International and indigenous diagnoses of mental disorder among Vietnamese living in Vietnam and Australia

BACKGROUND

Whether the prevalence rates of common mental disorders can be compared across countries depends on the cultural validity of the diagnostic measures used.

AIMS

To investigate the prevalence of Western and indigenously defined mental disorders among Vietnamese living in Vietnam and in Australia, comparing the data with an Australian-born sample.

METHOD

Comparative analysis of three multistage population surveys, including samples drawn from a community living in the Mekong Delta region of Vietnam (n=3039), Vietnamese immigrants residing in New South Wales, Australia (n=1161), and an Australian-born population (n=7961). Western-defined mental disorders were assessed by the Composite International Diagnostic Interview (CIDI) 2.0 and included DSM-IV anxiety, mood and substance use disorders as well as the ICD-10 category of neurasthenia. The Vietnamese surveys also applied the indigenously based Phan Vietnamese Psychiatric Scale (PVPS). Functional impairment and service use were assessed.

RESULTS

The prevalence of CIDI mental disorders for Mekong Delta Vietnamese was 1.8% compared with 6.1% for Australian Vietnamese and 16.7% for Australians. Inclusion of PVPS mental disorders increased the prevalence rates to 8.8% for Mekong Delta Vietnamese and 11.7% for Australian Vietnamese. Concordance was moderate to good between the CIDI and the PVPS for Australian Vietnamese (area under the curve (AUC)=0.77) but low for Mekong Vietnamese (AUC=0.59). PVPS- and CIDI-defined mental disorders were associated with similar levels of functional impairment.

CONCLUSIONS

Cultural factors in the expression of mental distress may influence the prevalence rates of mental disorders reported across countries. The findings have implications for assessing mental health needs at an international level.

Comparison of three cell fixation methods for high content analysis assays utilizing quantum dots

Semiconductor nanoparticles or quantum dots are being increasingly utilized as fluorescent probes in cell biology both in live and fixed cell assays. Quantum dots possess an immense potential for use in multiplexing assays that can be run on high content screening analysers. Depending on the nature of the biological target under investigation, experiments are frequently required on cells retaining an intact cell membrane or also on those that have been fixed and permeabilized to expose intracellular antigens. Fixation of cell lines before or after the addition of quantum dots may affect their localization, emission properties and stability. Using a high content analysis platform we perform a quantitative comparative analysis of three common fixation techniques in two different cell lines exposed to carboxylic acid stabilized CdTe quantum dots. Our study demonstrates that in prefixed and permeabilized cells, quantum dots are readily internalized regardless of cell type, and their intracellular location is primarily determined by the properties of the quantum dots themselves. However, if the fixation procedures are preformed on live cells previously incubated with quantum dots, other important factors have to be considered. The choice of the fixative significantly influences the fluorescent characteristics of the quantum dots. Fixatives, regardless of their chemical nature, negatively affected quantum dots fluorescence intensity. Comparative analysis of gluteraldehyde, methanol and paraformaldehyde demonstrated that 2% paraformaldehyde was the fixative of choice. The presence of protein in the media did not significantly alter the quantum dot fluorescence. This study indicates that multiplexing assays utilizing quantum dots, despite being a cutting edge tool for high content cell imaging, still require careful consideration of the basic steps in biological sample processing.

Sharing beliefs: what sexuality means to Muslim Iranian women living in Australia

In Iran, women's sexual self-understandings are strongly determined by religious teaching. This study explores the meanings generated through the lived experience of sexuality of women residing in Australia that may challenge certain received Islamic notions of sexuality. Interviews and focus group discussions were conducted with 51 Iranian women in Sydney alongside 10 semi-structured interviews with Shi'ite clergy in Iran. Findings suggest that the concept of sexual obedience within marriage is regarded as symbolic of an idealised Muslim femininity. Sexual obedience demonstrates women's high level of religious commitment but is also an indicator of modesty and self-respect. While some participants felt that it was a woman's duty to satisfy her husband on any sexual occasion, they did not utilize notions of subordination in their sexual lives. For other informants, however, concepts of subordination were more salient and tied to conservative religious leaders' interpretations of Quranic concepts and Iranian women's understandings of these same interpretations. Religion is an important factor influencing Iranian women's sexual self-understandings, being relevant both to sexual education and public health. Recognition of this issue will facilitate understanding of the cultural foundations of sexuality among Muslims and assist health providers in suggesting more culturally compatible forms of healthcare.

