (2) a state of variable alienation from social familiars, expressed as an inability to communicate the nature of the experience of the illness, its diagnosis and treatment; and (3) a persistent sense of boundedness, an awareness of limits to space, empowerment and available time. These subjectivities were experienced in varying degree by all patients in our study. Individual responses to these experiences were complex and variable. The experiences are best understood under the rubric of a category we call "liminality". We believe that all cancer patients enter and experience liminality as a process which begins with the first manifestations of their malignancy. An initial acute phase of liminality is marked by disorientation, a sense of loss and of loss of control, and a sense of uncertainty. An adaptive, enduring phase of suspended liminality supervenes, in which each patient constructs and reconstructs meaning for their experience by means of narrative. This phase persists, probably for the rest of the cancer patient's life. The experience of liminality is firmly grounded in the changing and experiencing body that houses both the disease and the self. Insights into the nature of the experience can be gained from the Existentialist philosophers and from the history of attitudes to death. Understanding liminality helps us to understand what it is that patients with cancer (and other serious illnesses) seek from the system to which they turn for help. Its explication should therefore be important for those who provide health care, those who educate health care workers and those concerned to study and use outcomes as administrative and policy making instruments.

Estimation of Acute Infarct Volume with Reference Maps: A Simple Visual Tool for Decision Making in Thrombectomy Cases / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Thrombectomy within 24 hours can improve outcomes in selected patients with a clinical-infarct mismatch. We devised an easy-to-use visual estimation tool that allows infarct volume estimation in centers with limited resources. METHODS: We identified 1,031 patients with cardioembolic or large-artery atherosclerosis infarction on diffusion-weighted images (DWIs) obtained before recanalization therapy and within 24 hours of onset, and occlusion of the internal carotid or middle cerebral artery. Acute DWIs were mapped onto a standard template and used to create visual reference maps with known lesion volumes, which were then used in a validation study (with 130 cases) against software estimates of infarct volume. RESULTS: The DWI reference map chart comprises 144 maps corresponding to 12 different infarct volumes (0.5, 1, 2, 3, 5, 7, 9, 11, 13, 15, 17, and 19 mL) in each of 12 template slices (Montreal Neurological Institute z-axis –15 to 51 mm). Infarct volume in a patient is estimated by selecting a slice with a similar infarct size at the corresponding z-axis level on the reference maps and then adding up over all slices. The method yielded good correlations to software volumetrics and was easily learned by both experienced and junior physicians, with approximately 1 to 2 minutes spent per case. The sensitivity, specificity, and accuracy for detecting threshold infarct volumes ( 90%). CONCLUSIONS: We developed easy-to-use reference maps that allow prompt and reliable visual estimation of infarct volumes for triaging patients to thrombectomy in acute stroke.

Quantitative Lymphoscintigraphy to Predict the Possibility of Lymphedema Development After Breast Cancer Surgery: Retrospective Clinical Study

OBJECTIVE: To predict the probability of lymphedema development in breast cancer patients in the early post-operation stage, we investigated the ability of quantitative lymphoscintigraphic assessment. METHODS: This retrospective study included 201 patients without lymphedema after unilateral breast cancer surgery. Lymphoscintigraphy was performed between 4 and 8 weeks after surgery to evaluate the lymphatic system in the early postoperative stage. Quantitative lymphoscintigraphy was performed using four methods: ratio of radiopharmaceutical clearance rate of the affected to normal hand; ratio of radioactivity of the affected to normal hand; ratio of radiopharmaceutical uptake rate of the affected to normal axilla (RUA); and ratio of radioactivity of the affected to normal axilla (RRA). During a 1-year follow-up, patients with a circumferential interlimb difference of 2 cm at any measurement location and a 200-mL interlimb volume difference were diagnosed with lymphedema. We investigated the difference in quantitative lymphoscintigraphic assessment between the non-lymphedema and lymphedema groups. RESULTS: Quantitative lymphoscintigraphic assessment revealed that the RUA and RRA were significantly lower in the lymphedema group than in the non-lymphedema group. After adjusting the model for all significant variables (body mass index, N-stage, T-stage, type of surgery, and type of lymph node surgery), RRA was associated with lymphedema (odds ratio=0.14; 95% confidence interval, 0.04–0.46; p=0.001). CONCLUSION: In patients in the early postoperative stage after unilateral breast cancer surgery, quantitative lymphoscintigraphic assessment can be used to predict the probability of developing lymphedema.

