Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students

Extensive attention has been paid over the past three decades to the stressors involved in training in the health professions. Although empirical studies have identified demographic subgroups of students most likely to become distressed during training, less research has been carried out to evaluate the impact of students' personality characteristics on their adjustment. Severe perfectionism is one such personality trait that has been shown to increase the risk for anxiety and depressive disorders in other populations. Another set of personality traits linked to increased psychological problems has been labelled the 'impostor phenomenon', which occurs when high achieving individuals chronically question their abilities and fear that others will discover them to be intellectual frauds. Both perfectionism and the impostor phenomenon would seem to be pertinent factors in the adjustment of health professional students; however, these character traits have not been empirically examined in this population. In the present study psychological distress, perfectionism and impostor feelings were assessed in 477 medical, dental, nursing and pharmacy students. Consistent with previous reports, the results showed that a higher than expected percentage of students (27.5%) were currently experiencing psychiatric levels of distress. Strong associations were found between current psychological distress, perfectionism and impostor feelings within each programme and these character traits were stronger predictors of psychological adjustment than most of the demographic variables associated previously with distress in health professional students. Implications for future research, limitations of this study and clinical recommendations are discussed.

Mergers--true integrations

This article is the second of a two part series on clinical consolidation in mergers. Part 1 addressed typical consolidations that occur in mergers and why clinical consolidation is so often overlooked. It discussed the quality and efficiencies improvements that can occur if clinical consolidation is carried out successfully. Part 2 details the steps of the clinical consolidation process that, if undertaken early and involving physicians and staff, will lead to a successful outcome.

Developmentally-regulated expression of a putative protease inhibitor gene in the lactating mammary gland of the tammar wallaby, Macropus eugenii

A novel milk protein, which is secreted only in the early stage of lactation, has been identified in the whey fraction of milk from the tammar wallaby (Macropus eugenii). The amino acid sequence currently available suggests the protein comprises 71 amino acids. The protein migrates at 18 kDa when analysed by SDS polyacrylamide gel electrophoresis but has a calculated molecular weight of 8 kDa. A partial cDNA clone of 153 bp has been isolated by reverse transcriptase PCR. Northern analysis of mammary gland RNA extracted from various stages throughout the entire lactation period showed a messenger RNA transcript of approximately 500 bp present only in the first third of lactation. The protein shares 74.5% similarity at the amino acid level with early lactation protein (ELP) from the brush-tailed possum (Trichosurus vulpecula) and 37% with bovine colostrum trypsin inhibitor, a member of the Kunitz family of protease inhibitors. We hypothesise that the expression of this gene may be controlled by changes in the sucking patterns of the dependent pouch young.

Trying to improve compliance with prophylactic penicillin therapy in children with sickle cell disease

AIMS

To evaluate compliance with prophylactic penicillin therapy in sickle cell disease (SCD) in children.

METHODS

Forty-five children aged 37 +/- 19 (9-84) months [mean +/- s.d; range] with homozygous SCD were recruited. After a baseline period of 2 months the patients were randomized to either the intervention or non-intervention group. The intervention consisted of a slide show explaining the pathogenesis of sickle cell disease and its complications; weekly phone calls by the clinic social worker; and a calendar. Compliance was again evaluated after the 2 month intervention period and after a further 2 month monitoring period without intervention. Compliance was monitored using the Medication Event Monitoring System. At the end of the 6 months, parents in both groups completed a questionnaire the aims of which were to determine knowledge and understanding of sickle cell disease and previous experience with infection. Patient admissions to the hospital during the study were recorded.

RESULTS

Compliance during the 2 month baseline assessment was 66.0 +/- 32.5 (1.3-98.2)% and 69.3+25.4 (19.8-96.5)% in the intervention (n = 13) and non-intervention (n = 10) groups respectively (P = 0.79). During the next 2 months, compliance in the intervention group (n = 11) was 79.0 +/- 31.4 (11.0-100.0)% and in the non-intervention group (n = 9) was 66.0 +/- 20.2 (42.2-96.8)% (P = 0.297). In the final 2 month monitoring period compliance was 82.0 +/- 34.7 (3.8-100.0)% and 65.8 +/- 25.3 (25.0-98.2)% in the intervention (n = 7) and the non-intervention (n = 6) groups respectively (P = 0.366). No statistically significant differences were found when comparing compliance between the groups.

CONCLUSIONS

Compliance with prophylactic antibiotic therapy in children with sickle cell disease is highly variable and its evaluation is problematic.