Successful aspiration of an LAD thrombus ‘cast’ using an Export catheter

The use of a mechanical device to aspirate thrombus prior to stent deployment during primary angioplasty is currently not routinely recommended as results are often disappointing. However, we report a remarkable case during which we were able to successfully aspirate a 31 mm continuous length of thrombus using an Export catheter with subsequent dramatic improvement in both TIMI-flow and ST-segment resolution.

Increased mortality among patients sustaining hip fractures requiring surgery in a district general hospital

Fractures of the femoral neck are a common condition the incidence of which continues to rise. Associated mortality remains very high and knowledge of factors contributing to this high mortality is crucial in understanding outcome for both patient and surgeon. A retrospective review of 1254 patients operated on for fracture neck of femur was conducted to identify mortality at 30 days, 90 days and one year. Age, type of fracture, sex and waiting time for surgery were evaluated along with mortality for 47 patients who sustained their fracture while already inpatients with other concurrent illnesses. Those patients who sustained an inpatient fracture were found to have significantly higher mortality at 30 days, 90 days and one year. We concluded that these patients represent a very high-risk group that needs special consideration in management of their fracture and concurrent medical condition to reduce their high mortality.

Distribution and activation of T-lymphocyte subsets in tuberculous bovine lymph-node granulomas

The immune response against mycobacterial infections is dependant upon a complex interaction between T lymphocytes and macrophages in the context of the granuloma. For this study, we performed the analysis of 18 stage I or II, and 13 stage III or IV granulomas found in lymph nodes from 8 experimentally and 2 naturally infected cattle. T-cell subpopulations (CD3(+), CD4(+), CD8(+), WC1(+), CD25(+)) were investigated by immunohistochemistry. In the majority of stage I/II lesions, CD8(+) and CD25(+) cells were predominantly found in the lymphocytic outer region of the granuloma, suggesting a possible role for activated CD8(+) cells in the initial attempt to restrain the granuloma growth. CD4(+) T cells appeared equally distributed in the lymphocytic mantle and in the internal areas of the granulomas. WC1(+) cells appeared interspersed among the macrophages. We speculated that this could indicate a role for these 2 subsets in the maintenance and the maturation of the granuloma. In stage III/IV lesions, all of the T-cell subsets investigated appeared interspersed among the mononuclear component of the granulomas. In general terms, there was a higher density of CD8(+) cells compared with CD4(+) cells. However, there was no sense of rimming effect for any of the investigated cell populations.

Serum levels of soluble CD163 correlate with the inflammatory process in coeliac disease

BACKGROUND

In coeliac disease, following the introduction of a gluten-free diet, monitoring mucosal disease activity requires repeated small intestinal biopsies. If a test measuring a circulating inflammatory marker was available, this would be clinically valuable.

AIM

To determine if levels of soluble CD163, a scavenger receptor shed by tissue macrophages, correlated with the inflammatory lesion in coeliac disease.

METHODS

Serum samples were collected from 131 patients with untreated coeliac disease, 40 patients with treated coeliac disease, 92 non-coeliac disease control subjects and 131 healthy controls. A capture enzyme linked immunosorbance assay was established to measure levels of soluble CD163 in sera. The extent of the histological lesion in coeliac biopsies was assessed using a Marsh grading system.

RESULTS

Levels of CD163 in untreated coeliac subjects were significantly elevated when compared with the treated coeliac patients, the disease control group and the healthy control subjects (P < 0.0001 in each instance). Moreover, coeliac patients with the most marked histological lesion (Marsh 3) had significantly higher levels of soluble CD163 than patients with Marsh grade 2 lesions (P < 0.0004), with grade 1 lesions (P < 0.0001) and grade 0 lesions (P < 0.0001).

