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P78 Figure 1ConclusionThis electronic system re-vitalised the use of PEF in our asthma clinic;it is paper-light, patient-friendly and has increased our PEF diary responses, without additional cost or the requirement of a smart-phone. An average daily diurnal PEF variability >10% is valuable for the diagnosis of asthma and to assess asthma control. We continue to utilise PEF and have shared this resource across our local asthma networks. This is also likely to be beneficial in primary care to support annual asthma reviews and the requirement for at least two confirmatory diagnostic tests in the 2020/2021 NHS Quality and Outcomes Framework.

As collaborative practice is progressively being introduced into our health care systems, interprofessional education (IPE) is being implemented in medical curricula as an effective preparation. However, the extent of the effect of IPE on program specific learning outcomes in medical students is not yet fully known. To assess the effectiveness of classroom-based interprofessional education in undergraduate medical education, a systematic review was performed. Searches were performed in EMBASE, Cochrane, Medline and PubMed. The eligibility criteria were: (1) any form of interprofessional learning; (2) sample including pre-clinical students from medicine and other health care professions; (3) pre- and post-intervention assessment; (4) a clear description of the learning objectives; (5) publication in English; and (6) (non-)experimental quantitative study designs. Exclusion criteria were: (1) unidisciplinary interventions; (2) postgraduate and/or clinical phase students; and (3) interventions not tested in an educational setting. The initial search yielded 3498 articles of which 7 articles were included. Included studies exhibit relatively low quality when subjected to Cochrane instruments measuring internal validity. Training formats include multiple techniques, ranging from traditional lectures to peer group assignments. Data on learning objectives show overlapping concepts of IPE, mainly focusing on teamwork and interprofessional collaboration (n = 6). A variety of instruments were used to assess learning objectives, including validated questionnaires and self-perception questionnaires. Positive results were shown in students’ attitudes towards learning (n = 4), and interprofessional collaboration (n = 3). Qualitative data presented in the studies, collected using focus groups, interviews, and surveys (n = 5), suggest educational (n = 5) and social gains (n = 4). Most reported concerns related to difficulties of IPE implementation (n = 3). Studies on interprofessional learning report positive outcomes of teaching pre-clinical students from medicine and other health care professions. Due to the variety of objectives, the lack of constructive alignment, and the impaired methodological quality of included studies, firm conclusions about IPE effectiveness cannot be formulated. To advance interprofessional collaboration in clinical and educational practice, more insight is required into the design of effective IPE curricula and set-up of IPE research.

In bats it has been shown that they adjust their emissions to situational demands. Here we report similar findings for human echolocation. We asked eight blind expert echolocators to detect reflectors positioned at various azimuth angles. The same 17.5 cm diameter circular reflector placed at 100 cm distance at 0°, 45° or 90° with respect to straight ahead was detected with 100% accuracy, but performance dropped to approximately 80% when it was placed at 135° (i.e. somewhat behind) and to chance levels (50%) when placed at 180° (i.e. right behind). This can be explained based on poorer target ensonification owing to the beam pattern of human mouth clicks. Importantly, analyses of sound recordings show that echolocators increased loudness and numbers of clicks for reflectors at farther angles. Echolocators were able to reliably detect reflectors when level differences between echo and emission were as low as −27 dB, which is much lower than expected based on previous work. Increasing intensity and numbers of clicks improves signal-to-noise ratio and in this way compensates for weaker target reflections. Our results are, to our knowledge, the first to show that human echolocation experts adjust their emissions to improve sensory sampling. An implication from our findings is that human echolocators accumulate information from multiple samples.

This document contains results of additional acoustic analyses: Bandwidth 3dB drop, bandwidth 10dB drop, Spectral centroid (amplitude), click intensity (based on peak intensity), RDLD (based on peak intensity).

Objectives to investigate the prevalence of anaemia in pregnancy according to the cut-off points used in the national clinical guideline ‘Anaemia in Primary Care Midwifery Practice', and to investigate a possible difference in prevalence between pregnant women of Northern European descent compared with women of non-Northern European descent. The study also investigated whether any difference in prevalence resulted in a higher risk of a transferred home delivery, thus reducing the chance for women to choose the place of birth. Design retrospective cohort study. Setting primary care midwifery practices in a highly urbanised area in Amsterdam, the Netherlands. Participants all patients in three midwifery practices over 1 year were selected provided that they met the inclusion and exclusion criteria. The practices were selected on the basis of urbanisation, resulting in an adequate ethnic population which was comparable with the ethnic mix in other similarly urbanised areas in the Netherlands. This resulted in a study population of 828 pregnant women of Northern European and non-Northern European descent with low-risk singleton pregnancies during 2003. Analysis mean haemoglobin level and anaemia rate were computed for the total study population as well as separate ethnic groups. Differences between groups were determined using χ 2 tests, and effect sizes were expressed in relative risks including 95% confidence intervals (CI). Findings the prevalence of anaemia in pregnancy was 3.4% ( n =28) at booking (first visit) and 2.7% ( n =22) at approximately 30 weeks of gestation. The relative risk of anaemia at booking was 5.9 (95% CI 2.1–16.7) for pregnant women of non-Northern European descent compared with those of Northern European descent. The relative risk of anaemia at approximately 30 weeks of gestation was 22 (95% CI 3–162) for pregnant women of non-Northern European descent compared with those of Northern European descent. The incidence of transferred home delivery was 3.1% in the study population. The relative risk for transferred home delivery was 24.1 (95% CI 3.3–176.7) for pregnant women of non-Northern European descent compared with those of Northern European descent. Key conclusions and implications for practice pregnant women of non-Northern European descent are a specific group in terms of anaemia and are at high risk of a low haemoglobin level for all cut-off values; they have a higher chance of becoming anaemic in pregnancy than women of Northern European descent. As a result, they have a higher risk of a transferred home delivery, taking away their opportunity to choose the place of birth. Haemoglobinopathies did not explain the higher risk of anaemia in pregnant women of non-Northern European descent. Being of non-Northern European descent should be added as a risk factor for anaemia in pregnancy until more is known about the background of this risk factor.

