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Using a strategy of gene deletion mutagenesis, we have examined the roles of genes putatively involved in lipopolysaccharide biosynthesis in the virulent facultative intracellular bacterial pathogen, Francisella tularensis subspecies tularensis , strain SCHU S4 in LPS biosynthesis, protein glycosylation, virulence and immunogenicity. One mutant, ΔwbtI , did not elaborate a long chain O -polysaccharide (OPS), was completely avirulent for mice, and failed to induce a protective immune response against challenge with wild type bacteria. Another mutant, ΔwbtC , produced a long chain OPS with altered chemical and electrophoretic characteristics. This mutant showed markedly reduced glycosylation of several known glycoproteins. Additionally this mutant was highly attenuated, and elicited a protective immune response against systemic, but not respiratory challenge with wild type SCHU S4. A third mutant, ΔkdtA , produced an unconjugated long chain OPS, lacking a detectable core structure, and which was not obviously expressed at the surface. It was avirulent and elicited partial protection against systemic challenge only.

Objective: The home birth rate in Sweden is less than 1 in 1000, and home birth is not included within the health care system. This study describes women's experiences concerning reactions to their decision to give birth at home., Design and Setting: A nationwide survey (SHE--Swedish Homebirth Experience) in Sweden was conducted between 1992 and 2005 whereas 735 women had given birth to 1038 children. Of 1038 questionnaires 1025 were returned., Measurements: In the questionnaires an open-ended question asked women to report their experience of reactions to their decision to give birth at home The question was answered by 594 women, and data were analysed using content analysis., Findings: The analysis yielded one overarching theme; "To be faced with fear for life and death" including being exposed to reactions about risks. This describes attitudes of professionals and family towards life and death and suggests perceptions of risk and fear of unexpected events. Four main categories were identified; Seen as an irresponsible person, Met with emotional arguments, Exposed to persuasion and Alienation., Conclusion: Women who plan for a home birth were confronted with negative attitudes and persuasion to make them change their mind. This made them feel alienated, and they searched for support among like-minded. Negative attitudes from health care professionals may erode their confidence in conventional health services and turn them towards other options., Implication for Practice: Women who want to give birth at home should be given evidence-based information about risks and benefits. Enhanced knowledge among public and professionals about home births would improve the options for respectful encounters., (Copyright © 2011 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Being confronted with negative attitudes influences the self-concept of pregnant women. Few women in Sweden give birth at home, and Sweden does not have national home birth guidelines. This study describes women's experiences concerning reactions to their decision to give birth at home. One in five women experienced negative attitudes to a high extent from health care staff during the study period (1992-2005). Fewer women reported this during the latter part of the period compared to the earlier part. The change in attitudes may be related to the introduction in 2002 of guidelines for planned home births in Stockholm County Council., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Background: The Francisella tularensis protein MglA performs complex regulatory functions since it influences the expression of more than 100 genes and proteins in F. tularensis. Besides regulating the igl operon, it has been suggested that it also regulates several factors such as SspA, Hfq, CspC, and UspA, all important to stress adaptation. Therefore, it can be hypothesized that MglA plays an important role for Francisella stress responses in general and for the oxidative stress response specifically., Results: We investigated the oxidative stress response of the ΔmglA mutant of the live vaccine strain (LVS) of F. tularensis and found that it showed markedly diminished growth and contained more oxidized proteins than the parental LVS strain when grown in an aerobic milieu but not when grown microaerobically. Moreover, the ΔmglA mutant exhibited an increased catalase activity and reduced expression of the fsl operon and feoB in the aerobic milieu. The mutant was also found to be less susceptible to H(2)O(2). The aberrant catalase activity and gene expression was partially normalized when the ΔmglA mutant was grown in a microaerobic milieu., Conclusions: Altogether the results show that the ΔmglA mutant exhibits all the hallmarks of a bacterium subjected to oxidative stress under aerobic conditions, indicating that MglA is required for normal adaptation of F. tularensis to oxidative stress and oxygen-rich environments.

We investigate a user-driven collaborative knowledge engineering and interaction design process. The outcome is a knowledge-based support application tailored to physicians in the local dementia care community. The activity is organized as a part of a collaborative effort between different organizations to develop their local clinical practice. Six local practitioners used the generic decision-support prototype system DMSS-R developed for the dementia domain during a period and participated in evaluations and re-design. Additional two local domain experts and a domain expert external to the local community modeled the content and design of DMSS-R by using the modeling system ACKTUS. Obstacles and success factors occurring when enabling the end-users to design their own tools are detected and interpreted using a proposed framework for improving care through the use of clinical guidelines. The results are discussed.

