Factors associated with symptomatic improvement and recovery from major depression in primary care patients

This article describes a post-hoc analysis of clinical and psychosocial factors and beliefs about health associated with treatment outcome in a sample of depressed primary care patients (N=181) randomly assigned to a standardized treatment or physician's usual care (UC). Different factors were found to predict clinical outcomes for treatment modality [UC vs. interpersonal psychotherapy (IPT) or nortriptyline (NT)] and the type of outcome evaluated (i.e., depressive symptoms at 8 months or symptomatic and functional recovery at 8 months). Factors associated with treatment-specific outcomes are also described. Consistent with prior studies, lower depressive symptom severity at 8 months was associated with higher baseline functioning, minimal medical co-morbidity, race, and standardized pharmacologic or psychotherapeutic treatment. Additionally, an interaction between treatment modality and health locus of control indicated that individuals perceiving more self-control of their health and who received a standardized treatment experienced greater depressive symptom reduction at 8 months. Factors associated with symptomatic and functional recovery from the depressive episode were also examined. Patients who received a standardized treatment (IPT or NT) perceived greater control of their health and lacked a lifetime generalized anxiety disorder or panic disorder were more likely to recover by month 8 than those who received usual care. While clinical severity and treatment adequacy play an important role in both symptomatic improvement and full recovery from a depressive episode, other key factors such as health beliefs and non-depressive psychopathology also influence recovery.

Analysis of membrane protein cluster densities and sizes in situ by image correlation spectroscopy

Communication between cells invariably involves interactions of a signalling molecule with a receptor at the surface of the cell. Typically, the receptor is imbedded in the membrane and it is hypothesized that the binding of the signalling molecule causes a change in the state of aggregation of the receptor which, in turn, initiates a biochemical signal within the cell. Subsequently, many of the occupied receptors bind to membrane-associated structures, called coated pits, which invaginate and pinch off to form coated vesicles, thereby removing the receptors from the cell surface. The state of aggregation of membrane receptors is obviously in constant flux. Any useful approach to measuring the state of aggregation must, therefore, allow for dynamic measurements in living cells. It is possible to use fluorescently labelled signalling molecules or antibodies directed at the receptor of interest to visualize the receptor on the cell surface with a fluorescence microscope. By employing a laser confocal microscope, high resolution images can be produced in which the fluorescence intensity is quantitatively imaged as a function of position across the surface of the cell. Calculations of autocorrelation functions of these images provide direct and accurate measures of the density of fluorescent particles on the surface. Combined with the average intensity in the image, which reflects the total average number of molecules, it is possible to estimate the degree of aggregation of the receptor molecules. We refer to this analysis as image correlation spectroscopy (ICS). We show how ICS can be used to measure the density of several receptors on a variety of cells and how it can be used to measure the density of coated pits and the number of molecules per coated pit. We also show how the technique can be used to monitor fusion of virus particles to cell membranes. Further, we illustrate that, by calculating cross-correlation functions between pairs of images, we can extend the analysis to measurements of the distributions as a function of time, on the second timescale, as well as to measurements of the movement of the receptor aggregates on the surface. Finally, we illustrate that, by this approach, we can measure the extent of interaction between two different receptors as a function of time. This represents the most quantitative measurement of the extent of co-localization of receptors available and is independent of the spatial resolution of the confocal microscope. The theory of ICS and image cross-correlation spectroscopy (ICCS), focussing on the interpretation of the data in terms of the biological phenomenon being probed, is discussed.

Early outcomes after allogeneic stem cell transplantation for leukemia and myelodysplasia without protective isolation: a 10-year experience

Although it is common practice to use some form of isolation to protect allogeneic stem cell transplant patients from infection, the necessity for these practices in all environments has not been demonstrated. The current study evaluated patterns of infection and 100-day transplant-related mortality in 288 patients with myelodysplasia and leukemia transplanted without isolation. Patients were allowed out of hospital at any time within constraints of the medication schedule. Fever, foci of infection, and positive cultures within 28 days and death within 100 days because of the transplant procedure were recorded. Fever occurred in 57% of patients, and 10% had a clinical or radiographic focus of infection. Most infections were apparently endogenous; blood cultures from 24% of recipients grew organisms, 87% of which were gram-positive bacteria. Four patients (1%) died with aspergillus infection in circumstances indicating that isolation would not have been helpful. Twenty percent of patients remained without evidence of infection throughout. Transplant-related mortality at 100 days was 1% for 108 patients with early leukemia receiving transplants from matched siblings. For patients at higher risk, by virtue of donor and/or disease status, mortality was 21%. These figures compare favorably with those reported to the International Bone Marrow Transplant Registry, the majority of patients having been subjected to some form of isolation. We conclude that allogeneic stem cell transplantation can be safely performed in some environments without confining patients continuously to the hospital.