Modulation of cytokine production by dehydroepiandrosterone (DHEA) plus melatonin (MLT) supplementation of old mice

Tissue levels of the antioxidants melatonin (MLT) and dehydroepiandrosterone (DHEA) decline with age, and this decline is correlated with immune dysfunction. The aim of the current study is to determine whether hormone supplementation with MLT and DHEA together would synergize to reverse immune senescence. Old (16.5 months) female C57BL/6 mice were treated with DHEA, MLT, or DHEA + MLT. As expected, splenocytes were significantly (P < 0.05) higher in old mice as compared to young mice. DHEA, MLT, and DHEA + MLT significantly (P < 0.005) increased B cell proliferation in young mice. However, only MLT and DHEA + MLT significantly (P < 0.05) increased B cell proliferation in old mice. DHEA, MLT, and DHEA + MLT help to regulate immune function in aged female C57BL/6 mice by significantly (P < 0.05) increasing Th1 cytokines, IL-2, and IFN-gamma or significantly (P < 0.05) decreasing Th2 cytokines, IL-6, and IL-10, thus regulating cytokine production. DHEA and MLT effectively modulate suppressed Th1 cytokine and elevated Th2 cytokine production; however, their combined use produced only a limited additive effect.

Mergers--true integrations

This article is the first of a two-part series focusing on clinical consolidation in mergers. While the frequency of hospital mergers is growing at tremendous rates, the actual consolidation of services following mergers is slow. This article will explain why, despite the enormous benefits that can be achieved, clinical consolidation is not tackled. Finally, the resources and key issues for successful clinical consolidation will be shared. Part 2 of this article, which follows in the next issue, will focus on the structure and process for successful clinical consolidation.

Development and characterisation of human 5-HT1B- or 5-HT1D-receptor specific antibodies as unique research tools

The serotonin 5-HT1B/1D-receptor family comprises of two closely related receptors encoded by two distinct genes. There are no pharmacological ligands which can adequately distinguish between these two receptor subtypes in human tissues. Therefore, we have developed human 5-HT1B- and 5-HT1D-receptor subtype specific polyclonal antibodies. Rabbits were immunised with synthetic peptides identical to unique amino acid sequences located in the third intracellular loops of these receptors. Polyclonal antibodies were subjected to immunoaffinity purification and were characterised using ELISA, dot blot analysis and immunostaining of stably-transfected CHO cell lines expressing either human 5-HT1B-receptors or 5-HT1D-receptors and in human trigeminal ganglia. The antibodies were specific for either the 5-HT1B- or 5-HT1D-receptors and did not cross-react. Both 5-HT1B- and 5-HT1D-immunoreactivities were detected on cell bodies in human trigeminal ganglia. In the absence of selective pharmacological agents, these antibodies represent unique and essential research tools to study the anatomical distribution of 5-HT1B/1D-receptor subtypes in human tissue.

Family systems therapy after Operation Desert Storm with European-theater veterans

We describe a quasi-experimental trial of time-limited family therapy with veterans and families of veterans who served in Europe, outside the war zone, during Operation Desert Storm (ODS). Family systems therapy was provided both to individuals and conjointly to couples or families during the acute postwar readjustment period. The intervention adapted strategies from structural, strategic, intergenerational, and behavioral family therapies in a brief-treatment protocol for systemic stressor resolution. Veterans given family system therapy were able to resume functional levels of psychosocial adjustment and reduce the risk of long-term (chronic or delayed) psychosocial impairment. Based on these preliminary findings, controlled evaluation of family systems therapy appears warranted for individuals and families exposed to subtraumatic stressors such as wartime non-war-zone military deployment.

Retroviral coexpression of thymidylate synthase and dihydrofolate reductase confers fluoropyrimidine and antifolate resistance

Retroviral gene transfer of dominant selectable markers into hematopoietic cells can be used to select genetically modified cells in vivo or to attenuate the toxic effects of chemotherapeutic agents. We show that retroviral gene transfer of thymidylate synthase (TS) confers resistance to TS directed anticancer agents and that co-expression of TS and dihydrofolate reductase (DHFR) confers resistance to TS and DHFR cytotoxic agents. Retroviral vectors encoding Escherichia coli TS, human TS, and the Tyr-to-His at residue 33 variant of human TS (Y33HhTS) were constructed and fibroblasts transfected with these vectors conferred comparable resistance to the TS-directed agent fluorodeoxyuridine (FdUrd, approximately 4-fold). Retroviral vectors that encode dual expression of Y33HhTS and the human L22Y DHFR (L22YhDHFR) variants conferred resistance to FdUrd (3- to 5-fold) and trimetrexate (30- to 140-fold). A L22YhDHFR-Y33HhTS chimeric retroviral vector was also constructed and transduced cells were resistant to FdUrd (3-fold), AG337 (3-fold), trimetrexate (100-fold) and methotrexate (5-fold). These results show that recombinant retroviruses can be used to transfer the cDNA that encodes both TS and DHFR and dual expression in transduced cells is sufficiently high to confer resistance to TS and DHFR directed anticancer agents.

