Patient reported no significant family history or risk factors for spontaneous subarachnoid hemorrhage. The physician reviewed the CT scan copy, which showed a frontal subarachnoid hemorrhage and small parafalcine subdural hematoma. The patient was admitted for observation and then discharged the next day with a diagnosis of traumatic subarachnoid hemorrhage and postconcussive syndrome. Because the patient was from another part of the state, he was given copies of his medical records and instructed to follow up with a local physician within two to four weeks or with worsening symptoms. Outcome: The patient apparently suffered worsening symptoms within several days and, 21 days after the motor vehicle accident, he collapsed with massive intraparenchymal and intraventricular hemorrhage. Subsequent work up revealed a ruptured interior communicating artery aneurysm. The patient suffered severe brain damage with persistent postoperative vegetative state requiring nursing home care until his death two weeks later. Board Comment: The Board encourages all physicians to employ the same practices now used by the physician in this case. Specifically: 1 ; When accepting a patient in transfer from an outside hospital, be sure to obtain written copies of all reports for all studies performed at the outside hospital. Do not rely on verbal reports or on copies of scans. 2 ; Do not rely on the patient or hospital staff to confirm that follow up appointments and referrals are obtained. All follow up appointments should be confirmed by the physician's office staff. A tickler file should be set up for all patients upon discharge to assure patient compliance and written feedback from consulting or following physicians. 3 ; The physician's office nurse contacts patients within one week following discharge for a "wellness check", and to make certain the patient understands and complies with discharge instructions.
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On the TOL spatial planning task, all three drug user groups solved significantly fewer problems correctly, and therefore needed more attempts relative to controls. However, on the easy stage of the task, performance was intact. Despite having problems with spatial planning, drug users did not deliberate longer on the problems. This stands in contrast to other patient groups with a fronto-striatal pathology, such as patients with Parkinson's Disease or with schizophrenia, who also perform poorly on the TOL Owen et al, 1992, 1995a; Pantelis et al, 1997 ; . The fact that our drug users and controls did not differ on response latency may indicate that drug users did not reflect sufficiently long to solve the problems accurately. The significantly higher number of errors on the TOL in our drug user groups compared to controls is in keeping with evidence for prefrontal dysfunction in chronic drug users Ersche et al, 2005; Hester and Garavan, 2004; Paulus et al, 2002 ; since the right DLPFC has shown to be critically involved in spatial planning on the TOL Baker et al, 1996; Manes et al, 2002 ; . Drug users' performance on the 3D-IDED task did not significantly differ from controls, although it has been reported that the right DLPFC is implicated in the critical EDS stage relative to IDS ; Rogers et al, 2000 ; . It is possible that group differences in performance on the 3D-IDED task did not emerge because only 78% of our controls, who were specifically selected to match the drug user groups, passed the EDS stage. The relatively high number of controls failing the EDS stage led to an overall pass rate of the task of 63%. Previous research with this task indicates a pass rate around 80% in healthy volunteers, albeit in participants with a high level of education Mehta et al, 1999 ; . On the other hand, unimpaired performance of substance users in comparison to healthy controls has been found on the WCST Grant and Berg, 1948 ; , which contains a similar set-shifting component to the 3D-IDED task Simon et al, 2002, in cocaine users; Rotheram-Fuller et al, 2004, in methadone-maintained opiate users; Pau et al, 2002, in former heroin users ; . Our results, however, contrast with the impaired performance on a related but different test of attentional setshifting in chronic substance users relative to healthy controls reported by Ornstein et al 2000 ; . There are a number of possible explanations for the differing findings. One possibility may be due to the fact that we used a different task, which includes three stimulus dimensions similar to the WCST. Using a two-dimension task, Ornstein et al 2000 ; reported an overall pass rate of 90% in controls, which may assist the detection of deficits in attentional setshifting. It is thus likely that, due to the poor performance of our controls on the EDS stage, the high number of EDS errors in amphetamine users, as shown in Table 3, did not reach significance. In addition, sample size, demographic, and clinical characteristics of the groups differed between the two studies. However, in accordance with Ornstein et al 2000 ; , we did not find significant group differences on reversal errors, which are considered to reflect orbitofrontal dysfunction Hornak et al, 2004 ; . Severe impairments in drug users relative to controls were evident in the PAL task, which requires forming associations between a stimulus what ; and a spatial.