Identification of the familial cylindromatosis tumour-suppressor gene

Familial cylindromatosis is an autosomal dominant genetic predisposition to multiple tumours of the skin appendages. The susceptibility gene (CYLD) has previously been localized to chromosome 16q and has the genetic attributes of a tumour-suppressor gene (recessive oncogene). Here we have identified CYLD by detecting germline mutations in 21 cylindromatosis families and somatic mutations in 1 sporadic and 5 familial cylindromas. All mutations predict truncation or absence of the encoded protein. CYLD encodes three cytoskeletal-associated-protein-glycine-conserved (CAP-GLY) domains, which are found in proteins that coordinate the attachment of organelles to microtubules. CYLD also has sequence homology to the catalytic domain of ubiquitin carboxy-terminal hydrolases (UCH).

Effect of asthma on the quality of life among children and their caregivers in the Atlanta Empowerment Zone

BACKGROUND AND OBJECTIVE

Asthma is the most common chronic pediatric disease and exacts a toll on the health-related quality of life of affected children and their primary caregivers. This investigation describes the relationship between the clinical severity of asthma among inner-city children and their quality of life and that of their primary adult caregivers.

METHODS

Telephone interview data were collected from individual adult caregivers of 5-12-year-old children with asthma. Questions addressed the history, diagnosis, and management of the child's asthma, the child's family and social background, the family's socioeconomic status, the caregiver's knowledge and attitude about asthma, and the health-related quality of life of both the child and the caregiver. An asthma severity score was calculated from the caregiver's responses to questions about their child's wheezing frequency, nocturnal and early morning symptoms, and speaking during an asthma attack, as well as the impact of the disease on their child's physical activity and breathing during the prior 4-month period. A clinical asthma triage score was determined from information collected at the emergency department about the child's oxygen saturation, alertness, use of accessory respiratory muscles, extent of breathlessness, and peak expiratory flow. Spearman correlation coefficients were used to identify association between quality of life and disease severity, caretaker's asthma knowledge, and functional impact of asthma symptoms.

RESULTS

Data from 240 of 755 eligible children were analyzed. Most children were younger than 11 years, male, black, and non-Hispanic. The children's median duration of asthma diagnosis was 86% of their life (range less than 1 to 11.3 years, median 5.0 years). Of the primary caregivers, 69% had at least completed high school, and 90% reported a total monthly household income of $1,600 or less. The maximum possible quality-of-life score and the median for caregivers were 91 and 70, respectively; for children, the same scores were 69 and 58, respectively. In addition, there was significant negative correlation of the quality-of-life scores of both the caregivers and children with the number of schooldays the children missed (r = -0.24 and r = -0.26, respectively, P < .001 for both) and the caregivers' and children's asthma severity scores (r = -0.39 and r = -0.47, respectively, P < .001 for both). The quality-of-life scores of the children and caregivers did not correlate significantly with the asthma triage scores.

CONCLUSIONS

The questionnaires captured baseline quality-of-life information about this urban population and will facilitate longitudinal monitoring. The fact that the quality-of-life scores of children with asthma correlated with those of their adult caregivers, but not with their clinical triage scores, highlights the impact of asthma on families and the importance of having a long-term comprehensive management plan that is not based on exacerbations, but that includes both the children and their primary caregivers.