Molecular characterisation and hormone-dependent expression of the porcine whey acidic protein gene

A 17.5 kDa protein was isolated from porcine whey by reverse phase HPLC and identified as a putative whey acidic protein (WAP) homologue by sequencing 35 and 40 amino acid residues of the amino- and carboxy-terminus respectively. Degenerate oligonucleotides to both of these amino acid sequences were designed and used in reverse transcriptase PCR with RNA from lactating porcine mammary gland as a template. A 162 bp PCR fragment was detected and sequenced. Compilation of the deduced and determined amino acid sequence revealed a protein of 111 amino acids, which had approximately 75, 50, 40 and 35% similarity at amino acid level to camel, rabbit, rat and mouse WAP respectively. It also included the four-disulphide core characteristic of all WAP proteins and most Kunitz-type protease inhibitors. This provides the first unequivocal evidence for WAP secretion in the pig. SDS PAGE analysis of the whey fraction showed that WAP is secreted as a major protein in sow's milk from farrowing to weaning. The molecular mass of WAP in SDS PAGE was significantly greater than the 11.7 kDa determined from amino acid sequence, indicating that porcine WAP is possibly glycosylated. Northern analysis detected a single mRNA transcript of approximately 600 bp in porcine RNA from the mammary gland of lactating sows. To examine the hormone-regulated expression of the WAP gene the mammary glands of sows at day 90 of pregnancy were biopsied and explants cultured for 3 days in the presence of various combinations of porcine insulin (I), cortisol (F) and porcine prolactin (P). Northern analysis of RNA extracted from the tissue indicated that WAP gene expression was barely detectable in the mammary gland prior to culture and there was no increment in explants cultured in the presence of I and F. However, a significant increase in the accumulation of WAP mRNA was observed in explants cultured in I, F and P. A similar result was observed for beta-casein and alpha-lactalbumin gene expression.

Effect of gender on outcomes following renal artery stent placement for renovascular hypertension

To study the effect of gender on outcome following renal artery stent placement for renovascular hypertension, we prospectIvely followed 66 patients (30 males, 36 females) who underwent Palmaz stent placement in 89 renal arteries. There was no difference in the incidence of procedure-related complications between males and females. At 6-mo follow-up, the decrease in systolic (35 +/- 30 mm Hg and 27 +/- 25 mm Hg) and diastolic (15 +/- 23 mm Hg and 14 +/- 14 mm Hg) blood pressures was similar in female and male patients, respectIvely. Late follow-up at 19 +/- 11 mo also showed no difference in blood pressure response. In 44 patients who underwent repeat angiography at a mean duration of 9.1 +/- 5.6 mo after stent deployment, the incidence of restenosis was 26% in females and 24% in males (P = 0.85). We conclude that gender has no effect on the incidence of complications, blood pressure response, or angiographic restenosis in patients undergoing renal artery stent placement.

Differential distribution of 5HT1D- and 5HT1B-immunoreactivity within the human trigemino-cerebrovascular system: implications for the discovery of new antimigraine drugs

Sumatriptan, a 5HT1B/1D-receptor agonist, is clinically effective as an antimigraine agent. Its therapeutic action may result partly from vasoconstriction of excessively dilated cranial blood vessels (a 5HT1B-receptor mediated response). The antimigraine activity of sumatriptan may also result from inhibition of the release of vasoactive neuropeptides from trigeminal sensory fibres within the meninges. The identity of the 5HT1B/1D-receptor subtype mediating this effect is unknown. Using 5HT1D- and 5HT1B-receptor-specific antibodies we have demonstrated a differential distribution of these receptor subtypes within the human trigemino-cerebrovascular system. Only 5HT1B-receptor protein was detected on dural arteries. In contrast, only 5HT1D-receptor protein was detected on trigeminal sensory neurones including peripheral and central projections to dural blood vessels and to the medulla. Within the medulla 5HT1D-receptor protein was confined to discrete areas associated with the trigeminal sensory system. These findings have important implications for the design of new antimigraine drugs.

Renal artery stent placement: utility in lesions difficult to treat with balloon angioplasty

OBJECTIVES

We assessed the safety and efficacy of stent placement in patients with poorly controlled hypertension and renal artery stenoses, which are difficult to treat with balloon angioplasty alone.