Background: Early initiation of continuous positive airway pressure (CPAP) applied by face mask benefits patients with acute cardiogenic pulmonary oedema (ACPE). The simple disposable Boussignac CPAP (BCPAP) has been used in ambulances by physicians. In the Netherlands, ambulances are manned by nurses and not physicians. It was hypothesised that ambulance nurses are able to identify patients with ACPE and can successfully apply BCPAP. A prospective case series of patients with presumed ACPE treated with BCPAP by ambulance nurses is described.Methods: After training of ambulance nurses, all 33 ambulances in the region were equipped with BCPAP. ACPE was diagnosed on clinical signs and pulse oximetry saturation (Spo(2)) 80%) was generated with an oxygen flow of 15 l/min. The physiological responses, experiences and clinical outcomes of the patients were collected from ambulance and hospital records, and ambulance nurses and patients received a questionnaire.Results: From March to December 2006, 32 patients (age range 61-94 years) received BCPAP during transport to six different regional hospitals. In 26 patients (81%) a diagnosis of ACPE was confirmed. With BCPAP, median (IQR) Spo(2) increased from 79% (69-94%) to 96% (89-98%) within 20 min. The median (IQR) duration of BCPAP treatment was 26 min (21-32). The patients had no negative recollections of the treatment. Ambulance personnel were satisfied with the BCPAP therapy.Conclusion: When applied by ambulance nurses, BCPAP was feasible and effective in improving oxygen saturation in patients with ACPE. Although survival benefit can only be demonstrated by further research, it is considered that BCPAP can be implemented in all ambulances in the Netherlands.

Using an indirect immunoperoxidase technique on frozen sections with the monoclonal antibody 96.5, we investigated the in situ distribution of melanotransferrin, a transferrin (Tf) and transferrin receptor (TfR) related glycoprotein, in human liver. Specimens included normal liver, liver in iron overload, hepatocellular carcinoma, angioma and foetal liver. On light microscopy, immunoreactivity was almost exclusively present on sinusoidal lining cells, apparently endothelial cells; the pattern was similar in normal and in iron-loaded liver. A gradient of more enhanced staining in acinar zone II and III was observed. The endothelial localization of the staining was supported by the positivity of the central vein endothelium and of the angiomas. Immunoelectron microscopy on three liver specimens showed positivity on sinusoidal endothelial cells but not on Ito and Kupffer cells. In addition, positivity on rough endoplasmic reticulum vesicles of some hepatocytes was also present. Four hepatocellular carcinomas showed an intense staining in tumour cells, 3 were weakly positive and 3 were negative. In the foetal livers, the central vein endothelium was positive from 21 weeks of gestation onward and additional positivity of zone III sinusoidal endothelial cells was present from 27 weeks on. The present results show that in the liver melanotransferrin has a localization different from Tf and the TfR. These latter molecules are predominantly localized in parenchymal cells. In addition, there does not appear to be a coordinate regulation secondary to iron storage, between melanotransferrin, Tf and the TfR. The observed gradient in the staining pattern in foetal and adult liver specimens further supports the heterogeneity of the endothelial cell population in the liver and suggests a developmental relationship between endothelial cells of sinusoids and central vein.

OBJECTIVE: The aim of this study was to describe the variation of normal maternal temperature during labour. Design A prospective cohort study. SETTING: Two hospitals in Amsterdam, the Netherlands. POPULATION: All women with a live singleton pregnancy and a gestational age of 36 weeks or more admitted to the delivery ward from June 2000 to January 2002. METHODS: Maternal temperature was measured rectally every 2-3 hours from admission until the beginning of second stage, and 1-hour postpartum. Normal labour (n = 843) was defined as gestational age > or =37 weeks, spontaneous onset of labour, rupture of membranes 0.05) but increased thereafter. CONCLUSIONS: At the beginning of labour, temperature was 37.1 degrees C. Temperature increased slowly during labour and was 37.4 degrees C (2SD 1.2) after 22 hours. The upper 2SD limit for normal temperature did not follow a circadian pattern and time of day is not relevant for the classification of normal versus elevated temperature

