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Overdose is a leading cause of pregnancy-associated morbidity and mortality in the United States. As such, all obstetric providers have a responsibility to provide evidence-based care for patients with opioid use disorder to mitigate adverse outcomes associated with substance use during pregnancy.

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

OBJECTIVE -- To compare steroids and their associations in men with type 1 diabetes and healthy control subjects. RESEARCH DESIGN AND METHODS -- We studied 52 adult men with type [...]

Anxiety disorders are effectively treated with exposure therapy, but relapse remains high. Fear may reinstate after reoccurrence of the negative event because the expectancy of the aversive outcome (unconditioned stimulus [US]) is adjusted but not its evaluation. Imagery rescripting (ImRs) is an intervention that is proposed to work through revaluation of the US. The aim of our preregistered study was to test the effects of ImRs and extinction on US expectancy and US revaluation. Day 1 (n= 106) consisted of acquisition with an aversive film clip as US. The manipulation (ImRs + extinction, extinction-only, or ImRs-only) took place on Day 2. Reinstatement of fear was tested on Day 3. Results showed expectancy learning in both extinction conditions but not in the ImRs-only condition and no enhanced revaluation learning in ImRs. The combination of ImRs and extinction slowed down extinction but did not protect against reinstatement, which pleads in favor of stand-alone interventions in clinical practice.

This is a follow-up article to "What's Wrong with this Picture?" in the May issue, page 30. There I addressed two management strategies. One strategy was based on the concept […]

The turf on the football field in the photo on this page has excellent density, outstanding color, great uniformity, and no sign of any disease or insect problems. So, what's […]

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Background. Recently, high pretreatment platelet counts and low pretreatment hemoglobin levels were found to be negative prognostic factors in patients with ovarian cancer. Interleukin-6 (IL-6) is a multifunctional cytokine with a diversity of functions leading to the induction of C-reactive protein (CRP), increased platelet counts, and low hemoglobin levels. Different epithelial ovarian cancer cell lines are found to produce varying amounts of IL-6. In this study, a possible relationship between IL-6 levels in cystic fluids of benign and malignant ovarian tumors and pretreatment serum CRP, platelet counts, and hemoglobin levels was evaluated. Methods. A bioassay and enzyme-linked immunosorbent assay (ELISA) were performed to determine the IL-6 levels in cystic fluids and serum from 42 patients with benign and malignant ovarian tumors. Results. The median IL-6 level was higher in cystic fluids of malignant tumors (n = 21) when compared with cystic fluids of benign tumors (n = 21) (P < 0.01 for bioassay and ELISA). Serum IL-6 levels in patients with malignant tumors were not significantly higher compared with IL-6 levels in patients with benign tumors, whereas CRP levels were higher in patients with malignant tumors (P < 0.01). Cystic fluid IL-6 levels were related to serum CRP levels (r = 0.60, P < 0.01 [bioassay]; r = 0.62, P < 0.01 [ELISA]), platelet counts (r = 0.60, P < 0.01 [bioassay]; r = 0.41, P < 0.01 [ELISA]), and were related inversely to hemoglobin levels (r = -0.57, P < 0.01 [bioassay]; r = 0.54, P < 0.01 [ELISA]). Conclusions. IL-6 levels are higher in cystic fluids of malignant ovarian tumors compared with benign tumors. The relationship of cystic fluid IL-6 levels with CRP, platelet counts, and hemoglobin levels suggests a possible causative role of tumor-derived IL-6 in the appearance of general side effects of ovarian cancer, which recently have been recognized as prognostic factors. Cancer 1995;75:1004-9.

