[Regionalization of perinatal care and in utero referrals]

Further improvement in perinatal morbidity and mortality figures implies in utero referral so high risk infants, particularly very early maturity infants, can be managed immediately in specialized centers. The success of such referrals depends directly on the coherence of the regional perinatal health care network. It has been demonstrated that the chances of survival and of sequelae-free survival are greater for very premature infants born in a center with a neonatal intensive care unit. The situation in France leaves room for improvement. Only 15% of the infants born before 33 months gestation and with birth weight under 1500 g are born in level III maternity wards equipped with a neonatal intensive care unit. The goal is 80%. We have tried to analyze the reasons behind this situation and propose ways to better organize perinatal health care.

Effects of ZDV-based patient education on intentions toward ZDV use, HIV testing and reproduction among a US cohort of women

This study examined the immediate effects of exposure to a patient education brochure concerning the risks and benefits of zidovudine (ZDV) therapy during pregnancy to reduce perinatal HIV transmission (protocol ACTG 076) on related knowledge, behavioural intentions and attitudes of women with and at-risk for HIV-infection. Self-reports were collected from 653 women of childbearing age from community family planning clinics and hospital-based HIV centres in 19 sites from nine US cities between May and November 1995. The intervention was a nine-page patient education brochure in Spanish, Creole and English versions, evently presenting the pros and cons of ZDV therapy to reduce perinatal HIV-transmission. Brochure exposure increased knowledge (p < 0.001) for all but one scale concerning ZDV resistance and increased the likelihood of women reporting intentions to take ZDV during pregnancy (p < 0.001) and to believe ZDV reduced transmission (p < 0.001). Brochure exposure had differential effects for some subpopulations. Intentions to have or terminate current or future pregnancies, knowledge about ZDV and attitudes toward ZDV varied mostly by ethnicity/race, language preference and HIV status. Pregnancy status, age, education and having an HIV-positive child had less impact on the brochure's effect, while income had no impact.

Socio-economic deprivation and the prevalence and prediction of depression in older community residents. The MRC-ALPHA Study

BACKGROUND

The Townsend index is a measure of social deprivation. It can be applied to postal districts and has been employed in studies examining the ecological associations of mental illness.

AIMS

We examine the utility of the Townsend index in identifying older populations with a high prevalence and risk of developing depression.

METHOD

The study was carried out in the context of a cohort study of an age- and gender-stratified sample of 5222 community residents aged 65 years and over. Subjects were interviewed at intervals of two years. The relationships between Townsend score and psychiatric diagnoses (in particular, depression) were examined.

RESULTS

High Townsend scores were associated with increased prevalence and incidence of depression and prevalence of organic psychiatric illness.

CONCLUSIONS

The Townsend index can be used to prioritize psychiatric and primary care resources so as to cater for older populations likely to suffer from depression and organic psychiatric conditions.

Fear of cognitive dyscontrol in relation to depression symptoms: comparisons between original and alternative measures of anxiety sensitivity

Previous research has found that a facet of anxiety sensitivity (AS), referred to as fear of cognitive dyscontrol or fear of mental incapacitation, is associated with severity of depressed mood. Other research has extended the "fear of fear" concept to include fear of losing control over emotion in general (including depression). Because anxiety and depression share the common feature of general distress (Clark & Watson, 1991. Journal of Abnormal Psychology, 93, 19-30), the present study took a conservative approach and statistically controlled for the effect of trait anxiety and negative affectivity before contributions of AS to depression were examined. In a large college student sample (N = 348), facets of the original and alternative measures of AS were evaluated in attempts to predict severity of depression symptoms. Fear of cognitive dyscontrol facets from both measures of AS were significant predictors in the regression analyses. A new set of items reflective of control over emotions was also significant and both cognitive and emotional control added to the prediction of depression symptoms in a complementary fashion. Implications of these findings for identifying a proposed "depression sensitivity" are discussed.

Natural history of pharmacotherapy of older depressed community residents. The MRC-ALPHA Study

BACKGROUND

Depression in older people is common and has a high mortality, but effective treatments exist.

AIMS

To describe drug prescribing in older community residents in relation to depression status.

METHOD

The MRC-ALPHA community cohort aged 65 and over were interviewed using the Geriatric Mental State examination drug data collected at index interview and at two and four years.

RESULTS

Antidepressants were used by 10.9% of the depressed population. Benzodiazepines were used frequently. Of the antidepressant users, 59.6% took low-dose antidepressants for two years, had a poor outcome and few drug changes.