The effect of the flood water salinity on the mobility of heavy metals was studied for intertidal sediments of the Scheldt estuary (Belgium). Soils and sediments of 4 sampling sites were flooded with water of different salinities (0.5, 2.5, and 5 g NaCl L-1). Metal concentrations were monitored in pore water and Surface water. To study the potential effects of flood water salinity on metal bioavailability, duckweed (Lemna minor) was grown in the surface water. The salinity was found to primarily enhance the mobility of Cd and its uptake by duckweed. Cadmium concentrations in pore water of soils and sediments and surrounding surface waters significantly exceeded sanitation thresholds and quality standards during flooding of initially oxidized sediments. Moreover, the effect was observed already at lower salinities of 0.5 g NaCl L-1. This implies that risks related to Cd uptake by organisms and Cd leaching to ground water are relevant when constructing flooding areas in the brackish zones of estuaries. These risks can be reduced by inducing sulphide precipitation because Cd is then immobilised as sulphide and its mobility becomes independent of flood water salinity. This could be achieved by permanently flooding the polluted sediments, because sulphates are sufficiently available in the river water of the brackish part of the estuary.

Whipple's disease is a multisystem disorder with protean manifestations and with poorly understood aetiopathogenesis. It is unclear how the immune system reacts, whether it functions normally or not, whether it protects the organism or is defeated in one way or another by the 'Whipple bacillus'. The purpose of our study was to assess humoral and cellular immunity at the level of the intestinal mucosa. This histochemical, immunocytochemical and electronmicroscopic study, based on 16 cases, has shown that the changes in components of the mucosal immune system in Whipple's disease are quite different from normal. The phagocytic capacity of the macrophages, assessed microscopically, is abnormal, the number of intra-epithelial lymphocytes is increased, the CD 4/CD 8 cell ratio is decreased and the IgM positive cells in the lamina propria outnumber the IgA positive cells. These changes may be inter-dependent.

The Nyctemera clatrathum complex (Lepidoptera: Arctiidae, Arctiinae, Callimorphini) is revised. It consists of seven species, occurring on New Guinea and surrounding islands, of which three are new to science: Nyctemera giloloensis sp. n., N. oninica sp. n. and N. dauila sp. n. Two taxa are synonymized: Leptosoma absurdum Swinhoe, 1892 syn. n. of Leptosoma clathratum Snellen van Vollenhoven, 1863 and Deilemera pratti Bethune-Baker, 1904 syn. n. of Nyctemera mesolychna Meyrick, 1889. Lectotypes are designated for Deilemera pratti Bethune-Baker, 1904 and Deilemera absurdum latimargo Rothschild 1915. Adults and genitalia of all species are figured and distribution maps are presented.

Objective: To describe the triage of patients operated for non-ruptured and ruptured abdominal aortic aneurysms (AAAs) before the endovascular era.Design: Retrospective single-centre cohort study.Methods: All patients treated for an acute AAA between 1998 and 2001 and admitted to our hospital were evaluated in the emergency department for urgent AAA surgery. All time intervals, from the telephone call from the patient to the ambulance department, to the arrival of the patient in the operating theatre, were analysed. Intraoperative, hospital and 1-year survival were determined.Results: 160 patients with an acute AAA were transported to our hospital. Mean (SD) age was 71 (8) years, and 138 (86%) were men. 34 (21%) of these patients had symptomatic, non-ruptured AAA (sAAA) and 126 patients had ruptured AAA (rAAA). All patients with sAAA and 98% of patients with rAAA were operated upon. For the patients with rAAA, median time from telephone call to arrival at the hospital was 43 min (interquartile range 33-53 min) and median time from arrival at the hospital to arrival at the operating room was 25 min (interquartile range 11-50 min). Intraoperative mortality was 0% for sAAA and 11% for rAAA (p = 0.042), and hospital mortality was 12% and 33%, respectively (p = 0.014).Conclusions: A multidisciplinary unified strategy resulted in a rapid throughput of patients with acute AAA. Rapid transport, diagnosis and surgery resulted in favourable hospital mortality. Despite the fact that nearly all the patients were operated upon, survival was favourable compared with published data.

We present the case of a 3.5-year-old boy with sudden anal blood loss at school. Sexual abuse was suspected, and, apart from anal fissures seen on sigmoidoscopy, no other clinical signs of any sort of disorder were present. As no medical explanation for the blood loss could be given, penetrating anal trauma was suggested. During follow-up consultations, there were complaints of occasional blood loss. Platelet aggregation tests and electron microscopy finally helped diagnose a delta-storage pool disease which is a rare haemostatic disorder involving the dense granules of the platelets. Although exclusion of well-known blood diseases through routine laboratory testing is a common practice in children with sudden blood loss, this case illustrates the value of more specialised investigation both from a diagnostic and forensic point of view.