Insulin-dependent diabetes mellitus (IDDM) is a metabolic disorder caused by destruction of the insulin-secreting pancreatic beta cells and consequent inability to regulate blood glucose levels. The resulting hyperglycemia (high blood sugar) has been shown to have a variety of serious consequences, and must be controlled as well as possible with injections of insulin. In normal subjects, there is a strong correlation between clearance of insulin from the blood and the physiological action of this hormone. This is thought to reflect the fact that insulin is internalized by cells (hence its disappearance from the blood), and only once inside the cell can it exert its effect. In order to investigate whether or not this sequence is maintained in IDDM patients, the relationship between plasma clearance rate of insulin and insulin-stimulated glucose disposal was measured in 15 healthy volunteers and 30 patients with IDDM. Insulin levels were maintained at several different levels; at low insulin levels, diabetic patients were unresponsive to the hormone. At high insulin levels, hormone action was normal. In normal subjects, appropriate responses were seen at all levels of plasma insulin. Additionally, in normal subjects, there was a strong correlation between plasma clearance rate of insulin and glucose disposal; no such relationship was observed in IDDM patients even when statistical corrections for the diabetic state were made. This disruption of the normal response to insulin may be the result of prolonged hyperglycemia caused by IDDM. (Consumer Summary produced by Reliance Medical Information, Inc.)

AbstractBackgroundWomen with opioid use disorder (OUD) report high rates of intimate partner violence (IPV) and there is limited understanding of how IPV influences substance use behaviors among women with OUD. Methods:Semi-structured qualitative interviews were conducted with a sample of 40 women with OUD participating in an ongoing clinical trial evaluating postpartum contraceptive utilization patterns for this population. Interviews were audio-recorded, transcribed verbatim and lasted approximately 45 min. Interview questions focused on women’s perceptions and experiences with IPV and how these experiences impacted their substance use behaviors. Transcripts were coded independently in Atlas.ti and qualitatively analyzed using a general qualitative inquiry approach for emerging themes. Results:Participants were aged 24–29, and the majority were white, single, unemployed, had Medicaid insurance and a high school degree. Although personal IPV experiences were not necessary to be selected for this qualitative sub-study, all participants reported some lifetime experience with IPV. Four overarching themes emerged: (1) women attributed physical IPV to their partner’s substance use; (2) emotional abuse prevented women from fully engaging in their recovery; (3) financial abuse prevented women from gaining independence from abusive partners; and (4) women coped with IPV experiences through substance use. Conclusions:IPV had a significant influence on women’s substance use behaviors including their perceived risk of relapse and treatment discontinuation. These findings demonstrate the need to integrate assessment, evaluation and management of IPV into substance use treatment settings.

Blebbistatin, para-nitroblebbistatin (NBleb), and para-aminoblebbistatin (AmBleb) are highly useful tool compounds as they selectively inhibit the ATPase activity of myosin-2 family proteins. Despite the medical importance of the myosin-2 family as drug targets, chemical optimization has not yet provided a promising lead for drug development because previous structure-activity-relationship studies were limited to a single myosin-2 isoform. Here we evaluated the potential of blebbistatin scaffold for drug development and found that D-ring substitutions can fine-tune isoform specificity, absorption-distribution-metabolism-excretion, and toxicological properties. We defined the inhibitory properties of NBleb and AmBleb on seven different myosin-2 isoforms, which revealed an unexpected potential for isoform specific inhibition. We also found that NBleb metabolizes six times slower than blebbistatin and AmBleb in rats, whereas AmBleb metabolizes two times slower than blebbistatin and NBleb in human, and that AmBleb accumulates in muscle tissues. Moreover, mutagenicity was also greatly reduced in case of AmBleb. These results demonstrate that small substitutions have beneficial functional and pharmacological consequences, which highlight the potential of the blebbistatin scaffold for drug development targeting myosin-2 family proteins and delineate a route for defining the chemical properties of further derivatives to be developed.