CONCLUSIONS

Trends of increasing antidepressant use have cost implications for primary care groups. Benzodiazepines may be mis-prescribed for treatment of depressive symptoms. Antidepressant users have poor outcome and follow-up.

Thermal balloon ablation versus endometrial resection for the treatment of abnormal uterine bleeding

This study compares the clinical efficacy and safety of a thermal uterine balloon system with hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. In all, 147 women were treated by two experienced gynaecological surgeons: one performed 73 thermal balloon ablations and the other 74 endometrial resections between November 1994 and April 1998. The inclusion criteria were similar in both groups. The operative time was reduced significantly with the uterine balloon technique. There were no intra-operative complications in either group and postoperative morbidities were minimal and not statistically different. Multivariate analysis noted two prognostic factors associated with failures: retroverted uterus with thermal balloon ablation and age under 43 years with endometrial resection. The overall success rate did not differ significantly between the two groups 83.0 +/- 5% for balloon ablation and 76.3 +/- 6% for endometrial resection. Uterine balloon ablation appears to be as efficacious as endometrial resection. The former is much easier to perform, making the technique readily reproducible, especially by those with limited expertise in hysteroscopic surgery, and thus more widely applicable and safer.

Pharmacological and biochemical study on the effects of selective phosphodiesterase inhibitors on human term myometrium

This study was aimed at evaluating the in vitro effects of phosphodiesterase inhibitors and beta2-adrenoceptor agonists on spontaneous contractions of human term myometrium. Rolipram, RP 73401 (3-cyclopentyloxy-N-(3,5(-dichloro-4-pyridil)-4-methoxybenzamide) and Ro 20-1724 (1-4-(3-butoxy-4-methoxybenzyl)-2-imidozolidinone) (phosphodiesterase 4 inhibitors) inhibited spontaneous myometrial contractions (Emax approximately 100%; pD2 of 6.80+/-0.28, 6.84+/-0.32 and 6.31+/-0.03, respectively). Salbutamol and formoterol were less effective (Emax=40+/-6% and 35+/-12%, respectively) than phosphodiesterase 4 inhibitors to reduce myometrial contractility. Inhibitors of phosphodiesterase 3 (milrinone and siguazodan) and 5 (zaprinast) were marginally effective. Rolipram (10-30 nM) and siguazodan (0.1 microM) potentiated the response to salbutamol (Emax=75+/-12%, 88+/-8% and 73+/-12% and pD2=6.51+/-0.20, 6.93+/-0.29 and 6.48+/-0.16, respectively). Sodium nitroprusside (pD2=6.76+/-0.29) and theophylline (pD2=5.15+/-0.22) were effective inhibitors of myometrial contractions. Chromatographic separation of phosphodiesterase isoenzymes demonstrated that phosphodiesterase 4 is predominant but other phosphodiesterase isoenzymes were also identified. In conclusion, phosphodiesterase 4 inhibitors alone or combined with beta2-adrenoceptor agonists have potential interest as tocolytic agents.

An ethical dilemma in school nursing

School nurses must consider the ethical principles that guide everyday practice. Autonomy, beneficence, justice, and nonmaleficence are the ethical principles most often confronted in the school setting. When beneficent care-giving begins to conflict with the family's decision-making autonomy, paternalism, a form of beneficence, affects the family's autonomy. This creates an ethical dilemma for the school nurse who guides his or her practice by ethical principles but who also must decide when it is appropriate to refer a child or family to a medical provider for further evaluation. A case study is presented to illustrate a specific ethical dilemma. The ethical dilemma is described using a model that examines external factors, professional responsibilities, and possible courses of action. The discussion includes cultural considerations and barriers pertinent to the case example.

The enzymology of sulfur activation during thiamin and biotin biosynthesis

The thiamin and biotin biosynthetic pathways utilize elaborate strategies for the transfer of sulfur from cysteine to cofactor precursors. For thiamin, the sulfur atom of cysteine is transferred to a 66-amino-acid peptide (ThiS) to form a carboxy-terminal thiocarboxylate group. This sulfur transfer requires three enzymes and proceeds via a ThiS-acyladenylate intermediate. The biotin synthase Fe-S cluster functions as the immediate sulfur donor for biotin formation. C-S bond formation proceeds via radical intermediates that are generated by hydrogen atom transfer from dethiobiotin to the adenosyl radical. This radical is formed by the reductive cleavage of S-adenosylmethionine by the reduced Fe-S cluster of biotin synthase.