CONCLUSIONS

Measurement of soluble CD163 may be a useful method of monitoring the inflammatory lesion in coeliac disease.

Interferon-gamma responses to ESAT-6 in tuberculosis patients early into and after anti-tuberculosis treatment

OBJECTIVE

To investigate T-cell responses to ESAT-6 by an interferon-gamma (IFN-gamma) ex vivo enzyme-linked immunospot (ELISpot) assay in tuberculosis (TB) patients early during treatment and in patients who have completed a course of anti-tuberculosis chemotherapy.

DESIGN

T-cell responses following overnight stimulation with 6-kD early secretory antigenic target (ESAT-6) antigen were compared to responses obtained using cells cultured with ESAT-6 for 6 days, using an ELISpot assay.

RESULTS

In the ex vivo ELISpot assay, the median IFN-gamma responses in TB patients, irrespective of treatment status, were significantly higher than in healthy BCG-vaccinated controls. In the 6-day ELISpot assay, median IFN-gamma responses were significantly higher in TB patients who had completed treatment than in patients early during therapy. There was considerable individual variability in the degree of expansion of ESAT-6 specific T-cells from day 1 to day 6 in both treatment groups.

CONCLUSION

Further studies are required to assess which type of assay provides the best indicator of a memory T-cell response and how ESAT-6 specific T-cells relate to protective immunity in TB infection.

"Brain drain" or ethical recruitment?

Recruitment by wealthy countries of health personnel from developing countries is threatening the viability of crucial health programs in poor countries, especially in sub-Saharan Africa. Australia has participated in this "brain drain", although the extent and impact of this on different countries has not been adequately assessed. Australia depends on overseas-trained doctors to fill vacancies in public hospitals and private practice, particularly in rural and outer suburban areas where locally trained professionals are reluctant to work. Australia should adopt national strategies to minimise harm and maximise benefits of skills migration; concerted international action will also be required.

Effects of human placental lactogen on the expression of CD163 and CD14 on human monocytes in culture

The effect of human placental lactogen (hPL), a member of the somatomammotrophin family, on the regulation of the scavenger receptor molecules CD14 and CD163 on human monocytes cultured for 48h was investigated. Cells were cultured in the presence or absence of the hormone and also in the presence or absence of IFN-gamma and dexamethasone. Monocytes cultured in the presence of hPL showed a significant increase in the expression of CD14 in both males and females compared to background. When IFN-gamma and dexamethasone were added to the cultures, CD14 expression was decreased and was not rescued by the presence of hPL. hPL alone had no effect on the expression of CD163 on cultured monocytes from either gender, although cells cultured in the presence of IFN-gamma and dexamethasone showed a profound increase in their expression of CD163. This expression was augmented further by the presence of hPL in the cultures over a 48-h period. These results support the hypothesis of a potential role of this hormone in the regulation of the innate immune response.

Evaluation of clinical guidelines for the management of Staphylococcus aureus bacteraemia

BACKGROUND

While treatment guidelines have been developed to guide the management of Staphylococcus aureus bacteraemia, there is a need to validate these guidelines in different clinical settings and to relate the effect of compliance to clinical outcome.

AIMS

To assess the impact of adherence to treatment guidelines on clinical outcome and to explore the role of transoesophageal echocardiography (TOE) in risk stratification.

METHODS

We undertook a 2-year mixed retrospective and prospective study of all cases of S. aureus bacteraemia at Fremantle Hospital, documenting the clinical and microbiological features of each case, the results of echocardiography, adherence with published clinical guidelines and clinical outcome.

RESULTS

Failure to comply with guidelines was observed in 41% (38 of 93) of cases, the majority receiving abbreviated treatment. An increased rate of relapse was observed among patients who received inadequate therapy (5/38 vs 1/55; P= 0.04). Ten of 28 eligible patients underwent TOE and the test led to significant changes in management in two of those cases.