Using model catalysts with well-defined particle sizes and morphologies to elucidate questions regarding catalytic activity and stability has gained more interest, particularly utilizing colloidally prepared metal(oxide) particles. Here, colloidally synthesized iron oxide nanoparticles (FexOy-NPs, size ∼7 nm) on either a titania (FexOy/TiO2) or a silica (FexOy/SiO2) support were studied. These model catalyst systems showed excellent activity in the Fischer–Tropsch to olefin (FTO) reaction at high pressure. However, the FexOy/TiO2catalyst deactivated more than the FexOy/SiO2catalyst. After analyzing the used catalysts, it was evident that the FexOy-NP on titania had grown to 48 nm, while the FexOy-NP on silica was still 7 nm in size. STEM-EDX revealed that the growth of FexOy/TiO2originated mainly from the hydrogen reduction step and only to a limited extent from catalysis. Quantitative STEM-EDX measurements indicated that at a reduction temperature of 350 °C, 80% of the initial iron had dispersed over and into the titania as iron species below imaging resolution. The Fe/Ti surface atomic ratios from XPS measurements indicated that the iron particles first spread over the support after a reduction temperature of 300 °C followed by iron oxide particle growth at 350 °C. Mössbauer spectroscopy showed that 70% of iron was present as Fe2+, specifically as amorphous iron titanates (FeTiO3), after reduction at 350 °C. The growth of iron nanoparticles on titania is hypothesized as an Ostwald ripening process where Fe2+species diffuse over and through the titania support. Presynthesized nanoparticles on SiO2displayed structural stability, as only ∼10% iron silicates were formed and particles kept the same size during in situ reduction, carburization, and FTO catalysis.

Repeat-associated non-AUG-initiated translation of expanded CGG repeats (CGG RAN) from the FMR15′-leader produces toxic proteins that contribute to neurodegeneration in fragile X-associated tremor/ataxia syndrome. Here we describe how unexpanded CGG repeats and their translation play conserved roles in regulating fragile X protein (FMRP) synthesis. In neurons, CGG RAN acts as an inhibitory upstream open reading frame to suppress basal FMRP production. Activation of mGluR5 receptors enhances FMRP synthesis. This enhancement requires both the CGG repeat and CGG RAN initiation sites. Using non-cleaving antisense oligonucleotides (ASOs), we selectively blocked CGG RAN. This ASO blockade enhanced endogenous FMRP expression in human neurons. In human and rodent neurons, CGG RAN-blocking ASOs suppressed repeat toxicity and prolonged survival. These findings delineate a native function for CGG repeats and RAN translation in regulating basal and activity-dependent FMRP synthesis, and they demonstrate the therapeutic potential of modulating CGG RAN translation in fragile X-associated disorders.

(Anesth Analg. 2022;135:912–925)Opioid use disorder (OUD) has been on the rise over the past decade and is the leading cause of mortality among pregnant women in the United States. Information and evidence-based recommendations on how to best treat pain in parturients with OUD is lacking. The aim of this scoping review was to highlight existing literature on peripartum pain management for women with OUD, both untreated and treated with medications for opioid use disorder (MOUD), and provide a summary of the information.

Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.

Wat doe je als jeugdhulp- of -zorgverlener wanneer je vermoedt dat een van je cliënten of patiënten slachtoffer is van huiselijk geweld of kindermishandeling? Eind 2018 kwamen 26 factsheets beschikbaar om professionals te helpen bij het signaleren van en handelen bij allerlei vormen van geweld. Medewerkers in de jeugdgezondheidszorg krijgen hiermee extra handvatten voor het signaleren van verschillende vormen van geweld, mishandeling, misbruik, verwaarlozing of uitbuiting, en om te bepalen hoe ze het beste kunnen handelen wanneer er signalen zijn.