Size-exclusion chromatography with on-line ultraviolet, proton nuclear magnetic resonance and mass spectrometric detection and on-line collection for off-line Fourier transform infrared spectroscopy

The coupling of HPLC with UV detection and on-line NMR spectroscopy and mass spectrometry combined with a dedicated interface for the collection of the chromatographic eluent for subsequent Fourier transform (FT) IR has been investigated using a number of polymer additives as model compounds. Size-exclusion chromatography was performed using deuterated chloroform as eluent with the separation monitored on-line by UV detection at 254 nm and on-flow 1H-NMR and MS. The effluent from the NMR probe was directed to a dedicated HPLC interface where it was deposited on a germanium plate for subsequent FT-IR. NMR and MS spectra were successfully obtained for 2,6-di-tert.-butyl-4-methylphenol, octadecyl-3-(3,5-di-tert.-butyl-4-hydroxyphenyl) propionate (Irganox 1076) and diisooctyl phthalate on-line and FT-IR spectra for all three compounds were obtained off-line. Practical problems encountered with this multiple hyphenation are described.

Isolation of recombinant protective Helicobacter pylori antigens

A total of seven clones producing both new and previously described Helicobacter pylori proteins were isolated from a library of H. pylori genomic DNA. The screening approach by which these proteins were detected relied on the use of antisera raised in mice vaccinated with Helicobacter felis sonicate plus cholera toxin, a regimen which protects mice from H. pylori challenge. This strategy was designed to maximize the possibility of obtaining antigens which might be capable of conferring protection from H. pylori infection. Two of the clones were shown to encode the urease enzyme and the heat shock protein HspB, which have already been identified as protective antigens. The other five clones were sequenced, protein coding regions were deduced, and these sequences were amplified by PCR for incorporation into Escherichia coli expression vectors. The proteins produced from these expression systems were purified to allow testing for protective efficacy in an H. pylori mouse model. All five proteins were able to facilitate the clearance of a challenge with H. pylori, as judged by an assay of gastric urease activity and light microscopy on stomach sections. These results clearly indicate that the screening strategy has successfully identified candidate vaccine antigens.

Asymptomatic urethritis and detection of HIV-1 RNA in seminal plasma

OBJECTIVE

To define risk factors for detection of HIV-1 RNA in semen in men attending the two largest HIV clinics in the West Midlands.

METHODS

94 HIV-1 seropositive men at any stage of infection donated matched semen and blood samples. 36 subjects (38%) were on no antiretroviral treatment, 12 (13%) were on dual therapy, and 46 (49%) were on three or more drugs. Median CD4 count was 291 cells x 10(6)/l. 87 subjects underwent a urethritis screen (Gram stained urethral smear and culture for gonococcus, and LCR for Chlamydia trachomatis on first pass urine). Quantitative cell free HIV-1 RNA was determined by commercial nucleic acid sequence based assay with a lower detection limit of 800 copies/ml for semen and 400 copies/ml for blood. Independent risk factors for seminal HIV RNA detection were defined by logistic regression.

RESULTS

In univariate analysis, subjects not taking antiretrovirals were 11 times more likely to shed HIV RNA (21/36 (58%) v 6/58 (10%); p < 0.0001). Seven subjects (8%) had urethritis (including one C trachomatis infection). Urethritis was significantly associated with detection of seminal HIV RNA (adjusted OR, 80.2; p = 0.006), as was blood plasma viral load (adj OR, 19.3 per factor 10 increase; p < 0.001) and age (adj OR, 1.16 per 1 year older; p = 0.001). Antiviral treatment status, absolute CD4 and CD8 count, clinical stage, treatment centre, ethnicity, and risk factor were not independent predictors. No subject with undetectable blood viral load had detectable seminal HIV RNA.

CONCLUSION

Asymptomatic urethritis is independently associated with seminal HIV RNA shedding.