Objective: To identify whether mothers of stillborn babies had had a premonition that their unborn child might not be well and how they dealt with that premonition. Design. A mixed method approach. , Setting: One thousand and thirty-four women answered a web questionnaire. , Sample:  Six hundred and fourteen women fulfilled the inclusion criteria of having a stillbirth after the 22nd gestational week and answered questions about premonition. , Methods: Qualitative content analysis was used for the open questions and descriptive statistics for questions with fixed alternatives. , Main Outcome Measure: The premonition of an unwell unborn baby. , Results: In all, 392 of 614 (64%) of the women had had a premonition that their unborn baby might be unwell; 274 of 614 (70%) contacted their clinic and were invited to come in for a check-up, but by then it was too late because the baby was already dead. A further 88 of 614 (22%) decided to wait until their next routine check-up, believing that the symptoms were part of the normal cycle of pregnancy, and that the fetus would move less towards the end of pregnancy. Thirty women (8%) contacted their clinic, but were told that everything appeared normal without an examination of the baby. , Conclusions: Women need to know that a decrease in fetal movements is an important indicator of their unborn baby's health. Healthcare professionals should not delay an examination if a mother-to-be is worried about her unborn baby's wellbeing., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background and Aims: Although endovascular stent treatment is increasingly used in infrainguinal atherosclerotic occlusive disease, outcome with focus on gender differences has not been reported in detail., Material and Methods: One hundred and twelve consecutive patients (67 [60%]) women, undergoing endovascular nitinol stent treatment of atherosclerotic lesions in the femoropopliteal segment were analysed concerning improvement in ankle brachial index (ABI), reinterventions, complications, amputation and survival rates up to 12 months after intervention. Risk factors for amputation and death were analyzed with logistic regression., Results: At presentation, women showed critical limb ischemia (CLI) more often than men (87% vs. 58 %; P = 0.001). After 12 months ABI had improved (from 0.40 ± 0.26 at baseline to 0.86 ± 0.22 after 12 months, P < 0.001), but 16 patients (15%) had been amputated and 27 patients (24 %) had died. After adjustment for age, diabetes mellitus and smoking, female gender was an independent risk factor for amputation (OR 9.0; 95% CI 1.1-76.5; P = 0.045)., Conclusions: Stent treatment of lesions in the femoropopliteal segment had favourable effects on ABI and limb salvage. Treated women more often had CLI and ran a higher risk for amputation within 12 months than men. This might reflect failure of clinicians to adequately appreciate symptoms of atherosclerotic leg artery disease in women.

Aim: This study aims to describe how mothers spend the period of time between being diagnosed with a dead baby in utero and the induction of the delivery., Material and Methods: Data were collected using a web questionnaire. Five hundred and fifteen women who had experienced a stillbirth after the 22nd week of gestation answered the open question: 'What did you do between the diagnosis of the child's death and the beginning of the delivery?' A qualitative content analysis method was used., Results: The results show that some mothers received help to adapt to the situation, while for others, waiting for the induction meant further stress and additional psychological trauma in an already strained situation., Conclusion: There is no reason to wait with the induction unless the parents themselves express a wish to the contrary. Health care professionals, together with the parents, should try to determine the best time for the induction of the birth after the baby's death in utero. That time may vary, depending on the parents' preferences., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

Francisella tularensis is a highly virulent intracellular bacterium capable of rapid multiplication in phagocytic cells. Previous studies have revealed that activation of F. tularensis-infected macrophages leads to control of infection and reactive nitrogen and oxygen species make important contributions to the bacterial killing. We investigated the effects of adding S-nitroso-acetyl-penicillamine (SNAP), which generates nitric oxide, or 3-morpholinosydnonimine hydrochloride, which indirectly leads to formation of peroxynitrite, to J774 murine macrophage-like cell cultures infected with F. tularensis LVS. Addition of SNAP led to significantly increased colocalization between LAMP-1 and bacteria, indicating containment of F. tularensis in the phagosome within 2 h, although no killing occurred within 4 h. A specific inhibitory effect on bacterial transcription was observed since the gene encoding the global regulator MglA was inhibited 50-100-fold. F. tularensis-infected J774 cells were incapable of secreting TNF-α in response to Escherichia coli LPS but addition of SNAP almost completely reversed the suppression. Similarly, infection with an MglA mutant did not inhibit LPS-induced TNF-α secretion of J774 cells. Strong staining of nitrotyrosine was observed in SNAP-treated bacteria, and MS identified nitration of two ribosomal 50S proteins, a CBS domain pair protein and bacterioferritin. The results demonstrated that addition of SNAP initially did not affect the viability of intracellular F. tularensis LVS but led to containment of the bacteria in the phagosome. Moreover, the treatment resulted in modification by nitration of several F. tularensis proteins.

Objective: To gain an understanding of fathers' experiences of a planned home birth., Study Design: In-depth interviews were conducted with eight Swedish fathers who had the experience of a total of 23 births, of which 17 were planned home births. The fathers were recruited by the midwives who had assisted with the planned home births. Content analysis was used., Results: Analysis revealed the main theme "she leads - he follows". The fathers were compliant to the woman's decision; they also described it as a deliberate choice and struggled with feelings of being different in comparison with the established way of becoming a father., Conclusion: The experience of a planned home birth for the father was a process in which he had to put his own ideas on giving birth aside and carefully follow his woman. Sharing fears and happiness during the process by being compliant to the woman may strengthen the new fatherhood. The fathers' role in the process of making an unconventional choice is an example that could probably be applied to similar situations in pregnancy and childbirth., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Objective: Carrying death instead of life is beyond understanding and a huge psychological challenge for a pregnant mother. The aim of this study was to investigate the mothers' experiences of the time from the diagnosis of the death of their unborn baby until induction of labour., Method: In this qualitative study, in-depth interviews were conducted with 21 mothers whose babies had died prior to birth. The interviews were then analysed using content analysis., Results: The overall theme that emerged from the mothers' experiences is understood as "waiting in no-man's-land", describing the feeling of being set aside from normality and put into an area which is unrecognized. Four categories were established: 'involuntary waiting' describes the sense of being left without information about what is to come; 'handling the unimaginable' concerns the confusing state of finding oneself in the worst-case scenario and yet having to deal with the birth; 'broken expectations' is about the loss not only of the baby but also of future family life; and 'courage to face life' describes the determination to go on and face reality., Conclusions: The mother's experiences during the time after the information of their baby's death in utero until the induction of labour can be understood as a sense of being in no-man's-land, waiting without knowing for what or for how long., (Copyright © 2011 Elsevier B.V. All rights reserved.)

The aim of this study was to describe fathers' experiences of being present on a postnatal ward and during the first days at home following a complicated birth. Fifteen fathers were interviewed, and content analysis was used for the analysis. The theme illustrated that fathers were a resource for both mother and child through practical and emotional engagement. The categories describe how the father empowers the mother and illustrates adapting to new family roles. Following complicated birth, fathers should be invited to stay around-the-clock on postnatal wards because it gives them the opportunity to place their resources at the disposal of mother and child. In antenatal courses, fathers should be prepared for their empowering role after a complicated birth.