New Evaluation Vector through the Stanford Mobile Inquiry-Based Learning Environment (SMILE) for Participatory Action Research / 대한의료정보학회지

OBJECTIVES: This article reviews an evaluation vector model driven from a participatory action research leveraging a collective inquiry system named SMILE (Stanford Mobile Inquiry-based Learning Environment). METHODS: SMILE has been implemented in a diverse set of collective inquiry generation and analysis scenarios including community health care-specific professional development sessions and community-based participatory action research projects. In each scenario, participants are given opportunities to construct inquiries around physical and emotional health-related phenomena in their own community. RESULTS: Participants formulated inquiries as well as potential clinical treatments and hypothetical scenarios to address health concerns or clarify misunderstandings or misdiagnoses often found in their community practices. From medical universities to rural village health promotion organizations, all participatory inquiries and potential solutions can be collected and analyzed. The inquiry and solution sets represent an evaluation vector which helps educators better understand community health issues at a much deeper level. CONCLUSIONS: SMILE helps collect problems that are most important and central to their community health concerns. The evaluation vector, consisting participatory and collective inquiries and potential solutions, helps the researchers assess the participants' level of understanding on issues around health concerns and practices while helping the community adequately formulate follow-up action plans. The method used in SMILE requires much further enhancement with machine learning and advanced data visualization.

An intraoperative device to restore femoral offset in total hip arthroplasty.

BACKGROUND: Leg length discrepancy (LLD) after total hip arthroplasty (THA) can lead to unsatisfactory outcome. Our objective was to design and evaluate a simple and reliable intraoperative device (Length-offset Lever) to minimize leg length discrepancy. METHODS: This device was used in 51 patients undergoing primary total hip replacements. The leg length discrepancy was measured pre- and postoperatively based on plain radiographs. RESULTS: Preoperative radiographic leg length discrepancy averaged 13.5 ± 6.2 mm. Leg length discrepancy showed significant improvement, with a postoperative average of 4.1 ± 2.3 mm (p < 0.0001). There were no complications associated with this device. CONCLUSIONS: The 'Length-offset Lever' is a useful intraoperative tool to restore anatomic femoral offset and height of femoral head.

Antibiotic treatment for Clostridium difficile-associated diarrhea in adults.