BACKGROUND

Preliminary experience with stent placement suggests improved results over balloon angioplasty alone in patients with atherosclerotic renal artery stenosis.

METHODS

Balloon-expandable stents were placed in 100 consecutive patients (133 renal arteries) with hypertension and renal artery stenosis. Sixty-seven of the patients had unilateral renal artery stenosis treated and 33 had bilateral renal artery stenoses treated with stents placed in both renal arteries.

RESULTS

Angiographic success, as determined by quantitative angiography, was obtained in 132 (99%) of 133 lesions. Early clinical success was achieved in 76% of the patients. Six months after stent placement, the systolic blood pressure was reduced from 173 +/- 25 to 147 +/- 23 mm Hg (p < 0.001); the diastolic pressure from 88 +/- 17 to 76 +/- 12 mm Hg (p < 0.001); and the mean number of antihypertensive medications per patient from 2.6 +/- 1 to 2.0 +/- 0.9 (p < 0.001). Angiographic follow-up at a mean of 8.7 +/- 5.0 months in 67 patients revealed restenosis (>50% diameter narrowing) in 15 (19%) of 80 stented vessels.

CONCLUSIONS

Renal artery stenting is an effective treatment for renovascular hypertension, with a low angiographic restenosis rate. Stent placement appears to be a very attractive therapy in patients with lesions difficult to treat with balloon angioplasty such as renal aorto-ostial lesions and restenotic lesions, as well as after a suboptimal balloon angioplasty result.

Traditional remedies and food supplements. A 5-year toxicological study (1991-1995)

Since 1991, the Medical Toxicology Unit (MTU) at Guys' Hospital, London, has been assessing the toxicological problems associated with the use of traditional and herbal remedies and dietary supplements. This assessment was carried out by evaluating reports to the National Poisons Information Service (London) [NPIS(L)] which provides emergency information to medical professionals. Relevant telephone enquiries to NPIS(L) were identified. Further case details were obtained by follow-up questionnaire, clinical consultation, toxicological analysis of samples from patients and/or products and botanical identification of plant material. Of 1297 symptomatic enquiries evaluated there was a possible/confirmed association in 785 cases. Case series have been identified which substantiate previous reports, including liver problems following the use of Chinese herbal medicine for skin disorders, allergic reactions to royal jelly and propolis and heavy metal poisoning caused by remedies from the Indian subcontinent. Although the overall risk to public health appears to be low, certain groups of traditional remedies have been associated with a number of potentially serious adverse effects. Considering the extent of use of herbal remedies and food supplements a comprehensive surveillance system for monitoring the adverse health effects of these products is essential. Surveillance of a large population is needed for the complex task of identifying the uncommon and unpredictable adverse effects which are potentially serious. In the UK, the Medicines Control Agency responded to the MTU report by recognising the need for vigilance and by incorporating adverse reactions reporting on unlicensed herbal remedies into their drug reaction monitoring function. As a further step to safeguard the patients/consumers an effective single regulatory system is required which would ensure the safety and quality of all herbal remedies and food supplements available in the UK.

Transdiaphragmatic herniation of peritoneal dialysis fluid post Nissen's operation: an unusual cause for a mass on the chest radiograph

A child on dialysis for chronic renal failure and who had had a Nissen's fundoplication showed transdiaphragmatic herniation of the peritoneum simulating a right lower zone chest mass. The imaging and possible causes are considered.

Quality of life, body composition and muscle strength in adult growth hormone deficiency: the influence of growth hormone replacement therapy for up to 3 years

OBJECTIVE

Adults with GH deficiency complain frequently of low energy levels, emotional lability and mental fatigue resulting in a low perceived quality of life (QOL). Body composition is altered with increased fat mass and decreased lean body mass and muscle strength is reduced. The aims of this study were to determine the effects of replacement GH treatment on: (a) body composition and muscle strength and (b) QOL, using specifically selected and adapted measures.

DESIGN

A 12-month study (double-blind placebo-controlled for the first 6 months and open for the second 6 months) of GH replacement injections (0.125 iu/kg/week for the first month and 0.25 iu/kg/week for the following 5 months of each study period) in GH deficient adults on QOL, body composition and muscle strength. This was followed by an open study of a further 12 months' GH treatment assessing QOL and muscle strength. Finally, QOL was assessed after up to 3 years of GH replacement treatment.

PATIENTS

Thirty of the 32 adult patients with GH deficiency enrolled completed the initial 12-month study (10 male, mean age 33.5 years, mean (SD) stimulated serum GH response 3.0 mU/l (2.86)). Nineteen patients then opted to continue GH treatment. Of these, 13 patients were available for assessment after a further 12 months' and 24 months' treatment.

