The changing pattern of mental health problems in HIV infection: the view from London, UK

As we end the second decade with AIDS, profound changes in our understanding of its aetiology, mechanism of disease and its treatment have led to significant improvements in survival, disease progression and quality of life for those individuals with HIV infection who are fortunate enough to have access to health care and to treatments for the infection and its complications. Unsurprisingly, the psychological and social consequences of HIV have also seen important shifts, giving rise to new and unforeseen difficulties, as well as a greater sense of hope. Here, some of the changes seen among people with HIV infection being looked after in a Central London teaching hospital and referred to the mental health services are reviewed and discussed.

Sexual dysfunction in gay and bisexual men with HIV infection: evaluation, treatment and implications

Sexual dysfunction problems are common in people with HIV infection, but their relevance has been recently highlighted in response to the increased survival shown by many individuals with HIV, and the publicity surrounding the development of new treatments for male sexual dysfunction. Thirty-four gay/bisexual men with HIV infection presenting with sexual dysfunction were assessed. Antiretroviral combination therapy including protease inhibitors was taken by 44%, other combinations not including protease inhibitors by 24%, while 32% were not taking any antiretrovirals. Primarily psychogenic sexual dysfunction was thought to be present in 44%, primarily organic dysfunction in 22% and a mixed aetiology in 34%. Treatments offered included psychological interventions and physical methods of treatment, alone or in combination. Treatment was effective, with 76% reporting resolution of the problems, 14% reporting improvement and only 10% reporting no change. Practical and ethical issues raised by the findings are discussed.

Asymptomatic Chiari Type I malformations identified on magnetic resonance imaging

OBJECT

Chiari Type I malformation (CMI) is a congenital disorder recognized by caudal displacement of the cerebellar tonsils through the foramen magnum and into the cervical canal. Frequently, associated findings include abnormalities of nearby bony and neural elements as well as syringomyelia. Cerebellar tonsillar ectopia is generally considered pathological when greater than 5 mm below the foramen magnum. However, asymptomatic tonsillar ectopia is an increasingly recognized phenomenon, the significance of which is poorly understood.

METHODS

The authors retrospectively reviewed the records of all brain magnetic resonance (MR) images obtained at our hospital over a 43-month period in an attempt to ascertain the relative prevalence and MR imaging characteristics of asymptomatic CMIs. Of 22,591 patients who underwent MR imaging of the head and cervical spine, 175 were found to have CMIs with tonsillar herniation extending more than 5 mm below the foramen magnum. Of these, 25 (14%) were found to be clinically asymptomatic. The average extent of ectopia in this population was 11.4 +/- 4.86 mm, and was significantly associated with a smaller cisterna magna. Syringomyelia and osseous anomalies were found in only one asymptomatic patient.

CONCLUSIONS

The authors suggest that the isolated finding of tonsillar herniation is of limited prognostic utility and must be considered in the context of all available clinical and radiographic data. Strategies for treating patients with asymptomatic CMIs are discussed.

BUBR1 phosphorylation is regulated during mitotic checkpoint activation

Eukaryotic cells have evolved a mechanism that delays the progression of mitosis until condensed chromosomes are properly positioned on the mitotic spindle. To understand the molecular basis of such monitoring mechanism in human cells, we have been studying genes that regulate the mitotic checkpoint. Our early studies have led to the cloning of a full-length cDNA encoding MAD3-like protein (also termed BUBR1/MAD3/SSK1). Dot blot analyses show that BUBR1 mRNA is expressed in tissues with a high mitotic index but not in differentiated tissues. Western blot analyses show that in asynchronous cells, BUBR1 protein primarily exhibits a molecular mass of 120 kDa, and its expression is detected in most cell lines examined. In addition, BUBR1 is present during various stages of the cell cycle. As cells enter later S and G2, BUBR1 levels are increased significantly. Nocodazole-arrested mitotic cells obtained by mechanical shake-off contain BUBR1 antigen with a slower mobility on denaturing SDS gels. Phosphatase treatment restores the slowly migrating band to the interphase state, indicating that the slow mobility of the BUBR1 antigen is attributable to phosphorylation. Furthermore, purified recombinant His6-BUBR1 is capable of autophosphorylation. Our studies indicate that BUBR1 phosphorylation status is regulated during spindle disruption. Considering its strong homology to BUB1 protein kinase, BUBR1 may also play an important role in mitotic checkpoint control by phosphorylation of a critical cellular component(s) of the mitotic checkpoint pathway.