BACKGROUND: Clostridium difficile is recognized as a frequent cause of antibiotic-associated diarrhea and colitis. OBJECTIVES: The aim of this review is to investigate the efficacy of antibiotic therapy for C. difficile-associated diarrhea (CDAD). SEARCH STRATEGY: MEDLINE (1966 to March 24, 2010), EMBASE (1980 to March 24, 2010), Cochrane Central Register of Controlled Trials and the Cochrane IBD/FBD Review Group Specialized Trials Register were searched using the following search terms: "pseudomembranous colitis and randomized trial"; "Clostridium difficile and randomized trial"; "antibiotic associated diarrhea and randomized trial". SELECTION CRITERIA: Only randomized, controlled trials assessing antibiotic treatment for CDAD were included in the review. The following outcomes were sought: initial resolution of diarrhea; initial conversion of stool to cytotoxin and/or culture negative; recurrence of diarrhea; recurrence of fecal evidence of CDAD; patient response to cessation of prior antibiotic therapy; emergent surgery; and death. DATA COLLECTION AND ANALYSIS: Three authors independently assessed abstracts and full text articles for inclusion. The risk of bias was independently rated by two authors. For dichotomous outcomes, relative risks (RR) and 95% confidence intervals (CI) were derived from each study and summary statistics obtained when appropriate, using a fixed effects model, except where significant heterogeneity was detected, at which time a random effects model was used. MAIN RESULTS: Fifteen studies (total of 1152 participants) with CDAD were included. Nine different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin and fidaxomicin (OPT-80). Most of the studies were active comparator studies comparing vancomycin with other antibiotics. The risk of bias was rated as high for 12 of 15 included studies. Patients with severe CDAD were often excluded from the included studies. In the only placebo-controlled trial vancomycin was found to be superior to placebo for treatment of CDAD for initial symptomatic cure. Initial symptomatic cure was achieved in 41% of vancomycin patients compared to 4% of placebo patients (1 study; 44 patients; RR 9.00; 95% CI 1.24 to 65.16). Vancomycin was significantly superior to placebo for initial bacteriologic response. Initial bacteriologic response was achieved in 45% of vancomycin patients compared to 4% of placebo patients (1 study; 44 patients; RR 10.00; 95% CI 1.40 to 71.62). The results of this study should be interpreted with caution due to the small number of patients and high risk of bias. No statistically significant differences in efficacy were found between vancomycin and metronidazole, vancomycin and fusidic acid, vancomycin and nitazoxanide, or vancomycin and rifaximin. No statistically significant differences in efficacy were found between metronidazole and nitazoxanide or metronidazole and fusidic acid. Vancomycin was significantly superior to bacitracin for initial bacteriologic response. Initial bacteriologic response was achieved in 48% of vancomycin patients compared to 25% of bacitracin patients (2 studies; 104 patients; RR 0.52; 95% CI 0.31 to 0.86). Teicoplanin, an antibiotic of limited availability and great cost, was significantly superior to vancomycin for initial bacteriologic response and cure. Initial bacteriologic response was achieved in 62% of vancomycin patients compared to 87% of teicoplanin patients (2 studies; 110 patients; RR 1.43; 95% CI 1.14 to 1.81). Bacteriologic cure was achieved in 45% of vancomycin patients compared to 82% of teicoplanin patients (2 studies; 110 patients; RR 1.82; 95% CI 1.19 to 2.78). These results should be interpreted with caution due to the small number of patients and the high risk of bias in the two studies in the pooled analysis. Teicoplanin was significantly superior to metronidazole for initial bacteriologic response. Initial bacteriologic response was achieved in 71% of metronidazole patients compared to 93% of teicoplanin patients (1 study; 59 patients; RR 0.76; 95% CI 0.60 to 0.98). This result should be interpreted with caution due to the small number of patients and high risk of bias in the study. Only one study investigated synergistic antibiotic combination, metronidazole and rifampin, and no advantage was demonstrated for the drug combination. This result should be interpreted with caution due to the small number of patients and high risk of bias in the study. Adverse events including surgery and death occurred infrequently in the included studies. There was a total of 18 deaths among 1152 patients in this systematic review. Among the studies that commented on the cause of mortality the deaths were attributed to underlying disease rather than CDAD or antibiotic treatment. One study reported a partial colectomy after failed CDAD treatment. AUTHORS' CONCLUSIONS: Current evidence leads to uncertainty whether mild CDAD needs to be treated. The studies provide little evidence for antibiotic treatment of severe CDAD as many studies excluded these patients. Considering the two goals of therapy: improvement of the patient's clinical condition and prevention of spread of C. difficile infection to other patients, one should choose the antibiotic that brings both symptomatic cure and bacteriologic cure. A recommendation to achieve these goals cannot be made because of the small numbers of patients in the included studies and the high risk of bias in these studies, especially related to dropouts. Most of the active comparator studies found no statistically significant difference in efficacy between vancomycin and other antibiotics including metronidazole, fusidic acid, nitazoxanide or rifaximin. Teicoplanin may be an attractive choice but for its limited availability (Teicoplanin is not available in the USA) and great cost relative to the other options. More research of antibiotic treatment and other treatment modalities of CDAD is required.

Specific interactions of mouse organ proteins with the 5'untranslated region of coxsackievirus B3: potential determinants of viral tissue tropism.