Background The best dressing for postoperative wounds healing by secondary intention is unknown. Methods A systematic review was conducted to assess the effectiveness of dressings and topical agents on such wounds. Main endpoints were wound healing, pain, patient satisfaction, costs and hospital stay. Systematic methodological appraisal and data extraction were performed by independent reviewers. Results Fourteen reports of 13 randomized clinical trials on dressings or topical agents (gauze, foam, bead, alginate and hydrocolloid dressing) for postoperative wounds healing by secondary intention were identified; they were of weak methodological quality. In general, no statistically significant differences in wound healing were found for various dressing comparisons (11 of 13 trials). Patients experienced significantly more pain (four of six trials) and were less satisfied when gauze was used (three of six trials). Gauze was inexpensive, but its use was associated with significantly more nursing time than dressing with foam (two of three trials). No substantial differences in hospital stay were found (four of five trials). Conclusions Only small, poor-quality trials exist, rendering the evidence insufficient. Foam is best studied as an alternative to gauze and appears to be preferable in terms of pain reduction, patient satisfaction and nursing time.

Objective:Assessment of clinimetric properties and diagnostic quality of a stress measurement scale (COMFORT scale).Design:Sample of an open population.Setting:Neonatology department (Neonatal Intensive Care Unit), Academic Medical Centre/Emma Children’s Hospital, Amsterdam, the Netherlands.Method:One clinical expert and 9 observers observed ventilated premature born babies simultaneously. Criterion validity was assessed by correlating the COMFORT scale with the clinical judgment regarding the amount of stress. Interobserver reliability was assessed on the clinical judgment as well as on the COMFORT scale. Diagnostic qualities were evaluated with a ROC curve.Results:On 19 ventilated prematurely born babies (mean gestational age 30 weeks, mean birth weight 1385 gm), one clinical expert and 9 observers made 30 paired observations. The criterion validity of the COMFORT scale was good (Pearson’s r of 0.84). The interobserver reliability of the clinical judgment was very good (weighted Kappa 0.84). The interobserver reliability of each item varied from good to almost perfect (weighted Kappa of 0.64 for muscle tone to 1.00 on heart rate). The reliability of the total COMFORT scale score was satisfying (intraclass correlation coefficient of 0.94). The diagnostic quality of the COMFORT scale was excellent, at a cut-off point of 20 the sensitivity was 100 percent, the specificity was 77 percent, and the area under the curve (AUC) of 0.95.Conclusion:In this first evaluation, the COMFORT scale appears to be a valid and reliable measurement tool to assess the stress of ventilated prematurely born babies.

Branding is a key strategic tool used to create awareness, reputation and build the organisation’s image. Marketers consider brands as carriers of values, and the development and implementation of branding strategies and programmes have lately expanded to include more than the traditional corporate, product and service domains of branding. In this article we set out to define and briefly discuss the nature of branding and indicate how brands are used to define the product to the customer. One of the major challenges facing South African business and marketing executives in the new millennium is to create world-class brands that will put South African brands on the national and international map.

Doel. Vaststellen van de klinimetrische eigenschappen en diagnostische kwaliteit van een meetinstrument voor stress ((comfort-schaal).

We report here a unique case of a 55-year-old woman presenting with a clinical picture of Parkinson disease, severe back pain, splenomegaly, and pronounced dyspnea. Radiographic examination of the spine showed multiple vertebral fractures. Niemann-Pick disease type B was diagnosed by findings of lipid-loaded histiocytes and a strongly reduced sphingomyelinase enzyme activity. She was homozygous for the deletion of codon 608 (delR608), which encodes an arginine residue in the Acid Sphingomyelinase gene. To investigate the cause of the unusual vertebral fractures, we screened for polymorphisms previously described as possibly associated with increased risk for osteoporosis and fractures. Our patient was heterozygous for the polymorphisms of the vitamin D receptor gene, the estrogen receptor gene, and the collagen 1A1gene. Increased physical activity after Parkinson treatment, a genetic predisposition, together with worsening disease due to interfering medications could explain the dramatic presentation of this patient. She was treated with cholesterol lowering drugs such as statins to decrease sphingomyelin synthesis, avoidance of drugs that inhibit sphingomyelinase, and bisphosphonates. No new fractures have occurred, but the interstitial lung disease has progressed.

Extragenital malignant mixed mesodermal (müllerian) tumors (MMMT) are rare neoplasms, with but 24 well documented cases in the literature. Neuroendocrine differentiation in mixed müllerian neoplasms has been mentioned only anecdotally. We report on the clinical, pathological, and immunohistochemical features of a hitherto-undescribed extragenital MMMT with prominent neuroendocrine differentiation arising from the jejunal mesentery. This lesion was composed of a poorly differentiated epithelial component and a spindle cell component with heterologous (rhabdomyoblastic) differentiation. The bulk of the tumor consisted of small cell neuroendocrine carcinoma, which exhibited strong immunoreactivity for NSE, LEU-7, chromogranin A and synaptophysin. Electronmicroscopy confirmed the presence of neurosecretory dense-core granules. The primary mesenteric origin of the tumor was established at autopsy. Along with a brief review of previously reported extragenital MMMT some histogenetic concepts relevant to this case are discussed.