Francisella tularensis, the causative agent of tularemia, is one of the most infectious bacterial pathogens known and is classified as a category A select agent and a facultative intracellular bacterium. Why F. tularensis subsp. tularensis causes a more severe form of tularemia than F. tularensis subsp. holarctica does is not known. In this study, we have identified prominent phenotypic differences between the subspecies, since we found that F. tularensis subsp. tularensis strains contained less iron than F. tularensis subsp. holarctica strains. Moreover, strain SCHU S4 of F. tularensis subsp. tularensis was less susceptible than FSC200 and the live vaccine strain (LVS) of F. tularensis subsp. holarctica to H(2)O(2)-induced killing. The activity of the H(2)O(2)-degrading enzyme catalase was similar between the strains, whereas the iron content affected their susceptibility to H(2)O(2), since iron starvation rendered F. tularensis subsp. holarctica strains more resistant to H(2)O(2). Complementing LVS with fupA, which encodes an important virulence factor that regulates iron uptake, reduced its iron content and increased the resistance to H(2)O(2)-mediated killing. By real-time PCR, it was demonstrated that FSC200 and LVS expressed higher levels of gene transcripts related to iron uptake and storage than SCHU S4 did, and this likely explained their high iron content. Together, the results suggest that F. tularensis subsp. tularensis strains have restricted iron uptake and storage, which is beneficial for their resistance to H(2)O(2)-induced killing. This may be an important factor for the higher virulence of this subspecies of F. tularensis, as reactive oxygen species, such as H(2)O(2), are important bactericidal components during tularemia.

There is a need to provide tools for the medical professional at the point of care in the assessment of a suspected dementia disease. Early diagnosis is important in order to provide appropriate care so that the disease does not cause unnecessary suffering for the patient and relatives. DMSS (Dementia Management and Support System) is a clinical decision-support system that provides support in the diagnosis of a dementia disease, which is in use in controlled clinical evaluation settings in four countries. This paper reports the results of evaluations done in use environments in these places during a period of two years. Data in 218 patient cases were collected by 21 physicians during their use of the system in clinical practice. In 50 of the cases the use of the system were also observed and the physicians were interviewed in 88 cases. The collected data and inferences made by the system were analyzed. To summarize the results, DMSS gave appropriate support considering the patient case, available information and the user's skills and knowledge in the domain. However, the results also illuminated the need for extended and personalized support for the less skilled physician in the assessment of basic information about patients.

Background: Childbirth can be an empowering event in a woman's life. However, little is known about women's own perceptions of power and empowering sources during childbirth. This study aimed to describe the factors experienced as empowering during a planned home birth., Methods: The inclusion criteria were women in Sweden who had a planned home birth between 1992 and 2005. All the women (n = 735) who agreed to participate received one questionnaire for each planned home birth. A total of 1,038 questionnaires were sent to the women. The written birth stories were analyzed using content analysis and descriptive statistics., Results: In the analysis of the participants' birth experience four categories and one overall theme emerged from the stories. The categories identified were sensations, guidance, tacit support, and identification of needs. Greater emphasis was put on guidance among first-time mothers than among multiparas, for whom tacit support was identified as the most empowering factor. The overall theme was identified as "resting in acceptance of the process." The empowerment women expressed by achieving and maintaining a sense of control allowed them to rest in acceptance of the efforts that are part of a normal birth., Conclusion: Women who choose to give birth at home find empowering sources within themselves from their environment and from the active and passive support of persons they have chosen to be present at the birth., (© 2010, Copyright the Authors. Journal compilation © 2010, Wiley Periodicals, Inc.)

Background: Opting for a home birth or requesting a cesarean section in a culture where vaginal birth in a hospital is the norm challenges the health care system. The aim of this study was to compare background characteristics of women who chose these very different birth methods and to see how these choices affected factors of care and the birth experience., Methods: This descriptive study employed a secondary data analysis of a sample of women who gave birth from 1997 to 2008, including 671 women who had a planned home birth and 126 women who had a planned cesarean section based on maternal request. Data were collected by means of questionnaires. Logistic regression with crude and adjusted odds ratios (OR) with a 95 percent confidence interval (95% CI) was calculated., Results: Women with a planned home birth had a higher level of education (OR: 2.3; 95% CI: 1.5-3.6), were less likely to have a high body mass index (OR: 0.1; 95% CI: 0.01-0.6), and were less likely to be smokers (OR: 0.2; 95% CI: 0.1-0.4) when compared with women who had planned cesarean sections. When adjusted for background variables, women with a planned home birth felt less threat to the baby's life during birth (OR: 0.1; 95% CI: 0.03-0.4), and were more satisfied with their participation in decision making (OR: 6.0; 95% CI: 3.3-10.7) and the support from their midwife (OR 3.9; 95% CI: 2.2-7.0). They also felt more in control (OR: 3.3; 95% CI: 1.6-6.6), had a more positive birth experience (OR: 2.9; 95% CI: 1.7-5.0), and were more satisfied with intrapartum care (OR: 2.3; 95% CI: 1.3-4.1) compared with women who had a planned cesarean section on maternal request., Conclusions: Women who planned a home birth and women who had a cesarean section based on maternal request are significantly different groups of mothers in terms of sociodemographic background. In a birth context that promotes neither home birth nor cesarean section without medical reasons, we found that those women who had a planned home birth felt more involvement in decision making and had a more positive birth experience than those who had a requested, planned cesarean section., (© 2010, Copyright the Authors. Journal compilation © 2010, Wiley Periodicals, Inc.)