Effects of vasoactive intestinal peptide on human sperm motility

Sperm flagellar activity is modulated by cAMP. In target tissues, vasoactive intestinal peptide (VIP) stimulates adenyl cyclase activity, which elevates intracellular cAMP levels and activates protein kinase activity. This study investigated the effects of VIP on motility of sperm from 17 subjects. Motile activities, monitored before (0 min, baseline) and for 40 min after incubation with VIP (0.2 microgram/mL cell suspension), were analyzed by computer-assisted semen analysis. The data (mean +/- SEM) are expressed as percentages of baseline values and changes were compared by trend analysis for interval level measures by repeated measures analysis of variance orthogonal polynominal contrasts. The addition of VIP significantly increased motile sperm concentration (110 +/- 17% [10 min], 132 +/- 15% [20 min], 152 +/- 18% [30 min], 125 +/- 18% [40 min]; p < .02) and sperm with rapid straight-line motility (V > 25 microns/s) (167 +/- 20%, 174 +/- 19%, 173 +/- 23%, 141 +/- 16%; p < .02). Mean track speed (micron/s) was increased (125 +/- 12%, 134 = 9%, 129 +/- 12% and 126 +/- 12%; p < .02), while mean progressive velocity, amplitude of head displacement, and beat frequency were not affected by VIP. These results indicate that VIP stimulates sperm motile activity by cAMP-mediated phosphorylation of axonemal proteins.

Anxiety sensitivity and the five-factor model of personality

Relations between anxiety sensitivity (AS) and the higher-order and lower-order dimensions of the 'Big Five' model of personality were examined in 317 university students. AS was significantly associated with a number of personality domains and facets of the NEO-PI-R. Regression analyses indicated that only the higher-order domains of neuroticism and extraversion (negatively) and the lower-order N facets of anxiety and self-consciousness, significantly predicted AS. Three lower-order factors within AS were identified and were also compared to NEO-PI-R domains and facets. In a hierarchical regression, the three AS factors significantly predicted variance in a measure of panic-related anxiety after the effects of the six N facets were statistically controlled. Results are discussed in the context of previous work with a Big Three taxonomy of personality and implications for understanding the nature and possible origins of AS are outlined.

Behavioral assessment: review and prospect

In this article I review the history and publication trends of the behavioral assessment (BA) section of the journal, outline future directions for the BA section and suggest avenues for future assessment research. BA began as a stand-alone journal in 1978 and was incorporated as a regular section of Behaviour Research and Therapy (BRT) in 1992. Throughout this article I will use 'BA' to refer to both the stand-alone assessment journal and the assessment section of BRT. Since its inception, the scope of BA has been broad, with behavioral assessment defined to include the assessment of motoric, cognitive, emotional and physiological responses. Several publication trends are identified, including a declining frequency in the number of submitted and published articles on behavioural assessment. This parallels the declining number of assessment articles published elsewhere. Despite these trends, assessment research continues to form a vital foundation for other types of psychological research (e.g. treatment outcome studies), and there is a continued need for assessment-related research. A number of potentially fruitful directions for assessment research are suggested.

Treatment of major depression in the context of panic disorder

BACKGROUND

Individuals with major depression frequently have panic attacks, and often panic disorder, but rarely have researchers studied the impact of comorbidity of panic on the outcome of psychological treatment of depression.

METHODS

In this study, patients with comorbid panic and depression were first treated with cognitive-behavioral therapy (CBT) for panic. Depression symptoms in this treated group were compared to a group of patients with major depression who were on a minimal therapist contact waitlist. In the second phase of the study, patients in both groups (comorbid and depression-only) were treated with CBT for depression.

RESULTS

CBT for panic had little effect on co-existing depression, suggesting a specificity of action for CBT directed at different disorders. In addition, the presence of current or recently remitted panic attacks or agoraphobic avoidance did not interfere with the outcome of CBT for depression.

CONCLUSION

These findings stand in contrast to previous studies showing greater linkage between depression and panic in treatment outcome.

LIMITATIONS

While there are implications for treatment planning, these conclusions may be limited by the exclusion criteria and the highly structured treatment approach of separating treatment for panic from treatment for depression.

Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility

In a retrospective case report series, we evaluated the efficacy of hysteroscopic adhesiolysis in patients with severe Asherman's syndrome. In 31 patients with permanent severe adhesions, hysteroscopic treatment was performed. In all patients, uterine cavity with at least one free ostial area was restored after one (n = 16), two (n = 7), three (n = 7), and four (n = 1) surgical procedures. All previously amenorrhoeic patients (n = 16) had resumption of menses. Twenty-eight patients were followed-up with a mean time of 31 months (range 2-84). Fifteen pregnancies were obtained in 12 patients and the outcomes were the following: two first trimester missed abortions, three second trimester fetal losses, one second trimester termination of pregnancy for multiple fetal abnormalities and nine live births in nine different patients. Pregnancy rate after treatment was 12/28 (42.8%) and live birth rate was 9/28 (32.1%). In patients </=35 years, 10 out of 16 conceived (62.5%) versus two out of 12 (16.6%) in patients >35 years (P = 0. 01). Three patients were lost to follow-up and their results omitted. In nine patients with live births, one Caesarean hysterectomy for placenta accreta and one hypogastric arteries ligation for severe haemorrhage and placenta accreta were performed. Hysteroscopic treatment of severe Asherman's syndrome appeared to be effective for the reconstruction of a functional uterine cavity with a 42.8% pregnancy rate. However, these pregnancies were at risk for haemorrhage with abnormal placentation.

