Randomized trial of reattribution on psychosocial talk between doctors and patients with medically unexplained symptoms

BACKGROUND

In reattribution, general practitioners (GPs) request psychosocial information directly and explain medically unexplained symptoms (MUS) using psychosocial information in the consultation. We explored whether reattribution training (RT) increased the communication of psychosocial information and decreased communication about somatic intervention between GPs and their MUS patients.

METHOD

A cluster randomized controlled trial (RCT) of RT versus usual treatment in GPs from 16 practices and 141 patients with MUS on audio-recorded and transcribed doctor-patient communication in an index consultation. In a secondary data analysis, the Liverpool Clinical Interaction Analysis Scheme (LCIAS) was applied by an experienced rater to each turn of speech in the transcript from the index consultation blind to treatment allocation.

RESULTS

After RT, patients were more likely to disclose and discuss psychosocial problems, and propose psychosocial explanations for symptoms; around 25% of patients discussed psychosocial information extensively. In the RT group, GPs did not seek new psychosocial disclosure but they reduced advocacy for somatic intervention. After RT, GPs suggested, on average, two utterances of psychosocial explanation and six utterances of somatic intervention.

CONCLUSIONS

After RT, some patients discussed psychosocial issues extensively but GPs did not probe underlying psychosocial issues. They gave mixed psychosocial and somatic messages about MUS, which may have increased patients' concerns about their health. GPs should actively seek the disclosure of underlying psychosocial problems and give clear, unambiguous messages to MUS patients when they are willing to discuss psychosocial issues.

Enhanced relapse prevention for bipolar disorder by community mental health teams: cluster feasibility randomised trial

BACKGROUND

Relapse prevention for bipolar disorder increases time to relapse but is not available in routine practice.

AIMS

To determine the feasibility and effectiveness of training community mental health teams (CMHTs) to deliver enhanced relapse prevention.

METHOD

In a cluster randomised controlled trial, CMHT workers were allocated to receive 12 h training in enhanced relapse prevention to offer to people with bipolar disorder or to continue giving treatment as usual. The primary outcome was time to relapse and the secondary outcome was functioning.

RESULTS

Twenty-three CMHTs and 96 service users took part. Compared with treatment as usual, enhanced relapse prevention increased median time to the next bipolar episode by 8.5 weeks (hazard ratio 0.79, 95% CI 0.45-1.38). Social and occupational functioning improved with the intervention (regression coefficient 0.68, 95% CI 0.05-1.32). The clustering effect was negligible but imprecise (intracluster correlation coefficient 0.0001, 95% CI 0.0000-0.5142).

CONCLUSIONS

Training care coordinators to offer enhanced relapse prevention for bipolar disorder may be a feasible effective treatment. Large-scale cluster trials are needed.

Inner-shell photoionization spectroscopy on deposited metal clusters using soft x-ray synchrotron radiation: an experimental setup

Exploration of mass-selected clusters by soft x-ray synchrotron radiation is well suited to receive element specific information on clusters in contact with a support and to systematically follow the evolution of size-dependent electronic and geometrical properties from the smallest clusters toward the bulk. Here we describe an experimental setup, which combines cluster synthesis, mass selection, soft landing, ultrahigh vacuum transfer, and photoionization experiments such as x-ray photoelectron spectroscopy, x-ray absorption, and Auger electron spectroscopy. First spectroscopic results and experimental conditions are briefly discussed for Cu(19) deposited onto the natural oxide layer of a Si-wafer surface.

Further pharmacological characterization of 5-HT(2C) receptor agonist-induced inhibition of 5-HT neuronal activity in the dorsal raphe nucleus in vivo

BACKGROUND AND PURPOSE

Recent experiments using non-selective 5-hydroxytryptamine (5-HT)(2C) receptor agonists including WAY 161503 suggested that midbrain 5-HT neurones are under the inhibitory control of 5-HT(2C) receptors, acting via neighbouring gamma-aminobutyric acid (GABA) neurones. The present study extended this pharmacological characterization by comparing the actions of WAY 161503 with the 5-HT(2C) receptor agonists, Ro 60-0275 and 1-(3-chlorophenyl) piperazine (mCPP), as well as the non-selective 5-HT agonist lysergic acid diethylamide (LSD) and the 5-HT releasing agent 3,4-methylenedioxymethamphetamine (MDMA).