Introduction: In Sweden, prospective fathers are encouraged and welcome to attend prenatal visits, and pregnant women assess their partners' involvement in prenatal care as very important. The aim of this study was to describe expectant fathers' experiences of and involvement in prenatal care in Sweden., Methods: Data were drawn from a 1-year cohort study of 827 Swedish-speaking fathers recruited during their partners' midpregnancy and followed up 2 months after childbirth., Results: The participants reported that the most important issues in prenatal care were the woman's physical and emotional well-being and the support she received from her midwife. However, care was identified as deficient in nearly all aspects of information, medical care, and fathers' involvement. "Excessive" care was also reported and related to how the father was treated by the midwife, mainly in terms of attention to his emotional well-being., Discussion: Although fathers prioritize the needs of their pregnant partners, it is important for caregivers to assess fathers' needs and incorporate a family-oriented approach to prenatal care., ((c) 2010 American College of Nurse-Midwives. Published by Elsevier Inc. All rights reserved.)

Background: The aim was to examine if self reported chronic regional pain (CRP) and chronic widespread pain (CWP) predicted inpatient care due to serious medical conditions such as cerebrovascular diseases, ischemic heart diseases, neoplasms and infectious diseases in a general population cohort over a ten year follow-up period., Methods: A ten-year follow up of a cohort from the general adult population in two health care districts with mixed urban and rural population in the south of Sweden, that in 1995 participated in a survey on health and musculoskeletal pain experience. Information on hospitalisation for each subject was taken from the regional health care register. Multiple logistic regression analyses were used to study the associations between chronic musculoskeletal pain and different medical conditions as causes of hospitalisation., Results: A report of CRP (OR = 1.6; p < 0.001) or CWP ( OR = 2.1; p < 0.001) predicted at least one episode of inpatient care over a ten year period, with an increased risk in almost all diagnostic subgroups, including cerebrovascular diseases, ischemic heart diseases, and infectious diseases. There was however no increased risk of hospitalisation due to neoplasms., Conclusions: The presence of especially CWP was associated with hospital inpatient care due to several serious medical disorders. This may imply a general vulnerability to different medical conditions that has to be addressed in the assessment and management of subjects with chronic musculoskeletal pain.

The need for improving dementia care has driven the development of the clinical decision support system DMSS (Dementia Management and Support System). A sociotechnical approach to design and development has been applied, with an activity-centered methodology and user participation throughout the process. Prototypes have been developed based on the characteristics of clinical practice and domain knowledge, while clinical practice has been subjected to different efforts for development such as education and organizational change. This paper addresses the lessons learned and role and impact DMSS has had, and is expected to have on the clinical assessment of dementia in different clinics in Sweden, South Korea and Japan. Furthermore, it will be described in what way the development of DMSS and the development of dementia care in these three areas are interlinked. Results indicate that the most important contribution of DMSS at the point of care, is the educational support that DMSS provides, part from the tailored explanatory support related to a patient case. This effect was partly manifested in a change of routines in the encounter with patients.

Background: A change in the pattern of movement of her unborn baby could be indicative that the baby might die., Aim: To study mothers' experiences during the time prior to receiving news that their baby has died., Method: Interviews with 26 mothers., Results: Premonition that something had happened to their baby, a sense based on a lack of movements were experienced. Six categories describe the mother's insight that the baby's life was threatened: not feeling in touch with their baby; worry feeling something is wrong; not understanding the unbelievable; wanting information; and being certain that their baby had died. The overarching theme "There is something wrong" was formulated., Conclusion: The mother could not understand the unbelievable: that the baby had died in utero., Implications: Mother's should be cautioned to trust their insights and seek medical advice if they are concerned over the lack of movement from the unborn baby.

We investigated the role of the 58-kDa FTT0918 protein in the iron metabolism of Francisella tularensis. The phenotypes of SCHU S4, a prototypic strain of F. tularensis subsp. tularensis, and the Delta FTT0918 and Delta fslA isogenic mutants were analyzed. The gene product missing in the Delta fslA mutant is responsible for synthesis of a siderophore. When grown in broth with various iron concentrations, the two deletion mutants generally reached lower maximal densities than SCHU S4. The Delta FTT0918 mutant, but not the Delta fslA mutant, upregulated the genes of the F. tularensis siderophore locus (fsl) operon even at high iron concentrations. A chrome azurol sulfonate plate assay confirmed siderophore production by all strains except the Delta fslA strain. In a cross-feeding experiment using medium devoid of free iron, SCHU S4 promoted growth of the Delta fslA strain but not of the Delta FTT0918 strain. The sensitivity of SCHU S4 and the Delta FTT0918 and Delta fslA strains to streptonigrin demonstrated that the Delta FTT0918 strain contained a smaller free intracellular iron pool and that the Delta fslA strain contained a larger one than SCHU S4. In contrast to the marked attenuation of the Delta FTT0918 strain, the Delta fslA strain was as virulent as SCHU S4 in a mouse model. Altogether, the data demonstrate that the FTT0918 protein is required for F. tularensis to utilize iron bound to siderophores and that it likely has a role also in siderophore-independent iron acquisition. We suggest that the FTT0918 protein be designated Fe utilization protein A, FupA.

The Francisella tularensis live vaccine strain (LVS), in contrast to its iglC mutant, replicates in the cytoplasm of macrophages. We studied the outcome of infection of the murine macrophagelike cell line J774A.1 with LVS and with iglC, iglD, and mglA mutants, the latter of which is deficient in a global regulator. Compared to LVS, all of the mutants showed impaired intracellular replication up to 72 h, and the number of the mglA mutant bacteria even decreased. Colocalization with LAMP-1 was significantly increased for all mutants compared to LVS, indicating an impaired ability to escape into the cytoplasm. A lysosomal acidity-dependent dye accumulated in approximately 40% of the vacuoles containing mutant bacteria but not at all in vacuoles containing LVS. Preactivation of the macrophages with gamma interferon inhibited the intracellular growth of all strains and significantly increased acidification of phagosomes containing the mutants, but it only slightly increased the LAMP-1 colocalization. The intracellular replication and phagosomal escape of the iglC and iglD mutants were restored by complementation in trans. In conclusion, the IglC, IglD, and MglA proteins each directly or indirectly critically contribute to the virulence of F. tularensis LVS, including its intracellular replication, cytoplasmic escape, and inhibition of acidification of the phagosomes.