A genome-wide search for susceptibility loci to human essential hypertension

We undertook a systematic search of the entire human genome with the affected sibling-pair model to identify major susceptibility loci to essential hypertension. Affected nuclear families (n=263) were recruited and divided according to definite or probable genetic contribution to hypertension depending on number of hypertensive siblings. The largest nuclear families were first screened with a set of microsatellite markers. Regions on the genome with P<0.05 were tested against the second set of smaller families. An exclusion map was generated to identify regions in which hypertension-causing genes are unlikely to reside. Sibling-pair linkage analysis identified a single locus on chromosome 11q (P<0.004) in the first pass. A second pass with nuclear families that had only affected sibling pairs was, as expected, insufficient to support linkage to 11q. Multipoint exclusion-linkage analysis showed that 3 genetic loci are necessary to explain familial aggregation of essential hypertension. Our preliminary findings suggest that no single region within the human genome contains genes with a major contribution to essential hypertension. We show that the disease is indeed polygenic, with each gene providing a relatively small risk. Our exclusion map will help future investigators to concentrate on areas likely to contain these genes. The region on chromosome 11 is the first to point to a new candidate gene for hypertension that has arisen out of a genome search, but replication of these results at a higher significance is necessary before positional cloning can be justified.

Daily smoking by Louisiana students: sixth through twelfth grades, 1996-1997

OBJECTIVES

We sought to determine the prevalence of daily smoking in Louisiana in grades 6 through 12 and to compare Louisiana students' daily smoking to that of national student and Louisiana adult rates.

METHODS

A statewide, randomized, stratified classroom-based survey of 11,736 subjects was done for the school year 1996-1997.

RESULTS

We found that 17.3% of sixth grade students smoked daily, increasing to 36.1% in twelfth grade. Native American (43.7%), white (37.8%), and public school (28.5%) students had the highest rates of daily smoking. Males and females smoked at similar rates. Louisiana students in grades 8, 10, and 12 smoked daily at much higher rates (331%, 193%, and 146%, respectively) than comparable national samples. In 1997, Louisiana students smoked daily at higher rates than did Louisiana adults (28.9% vs 24.6%), primarily due to higher rates of smoking in student females (27.1%) compared to adult females (20.4%).

CONCLUSIONS

Student smoking in Louisiana is a significant public health problem.

An approach to the control of disease transmission in pig-to-human xenotransplantation

Although several major immunologic hurdles need to be overcome, the pig is currently considered the most likely source animal of cells, tissues and organs for transplantation into humans. Concerns have been raised with regard to the potential for the transfer of infectious agents with the transplanted organ to the human recipient. This risk is perceived to be increased as it is likely that the patient will be iatrogenically immunocompromised and the organ-source pig may be genetically engineered in such a way to render its organs particularly susceptible to infection with human viruses. Furthermore, the risk may not be restricted to the recipient, but may have consequences for the health of others in the community. The identification of porcine endogenous retroviruses and of hitherto unknown viruses have given rise to the most concern. We document here the agents we believe should be excluded from the organ-source pigs. We discuss the likelihood of achieving this aim and outline the potential means by which it may best be achieved.

Primary care patients' opinions regarding the importance of various aspects of care for depression

The objectives of this study were to 1) ascertain the importance of various aspects of depression care from the patient's perspective and 2) select items and scales for inclusion in a new instrument to measure primary care patients' attitudes toward and ratings of depression care. We used a cross-sectional survey at a university-based urban primary care clinic; the subjects were adult patients being recruited for a study of minor depression. To help prioritize attitudinal domains, including 126 items identified previously in focus groups, we asked patients to rate the importance of each aspect of depression care on a five-point scale. Items were ranked according to mean scores and the percentage of patients ranking the items as extremely important. The items were selected for inclusion in an instrument to measure patients' attitudes toward depression care based on their importance ratings. We performed reliability and validity testing of scales comprising the 30 most important items and a shortened version that includes 16 items. The sample included 76 patients (mean age 34.8 years; mean CES-D score, 22.2; 72% women; 36% African-American; 32% college graduates). Forty-six percent had visited a mental health professional in the past. The top 30 items for the overall sample came from the following domains: 1) health care providers' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, and 7) financial access to services. Scales comprising items from these domains show adequate internal consistency (Cronbach's alpha >0.70) as well as convergent and discriminant validity. We have designed a brief patient-centered instrument for measuring attitudes toward depression care that has evidence for internal item consistency reliability and discriminant validity.