Coxsackievirus B3 (CVB3) infects multiple organs of humans and causes different diseases such as myocarditis, pancreatitis, and meningitis. However, the mechanisms of organ-specific tropism are poorly understood. Coxsackievirus and adenovirus receptor (CAR) have been known to be important determinants for tissue tropism. However, current data on CAR mRNA expression in certain organs of mouse did not correlate well with the susceptibility of the respective tissues, suggesting that intracellular proteins may also play important roles in the regulation of viral infectivity through interaction with viral RNA. To search for such proteins and their interacting sites, we performed in situ hybridization to detect viral RNA in the organs of 4-week- and 10-week-old CVB3-infected mice and then correlated the data to patterns of host protein-viral RNA interactions. We found that heart and pancreas are the most heavily infected organs while the kidney remains highly resistant to the virus. The brain exhibited localized foci of viral replication, while the heart and liver showed random distribution of CVB3 RNA. The exocrine pancreas is highly susceptible to CVB3 infection but the endocrine cell type is resistant. In contrast to infections in other organs, mouse heart appears more resistant to CVB3 infection with increasing age. This resistance to infection in the kidney and older heart correlates well with the interaction of a 28 kDa mouse protein with the antisense sequence of nucleotides 210-529 of CVB3 5UTR. In addition, more intensified protein interactions were found within the nucleotides 530-630, a region that contains the internal ribosome entry site, which supports the previous findings that this segment plays critical roles in regulation of viral replication.

A Case of Proliferative Glomerulonephritis with Monoclonal IgG Deposits / 대한신장학회잡지

Proliferative glomerulonephritis with monoclonal IgG deposits is a novel disease entity characterized by (1) glomerular monoclonal IgG deposits restricted to a single IgG subclass and a single light chain isotype, associated with proliferative GN; (2) granular deposits by EM; (3) no clinical and laboratory evidence of cryglobulinemia. A 47-year-old male presented with edema and muscle cramps. Urinalysis revealed protein 3+ and 5-9 RBC's/HPF. BUN/Cr were 25/1.7 mg/dL, 24 hour urine protein 5.4 g/day, and CCr 56.3 mL/min/1.73m2. Cryglobulin was negative. The histologic findings of the renal biopsy showed mesangial cell proliferation with double contour of GBM on LM, diffuse finely granular electron-dense deposit in subendothelial & mesangial area with no amyloid fibril on EM, and strong immune reactivity to IgG and kappa light chain along the glomerular basement membrane on IF. Serum and urine protein EP, IEP and immunofixation EP showed no evidence of monoclonal gammopathy. Bone marrow aspiration & biopsy were negative for plasma cell infiltration. The patient is on supportive management with an AII blocking agent.

A Case of Dicamba Poisoning with Rhabdomyolysis and Acute Renal Failure Treated by Hemodialysis / 대한신장학회잡지

Dicamba is 3, 6-dichloro-2-methoxybenzoic acid and classified as a chemically related chlorophenoxy herbicide. This herbicide has been widely used for control of broad-leaved weeds. The poisoning is uncommon and of low toxicity, but massive self-ingestion may be fatal. We experienced a case of dicamba poisoning with rhabdomyolysis and acute renal failure in a 53-year-old male. This patient showed vomiting, confused mental status, and myotonia. Electrolyte abnormalities, rhabdomyolysis, and acute renal failure also developed together with fever, hepatotoxicity, pancreatic toxicity, hematologic abnormalities and cardiac ischemia. He was treated by 7 sessions of hemodialysis with supportive treatment and recovered.

A Case of Successful Endoscopic Therapy in Iatrogenic Perforation of the Colon during Colonoscopy / 대한소화기내시경학회지

Colonoscopy is a safe and standard procedure for diagnosis and therapy of colonic disorders. Iatrogenic colonic perforation during diagnostic colonoscopy, a rare abdominal emergency, has an 0.3~0.8% incidence rate. The choice of treatment for this complication remains controversial. Prompt operative intervention is preferred to minimize morbidity and mortality. However, operative intervention is invasive and needs a long-term recovery period. Conservative treatment is less invasive but can lead to more extensive surgery in case of treatment failure. Very important point on the treatment of iatrogenic perforation of the colon during diagnostic colonoscopy is to avoid the leaking of intestinal contents into the intraperitoneal cavity. We report here a case in which an iatrogenic perforation of the colon during diagnostic colonoscopy was successfully treated by endoscopic clip therapy.