EXPERIMENTAL APPROACH

5-HT neuronal activity was measured in the dorsal raphe nucleus (DRN) using extracellular recordings in anaesthetized rats. The activity of DRN GABA neurones was assessed using double-label immunohistochemical measurements of Fos and glutamate decarboxylase (GAD).

KEY RESULTS

Ro 60-0175, like WAY 161503, inhibited 5-HT neurone firing, and the 5-HT(2C) antagonist SB 242084 reversed this effect. mCPP also inhibited 5-HT neurone firing ( approximately 60% neurones) in a SB 242084-reversible manner. LSD inhibited 5-HT neurone firing; however, this effect was not altered by either SB 242084 or the 5-HT(2A/C) receptor antagonist ritanserin but was reversed by the 5-HT(1A) receptor antagonist WAY 100635. Similarly, MDMA inhibited 5-HT neurone firing in a manner reversible by WAY 100635, but not SB 242084 or ritanserin. Finally, both Ro 60-0275 and mCPP, like WAY 161503, increased Fos expression in GAD-positive DRN neurones.

CONCLUSIONS AND IMPLICATIONS

These data strengthen the hypothesis that midbrain 5-HT neurones are under the inhibitory control of 5-HT(2C) receptors, and suggest that the 5-HT(2C) agonists Ro 60-0175, mCPP and WAY 161503, but not LSD or MDMA, are useful probes of the mechanism(s) involved.

The effects of ranibizumab (Lucentis) on retinal function in isolated perfused vertebrate retina

BACKGROUND

Intraocular ranibizumab (Lucentis, Novartis, Basel Switzerland) is the primary choice in the treatment of neovascular age-related macular degeneration (AMD). Vascular endothelial growth factor (VEGF) is known to be a survival factor for neuronal cells. Therefore, blockage of all VEGF isoforms by ranibizumab could induce retinal dysfunction.

METHODS

Using isolated bovine retinas, the electroretinogram (ERG) was recorded as a transretinal potential using Ag/AgCl electrodes, while the retinas were perfused with an oxygen preincubated nutrient solution. For 45 min, ranibizumab was applied at a concentration of 0.2 mg/ml and alternatively the solvent carrier without the active agent. The ERG was monitored before, during and after exposure.

RESULTS

The concentration of 0.2 mg/ml ranibizumab induced a non-significant b-wave reduction of 22.32% after exposure (p = 0.13). For the a-wave amplitude only a reduction of 4% was detected (p = 0.18). The solvent carrier induced no significant reduction of the a- and b-wave amplitudes (p = 0.30 and p = 0.979, respectively).

CONCLUSION

In the ex vivo model, the isolated perfused vertebrate retina, ranibizumab has been proven to be a safe compound at the concentrations applied. The stability of the ERG-amplitudes rules out a considerable retinal dysfunction after an injection of up to 1 mg ranibizumab.

[The role of EGFR in non-small cell lung carcinoma]

EGFR receptor is expressed on most of the non small cell lung carcinoma (NSCLC) cells. Its relative importance in oncogenesis and tumour progression seems to greatly vary among NSCLC. Two molecules targeting differently EGFR are currently used for the treatment of metastatic NSCLC. cetuximab, a monoclonal antibody directed against the extracellular domain of the receptor, leads to a moderate survival benefit when associated with standard first-line chemotherapy. Erlotinib, a small EGFR tyrosine-kinase inhibitor molecule is used in 2nd or 3rd treatment line. Predictive factors for efficiency of these new treatments are subjects of intense research, in order to allow a better selection of the patients who could benefit from such a strategy.