AbstractBackground:Opioid use disorder (OUD) during pregnancy has increased dramatically over the past decade, as have associated adverse maternal health outcomes. Although Medicaid has long been the largest payer for deliveries in the United States, states’ decisions to expand Medicaid eligibility to low-income adults has the potential to increase access to care for women in the postpartum period. This study aimed to determine the impact of the 2015 Pennsylvania Medicaid expansion on postpartum insurance coverage and preventive care utilization among pregnant women with opioid use disorder (OUD). Methods:In 2017, we conducted a retrospective cohort study using 2013–2015 administrative Medicaid data provided by the Pennsylvania Department of Human Services. We identified 1562 women with opioid use disorder who had a live birth delivery in a pre-Medicaid expansion or post-expansion study period. We compared length of continuous enrollment in Medicaid following delivery, postpartum visit attendance, and contraception initiation between groups. Results:More women in the post-expansion group remained enrolled in Medicaid at 300 days postpartum, relative to the pre-expansion group (87% vs. 81%). Medicaid expansion was not associated with differences in postpartum visit attendance or contraceptive use. However, women who remained enrolled in Medicaid for at least 300 days post delivery had an increased odds of postpartum visit attendance (odds ratio [OR]: 1.6, 95% confidence interval [CI]: 1.04, 2.4). Conclusion:The rate of continuous Medicaid enrollment among postpartum women with OUD was significantly higher after expansion, whereas rates of preventive care utilization were unaffected. Although improving insurance coverage for women with OUD is an important step to improve access to recommended preventive care, additional efforts are needed to ensure utilization of such care.

The article presents a panoramic view of the radio sky, based from observations with the Ohio State University, Columbus, Ohio radio telescope. The picture suggests how the sky would appear if human eyes were sensitive to radio waves instead of to light. It shows the relationship of the celestial sphere to the earth and the portion of the sky covered by the panoramic view.

The market for inflight entertainment (IFE) systems is in a state of flux. Keeping passengers 'entertained' is now only part of the story; increasingly, the airlines are looking for a […]

Hyperglycemia and dyslipidemia is associated with the increased incidence of cardiovascular disease in diabetes mellitus (DM). In vitro studies suggest that glycation of lipoproteins may play a role in the [...]

IntroductionPrior to deployment of the Netherlands Army Task Force Urozgan in Afghanistan, the Dutch Military and civilian healthcare systems had limited experience in treating blast injuries and their long-term consequences. This meant that guidelines for treatment and rehabilitation were lacking. The aim of this cohort study was to quantify kinematic and kinetic abnormalities in service members with foot injuries in relation to functional outcome using gait analysis.MethodIn nine service members with combat-related talus, calcaneus and/or navicular bone (TCN) fractures and nine controls, gait parameters were measured using Gait Real-Time Analysis Interactive Lab system. High-level mobility was evaluated by the Comprehensive High-Level Activity Mobility Predictor (CHAMP), and functional ability was assessed by Lower Extremity Functional Scale (LEFS) questionnaire.ResultsSignificant differences were found for LEFS and CHAMP scores (P<0.01), comfortable walking speed and ankle joint range of motion (ROM) (P<0.05), all lower in the group with TCN fractures. For this group, a trend (0.1>P>0.05) for higher step width and lower stride duration and peak power was found. A strong correlation (0.6>r>0.79) is shown between LEFS and comfortable walking speed and CHAMP and ankle joint ROM. The correlations between LEFS and stride duration, step width, ankle joint ROM and peak power, and between CHAMP and comfortable walking speed and stride duration, were moderate (0.4>r>0.59).ConclusionsThis study demonstrated that service members with TCN fractures, compared with healthy controls, have altered gait characteristics, specifically lower walking speed and ankle joint ROM, both related to lower physical functioning. Patients with bilateral depressed Bohler’s angle had the worse functional performance, and further research is recommended to evaluate the relationship between Bohler’s angle and physical performance.Clinical TrialThe Dutch Ministry of Defence (MOD) and the Institutional Review Board and Medical Ethics Review Committee Brabant, The Netherlands, approved this study (P1550).

An important factor within the military medical logistical chain is the capability of expeditious evacuation from point of injury, through a Medical Treatment Facility, to the country of residence where highest level of care can be provided. Although many factors can relate to patient outcome, the evaluation of the medical evacuation chain related to long-term patient outcome can be important for investigating possibilities for performance improvement in this domain. This article aims to provide a means to evaluate the quality of care of the medical evacuation chain.