A Case of Milk-Alkali Syndrome Due to Calcium Carbonate Overdose / 대한신장학회잡지

Milk-Alkali syndrome can be caused by ingesting large amount of calcium and absorbable alkali. Coincident with promotion of calcium therapy for the treatment of osteoporosis in postmenopausal women and secondary hyperparathyroidism in patients with chronic renal failure, the Milk-Alkali syndrome is now a common cause of hypercalcemia. We experienced a case of a woman who had took calcium for hypoparathyroidism after thyroidectomy (and incidental parathyroidectomy) for thyroid papillary adenocarcinoma. Recently she ingested unusually large amount of calcium (10.8 g/day) for a week mistakenly. She presented voiding difficulty, anorexia and irritability with the triad of hypercalcemia, metabolic alkalosis and acute renal failure. All the metabolic abnormalities were normalized and renal function was improved with fluid and diuretic therapies.

Hart's survival curve are Very Useful for Predicting Prognosis in Paraquat Poisoning / 대한신장학회잡지

BACKGROUND: Paraquat is highly toxic herbicide used in agriculture, and mortality of paraquat poisoning is very high. The predictions of severity of poisoning assessed with the amount of ingestion, results of urine dithionite test and laboratory findings are not accurate. The aims of this study are to investigate whether Hart's probability of survival curves are useful for predicting outcomes of paraquat-poisoned patients and which factors influence the outcomes of the patients. METHODS: We grouped 175 patients with paraquat poisoning into seven groups using curves of probability of survival suggested by Hart, et al. Group A was patients with plasma paraquat concentration below 90% probability of survival curve, group B patients with paraquat levels between 90% and 70% probability of survival curves, group C patients with paraquat levels between 70 and 50% probability of survival curves, group D the ones with paraquat levels between 50% and 30% probability of survival curves, group E the ones with paraquat levels between 30 and 20% probability of survival curves, group F paraquat levels between 20 and 10% probability of survival curves, and group G patients with paraquat levels above 10% probability of survival curve. And we analyzed the survival and mortality rates of each groups. RESULTS: The mortality rates of groups A, B, C, D, E, F and G were 7.4%, 26.7%, 37.5%, 55.6%, 63.6 %, 83.3% and 96.8% respectively (p<0.0005). The most important risk factor for death of patients was the paraquat concentration grouping with odds ratios (95% CI) of 4.4 (0.7-27.5, group B), 7.2 (0.9-54.9, group C), 15.0 (52.1-105.6, group D), 21.0 (3.2-139.7, group E), 60.0 (7.4-487.1, group F), and 359.9 (56.9- 2277.9, group G). CONCIUSION: In assessing prognosis of patients with paraquat poisoning, grouping of the patients using initial plasma paraquat concentrations is the most important, and the policy of treatment can be decided according the results.

Hart's survival curve are Very Useful for Predicting Prognosis in Paraquat Poisoning / 대한신장학회잡지

BACKGROUND: Paraquat is highly toxic herbicide used in agriculture, and mortality of paraquat poisoning is very high. The predictions of severity of poisoning assessed with the amount of ingestion, results of urine dithionite test and laboratory findings are not accurate. The aims of this study are to investigate whether Hart's probability of survival curves are useful for predicting outcomes of paraquat-poisoned patients and which factors influence the outcomes of the patients. METHODS: We grouped 175 patients with paraquat poisoning into seven groups using curves of probability of survival suggested by Hart, et al. Group A was patients with plasma paraquat concentration below 90% probability of survival curve, group B patients with paraquat levels between 90% and 70% probability of survival curves, group C patients with paraquat levels between 70 and 50% probability of survival curves, group D the ones with paraquat levels between 50% and 30% probability of survival curves, group E the ones with paraquat levels between 30 and 20% probability of survival curves, group F paraquat levels between 20 and 10% probability of survival curves, and group G patients with paraquat levels above 10% probability of survival curve. And we analyzed the survival and mortality rates of each groups. RESULTS: The mortality rates of groups A, B, C, D, E, F and G were 7.4%, 26.7%, 37.5%, 55.6%, 63.6 %, 83.3% and 96.8% respectively (p<0.0005). The most important risk factor for death of patients was the paraquat concentration grouping with odds ratios (95% CI) of 4.4 (0.7-27.5, group B), 7.2 (0.9-54.9, group C), 15.0 (52.1-105.6, group D), 21.0 (3.2-139.7, group E), 60.0 (7.4-487.1, group F), and 359.9 (56.9- 2277.9, group G). CONCIUSION: In assessing prognosis of patients with paraquat poisoning, grouping of the patients using initial plasma paraquat concentrations is the most important, and the policy of treatment can be decided according the results.