Objective: Treatment with dopamine agonists has been associated with cardiopulmonary fibrotic reactions, predominantly in patients treated for Parkinson's disease. To our knowledge, these reactions have previously not been associated with low-dose cabergoline treatment for hyperprolactinaemia., Method: A case of constrictive pericarditis in a patient treated with cabergoline for hyperprolactinaemia is presented. The patient has been treated at a county hospital and a university hospital in southern Sweden., Results: A 20-year-old woman with a 3-year history of amenorrhoea was referred to the department in 1992. From 2001 to 2005, she was given cabergoline, 0.5-1.5 mg/week. In 2005 a pericardectomy was performed due to fibrotic, constrictive pericarditis., Conclusions: Our present case suggests that constrictive pericarditis may develop even on low-dose cabergoline, which might indicate that this reaction, as opposed to valvular fibrosis, is not mediated by a 5-HT(2B) agonistic mechanism.

In this paper, a case study is presented in which an early prototype of a decision-support system was integrated in the process of investigating patients with suspected dementia and evaluated. The aims were to capture and model the complex target activity for the purpose of knowledge acquisition and formalization, and qualitatively evaluate the system's compliance with reasoning and work processes as part of the development of a decision-support system for the domain. The results show that contextual factors such as local routines in clinical practice motivate further development of the support integrated in the system for establishing preliminary diagnoses in the investigation process.

Francisella tularensis is a facultative intracellular bacterial pathogen capable of proliferating within host macrophages. The mechanisms that explain the differences in virulence between various strains of the species are not well characterized. In the present study, we show that both attenuated (strain LVS) and virulent (strains FSC200 and SCHU S4) strains of the pathogen replicate at similar rates in resting murine peritoneal exudate cells (PEC). However, when PEC were activated by exposure to gamma interferon (IFN-gamma), they killed LVS more rapidly than virulent strains of the pathogen. Addition of N(G)-monomethyl-l-arginine, an inhibitor of inducible nitric oxide synthase, to IFN-gamma-treated PEC, completely inhibited killing of the virulent strains, whereas it only partially blocked the killing of LVS. Similarly, in a cell-free system, SCHU S4 and FSC200 were more resistant to killing by H(2)O(2) and ONOO(-) than F. tularensis LVS. Catalase encoded by katG is a bacterial factor that can detoxify bactericidal compounds such as H(2)O(2) and ONOO(-). To investigate its contribution to the virulence of F. tularensis, katG deletion-containing mutants of SCHU S4 and LVS were generated. Both mutants demonstrated enhanced susceptibility to H(2)O(2) in vitro but replicated as effectively as the parental strains in unstimulated PEC. In mice, LVS-DeltakatG was significantly attenuated compared to LVS whereas SCHU S4-DeltakatG, despite slower replication, killed mice as quickly as SCHU S4. This implies that clinical strains of the pathogen have katG-independent mechanisms to combat the antimicrobial effects exerted by H(2)O(2) and ONOO(-), the loss of which could have contributed to the attenuation of LVS.

The capacity of several weak and strong cation-exchangers to adsorb 2-diethylaminoethanol (DEAE) and (2,3-hydroxypropyl) trimethylammonium chloride (HPMAC) from sodium-containing process water streams, and the ease of subsequently eluting the amines and regenerating the exchangers, were investigated. (2,3-hydroxypropyl) trimethylammonium chloride was enriched 40-fold compared with the initial amine/sodium-ratio in the bulk fluid by Amberlite IRC-50. The highest selectivity for 2-diethylaminoethanol (26-fold) was provided by Imac HP336. Neither of the selected strong cation-exchangers showed any selectivity towards 2-diethylaminoethanol, but they enriched (2,3-hydroxypropyl) trimethylammonium chloride approximately three to four fold. These findings suggest that weak cation-exchangers (WCX) could be readily used for the selective removal of these or similar amines from sodium-containing process waters.

Objective: to describe home-birth risk assessment by parents., Design: interviews using a semi-structured interview guide. Data were analysed using a phenomenological approach., Setting: independent midwifery practices in Sweden., Participants: five couples who had had planned home births., Findings: the parents had a fundamental trust that the birth would take place without complications, and they experienced meaningfulness in the event itself. Risks were considered to be part of a complex phenomenon that was not limited to births at home. This attitude seems to be part of a lifestyle that has a bearing on how risks experienced during the birth were handled. Five categories were identified as counterbalancing the risk of possible complications: (1) trust in the woman's ability to give birth; (2) trust in intuition; (3) confidence in the midwife; (4) confidence in the relationship; and (5) physical and intellectual preparation., Key Conclusions: although the parents were conscious of the risk of complications during childbirth, a fundamental trust in the woman's independent ability to give birth was central to the decision to choose a home birth. Importance was attached to the expected positive effects of having the birth at home., Implications for Practice: knowledge of parents' assessment can promote an increased understanding of how parents-to-be experience the risks associated with home birth.