The physical association and phosphorylation of Cdc25C protein phosphatase by Prk

prk encodes a protein serine/threonine kinase involved in regulating M phase functions during the cell cycle. We have expressed His6-Prk and His6-Cdc25C proteins using the baculoviral vector expression system. Purified recombinant His6-Prk, but not a kinase-defective mutant His6-PrkK52R, is capable of strongly phosphorylating His6-Cdc25C in vitro. Co-immunoprecipitation and affinity column chromatography experiments demonstrate that GST-Prk and native Cdc25C interact. When co-infected with His6-Prk and His6-Cdc25C recombinant baculoviruses, sf-9 cells produce His6-Cdc25C antigen with an additional slower mobility band on denaturing polyacrylamide gels compared with cells infected with His6-Cdc25C baculovirus alone. In addition, His6-Cdc25C immunoprecipitated from sf-9 cells co-infected with His6-Prk and His6-Cdc25C baculoviruses, but not with His6-PrkK52R and His6-Cdc25C baculoviruses, contains a greatly enhanced kinase activity that phosphorylates His6-Cdc25C in vitro. Moreover, phosphopeptide mapping shows that His6-Prk phosphorylates His6-Cdc25C at two sites in vitro and that the major phosphorylation site co-migrates with the one that is phosphorylated in vivo in asynchonized cells. Further studies reveal that His6-Prk phosphorylates Cdc25C on serine216, a residue also phosphorylated by Chk1 and Chk2. Together, these observations strongly suggest that Prk's role in mitosis is at least partly mediated through direct regulation of Cdc25C.

The burden of care: the impact of HIV-associated dementia on caregivers

It has been suggested that up to 15% of patients with AIDS may develop HIV-associated dementia. The syndrome may be either abrupt or insidious and is characterized by poor prognosis. Increasing cognitive impairment will necessitate the patient receiving a substantial amount of care and support in the community in addition to medical treatment and periods of hospitalization. The impact of caregiver burden is reasonably well documented in Alzheimer's disease, but there is a dearth of literature relating to caregiving and HIV-associated dementia. The current investigation is an observational study based on a small group of individuals which evaluates the experiences of these particular individuals as they care for their partner, friend, or son with HIV-associated dementia. The caregivers experience the stresses described in the non-HIV dementia literature; however, the nature of HIV disease means that there are issues involved in caring for this patient group that distinguish it from other types of dementia care; these include difficulties relating to specific HIV medical problems and problems with service shortfalls. The caregiver is more likely to be a parent or partner than a child of the patient due to the early age onset seen in this disease compared with Alzheimer's disease. Caregivers express their need for information about dealing with the everyday physical, behavioral, and emotional challenges and about services and benefits available. The interviewees expressed concerns over a perceived lack of communication and information from professionals involved in the patient's care and in the provision of services. The study offers an insight into the relevant issues affecting such caregivers and suggests areas of unmet needs that might be addressed in future service provisions.