The burden of alcohol misuse on an inner-city general hospital

Alcohol consumption in the UK has been increasing steadily. We prospectively studied the burden on hospital services caused by overt alcohol misuse, in an inner-city hospital in north-west England. All Accident & Emergency (A&E) patients were assessed to determine whether their hospital attendance was alcohol-related, and whether this resulted in admission and/or generated new out-patient appointments. Over 2 months, 1915 patients attended A&E with alcohol-related problems, accounting for 12% of attendances; 50% were aged 18-39 years, and acute alcohol intoxication was the commonest presenting complaint. Overall, 6.2% of all hospital admissions were due to alcohol-related problems. Over 2800 new out-patient visits were likely to have been generated over an 18-month period from initial attendance with an alcohol-related problem, mostly for orthopaedic clinics. The burden placed by overt alcohol-related problems on hospitals is enormous, both in terms of the emergency and out-patient services. The implementation of education, screening and intervention strategies in A&E departments, and employment of key trained personnel, should be considered, to optimize the clinical management of these patients.

B lymphocytes inhibit human osteoclastogenesis by secretion of TGFbeta

The role of B lymphocytes in osteoclast (OC) formation is controversial, because both stimulatory and inhibitory effects of B-lineage cells on osteoclastogenesis and life span have been reported. In this study, we have investigated the effects of mature B cells on human osteoclastogenesis using cultures of peripheral blood stem cells (PBSC), a system that generates functional OCs in the absence of stromal cells. We report that B cells inhibit the formation of OCs and shorten the life span of mature OCs by secreting transforming growth factor beta (TGFbeta), a factor that induces apoptosis in these cells. The antiosteoclastogenic effects of B cells are abolished by addition of anti-TGFbeta antibody to osteoclast cultures and mimicked by treatment of B cell-deprived PBSC cultures with recombinant TGFbeta, thus confirming TGFbeta as the B cell produced antiosteoclastogenic activity. Thus, the ability of B cells to downregulate osteoclastogenesis by secretion of the apoptotic cytokine TGFbeta provides new insights into the ability of immune cells to regulate OC formation under basal and inflammatory conditions.

The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function

This article presents the development of a brief, self-report measure of female sexual function. Initial face validity testing of questionnaire items, identified by an expert panel, was followed by a study aimed at further refining the questionnaire. It was administered to 131 normal controls and 128 age-matched subjects with female sexual arousal disorder (FSAD) at five research centers. Based on clinical interpretations of a principal components analysis, a 6-domain structure was identified, which included desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. Overall test-retest reliability coefficients were high for each of the individual domains (r = 0.79 to 0.86) and a high degree of internal consistency was observed (Cronbach's alpha values of 0.82 and higher) Good construct validity was demonstrated by highly significant mean difference scores between the FSAD and control groups for each of the domains (p < or = 0.001). Additionally, divergent validity with a scale of marital satisfaction was observed. These results support the reliability and psychometric (as well as clinical) validity of the Female Sexual Function Index (FSFI) in the assessment of key dimensions of female sexual function in clinical and nonclinical samples. Our findings also suggest important gender differences in the patterning of female sexual function in comparison with similar questionnaire studies in males.

Opioid and benzodiazepine withdrawal syndrome in adult burn patients

The prolonged use of continuous intravenous sedation [benzodiazepines (BZDs)] and pain medication [opioids (OPs)] is now common in intensive care units. Few studies have evaluated the characteristics that may lead to an acute withdrawal syndrome when these long-term medications are withdrawn. Those studies that have made recommendations for weaning rates to prevent withdrawal have given these recommendations with minimal data to support their recommendations. The purpose of this study was to retrospectively review the records of adult burn patients for the presence of acute BZD or OP withdrawal syndrome and to characterize whether patterns of BZD or OP administration or weaning rates contribute to the development of acute withdrawal syndrome. We found no relation of acute withdrawal syndrome to peak dose, total dose, or duration of dose of BZD/OP before the terminal withdrawal phase. There was a significant relationship between the rate of BZD/OP weaning in the terminal drug withdrawal phase and the percentage of days that patients experienced withdrawal symptoms (P < 0.005). Those patients who underwent a prolonged terminal weaning from these medications experienced fewer symptoms. The optimal rate of weaning that would allow decreased ventilator and intensive care unit length of stay without development of acute withdrawal symptoms is yet to be determined.