Background: Volumetric changes and glial pathology have been reported in the central nervous system (CNS) of patients with depressive disorder, an illness often associated with elevated glucocorticoid levels. Glucocorticoids reduce gliogenesis in the adult rat CNS. Electroconvulsive seizure (ECS)-treatment, an animal model for the antidepressant treatment electroconvulsive therapy, can enhance proliferation of glial cells. This study examined glial cell proliferation in response to ECS in rats whose glucocorticoid levels were elevated to mimic the conditions seen in depression., Methods: Rats were injected daily for seven days with either corticosterone or vehicle. ECS- or sham- treatment was given once daily during the first five days. Proliferating cells in the hippocampus were labeled with bromodeoxyuridine and analyzed for co-labeling with the glial cell markers NG2, Ox42, S-100beta and Rip., Results: ECS counteracted the glucocorticoid-induced inhibition of NG2+, Ox42+ and Rip+ cell proliferation, and the gliogenesis rate was restored to baseline levels. Volumetric changes in rats treated with ECS were detected., Conclusions: Our results show that ECS-treatment affects the proliferation of glial cells even in the presence of elevated levels of glucocorticoids. This result adds to an increasing number of studies suggesting that antidepressant treatment can counteract degenerative processes associated with major depression.

Francisella tularensis subsp. tularensis (type A) strain SCHU S4 is a prototypic strain of the pathogen that is highly virulent for humans and other mammals. Its intradermal (i.d.) 50% lethal dose (LD50) for mice is <10 CFU. We discovered a spontaneous mutant, designated FSC043, of SCHU S4 with an i.d. LD50 of >10(8) CFU. FSC043 effectively vaccinated mice against challenge with a highly virulent type A strain, and the protective efficacy was at least as good as that of F. tularensis LVS, an empirically attenuated strain which has been used as an efficacious human vaccine. Comparative proteomics was used to identify two proteins of unknown function that were identified as defective in LVS and FSC043, and deletion mutants of SCHU S4 were created for each of the two encoding genes. One mutant, the DeltaFTT0918 strain, failed to express a 58-kDa protein, had an i.d. LD50 of approximately 10(5) CFU, and was found to be less capable than SCHU S4 of growing in peritoneal mouse macrophages. Mice that recovered from sublethal infection with the DeltaFTT0918 mutant survived when challenged 2 months later with >100 LD50s of the highly virulent type A strain FSC033. This is the first report of the generation of defined mutants of F. tularensis subsp. tularensis and their use as live vaccines.

Background: Longstanding musculoskeletal pain is common in the general population and associated with frequent use of health care. Plain radiography is a common diagnostic approach in these patients despite knowledge that the use in the investigation of musculoskeletal pain is associated with low diagnostic yield, substantial costs and high radiation exposure. The aim of this study was to assess the use of diagnostic imaging and the proportion of pathological findings with regard to duration and distribution of pain in a cohort from the general population., Methods: An eight-year longitudinal study based on questionnaires at three occasions and medical records on radiological examinations done in medical care. Thirty subjects were selected from an established population based cohort of 2425 subjects that in 1995 answered a postal survey on pain experience. At baseline there were ten subjects from each of three pain groups; No chronic pain, Chronic regional pain, and Chronic widespread pain (CWP). Those who presented with CWP at two or all three occasions were considered to have a longstanding or re-occurring CWP. In total the thirty subjects underwent 102 radiological examinations during the eight year follow up., Results: There was a non-significant (p = 0.10) finding indicating that subjects with chronic pain at baseline (regional or widespread) were examined three times more often than those with no chronic pain. When the indication for the examination was pain, there was a low proportion of positive findings in subjects with longstanding CWP, compared to all others (5.3% vs 28.9%; p = 0.045). On the other hand, in examinations on other indications than pain the proportion of positive findings was high in the CWP group (62.5% vs 14.8%; p = 0.001)., Conclusion: Radiological examinations had a low diagnostic yield in evaluation of pain in subjects with longstanding/reoccurring CWP. These subjects had on the other hand more often positive findings when examined on other indications than pain. This may indicate that subjects with longstanding/reoccurring CWP are more prone to other diseases. It is a challenge for caregivers, often primary care physicians, to use radiological examinations to the best for their patients.

Intracellular killing of Francisella tularensis by macrophages depends on interferon-gamma (IFN-gamma)-induced activation of the cells. The importance of inducible nitric oxide synthase (iNOS) or NADPH phagocyte oxidase (phox) for the cidal activity was studied. Murine IFN-gamma-activated peritoneal exudate cells (PEC) produced nitric oxide (NO), measured as nitrite plus nitrate, and superoxide. When PEC were infected with the live vaccine strain, LVS, of F. tularensis, the number of viable bacteria was at least 1000-fold lower in the presence than in the absence of IFN-gamma after 48 h of incubation. PEC from iNOS-gene-deficient (iNOS-/-) mice killed F. tularensis LVS less effectively than did PEC from wild-type mice. PEC from phox gene-deficient (p47phox-/-) mice were capable of killing the bacteria, but killing was less efficient, although still significant, in the presence of NG-monomethyl-L-arginine (NMMLA), an inhibitor of iNOS. A decomposition catalyst of ONOO-, FeTPPS, completely reversed the IFN-gamma-induced killing of F. tularensis LVS. Under host cell-free conditions, F. tularensis LVS was exposed to S-nitroso-acetyl-penicillamine (SNAP), which generates NO, or 3-morpholinosydnonimine hydrochloride (SIN-1), which generates NO and superoxide, leading to formation of ONOO-. During 6 h of incubation, SNAP caused no killing of F. tularensis LVS, whereas effective killing occurred in the presence of equimolar concentrations of SIN-1. The results suggest that mechanisms dependent on iNOS and to a minor degree, phox, contribute to the IFN-gamma-induced macrophage killing of F. tularensis LVS. ONOO- is likely to be a major mediator of the killing.