(N Engl J Med. 2022;387:2085–2086)Opioid use during pregnancy continues to rise and result in adverse maternal and neonatal outcomes. Buprenorphine and methadone are medications used for opioid use disorder (OUD) treatment to help prevent risks such as overdose and preterm birth. While methadone was used for decades to treat perinatal OUD, it suffers from several issues. The primary issue is that it can only be given by federally licensed drug and alcohol treatment programs, which can be a barrier for many women requiring treatment. Another issue is that it is a long-acting drug.

As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and their infants. This review summarises how increasing rates of neonatal abstinence syndrome resulted in a need to improve care to pregnant women and opioid-exposed infants. We discuss the variations in care delivery with particular emphasis on screening at-risk mothers, scoring systems for neonatal drug withdrawal, type and duration of pharmacotherapy, and discharge safety.

Johann Jakob Wettstein (1683-1754) worked almost all his life toward the publication of his landmark 1751-52 edition of the Greek New Testament. In recent years, a large number of previously unknown sources on and by Wettstein has come to light, scattered over libraries in Europe, that provide new insights into his life and his New Testament project. This paper explores the diversity of these sources, their genres, their connections, their state of conservation and accessibility and the like. Starting from the idea that the collection offers an excellent opportunity for mapping a single scholar’s projects and international networks over time and space, it envisages a project that brings together this wealth of material. It asks what challenges and possibilities for international digital research the collection entails and formulates the desiderata concerning the necessary digital infrastructure and collaboration across traditional scholarly boundaries.

The Fischer–Tropsch to olefins (FTO) process is a method for the direct conversion of synthesis gas to lower C2–C4olefins. Carbon-supported iron carbide nanoparticles are attractive catalysts for this reaction. The catalytic activity can be improved and undesired formation of alkanes can be suppressed by the addition of sodium and sulfur as promoters but the influence of their content and ratio remains poorly understood and the promoted catalysts often suffer from rapid deactivation due to particle growth. A series of carbon black-supported iron catalysts with similar iron content and nominal sodium/sulfur loadings of 1–30/0.5–5wt% with respect to iron are prepared and characterized under FTO conditions at 1 and 10bar syngas pressure to illuminate the influence of the promoter level on the catalytic properties. Iron particles and promoters undergo significant reorganization during FTO operation under industrially relevant conditions. Low sodium content (1–3wt%) leads to a delay in iron carbide formation. Sodium contents of 15–30wt% lead to rapid loss of catalytic activity due to the covering of the iron surface with promoters during particle growth under FTO operation. Higher activity and slower loss of activity are observed at low promoter contents (1–3wt% sodium and 0.5–1wt% sulfur) but a minimum amount of alkali is required to effectively suppress methane and C2–C4paraffin formation. A reference catalyst support (carbide-derived carbon aerogel) shows that the optimum promoter level depends on iron particle size and support pore structure.