Nurses' cognitive structural models of work-based stress

This study examined the causes of stress experienced by National Health Service nurses in England over the course of a single week with the aim of generating a cognitive structural model. Qualitative data served as the foundation of a network study which employed inductive eliminative analysis. These data were also analysed using conventional qualitative methods and by content analysis. The results were consistent with previous studies that identified a number of primary sources of stress. However, the network study indicated that two systems of causation were operating. The first centres on inadequate staffing levels, which were seen as leading to poor attitudes and abilities among colleagues, multiple work roles and lack of support. Lack of support also contributed to powerlessness and poor attitudes and abilities. The behaviour of managers was strongly endorsed as a direct cause of stress, but the strongest explanatory link was through staffing levels and powerlessness. The second system of causation related patients' suffering to stress. The qualitative data validated the network study results through elaborating the understanding of the respondents' nominated causes. Discussion focused on the pressure and frustration experienced by nurses because of organizational factors and interaction effects with the caring nature of nursing work. It is suggested that nursing discourse is subordinated to managerial and biomedical discourse reflecting the relative powerlessness of nurses. The extent to which such powerlessness is primarily a result of the failure of nurses to assert themselves or intrinsic organizational factors is not clear. The consequences of a stressed and demoralized nursing workforce on the quality of patient care and risk profile are identified as the focus for future research.

Local recurrence and survival among black women with early-stage breast cancer treated with breast-conservation therapy or mastectomy

BACKGROUND

Black women with breast cancer have significantly worse survival rates and receive diagnoses at relatively younger ages, compared with white patients with breast cancer, in the United States. Young age at diagnosis has been associated with increased risk for local recurrence (LR) after breast-conservation therapy (BCT). The goal of this study was to evaluate the impact of age and BCT on LR and survival rates among black patients with breast cancer.

METHODS

The records for 363 black women treated for breast cancer (excluding stage IV disease) at a comprehensive cancer center were reviewed.

RESULTS

Fifty-eight percent of patients (n = 211) had tumors < or = 5 cm in diameter. Forty-two of these patients (19.9%) received BCT; the LR rate for this group was 9.8%. A total of 168 patients (79.6%) underwent mastectomy; the LR rate for this group was 8.9%. Data on the primary operation were unavailable for one patient. Five-year disease-free survival rates were similar for patients treated with BCT and those treated with mastectomy (88% and 73%, respectively). LR was associated with significant decreases in 5-year overall survival rates for both the BCT group (67% vs. 95%, P < .01) and the mastectomy group (43% vs. 76%, P < .01). LR and 5-year disease-specific survival rates were similar for patients <50 years of age and patients > or = 50 years of age, regardless of treatment.

CONCLUSIONS

LR and survival rates are not compromised by the use of BCT among black American patients. LR is associated with an increased risk of breast cancer death, regardless of treatment type. Younger age at diagnosis was not associated with an increased rate of LR after BCT in this series.

Thiamin biosynthesis in prokaryotes

Twelve genes involved in thiamin biosynthesis in prokaryotes have been identified and overexpressed. Of these, six are required for the thiazole biosynthesis (thiFSGH, thil, and dxs), one is involved in the pyrimidine biosynthesis (thiC), one is required for the linking of the thiazole and the pyrimidine (thiE), and four are kinase genes (thiD, thiM, thiL, and pdxK). The specific reactions catalyzed by ThiEF, Dxs, ThiDM, ThiL, and PdxK have been reconstituted in vitro and ThiS thiocarboxylate has been identified as the sulfur source. The X-ray structures of thiamin phosphate synthase and 5-hydroxyethyl-4-methylthiazole kinase have been completed. The genes coding for the thiamin transport system (thiBPQ) have also been identified. Remaining problems include the cloning and characterization of thiK (thiamin kinase) and the gene(s) involved in the regulation of thiamin biosynthesis. The specific reactions catalyzed by ThiC (pyrimidine formation), and ThiGH and ThiI (thiazole formation) have not yet been identified.