Discourse in different voices: reconciling N = 1 and N = many.

When groups are convened to discuss the making of policy, people are chosen to represent particular interests because they have relevant experience. Different stakeholders, however, may use differing discourses, and particular discourses may be privileged in particular contexts. This means that important contributions to the discussion may not be reflected in final reports. Discursive incommensurability is particularly seen when individual, personal experience is presented in meetings where quantification or "numbers talk" is privileged. While pooled personal experience may carry some weight in such a context, individual anecdote does not. The inclusion of 'consumers' in policy making groups may result in their dysempowerment. Their presence promises that they will have influence, but their voices disappear from the final document. The promise of empowerment is not realised. Dysempowerment may translate into empowerment with time, as it has done with feminism and the HIV/AIDS lobby. In order to speed the process, we suggest some practical means whereby mixed discourses may be generated and monitored. For constructive interchange, each party to the discourse needs to express the interests and arguments relevant to the group he or she represents. Supporting this principle of representation are principles of implicature and radical respect. Implicature is the act of implying what is relevant to others involved in the discourse. Radical respect is a fundamental and foundational respect for others in their roles as representatives of stakeholders with legitimate interests in the topic of the discourse.

Survivorship and discourses of identity.

Personal identity is self-evidently important to us all. Identity is a philosophically complex subject, but there is some agreement that memory, embodiment and continuity are essential components. The sense of memory includes 'future memory', the kind of memory we would like to construct for ourselves as our lives proceed. While the sense of personal identity is internal to the individual, a sense of that person's identity exists in the minds of others. Extreme experiences threaten the element of continuity, because they may bring bodily changes as well as cognitive changes that challenge central values. Restoring or preserving continuity is a major task for survivors. The ways in which people experience discontinuity because of cancer illness, and the ways in which they manage this experience emerges from the narratives of the survivors of cancer and in the narratives of health care workers who look after them. People manage discontinuity by reference to stable 'anchor points' in their beliefs and values; by re-constructing versions of their pre-experience identities, drawing on past memory and finding ways to preserve a continuity between past memory, present experience and constructions of the future; by using the experience to develop established facets of identity; and by imbuing the experience with meaning and recognising the enlarged identity made possible by survival. Those who cannot achieve a sense of continuity may feel alienated from themselves, their friends and family. All these methods of management may be used by one person to negotiate the post-experience identity in its different social interactions. The experience of the survivor can be further understood by recognising the challenge posed by extreme experience to the sense of continuity of both embodied self and memory. A satisfactory discourse of survival has yet to enter the public domain. This lack adds to the burdens of survivors, including those who have survived cancer.

Selective inhibition of glutamate uptake by mercury in cultured mouse astrocytes

We studied the effects of organic and inorganic mercury (Hg) on the uptake of L-[3H] glutamate (L-GLU) in cultured mouse astrocytes. Following exposure to mercuric chloride (MC) [0.2 approximately 5.0 microM], selective and dose-dependent inhibition of L-GLU uptake to 50% of control levels was observed, whereas 2-deoxyglucose (2-DG) uptake was not significantly affected. Methylmercuric chloride (MMC) also inhibited L-GLU uptake but 50% reduction was reached only at a concentration of 10 microM. Inhibition of L-GLU uptake by MMC appears to be closely linked to voltage-sensitive calcium channels as evidenced by the lack of L-GLU uptake inhibition by MMC in calcium-free medium or in the presence of the channel blocker verapamil. Exposure to a variety of divalent metallic ions, including CuCl2, FeCl2 and ZnCl2, did not affect L-GLU uptake in astrocytes in vitro. Exposure to PbCl2, however, resulted in a decline in L-GLU uptake, though to a much smaller degree than that observed with Hg compounds. Selective impairment of astroglial L-GLU transport may represent a critical early pathogenetic feature of Hg-induced neurotoxicity.