ABSTRACTBackground:Buprenorphine has recently emerged as a safe and effective treatment option for pregnant women with opioid use disorder (OUD) and is associated with superior neonatal outcomes. This study characterized and compared patient populations who used buprenorphine versus methadone during pregnancy in an academic medical center. Methods:Observational retrospective cohort evaluation of 791 pregnant women with OUD on opioid maintenance treatment from 2009 to 2012. Buprenorphine versus methadone use was defined as use after either (a) conversion from illicit opioid use during pregnancy or (b) ongoing prepregnancy use. Multivariable logistic regression was used to identify patient characteristics predictive of buprenorphine use. Results:Among 791 pregnant women, 608 (76.9%) used methadone and 183 (23.1%) used buprenorphine. From 2009 to 2012, buprenorphine use during pregnancy increased from 10.1% to 33.2%. Pregnant women using buprenorphine were significantly more likely to be older, married, employed, have more education, and have a history of prescription opioid use compared with women using methadone. In contrast, pregnant women using methadone were significantly more likely to have hepatitis C virus infection, use cocaine, benzodiazepines, or marijuana, and have a history of heroin and/or intravenous opioid use. In multivariable analysis, pregnant women who were older (odds ratio [OR] = 1.01; 95% confidence interval [CI]: 1.02, 1.11), were employed (1.87; 1.20, 2.90), and had a history of opioid maintenance treatment prior to pregnancy (2.68; 1.78, 4.02) were more likely to use buprenorphine during pregnancy. Pregnant women with a history of benzodiazepine use (0.48; 0.30, 0.77), who had children no longer in their legal custody (0.63; 0.40, 0.99), and who had a partner with a substance use history (0.37; 0.22, 0.63) were less likely to use buprenorphine during pregnancy. Conclusions:Disparities exist among patients who use buprenorphine versus methadone during pregnancy and indicate the need to improve the availability and accessibility of buprenorphine for many pregnant women.

ABSTRACTBackground: The purpose of this study was to describe the delivery of prenatal care services to women with opioid use disorder (OUD) on opioid maintenance therapy at high risk for hepatitis C virus (HCV) infection. Methods: We conducted a retrospective cohort evaluation of 791 pregnant women with OUD from 2009 to 2012. HCV screening was defined as documentation of (a) an anti-HCV antibody test or (b) a provider discussion regarding a known HCV diagnosis during pregnancy. Multivariate logistic regression was used to identify predictors of HCV screening during pregnancy. Results: Among 791 pregnant women with OUD, 611 (77.2%) were screened for HCV infection and 369/611 (60.4%) were HCV positive. In multivariable analysis, patients who were married (odds ratio [OR] = 0.52; 95% confidence interval [CI] = 0.29, 0.91), used buprenorphine (OR = 0.45; 95% CI = 0.28, 0.71), and were cared for by private practice providers (OR = 0.29; 95% CI = 0.19, 0.45) were significantly less likely to be screened. In contrast, patients who used benzodiazepines (OR = 1.72; 95% CI = 1.02, 2.92), intravenous (IV) opioids (OR = 6.15; 95% CI = 3.96, 9.56), had legal problems (OR = 2.23; 95% CI = 1.12, 4.45), had children not in their custody (OR = 1.81; 95% CI = 1.01, 3.24), and who had a partner with substance abuse history (OR = 2.38; 95% CI = 1.23, 4.59) were significantly more likely to be screened. Of 369 HCV-positive patients, a new diagnosis of HCV was made during pregnancy for 108 (29.3%) patients. Only 94 (25.5%) had HCV viral load testing, 61 (16.5%) had HCV genotype testing, and 38 (10.4%) received an immunization for hepatitis A. Although 285 (77.2%) patients were referred to hepatology, only 71 (24.9%) attended the consultation. Finally, only 6 (1.6%) patients received HCV treatment 1 year following delivery. Conclusions: Prenatal care approaches to HCV infection remain inconsistent, and the majority of patients diagnosed with HCV infection during pregnancy do not receive treatment after delivery.

The Europeanization of national civil procedure law consists out of several pillars. The influence of the European Convention on Human Rights (ECHR) is well known. A second pillar of the European influence on civil procedure law is the growing number of European regulations concerning the crossroads of civil procedure law and private international law. This article focuses on the Europeanization of national law by a third, 'invisible pillar'. The European influence in the 'invisible pillar' concerns many topics, such as ex officio application law, burden of proof, means of proof, costs, the free choice of a lawyer, the threshold amount exempt from seizure and arbitration. The first part of this invisible pillar follows from the role of national civil procedure law in enforcing EU law. The European Court leaves the procedural law to the national courts. The second area of the invisible pillar concerns procedural rules in Directives. A close look at several Directives reveals that the list of procedural topics touched upon by Directives is far from small. Directives contain procedural rules relevant for various capita of the civil procedure law of the Member States. This article seeks to shine some light on parts of this pillar by examining three topics: ex officio application, costs and the free choice of a lawyer, and legal expenses insurance. These examples serve to demonstrate that this area covers a wide variety of topics. Three problems relating to this invisible pillar will be identified: uncertainty, external differences, and internal differences. [ABSTRACT FROM AUTHOR]