CONCLUSIONS

While non-adherence with clinical guidelines was associated with an increased risk of relapse, the role of TOE in risk stratification was limited by factors including cost, limited acceptance of the test and the need for prolonged therapy for other indications.

Flow cytometric measurement of intracellular migration inhibition factor and tumour necrosis factor alpha in the mucosa of patients with coeliac disease

There is increasing evidence that proinflammatory cytokines contribute to many of the small intestinal features in coeliac disease. The aim of the study was to investigate the expression of two proinflammatory cytokines, migration inhibition factor (MIF) and tumour necrosis factor alpha (TNF-alpha) in duodenal biopsy specimens from patients with coeliac disease on a gluten-free diet and normal control subjects. A flow cytometric system was used to analyse intracellular protein levels of MIF and TNF-alpha in freshly isolated cells from duodenal biopsies taken from 12 patients with treated coeliac disease and 10 healthy control subjects. From the biopsy specimens, single cell suspensions of the epithelium and lamina propria were prepared using EDTA/DTT and enzymes. Intracellular cytokine expression was studied in intraepithelial lymphocytes (IELs), lamina propria T cells (LP T) and intestinal epithelial cells using different surface labelling antibodies. MIF protein was constitutively expressed in IELs, LP T cells and epithelial cells from normal intestinal mucosa. In contrast, although TNF-alpha was found in LP T cells, this cytokine was virtually undetectable in either IELs or epithelial cells. In coeliac disease, intracellular levels of MIF were significantly higher in epithelial cells compared with control subjects (P = 0.005). Raised levels of TNF-alpha were found in epithelial cells (P = 0.03) as well as IELs (P = 0.045) from coeliac patients compared with controls. The findings from this study show up-regulated expression of MIF and TNF-alpha in IELs and epithelial cells of histologically normal mucosa in patients with coeliac disease. Increased expression of proinflammatory cytokines in cells occupying the epithelial layer could help explain the rapidity with which the coeliac mucosa may respond to gluten challenge.

Bringing the human genome and the revolution in bioinformatics to the medical school classroom: a case report from Washington University School of Medicine

The human genome project is revolutionizing medical research and the practice of clinical medicine. To understand and participate in this revolution, physicians must be fluent in human genomics and bioinformatics. At Washington University School of Medicine (WUSM), the authors designed a module for teaching these skills to first-year students. The module uses clinical cases as a platform for accessing information stored in GenBank, Online Mendelian Inheritance in Man (OMIM), and PubMed databases at the National Center for Biotechnology Information (NCBI). This module, which is also designed to reinforce problem-solving skills, has been integrated into WUSM's first-year medical genetics course.

Enhanced contact tracing and spatial tracking of Mycobacterium tuberculosis infection by enumeration of antigen-specific T cells

BACKGROUND

Identification of individuals latently infected with Mycobacterium tuberculosis is an important part of tuberculosis control. The current method, the tuberculin skin test (TST), has poor specificity because of the antigenic cross-reactivity of purified protein derivative (PPD) with M bovis BCG vaccine and environmental mycobacteria. ESAT-6 is a secreted antigen that is highly specific for M tuberculosis complex, but is absent from M bovis BCG. With an enzyme-linked immunospot (ELISPOT) assay for interferon gamma, we have identified ESAT-6-specific T cells as an accurate marker of M tuberculosis infection.

METHODS

We did a prospective, masked study of 50 healthy contacts, with varying but well defined degrees of exposure to M tuberculosis, who attended an urban contact-tracing clinic. We assessed and compared the efficacy of our assay and TST for detection of symptomless infected individuals by correlation of test results with the degree of exposure to an infectious index case.