Purification, cDNA cloning and functional expression of NADPH-cytochrome P450 reductase from Centaurium erythraea cell cultures

Solubilised NADPH-cytochrome P450 reductase (CPR) was purified from the microsomal fraction of centaury (Centaurium erythraea) cell cultures by Q-anion exchange chromatography and affinity chromatography on adenosine 2',5'-diphosphate agarose. SDS-PAGE demonstrated the presence of three CPR isoforms with molecular masses of 77, 79 and 81 kDa. The 79- and 81-kDa isoforms were identified as glycoproteins when blotted following SDS-PAGE and subjected to a sugar detection procedure. A homology-based approach led to the isolation of a CPR cDNA encoding the 77-kDa isoform. The enzyme was a class I CPR, possessing a short N-terminus upstream of the membrane anchor. The amino acid sequence contained a putative N-glycosylation site, indicating that the two major isoforms of 77 and 79 kDa are related through attachment of an oligosaccharide chain. This glycosylation process was also found upon heterologous expression in yeast. When co-expressed in yeast together with centaury coniferyl alcohol 5-hydroxylase, CPR efficiently supported the activity of the P450 enzyme. The genome of C. erythraea was found to contain a second CPR gene. RT-PCR experiments using gene-specific primers revealed differential regulation of the two CPR genes. While CPR 2 mRNA was strongly induced by the addition of methyl jasmonate to the cell cultures, the CPR 1 expression level did not change after this elicitation.

[Chances and risks of anti-VEGF therapy]

Vascular endothelial growth factor (VEGF) plays a pivotal role in angiogenesis. Through regulation of haemodynamics, haematopoesis and the immune system, endocrinology and reparative processes, inhibition of VEGF can cause multiple adverse events. Previous data suggest that--even after intravitreal injection--systemic exposure might occur, thus bearing the risk of manifestation of side effects. Experience with intravenous administration of the antibody bevacizumab (Avastin) pointed to the potential consequences of a pan-VEGF blockade. The change of haemodynamic parameters implies a potential influence on the patient's morbidity. Studies already conducted during the approval process do not provide sufficient statistical power when evaluating whether systemic events significantly differ between the treatment and control groups. Retinal perfusion showed an altered vascular tone (change in vessel diameter) following anti-VEGF treatment. Physiological fenestration of the choroicapillaris is significantly reduced. Possible effects on the local oxygen supply in ischaemic tissue have to be considered. In contrast to destructive treatment modalities (laser, cryo), VEGF inhibitors promise the prompt and efficient response of retinal neovascularisation and the preservation of a better function (visual fields). The maturation of growing vessels (pericytes) and the secondary formation of membranes are limiting factors with regard to the time-point at which anti-VEGF therapy is most effective. A diligent use of the available drugs has to take into account which types of exudative retinopathy are showing no or only very limited response to the treatment.

Establishing an oral anticoagulant monitoring service in a multiethnic developing country

We describe the establishment of an International Normalized Ratio (INR)-based system for monitoring oral anticoagulant therapy in a multiethnic developing country. There was significant variation in geometric mean normal prothrombin time among ethnic groups: 12.7 s for Indians, 13.4 s for Africans and 13.7 s for subjects of mixed ancestry. About 4129 INR measurements were performed in the first 2 years. The majority (55.2%) of achieved INRs were subtherapeutic. We found 31 (0.8%) instances of severe overanticoagulation (INR > 8.0). There were no bleeding manifestations in 24 (77%) of them. Only two experienced life-threatening haemorrhage. The management of bleeding and excessive anticoagulation was not always in accordance with international recommendations. The high incidence of underanticoagulation in Trinidad and Tobago may be due to genetically determined warfarin resistance or underdosing. Oral anticoagulant monitoring in Trinidad and Tobago could benefit from the centralization of such services to designated clinics with specialized staff and computer-assisted dosing which adopt internationally accepted guidelines for practice.