The article discusses the Dutch Class Action (Financial Settlement) Act (Wet Collectieve Afwikkeling Massaschade), mass damage claims, and the Amsterdam Court of Appeal's rulings in the cases of Shell and Converium as of June 2012. It states that class actions do not exist under Dutch law, but claims for injunctive relief are allowed. The court in the Shell case deals with losses incurred by shareholders. Investor losses are considered in the Converium Swiss reinsurance company case.

Current cognitive theories of posttramatic stress disorder explain the development of intrusive visual images according to the encoding of the perceptual (visual) information of the traumatic event. However, recent studies have, under controlled circumstances, shown that visual intrusive images can also develop from listening to a verbal trauma report. Posttraumatic stress symptoms resulting from seeing versus listening to a trauma were compared to help elucidate possible working mechanisms. Participants were randomly assigned to a film group or an imagery group. Participants in the film group were shown a trauma film of traffic accidents, whereas participants in the imagery group listened to a verbal report of this film and imagined the scenes. The main finding was that a preference for visual processing was positively related to intrusion frequency in the imagery condition but not in the film condition. In addition, participants in the imagery condition reported more avoidance and negative cognitions about the world after 1 week. Limitations and implications for the etiology and treatment of intrusive traumatic memories are discussed.

The present study investigated the predictive power of trait dissociation on the development of intrusive images and the mediating role of peritraumatic state dissociation and horror in this relationship. An observational quasi-experimental design was used with an aversive film to model a traumatic experience. Participants (N= 99) were exposed to a 10-minute trauma film after completing the Dissociative Experiences Scale C. After the film participants completed the Dissociative States Subscale and indicated their subjective horror. Intrusive images of the film were recorded in the subsequent week using an intrusion diary. Results showed that trait dissociation predicted intrusion frequency. This effect disappeared after controlling for peritraumatic horror, suggesting that state horror could have mediated the trait dissociation-intrusion relationship. State dissociation was associated with intrusion frequency in univariate, partial correlations but not in the final model including horror. The results underscore the importance of peritrauma emotions in the prediction of PTSD and as a possible explaining factor of the predictive power of dissociation.

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Off‐type bermudagrasses (Cynodonspp.) continue to be a major concern on southern U.S. golf greens because of the disruption of surface uniformity and playability. The current study was undertaken to measure the genetic stability of six bermudagrass cultivars (Champion, Floradwarf, MS‐Supreme, Tifdwarf, TifEagle, and Tifgreen) in response to the two dinitroaniline herbicides pendimethalin {N‐(1‐ethylpropyl)‐3,4‐dimethyl‐2, 6‐dinitrobenzenamine} and oryzalin (3,5‐dinitro‐N4N4‐dipropylsuffanilamide), which are commonly applied for preemergent weed control in turf management. Four off‐types (Off‐Type 1, Off‐Type 2, Off‐Type 3, and Off‐Type 4) were derived from Champion treated with dinitroanilines during the experimental cycles. The amplified fragment length polymorphism (AFLP) analysis identified a total of 311 informative fragments with seven primer combinations, of which 162 (52.09%) were polymorphic. The number of polymorphisms detected per primer combination ranged from 18 to 27. The grouping of cultivars according to molecular and morphological data was made by multidimensional analyses: cluster analysis and canonical discriminant analysis (CDA). Phenetic analysis as well as CDA revealed that all bermudagrasses and off‐types were genetically diverse. Pairwise D2estimates ranged from 0.69 to 0.99 with Off‐Type 3 being the most genetically dissimilar. Unweighted pair‐group method arithmetic average analysis (UPGMA) produced two major clusters. The first contained the six bermudagrass cultivars and Off‐Type 1, Off‐Type 2, and Off‐Type 4, while Off‐Type 3 formed the second cluster. Total gene diversity (HT) across all bermudagrasses was estimated to be 0.15 and within Champion and derived off‐types gene diversity (Hc) was 0.18. Cytological analysis as well as AFLP comparison with African bermudagrass (C. transvaalensisBurtt Davy) supports our assertion that Off‐Type 3 (2n= 38) is derived from common bermudagrass. In general, results suggest that dinitroaniline herbicide principles may be used as a pathway to understand the evolutionary processes and the origin of off‐types in bermudagrass.