FINDINGS

The ESAT-6 ELISPOT assay results had a strong positive relation with increasing intensity of exposure (odds ratio=9.0 per unit increase in level of exposure [95% CI 2.6--31.6], p=0.001), whereas TST results had a weaker relation with exposure (1.9 [1.0--3.5], p=0.05). By contrast, ELISPOT results were not correlated with BCG vaccination status (p=0.7), whereas TST results were significantly more likely to be positive in BCG-vaccinated contacts (12.1 [1.3--115.7], p=0.03).

INTERPRETATION

This new antigen-specific T cell-based assay could allow more accurate identification of symptom-free individuals recently exposed to M tuberculosis, and thereby help to improve tuberculosis control.

A guinea pig model of low-dose Mycobacterium bovis aerogenic infection

In order to develop a model of Mycobacterium bovis infection with pathogenetical relevance, a modified version of the Henderson apparatus was used to deliver infectious aerosols directly to the snouts of guinea pigs. Aerosols generated from 10(6), 10(7), 10(8)CFU/ml M. bovis suspensions established disease in every animal, with estimated retained doses of 10, 100, 1000 CFU, respectively. For comparison, other guinea pigs were inoculated with 100 CFU M. bovis intramuscularly (i.m.). Pathology and bacterial colonisation of lungs and spleen varied according to the dose and route of inoculation. Animals inoculated i.m. gave a significant cutaneous tuberculin hypersensitivity reaction earlier after testing than those infected aerogenically. A serological response to M. bovis antigens was detected in all infected animals. Intensity of antigen recognition was dose-dependent and although the range of antigens recognised varied between animals, a 25 kDa antigen present in the cell fraction was serodominant. Thus, a reproducible guinea pig model has been defined that may be suitable for virulence, vaccination, and immunological studies.

Use of synthetic peptides derived from the antigens ESAT-6 and CFP-10 for differential diagnosis of bovine tuberculosis in cattle

In Great Britain an independent scientific review for the government has concluded that the development of a cattle vaccine against Mycobacterium bovis infection holds the best long-term prospect for tuberculosis control in British herds. A precondition for vaccination is the development of a complementary diagnostic test to differentiate between vaccinated animals and those infected with M. bovis so that testing and slaughter-based control strategies can continue alongside vaccination. To date bacillus Calmette-Guérin (BCG), an attenuated strain of M. bovis, is the only available vaccine for the prevention of tuberculosis. However, tests based on tuberculin purified protein derivative cannot distinguish between M. bovis infection and BCG vaccination. Therefore, specific antigens expressed by M. bovis but absent from BCG constitute prime candidates for differential diagnostic reagents. Recently, two such antigens, ESAT-6 and CFP-10, have been reported to be promising candidates as diagnostic reagents for the detection of M. bovis infection in cattle. Here we report the identification of promiscuous peptides of CFP-10 that were recognized by M. bovis-infected cattle. Five of these peptides were formulated into a peptide cocktail together with five peptides derived from ESAT-6. Using this peptide cocktail in T-cell assays, M. bovis-infected animals were detected, while BCG-vaccinated or Mycobacterium avium-sensitized animals did not respond. The sensitivity of the peptide cocktail as an antigen in a whole-blood gamma interferon assay was determined using naturally infected field reactor cattle, and the specificity was determined using blood from BCG-vaccinated and noninfected, nonvaccinated animals. The sensitivity of the assay in cattle with confirmed tuberculosis was found to be 77.9%, with a specificity of 100% in BCG-vaccinated or nonvaccinated animals. This compares favorably with the specificity of tuberculin when tested in noninfected or vaccinated animals. In summary, our results demonstrate that this peptide cocktail can discriminate between M. bovis infection and BCG vaccination with a high degree of sensitivity and specificity.

Prophylactic oophorectomy and ovarian cancer surveillance. Patient perceptions and satisfaction

OBJECTIVE

To evaluate decision making, information gathering, satisfaction and regret in women at increased risk of ovarian cancer who had undergone prophylactic oophorectomy or ovarian cancer surveillance.

STUDY DESIGN

Thirty women undergoing prophylactic oophorectomy (median age, 47 years) and 30 women who had undergone ovarian cancer surveillance (median age, 43) completed an in-depth telephone interview consisting of open-ended questions.