Aims: Synovial sarcoma with extensive calcification and ossification is a rare variant, the ultrastructural, cytogenetic and molecular analysis of which has not been reported previously. Methods and results: A large mass in the shoulder of a 20-year-old male patient led to a deformity of the chest wall, thus supporting the hypothesis that this is a slowly growing variant of synovial sarcoma. Nevertheless, the patient developed metastatic lung disease 7 months after resection. On histology, the monophasic spindle cell proliferation was in several areas obscured by the massive calcification and ossification. Immunohistochemistry showed keratin, epithelial membrane antigen, vimentin and CD99 expression. The cytogenetic analysis revealed a single t(X;18)(p11.2; q11.2), typical for synovial sarcoma. Additional fluorescence in-situ hybridization revealed SSX2 involvement. At the ultrastructural level, prominent needle-shaped intramitochondrial crystals were present, both in the cytoplasm and in the extracellular matrix. Conclusion: The presence of the t(X;18) with SSX2 involvement definitively characterizes this tumour as a variant of synovial sarcoma. In addition, the needle-like mitochondrial calcifications give a possible clue to the pathogenesis of the extensive metaplastic ossification and calcification.

Immunocompromised patients may have severe forms of infections. Since there is an increasing number of patients maintained under immunosuppressive therapy, we will be confronted with increasing frequency with these infectious problems. Effective treatments will be of great value. The case is described of a renal transplant with a giant orf lesion, which continued growing instead of regressing spontaneously as is observed usually. The treatment options in such patients are limited. It was decided to treat the patient with the antiviral drug cidofovir (HPMPC, Vistide. Topical cidofovir treatment resulted in complete regression of the lesion. This case is discussed in the context of the known literature on orf (ecthyma contagiosum).

Aims After their original recognition in the kidney, angiomyolipomas (AMLs) have been reported in the liver for more than 20 years. In the kidney, five cases of malignant AML have been reported. We report the first case of malignant hepatic AML. Methods and results A 70-year-old female patient presented with abdominal discomfort. Clinical examination revealed a palpable liver. CT scan showed a polymorphous hypervascular lesion in the right liver lobe. A biopsy was taken and resulted initially in a differential diagnosis between a hepatocellular carcinoma, a metastatic tumour (possibly of renal origin) and angiomyolipoma (AML). After immunohistochemistry, a hepatic AML was suggested, given the immunoreactivity for HMB45/NKIC-3. The mass was resected 5 years later because of relapsing abscess formation. Gross examination of the resection specimen showed a focally encapsulated brown mass with focal necrosis. Microscopic examination showed a tumour growing in sheets, separated by sinusoidal-like vessels. Most of the tumour cells had a large, polygonal, clear cytoplasm, often with eosinophilic condensation around the nucleus. There was prominent vascular invasion. Immunohistochemistry (reactivity for HMB-45, NKIC-3, S100 and alpha smooth muscle actin, negativity for cytokeratin and vimentin) and electron microscopy confirmed the diagnosis of monomorphic epithelioid AML with prominent vascular invasion. Seven months after tumour resection, the patient died of recurrent disease. Conclusions This case highlights the importance of immunohistochemistry and electron microscopy in diagnosing this type of tumour. Possibly, in the past, malignant AML of the liver has been misdiagnosed as HCC.

Single cells or small cell clusters, isolated from the rat lacrimal gland, were incubated on reconstituted basement membrane (matrigel) in a well-defined serum-free medium. During the first days of culture, cells reassociated and reorganized in structures resembling acini. These multicellular structures, maintained in culture for 2 weeks, consisted of well-polarized cuboidal cells surrounding a central lumen and exhibiting apically located microvilli. Myoepithelial cells were observed at the periphery of the acinar structures. Both in the native lacrimal and in the cultured aggregates, epithelial cells displayed strong immunoreactivity for cytokeratin 8, while myoepithelial cells were immunoreactive for vimentin and alpha-smooth muscle isoactin. These data indicate that the cultured aggregates closely mimic the in vivo architecture of lacrimal glands both by morphology and immunohistochemistry. We further demonstrated the presence of an intact androgen receptor and the ability of the cultured aggregates to respond to androgens with increased secretion of the secretory component. Comparable androgen responses were observed in lacrimal gland cultures of 5-week-old male and female rats. In conclusion, we report a morphologically and functionally differentiated culture system of primary rat lacrimal cells, in which androgen-regulated gene expression was observed. This culture model provides a unique experimental paradigm for studying the effects of hormones, cytokines, and growth factors on the morphogenesis, growth, and functional differentiation of lacrimal glands. (C) 1998 Academic Press.

The purpose of this study was to describe the chain of survival in Amsterdam and its surroundings and to suggest areas for improvement. To ensure accurate data, collection was made by research personnel during the resuscitation, according to the Utstein recommendations. Between June 1, 1995 and August 1, 1997 all consecutive cardiac arrests were registered. Patient characteristics, resuscitation characteristics and time intervals were analyzed in relation to survival. From the 1046 arrests with a cardiac etiology and where resuscitation was attempted, 918 cases were not witnessed by EMS personnel. The analysis focussed on these 918 patients of whom 686 (75%) died during resuscitation, 148 (16%) died during hospital admission and 84 patients (9%) survived to hospital discharge. Patient and resuscitation characteristics associated with survival were: age, VF as initial rhythm, witnessed arrest and bystander CPR. EMS arrival time was significantly shorter for survivors (median 9 min) compared to non-survivors (median 11 min). In 151 cases the police was also alerted and arrived 5 min (median) earlier than EMS personnel. Using the OPC/CPC good functional health was observed in 50% of the survivors and moderate performance in 29%. All links in the chain of survival must be strengthened, but equipping the police with semi-automatic defibrillators may be the most useful intervention to improve survival.