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Sales growth in Europe was boosted by a dynamic performance across the entire portfolio, especially Lantus up 40.5% on a comparable basis ; , Eloxatine up 31.4% on a comparable basis ; , Taxotere up 20.1% on a comparable basis ; and Plavix up 20.5% on a comparable basis ; . Overall, our net sales advanced by 8.2% in Europe on a comparable basis, despite less dynamic performances in Germany and France towards the end of the year. In Germany, price pressure intensified, due largely to the extension of the reference price system to new therapeutic classes. In France, our sales were adversely affected by purchasers holding back in anticipation of the healthcare system reforms planned for 2006 and by price reductions. In the United States, our net sales grew by 11.5% in 2005 on a comparable basis. Growth was affected by competition from generics of four products Allegra, Amaryl, A4ava and DDAVP ; . Excluding the net sales impact of the four products affected by competition from generics i.e., excluding our net U.S. sales of Allegra and Araava since September, of Amaryl since October and of DDAVP since July, for both 2005 and 2004 ; , our remaining sales increased by 17.4% on a comparable basis. Our net sales in "Other countries" increased by 8.2% on a comparable basis during 2005 to 5, 611 million. Other Revenues In 2005, other revenues amounted to 1, 202 million, compared with 1, 109 million in 2004. The increase was mainly due to higher royalties from the Plavix and Aprovel worldwide alliance with BMS. Gross Profit Our consolidated gross profit amounted to 20, 947 million in 2005, compared to 19, 390 million on a pro forma basis in 2004, an increase of 8.0%. The gross margin ratio was 76.7% in 2005, compared with pro forma 76.9% in 2004. The impact of the workdown of Aventis inventory remeasured at fair value on this line amounts to 394 million in 2005. Without this impact, the gross margin ratio would amount to 78.1%, the improvement compared to pro forma 2004 was due to stronger sales, a more favorable product mix, productivity gains and our purchasing policy. Research and Development Expenses Our research and development expenses totaled 4, 044 million, equivalent to 14.8% of net sales, and 2.0% higher than the pro forma 2004 figure. The year-on-year trend reflects: a marked increase in headcount during the second half of 2005; tight control over operating costs, plus the direct impact of purchasing efficiencies within the enlarged Group and the favorable effects of greater internationalization of our scientific activities; and an in-depth review of the product portfolio, which led to the discontinuation of some third-party collaborations and atorvastatin.
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1. Travel Cases were identified who had travelled in the United Kingdom or abroad in the month prior to the date of notification or in the month prior to the onset of illness. Fourteen 14% ; cases had travelled in the United Kingdom and 13 ; had travelled abroad in the month prior to notification of giardial infection. However, in the month before the onset of illness, although the same number had travelled in the United Kingdom, a much higher proportion, 22 23% ; , had travelled abroad. Of these 22 cases, eight had visited India and Nepal, three Africa, two Tenerife, and the remaining nine had visited Europe or the Mediterranean. Of the 14 cases travelling in the United Kingdom prior to the onset of symptoms, three had been camping and four caravanning. Adults aged 20 years and over were significantly more likely to have travelled abroad in the month prior to illness than those less than 20 years of age odds ratio 5.6; p 0.02 ; . Twentyeight per cent of cases reported in July and August had travelled abroad prior to their illness; only 15% of those reported in the rest of the year had done so. The mean duration of illness for all cases was 23.2 days. In those who had not travelled abroad it was 18.3 days; in those who had travelled to Europe in the month prior to the onset of their illness it was 27.8 days, and for those who had.
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