We investigated, in cervical cancer, the relation between telomerase activity, telomerase RNA (hTR) and mRNA of the catalytic subunit of telomerase, hTERT, with “classic” clinicopathological factors as well as survival. Frozen specimens were obtained from 107 consecutive patients with cervical cancer, treated with surgery or radiotherapy with or without chemotherapy. Telomerase activity was determined with fluorescence-based TRAP and hTR and hTERT with semi-quantitative RT-PCR. Eight normal cervical specimens served as controls. Analysis of prognostic factors and survival was limited to early-stage patients, treated primarily with radical hysterectomy. Telomerase activity was not detected in normal cervices and was present in 85 of 107 (79%) cervical cancers (p &lt; 0.001). hTR was detected in all normal cervices and cervical cancers, while hTERT mRNA was detected in 1 of 8 (13%) normal cervices and in 83 of 104 (80%) cervical cancers (p &lt; 0.001). In contrast to semi-quantitative hTR expression levels, semi-quantitative hTERT mRNA levels were related to telomerase activity levels (p &lt; 0.01). In all patients, telomerase activity levels were related to differentiation grade (p &lt; 0.05) but not to stage and histotype. In early-stage patients, telomerase activity, hTR and hTERT were not related to tumor volume, vascular invasion or presence of metastatic lymph nodes. Tumor volume, vascular invasion and presence of metastatic lymph nodes were related to (progression-free) survival, while telomerase activity and its subunits were not. Frequent up-regulation of telomerase activity and hTERT mRNA is especially observed in cervical cancers, while hTR is also detected in normal cervices. Telomerase is not applicable as a prognostic factor in early-stage cervical cancer patients. © 2001 Wiley-Liss, Inc.

The objective of this study was to present the long-term results of total adrenalectomy for Cushing's disease. Forty-four patients undergoing total adrenalectomy for Cushing's disease between 1953 and 1989 at Leiden University Medical Center, The Netherlands, were studied retrospectively. Remission was achieved in 42 patients (95%), with a mean duration of 19 years. Adrenal remnants were observed in 12 patients (27%), and were without clinical consequence in the majority of patients, but caused early recurrent disease in 2 patients. Nine patients (20%) experienced Addisonian crises up to 30 years following treatment. Nelson's syndrome developed in 10 patients (23%) 7–24 years following total adrenalectomy. Prior pituitary irradiation was a protective factor against Nelson's syndrome as it delayed its onset (p= 0.025). On the other hand, subnormal dose or noncontinuous glucocorticoid replacement therapy was associated with increased risk of development of Nelson's syndrome (p= 0.047). The incidence of Nelson's syndrome increased with prolonged follow-up, and female patients seemed to be at increased risk. Quality-of-life assessment showed less favorable scores on mental health and health perception scales, for which no explanation can be found except the long-lasting metabolic effects of Cushing's disease, even when successfully treated. In conclusion, total adrenalectomy remains the final treatment for Cushing's disease. The presence of adrenal remnants which can cause recurrent disease and the development of Nelson's syndrome during prolonged follow-up enhance the need for continued regular follow-up. Pituitary irradiation prior to total adrenalectomy delays the onset of Nelson's syndrome.