We have previously reported that the C-Med 100 extract of the plant Uncaria tomentosa induces prolonged lymphocyte half life and hence increased spleen cell number in mice receiving the extract in their drinking water. Further, the extract induces cell proliferation arrest and inhibits activation of the transcriptional regulator nuclear factor kappaB (NF-kappaB) in vitro. We now report that mice exposed to quinic acid (QA), a component of this extract, had significantly increased number of spleen cells, thus recapitulating the in vivo biological effect of C-Med 100 exposure. Commercially supplied QA (H(+) form) did not, however, inhibit cell proliferation in vitro, while the ammonia-treated QA (QAA) was a potent inhibitor. Both QA and QAA inhibited NF-kappaB activity in exposed cells at similar concentrations. Thus, our present data identify QA as a candidate component for both in vivo and in vitro biological effects of the C-Med 100 extract.

Reactive nitrogen species (RNS) and reactive oxygen species (ROS) are important mediators of the bactericidal host response. We investigated the contribution of these two mediators to the control of infection with the facultative intracellular bacterium Francisella tularensis. When intradermally infected with the live vaccine strain F. tularensis LVS, mice deficient in production of RNS (iNOS(-/-) mice) or in production of ROS by the phagocyte oxidase (p47(phox-/-) mice) showed compromised resistance to infection. The 50% lethal dose (LD(50)) for iNOS(-/-) mice was <20 CFU, and the LD(50) for p47(phox-/-) mice was 4,400 CFU, compared to an LD(50) of >500,000 CFU for wild-type mice. The iNOS(-/-) mice survived for 26.4 +/- 1.8 days, and the p47(phox-/-) mice survived for 10.1 +/- 1.3 days. During the course of infection, the serum levels of gamma interferon (IFN-gamma) and interleukin-6 were higher in iNOS(-/-) and p47(phox-/-) mice than in wild-type mice. Histological examination of livers of iNOS(-/-) mice revealed severe liver pathology. Splenocytes obtained 5 weeks after primary infection from antibiotic-treated iNOS(-/-) mice showed an in vitro recall response that was similar in magnitude and greater secretion of IFN-gamma compared to cells obtained from wild-type mice. In summary, mice lacking expression of RNS or ROS showed extreme susceptibility to infection with F. tularensis LVS. The roles of RNS and ROS seemed to be distinct since mice deficient in production of ROS showed dissemination of infection and died during the early phase of infection, whereas RNS deficiency led to severe liver pathology and a contracted course of infection.

The highly virulent bacterium Francisella tularensis is well adapted to the intracellular habitat but the mechanisms behind its intracellular survival have been elusive. Recently, it was shown that the bacterium is capable of escaping from the phagosome of human and mouse monocytic cells. Here it is shown that this escape is affected by gamma interferon (IFN-gamma) treatment of mouse peritoneal exudate cells since in treated cells the proportion that escaped was significantly lower (80%) than in untreated cells (97%) as determined by transmission electron microscopy. By contrast, < 1% of mutant bacteria lacking expression of a 23 kDa protein denoted IglC were able to escape from the phagosome. Infection with the DeltaiglC strain complemented with the iglC gene resulted in 60% of the bacteria escaping from the phagosome. Whereas IFN-gamma treatment conferred a static effect on intracellular wild-type bacteria, the treatment had a bactericidal effect on the DeltaiglC strain. The results show that the activation status of infected cells affects the escape of F. tularensis from the phagosome. An even more profound effect on this escape is related to expression of IglC by F. tularensis. Its absence rendered the mutant bacteria incapable of escaping from the phagosome and of multiplying intracellularly.

Previous reports have demonstrated that extracts of the plant Uncaria tomentosa inhibit tumor cell proliferation and inflammatory responses. We have confirmed that C-Med 100, a hot water extract of this plant, inhibits tumor cell proliferation albeit with variable efficiency. We extend these findings by showing that this extract also inhibits proliferation of normal mouse T and B lymphocytes and that the inhibition is not caused by toxicity or by induction of apoptosis. Further, the extract did not interfere with IL-2 production nor IL-2 receptor signaling. Since there was no discrete cell cycle block in C-Med 100-treated cells, we propose that retarded cell cycle progression caused the inhibition of proliferation. Collectively, these data suggested interference with a common pathway controlling cell growth and cell cycle progression. Indeed, we provide direct evidence that C-Med 100 inhibits nuclear factor kappa B (NF-kappa B) activity and propose that this at least partially causes the inhibition of proliferation.

T cells are crucial to the control and eradication of the facultative intracellular bacterium Francisella tularensis. A contributory role of humoral antibodies in the host defence remains to be assessed. We used B-cell-deficient mice to study the possible contribution of antibodies to the defence against the live vaccine strain (LVS) or a clinical isolate of F. tularensis, both belonging to the subspecies holarctica (type B). When B-cell-deficient (Igmu(-/-)) mice of the C57BL/10 background were administered immune serum one day before intradermal injection of LVS, they developed lower bacterial numbers in skin, liver, and spleen than did mice receiving normal serum, and survived a challenge inoculum that was lethal for mice given normal serum. Administration of immune serum to C57BL/10 mice afforded protection also against infection with the clinical isolate of F. tularensis subsp. holarctica. Five days after intradermal inoculation of bacteria of the isolate, animals receiving immune serum showed 4log10 lower bacterial counts in liver and spleen than mice administered normal serum. In mice primed by LVS infection, T-cell immunity and host protection were strong and only a marginal contribution of immune serum against a secondary intradermal infection was demonstrated. Together, these findings show that specific antibodies contribute to the host defence of mice against F. tularensis subsp. holarctica.