This paper presents the design and development of a dual-band switched-beam microstrip array for global navigation satellite system (GNSS) applications such as ocean reflectometry and remote sensing. In contrast to the traditional Butler matrix, a simple, low cost, broadband and low insertion loss beam switching feed network is proposed, designed and integrated with a dual band antenna array to achieve continuous beam coverage of ±25° around the boresight at the L1 (1.575 GHz) and L2 (1.227 GHz) bands. To reduce the cost, microstrip lines and PIN diode based switches are employed. The proposed switched-beam network is then integrated with dual-band step-shorted annular ring (S-SAR) antenna elements in order to produce a fully integrated compact-sized switched-beam array. Antenna simulation results show that the switched-beam array achieves a maximum gain of 12 dBic at the L1 band and 10 dBic at the L2 band. In order to validate the concept, a scaled down prototype of the simulated design is fabricated and measured. The prototype operates at twice of the original design frequency, i.e., 3.15 GHz and 2.454 GHz and the measured results confirm that the integrated array achieves beam switching and good performance at both bands.

This paper presents the design of a novel multipath mitigating ground plane for global navigation satellite system (GNSS) antennas. First, the concept of a compact low multipath cross-plate reflector ground plane (CPRGP) is presented. In comparison with the choke ring and electromagnetic band gap (EBG) ground planes, the proposed CPRGP has compact size, low mass, wide operational bandwidth, and simple configuration. The proposed CPRGP is then integrated with a circularly polarized dual-band GNSS antenna in order to assess the multipath mitigating performance over two frequency bands. Measurement results of the proposed CPRGP with GNSS antenna achieves a front-to-back ratio (FBR) over 25 dB at L1 (1.575 GHz) and L2 (1.227 GHz) bands and maximum backward cross-polarization levels below ${-}$ 23 dB at both bands. Antenna phase center variation remains less than 2 mm across both L1 and L2 bands. Furthermore, the performance comparison of the proposed CPRGP with the commercially available pinwheel antenna and the shallow corrugated ground plane is presented, showing the advantages of CPRGP for high precision GNSS applications.

The mechanism of bile ductular reaction and accompanying fibrogenesis depends on interactions of ductular cells with the matrix and growth factors. Heparan sulfate proteoglycans (HSPGs) are essential cofactors in cell-matrix adhesion processes, in cell-cell recognition systems, and in receptor-growth factor interactions. We used monoclonal antibodies specific for the cell surface HSPGs (syndecans, glypican), for matrix HSPG (perlecan), and for heparan sulfate carbohydrate (HS) to investigate their immunohistochemical expression in 20 specimens with chronic cholestatic liver disease and in five normal human liver specimens. Because activated hepatic stellate cells (HSC are a major source of fibrosis in the liver, we also examined HSPG expression in primary cultures of human activated HSC using immunocytochemistry and Western blotting and for syndecan-1 also Northern blotting. In comparison with bile ductular cells of normal liver, reactive ductules in chronic cholestasis were marked by an elevated expression of syndecan-1, surrounded by an increased perlecan expression. In acinar zone 1, large stimulated macrophages and HSC, present in increased numbers, were strongly positive for syndecan-3. Cultured HSC showed a membranous staining pattern for syndecan-1, syndecan-3, and heparan sulfate, and in addition intracellular staining for syndecan-2, -3, and 4. Perlecan immunoreactivity was detected as intercellular strings. Western blotting revealed positive bands with all antibodies and Northern blotting for syndecan-1 was also positive. These results show that cultured human HSC can synthesize all four syndecans, glypican, and perlecan. These data reveal changes in the expression of syndecan-1, syndecan-3, and perlecan in human chronic cholestatic liver disease, that may be important in the deposition of matrix components and activation of growth factors that support ductular reaction and accompanying fibrogenesis.

Vacuum based insulation technology results, when introduced into appliances, in a substantial reduction in energy consumption of these appliances. This reduction depends on two factors: primarily on the vacuum panel technology used, but also, very importantly, on the quality of the polyurethane foam used to fill the confined space in the refrigerator walls after incorporation of the vacuum panels. ICI Polyurethanes has now developed both an open-celled, fine-celled polyurethane foam, eminently suitable for vacuum panel technology, and a polyurethane foaming technology, based on both CO2 and physical blowing agents, including alkanes, specifically designed to complement the vacuum panel technology. This paper reports on the status of both technologies. Since the morphology and physical properties of the open-celled polyurethane foam are substantially different from existing vacuum technologies, a complete assessment of the technical requirements for the open-celled foam has been performed. We believe the cost effectiveness, weight and ease of production weigh heavily in favour of the polyurethane foam based vacuum technology. In addition, the specific requirements for the encapsulation foam will be presented in terms of flow performance, pressure and temperature build-up and adhesion towards several liner materials. Evaluation of our technology is ongoing with a number of appliance manufacturers.