Attempted eradication of salmonellosis from a colony of short-tail grey opossums (Monodelphis domestica)

Prior to re-housing a colony of laboratory short-tail grey opossums, the animals were found to harbour salmonella. This paper describes an unsuccessful attempt to eradicate the infection from the colony by means of antibiotic treatment and hygienic measures. A pilot treatment of five animals which received enrofloxacin 10 mg/kg for 5 days appeared to be successful in that no salmonellae were recovered from faeces or organs sampled after treatment. The process was repeated on the whole colony prior to a change of accommodation but 2 animals were found to be still infected, 5 weeks after cessation of treatment.

Identifying agent(s) associated with poult enteritis mortality syndrome: importance of the thymus

Poult enteritis mortality syndrome (PEMS), a highly infectious disease of young turkeys, causes serious financial losses to the turkey industry. Clinically, PEMS is defined by mortality profiles, diarrhea, growth depression, and immunosuppression. Although many viruses, bacteria, and parasites are found in PEMS-infected birds, the inciting agent remains unknown. Experimentally, PEMS can be reproduced by exposing naïve poults to the intestinal contents from infected birds. Previous reports suggest that extraintestinal tissues fail to reproduce the disease. Histopathologic examination of tissues from PEMS-infected poults suggested that the thymus exhibited the earliest signs of pathology. On the basis of these observations, we hypothesized that the thymus harbors an agent(s) involved in PEMS. In these studies, naïve turkey poults were orally inoculated with a bacteria-free filtrate composed of either the intestines and feces or the thymus from PEMS-infected birds and were monitored for clinical signs of PEMS. Poults exposed to a filtrate composed solely of the thymus from PEMS-infected birds exhibited diarrhea, growth depression, mortality, pathology, and, most importantly, immunosuppression similar to poults exposed to the intestinal filtrate. The results of this study suggest that the thymus of infected birds harbors the agent(s) that can reproduce a PEMS-like disease in turkey poults.

The isolation and characterisation of human monoclonal HLA-A2 antibodies from an immune V gene phage display library

Molecular cloning techniques and V gene phage display have revolutionised the production of human monoclonal antibodies. Antibodies of a defined specificity can be obtained by selecting phage display libraries on antigen in a process known as panning. We have applied these techniques to the isolation of three HLA-A2-specific single chain variable domain fragments (scFv) from a patient alloimmunised by blood transfusion. Analysis of specificity with cells of HLA genotyped donors revealed the following: i) in addition to the major reactivity with HLA-A2, cross-reactivity with the HLA-A28 epitope; and ii) inhibition of scFv binding to the antigen by the patients' antibodies. The heavy chain variable genes of all three were derived from the germline gene Cos-3, carry the hallmarks of somatic hypermutation, and are most likely derived from clonally related B cells. The light chain variable domains were encoded by DPK1 and DPK8 from the VkappaI family. These data show that phage display can be used to clone HLA-specific alloantibodies that recognise the native antigen from alloimmunised patients.

Consumer empowerment through occupational therapy: the Americans With Disabilities Act Title III

OBJECTIVE

The purpose of this study was to determine whether occupational therapists (a) value a role educating consumers about the Americans With Disabilities Act of 1990 (ADA; Public Law 101-336); (b) are knowledgeable regarding Title III of the ADA; and (c) implement provisions and empower consumers who use wheelchairs to access public accommodations.

METHOD

A random sample of 510 occupational therapists was surveyed, with 229 responding. Of those surveys returned, 152 respondents who serve clients who use wheelchairs met inclusion criteria.

RESULTS

Although 90% of the participants agreed that occupational therapists should have ADA knowledge and should educate consumers, the mean score of ADA accessibility knowledge on a 10-point quiz was 1.85. The mean score of reported actions to implement ADA provisions with clients was 11.78 of a possible 40 points. There was a significant positive correlation between implementation and attitude (r = .3609, p = .01) and between implementation and knowledge (r = .3376, p = .01); however, the correlation between attitude and knowledge (r = .1673, p = .05) was not significant.

CONCLUSION

Therapists' lack of knowledge and their self-reported inaction with regard to ADA Title III may affect the accessibility of the environment, independence, and empowerment of clients who are wheelchair mobile and, therefore, may impede progress toward fully inclusive communities.