Purpose: Compare the effects of Nembutal, a barbiturate, and Telazol, a dissociative anesthetic, on photoreceptor and post-receptoral retinal responses., Methods: Dark adapted infant and adult albino rats were anesthetized with intraperitoneal injection of Nembutal or Telazol. ERG responses to full-field stimuli were recorded over a 6-8 log unit range from dim intensities at which the scotopic threshold response (STR) was observed to those that saturate the a-wave. The rod photoresponse, b-wave, oscillatory potentials (OPs), and STR parameters of rats in the Nembutal and Telazol groups were compared., Results: For both infants and adults, the saturated amplitudes of the photoresponse and the b-wave were larger in Telazol than Nembutal rats, but sensitivity of the photoresponse did not differ significantly between Telazol and Nembutal rats. The STR was seen only in the Telazol responses of adults. There was little differential effect of the two agents on the OPs., Conclusions: Photoreceptor and postreceptoral responses recorded under Nembutal and Telazol anesthesia differ significantly. These results may inform selection of anesthetic for studies of animal models.

In this study we use the N-substituted benzamides declopramide (3-CPA) and N-acetyl declopramide (Na-3-CPA) to investigate the involvement of the transcription factor NF-kappaB in the induction of apoptosis and surface immunoglobulin kappa (Igkappa) expression in the mouse pre-B cell line 70Z/3. We first showed that 3-CPA-induced apoptosis at doses around 500 microM and that the 3-CPA-induced apoptosis could be suppressed by over-expression of the Bcl-2 protein. Na-3-CPA was shown to be non-apoptotic at doses up to 1-2 mM. On the other hand, Na-3-CPA inhibited LPS-induced Igkappa expression while 3-CPA had no effect. Further analysis showed that while 3-CPA inhibited breakdown of IkappaBalpha, Na-3-CPA inhibited breakdown of IkappaBbeta. In addition, we used a 70Z/3 cell line expressing a dominant negative IkappaBalpha (70Z/3(deltaNIkappaBalpha)). The 70Z/3(deltaNIkappaBalpha) cell line was shown to be more sensitive to apoptosis and cytotoxicity induced by 3-CPA as well as by LPS, probably due to a defect in NF-kappaB rescue mechanism. Taken together, our data implicate distinct roles for IkappaBalpha and IkappaBbeta in regulating various NF-kappaB activities.

We have analysed the mechanism of action for induction of apoptosis by N-substituted benzamides using declopramide as a lead compound. We show here that declopramide at doses above 250 microM in the mouse 70Z/3 pre-B cell line or in the human promyeolocytic cancer cell line HL60 induced cytochrome c release into the cytosol and caspase-9 activation. The broad spectrum caspase inhibitor zVADfmk and caspase-9 inhibitor zLEDHfmk inhibited apoptosis and improved cell viability when administrated to cells 1 h before exposure to declopramide, whereas the caspase-8 inhibitor zIEDHfmk had less effect. Also, the over expression of Bcl-2 by transfection in 70Z/3 cells inhibited declopramide-induced apoptosis. Prior to the induction of apoptosis, a G(2)/M cell cycle block was induced by declopramide. The cell cycle block was also observed in the presence of broad spectrum caspase inhibitor zVADfmk and in a transfectant expressing high levels of Bcl-2. Furthermore, while p53 was induced in 70Z/3 cells by declopramide, neither the apoptotic mechanism nor the G(2)/M cell cycle block were dependent on p53 activation since both effects were also seen in p53 deficient HL60 cells after addition of declopramide., (Copyright 2002 Cancer Research UK)

In this paper we present a prototype system as a tool for clinical decision support in the domain of cognitive diseases. The number of patients is increasing while the number of patients that the general practitioner (GP) meets in primary care still is too low to make the GP well trained in diagnostics and management of patients in the area of cognitive diseases. In addition, new treatment strategies are established in clinical routine directed towards cognitive deficiencies with behavioural and psychological symptoms in the presence of dementia (BPSD).

N-substituted benzamides are compounds that have recently been reported to inhibit nuclear factor-kappaB (NF-kappaB) activity and induce apoptosis in a pre-B cell line. In this study, we focused on the effects of N-substituted benzamides on transcriptional regulation in Jurkat T cells. We used a model system where the cells can be stimulated either through TCR/CD28 or by treatment of the cells with PMA and ionomycin to induce transcription factors typical for T lymphocyte activation. Treatment of the Jurkat cells with procainamide did not influence the transcription factor profile of stimulated cells, while treatment with a derivative having an acetyl group in position 4 of the aromatic ring inhibited NF-kappaB and nuclear factor of activated T cells (NFAT) activity. Declopramide, which contains a chloride in position 3 of the aromatic ring, was inactive in this system, whereas also the acetylated derivative of this compound inhibited NF-kappaB and NFAT activity. In contrast, the transcriptional activity and nuclear expression of activator protein 1 induced by TCR/CD28 stimulation or PMA and ionomycin treatment was enhanced by the acetylated variants of the N-substituted benzamides. Finally, we investigated the effect of N-substituted benzamides on intact promoters for two genes central in immune regulation; the CD40 ligand (CD40L) and IL-2 promoters. The transcriptional activity of the CD40L promoter as well as surface expression of the CD40L induced by signaling through TCR/CD28 was inhibited by addition of acetylated N-substituted benzamides, while the transcriptional activity of the IL-2 promoter was enhanced. Taken together, these data indicate that derivatives of N-substituted benzamides are potential drug candidates for quantitative as well as qualitative modulation of immune functions.

We have analyzed the murine CD40 ligand promoter with regard to stimulation of transcriptional activity in Jurkat T cells after signaling via the TCR and the costimulatory molecules CD28 and CD2. TCR engagement was necessary for the induction of transcriptional activity from the CD40 ligand promoter, and costimulation through either CD28 or CD2 further increased the activity. Analysis of promoter deletants showed that the DNA elements needed for transcriptional activity induced by costimulatory molecules were located within two regions containing previously identified transcription factor NFAT sites. Further studies of the proximal NFAT site showed that it was not dependent on AP-1 binding for transcriptional activity induced by costimulation through CD28. Instead, a region between the TATA box and the proximal NFAT site was shown to bind proteins of the early growth response family and to contribute to NFAT-mediated transcriptional activation.