MEASUREMENTS

Health-related QOL was assessed using 2 specifically adapted scales for adults with GH deficiency: the Life Fulfillment Scale and the Impact Scale. In addition 4 other self-rating questionnaires were used: Nottingham Health Profile, Hospital Anxiety and Depression Scale, Self Esteem Scale and Mental Fatigue Scale. Body composition was assessed by DEXA and quadriceps muscle strength by measuring maximum voluntary contractions.

RESULTS

In the initial 12 months' placebo-controlled study perceived energy levels increased after 6 and 12 months of GH treatment (P < 0.01 compared with baseline) in the patients receiving GH for the full 12-month period. There were no changes in energy levels throughout the study in the group receiving placebo for the first 6 months. Also small improvements in impact scores were found after 6 months of GH treatment (P < 0.05) but this was not sustained at 12 months. In both GH and placebo groups life fulfillment worsened after 6 months, but then improved to baseline values after 12 months. In the patients who persisted with GH replacement, energy levels continued to improve (at 2 years, P < 0.01 compared with baseline) but then fell (at 3 years, P = NS compared with baseline). A similar pattern was observed in emotional reaction scores. However, improvements in self-esteem were maintained (at 3 years, P < 0.05 compared with baseline). Body composition altered favourably over the initial 12-month study period with a significant increase in lean mass and decrease in fat mass in both groups after 6-12 months of GH. There were no changes in muscle strength in either group during the initial 12-month study. However, in the patients who were available for assessment after a further 12 months of GH treatment, muscle strength increased significantly (P < 0.02 compared with baseline).

CONCLUSION

GH replacement treatment for 6-12 months leads to significant improvements in body composition (DEXA) but longer-term treatment may be needed to increase muscle strength. Self-esteem scores improve and are maintained after 3 years of treatment. Energy levels and emotional reaction improve during treatment for up to 2 years but decline thereafter.

Time-limited psychotherapy with Operation Desert Storm veterans

Time-limited psychotherapy conducted 2 to 9 months after demobilization was evaluated with Persian Gulf Theater veterans of Operation Desert Storm (ODS). Thirty five treatment-seeking veterans were contrasted with 20 non-treatment-seeking ODS Persian Gulf veterans in a repeated measures design at pretest, posttest, and 6-week followup assessments. In addition, psychotherapy participants at followup were contrasted with 80 non-treatment-seeking ODS Persian Gulf veterans from the same military units who were assessed one time at a comparable time point. Time-limited psychotherapy was associated with sustained improved psychosocial functioning and reduced levels of psychiatric and stress-related symptomatology.

Effects of renal artery stent implantation in patients with renovascular hypertension presenting with unstable angina or congestive heart failure

This study evaluates the effect of renal artery stent implantation in patients with renovascular hypertension presenting with unstable angina (n = 20) or congestive heart failure (n = 28). There was a significant improvement in the Canadian Cardiovascular Society angina class and the New York Heart Association functional class, and at 8.4 +/- 6.4 month follow-up.

The tammar wallaby: a model to study putative autocrine-induced changes in milk composition

The marsupial newborn is immature and the mother has the capacity to alter milk composition significantly during lactation, presumably to meet the nutritional requirements of the developing young. Furthermore, macropodid marsupials may practice asynchronous concurrent lactation (ACL)7 whereby the mother provides milk which differs in all the major components from adjacent mammary glands for two young of different ages. This phenomenon suggests that local regulation of mammary function, in addition to endocrine stimuli, is likely to be important for controlling milk composition. This paper explores the possibility that changes in sucking patterns of the young represent the first step in a mechanism to signal the mammary gland for putative autocrine-induced changes in milk composition.

First trimester fetal heart rate: response to chorionic villus sampling in the chromosomally normal fetus

The objective of this prospective study was to evaluate the fetal heart rate before and after the procedure and whether this had any effect on the risk of pregnancy loss following chorionic villus sampling (CVS) and chromosomally normal pregnancies. Four hundred and seventeen pregnancies were evaluated. The heart rate before the procedure was similar for both male and female fetuses. Significant procedure-related changes in fetal heart rate occurred only with male fetuses undergoing the transabdominal CVS technique. Fetal heart rate decelerations following CVS were more common than accelerations. Fetal heart rate changes following CVS were not able to predict the pregnancies ending in spontaneous abortion. Transabdominal CVS had a lower loss rate after the procedure, compared to the transcervical technique (p = 0.0001). Small-for-date fetuses had a higher loss rate after the procedure compared to normal-sized fetuses (p = 0.001).