We report on the predominance of a special type of small histiocyte in the inflammatory infiltrate accompanying herpetic bullae. These histiocytes, which have previously been taken to be neutrophils, are freshly arrived cells with a hitherto unknown function. Until now, they have been found only in Sweet's syndrome and erythema nodosum where they form Miesscher's radial granulomas. Similar small histiocytes were found in half of those herpetic lesions with intact bullae, and in over two-thirds of ulcerated lesions in which these cells formed a palisade in the fibrinoid material covering the floor of the ulcerated vesicles. Small histiocytes, admixed with neutrophils, were in close proximity to virally infected keratinocytes. Immunohistochemical analysis confirmed their histiocytic nature. With the exception of ecthyma contagiosum (orf), similar small histiocytes were not found in other viral infections or in nonspecific ulcers of the skin. In cases of herpetic folliculitis, small histiocytes showed massive epidermotropism towards hair follicle epithelium. We conclude that cutaneous and oral herpetic infections represent yet another disease in which small, freshly arrived histiocytes occur. They may be involved in antigen presentation, or in killing of infected keratinocytes.

Focal nodular hyperplasia is a tumour like lesion, characterized by a central fibrous scar with irradiating fibrous septa that surround hyperplastic nodules and contain multiple bile ductules. The origin of the bile ductular structures is not clear. Recently, we found evidence for the existence of human counterparts of rat oval cells (potential stem cells) that have the ability of differentiating towards both bile duct cells and hepatocytes. These cells were found in regenerating human liver as well as in chronic cholestatic conditions. Because cholestatic features are seen in focal nodular hyperplasia, we initiated an immunohistochemical study on 23 surgical specimens using antibodies specific for cytokeratins 7 and 19 (bile duct type cytokeratins), OV6 (rat oval cell marker), chromogranin-A (shown to be positive in reactive bile ductules and human oval-like cells) and neural cell adhesion molecule--NCAM (shown to be positive in reactive bile ductules) to investigate whether 'undifferentiated progenitor cells' are also present in focal nodular hyperplasia. Electronmicroscopy was applied in five cases. Bile ductules invariably showed immunoreactivity for CK7 and 19, OV6, chromogranin-A and NCAM. In addition, small individual cells with an oval nucleus and a small rim of cytoplasm, in the vicinity of the septa, were immunoreactive for chromogranin-A, CK7 and 19 and OV6. These cells were hardly recognizable on routine light microscopy. Clusters of periseptal hepatocytes, seemingly in continuity with bile ductular structures, had a transitional phenotype: they stained positive for chromogranin-A, CK7 and OV6 and sometimes formed liver cell rosettes. The number of OV6-positive hepatocytes was greater than the number of chromogranin-A and CK7 positive hepatocytes. This indicates that, in human liver, OV-6 is not purely a marker of progenitor cells. Ultrastructurally, small immature cells, highly resembling rat oval cells, were recognized in the vicinity of septa. In addition, transitional cells displaying characteristics both of hepatocytes and bile duct cells were also present. These results confirm the presence of 'undifferentiated progenitor cells' in focal nodular hyperplasia and suggest that the ductular reaction in these lesions results, at least partly, from activation of these cells.

Epinephrine is the only physiological platelet activator which induces platelet aggregation without a preceding change in platelet shape. The reason why epinephrine cannot induce this shape change is not known. Electron microscopically, we could show that during the first phase of epinephrine-induced platelet aggregation, the platelet aggregate is composed of discoid platelets, lying in rather loose contact with neighbouring platelets. During the second wave of epinephrine-induced aggregation (this is when thromboxane (TX)A(2) production has taken place), platelets have completely lost their discoid shape and are very tightly bound. In EDTA-platelet rich plasma (PRP), we could demonstrate a clear synergistic action of epinephrine 10-20 μM on the first phase of shape change (disc-to-sphere transformation), induced by low concentrations of arachidonic acid (AA), collagen, adenosine diphosphate (ADP) and platelet activating factor (PAF). In combination with moderate concentrations of AA or collagen, epinephrine induced a clear aggregation-independent secretion of platelet granules, which in the absence of epinephrine, only takes place with higher inducer concentrations. All these synergistic actions could be demonstrated in the aggregometer and electron microscopically. To explain these findings, we hypothesize that the inability of epinephrine to induce a shape change that precedes aggregation is due to slow generation of TXA(2) which is only formed as a positive feedback mechanism of aggregation. This TXA(2) will bind to its own receptor and produce a shape change coinciding with the second wave of epinephrine-induced aggregation. Collagen, in contrast, induces very rapid TXA(2) generation, causing Ca(2+) mobilization and myosin light chain-phosphorylation, leading to shape change, clearly before aggregation starts.