RESULTS

Most commonly cited concerns before prophylactic oophorectomy included the physical discomfort of surgery and recovery (40%) and issues of immediate menopause and hormone replacement (37%). Fourteen women (47%) would have liked more information prior to surgery. Two women (7%) expressed regret about their decision. The remaining 28 women (93%) undergoing prophylactic oophorectomy expressed no regret about the decision. Nine women (37%) would have liked more information prior to considering ovarian cancer surveillance. Nearly half the women undergoing surveillance did not recall receiving any information about prophylactic oophorectomy as an option. Fifteen women (50%) expressed some regret about ovarian cancer surveillance, and three were frankly dissatisfied.

CONCLUSION

Few women undergoing prophylactic oophorectomy had regret about their decision, though half these women would have liked more information prior to surgery. Many women undergoing ovarian cancer surveillance had some regret about or dissatisfaction with their decision.

Reforming the core clerkship in internal medicine: the SGIM/CDIM Project. Society of General Internal Medicine/Clerkship Directors in Internal Medicine

Dramatic changes in health care have stimulated reform of undergraduate medical education. In an effort to improve the teaching of generalist competencies and encourage learning in the outpatient setting, the Society of General Internal Medicine joined with the Clerkship Directors in Internal Medicine in a federally sponsored initiative to develop a new curriculum for the internal medicine core clerkship. Using a broad-based advisory committee and working closely with key stakeholders (especially clerkship directors), the project collaborators helped forge a new national consensus on the learning agenda for the clerkship (a prioritized set of basic generalist competencies) and on the proportion of time that should be devoted to outpatient care (at least one third of the clerkship). From this consensus emerged a new curricular model that served as the basis for production of a curriculum guide and faculty resource package. The guide features the prioritized set of basic generalist competencies and specifies the requisite knowledge, skills, and attitudes/values needed to master them, as well as a list of suggested training problems. It also includes recommended training experiences, schedules, and approaches to faculty development, precepting, and student evaluation. Demand for the guide has been strong and led to production of a second edition, which includes additional materials, an electronic version, and a pocket guide for students and faculty. A follow-up survey of clerkship directors administered soon after completion of the first edition revealed widespread use of the curricular guide but also important barriers to full implementation of the new curriculum. Although this collaborative effort appears to have initiated clerkship reform, long-term success will require an enhanced educational infrastructure to support teaching in the outpatient setting.

Occurrence of IgA and IgG autoantibodies to calreticulin in coeliac disease and various autoimmune diseases

Calreticulin (CRT), a high-affintiy calcium binding protein and chaperone, was recently identified as one of the targets of autoantibodies in coeliac disease. We evaluated the level of IgA and IgG antibodies to CRT in sera from patients with coeliac disease and various autoimmune diseases. The level of antibodies to gliadin (shown previously to cross-react with CTR), isolated enterocytes and tissue transglutaminase were determined for comparison. The mean level of IgA antibodies to CRT was significantly higher (P< 0.001) in sera from coeliac patients with active disease (139.9+/-11.2 AU/+/-SE) than in healthy controls (20.9+/-1.7 AU). In sera of patients with systemic lupus erythematosus (SLE), insulin dependent diabetes mellitus (IDDM), multiple sclerosis (MS) and autoimmune thyroiditis (AT) or inflammatory bowel disease (IBD) the mean level (25.8+/-3.7 to 38.1+/-5.6 AU) did not exceed the cut-off value. A low level of these antibodies, however, was detected in some sera of patients with MS and IBD. The level of IgG anti-CRT antibodies was increased in coeliac patients (mean 125.4+/-8.0 AU, P< 0.001) when compared to that in healthy controls (33.9+/-2.3 AU). The IgG anti-CRT antibodies were also detected in about 30% of SLE patients sera (54.1+/-3.6 AU, P< 0.001), but the mean level reached only half that detected in coeliac patients.