Background & aims Both undernutrition – low fat free mass (FFM) – and obesity – high fat mass (FM) – have been associated with adverse outcome in cardiac surgical patients. However, whether there is an additional effect on outcome of these risk factors present at the same time, that is sarcopenic obesity (SO), is unknown. Furthermore, the association between SO and muscle function is unidentified. Methods and results In 325 cardiac surgical patients, we prospectively analysed the association between preoperative FFM and FM, measured by bioelectrical impedance spectroscopy, and postoperative adverse outcomes, and their correlation with muscle function – handgrip strength (HGS). SO was associated with postoperative infections (28.2% vs. 5.3%, adj. odds ratio (OR): 7.9; 95% confidence interval (CI): 1.2–54.1; p = 0.04). Further, a low FFM index (FFMI; kg m −2 ) was associated with postoperative infections (18.5% vs. 4.7%, adj. OR: 6.6; 95% CI: 1.7–25.2; p = 0.01) while a high FM index (FMI; kg m −2 ) was not. Both components of SO, FFMI and FMI, correlated with HGS (FFMI: r = 0.570; p r = −0.263; p Conclusion SO is associated with an increased occurrence of adverse outcome after cardiac surgery. Our results suggest an additional risk of a low FFMI and high FMI present at the same time. Furthermore, SO is characterised by less muscle function. We advocate determining body composition in cardiac surgical patients to classify and treat undernourished patients, in particular those who are also obese.

Since 1989, the appliance industry has progressively adopted 50 percent reduced-CFC foam systems, following the establishment of the Montreal Protocol. However, a variety of options to fully replace CFC-11 are under investigation. The 1990 Montreal Protocol Amendment introduced the concept of «transitional substances» to describe partially halogenated compounds (HCFCs) which show a greatly reduced ozone depletion potential (ODP). These materials are seen by the polyurethanes industry as the most viable short- and medium-term alternatives for foam blowing

A typical case of alveolar soft-part sarcoma was examined using ultrastructural, immunohistochemical and cytogenetic methods. Immunohistochemical stains were performed on frozen sections and showed strong desmin expression with the three anti-desmin antibodies used. In addition, the tumour cells were weakly positive for vimentin and myosin. Neural markers were negative. Chromosomal analysis showed consistent involvement of 17q25--an abnormality which has been reported in another alveolar soft-part sarcoma. The histogenesis of alveolar soft-part sarcoma is still debatable but our findings support a myogenic origin. The finding of an apparently identical chromosomal abnormality in two of three thus far examined cases of alveolar soft-part sarcoma is of interest and must await further confirmation, but it may result in the identification of a chromosomal marker for this enigmatic tumour and thus pave the way for further molecular elucidation.

Summary. Background: Regulator of G-protein signaling (RGS) 2 negatively regulates Gs signaling by inhibiting the activation of adenylyl cyclase (AC). RGS2 mRNA contains four translation initiation sites, leading to four isoforms with different abilities to inhibit AC activity; the largest isoform is the most pronounced inhibitor. A role for RGS2 in platelets is not known. Objective: To describe a heterozygous RGS2 mutation (G23D) in three related patients, leading to Gs hypofunction in their platelets, and to study the mechanism behind the effect of the RGS2 mutation on platelet function and morphology. Methods: Gs signaling was studied ex vivo in platelets and in vitro in transfected cells. Translation initiation was evaluated in vitro, and the interaction of wild-type and G23D RGS2 with AC was unraveled via immunoprecipitation. Platelet granule content was analyzed with proteomics. Results: The mutation leads to reduced cAMP production after stimulation of Gs-coupled receptors. The largest RGS2 isoforms, with strong AC inhibitor activity, are enriched when the mutation is present, as compared with wild-type RGS2. Moreover, the mutation results in a stronger interaction of RGS2 with AC. G23D RGS2 carriers have enlarged, round platelets with abnormal α-granules. Proteomics of the platelet releasate revealed altered expression of some proteins involved in actin assembly, and carriers seemed to have a reduced platelet shape change. Conclusions: We present the first platelet Gs signaling defect caused by a heterozygous RGS2 variant that results in a unique mutational mechanism, such as the differential use of translation initiation sites resulting in different functional RGS2 isoforms.

A case of primary malignant rhabdoid tumour of the liver occurring in a 5-month-old girl is reported. Histologically the neoplasm presented the 'typical' features as described in malignant rhabdoid tumour arising in the kidney. In addition, some areas of the tumour showed a 'pseudoglandular' growth pattern. Immunohistochemistry revealed the neoplastic cells to be intensively positive for vimentin and for cytokeratin 19. Variable immunoreactivity for cytokeratin polypeptides 7, 8 and 19 was also detected. On electronmicroscopy the neoplastic cells contained bundles of intermediate filaments, tonofilaments and intercellular junctions. These findings are suggestive of a primitive epithelial differentiation.

Summary. Background: The effect of cholestatic liver disease on primary hemostasis function remains ill-defined. Objectives: To determine platelet function and identify the mechanisms involved in the observed platelet function in cholestatic rats. Methods: Platelet function was studied in a model of 2-week bile duct ligation and compared to that in sham-operated rats with and without a storage pool defect. Results: ADP-induced and collagen-induced platelet aggregation were clearly impaired following bile duct ligation (P