Human Bub1: a putative spindle checkpoint kinase closely linked to cell proliferation

Eukaryotic cells have evolved a mechanism that delays the onset of anaphase until chromosomes are properly positioned on the spindle. To understand the molecular basis of such surveillance mechanism in human cells, we have cloned a full-length cDNA encoding a putative mitotic checkpoint kinase termed hBub1. Sequence comparison reveals that hBub1 is a structurally conserved protein, sharing 23% amino acid residue identity with BUB1 of budding yeast. In addition, the NH2-terminal portion (161 amino acids) of hBub1 shows a significant homology to yeast MAD3, a protein also known to be involved in the mitotic checkpoint response pathway. Northern blot analyses show that the hBub1 mRNA level is abundantly expressed in tissues or cells with a high mitotic index. When Dami cells undergo terminal differentiation after treatment with phorbol ester, hBub1 expression in this cell line is down-regulated rapidly. The hBub1 protein level is low in G1 and remains relatively constant in S, G2, and M phases. Immunofluorescence analysis shows that hBub1 protein colocalizes with a centromere-kinetochore antigen CREST in interphase, mitotic prophase, and nocodazole-treated cells. Antibody electroporation experiments show that hBub1 is an important component of the spindle checkpoint pathway. Furthermore, fluorescence in situ hybridization analysis maps the hBub1 gene to chromosome 2q12-13. Our studies suggest that hBub1 expression is restricted to proliferating cells and appears to be involved in regulating cell cycle progression. The molecular cloning of hBub1 cDNA will facilitate the study of its role in spindle checkpoint control as well as its potential role in certain genetic disorders.

Mental health problems in older adults with HIV referred to a psychological medicine unit

Although HIV is still seen by many as a disease affecting younger adults, it is known that at least 11% of individuals with AIDS in Britain are over the age of 50. It is likely that this older age representation will continue and increase and whilst much is known about the psychological wellbeing of younger individuals with HIV, it is crucial that we consider the differing experiences and needs of older adults with the disease. Fifty-two adults with HIV over the age of 54 were referred to the Department of Psychological Medicine between June 1990 and December 1996. Data for these patients were compared with corresponding information for a random sample of younger patients with HIV. The older adults were found to differ significantly from the younger individuals on a variety of social, psychological and medical variables including social isolation, employment worries, sexuality, previous psychiatric history and stage of HIV at referral. It seems that current HIV services may actually alienate a significant proportion of potential users through not being sensitive to the needs and views of these older individuals. This must be addressed by policy makers and practitioners to ensure that psychiatric and psychological services become more acceptable and accessible to the older adult.

Are reported stress and coping style associated with frequent recurrence of genital herpes?

OBJECTIVES

This paper reports on the cross sectional data from the longitudinal study examining the impact of genital herpes simplex virus (HSV) infection on quality of life. In particular the report sought to study the relation between recurrence of genital HSV and coping style, mood, personality, and quality of life, among other factors.

SETTING AND SUBJECTS

116 patients with a known history of genital herpes simplex infection attending the Department of Genitourinary Medicine at Chelsea and Westminster Hospital.

METHODS

Psychosocial factors (stress, anxiety, depression, health locus of control, personality, social support, coping skills, and quality of life) and the reported frequency of genital herpes episodes were measured using self administered questionnaires designed to examine the relation between psychosocial status and the frequency of genital HSV episodes.

RESULTS

The number of recurrences reported by patients was significantly related to the style of coping skills used. Higher recurrences were less likely to use problem focused coping skills of planning and active coping, and the emotion focused coping skills of positive reinterpretation and growth. There was a significant difference in the number of patients who believed that psychological stress was related to the number of recurrences they experienced. This belief was related to neuroticism on the Eysenck Personality Questionnaire scale, and not to any of the other measures investigated.

CONCLUSION

The findings suggest that it is the way individuals cope, and their personality characteristics rather than actual levels of psychological stress, that influence their belief in a link between recurrent genital HSV and stress. HSV may become the focus of existing concerns and be viewed as the physical manifestation of stress.

Regional specialization in the eye of the sphingid moth Manduca sexta: blue sensitivity of the ventral retina

The compound eye of the tobacco hornworm moth Manduca sexta contains green-, blue-, and ultraviolet-sensitive photoreceptors. Electroretinogram spectral-sensitivity measurements were recorded from different regions of the retina in order to broadly map the distribution of the three receptor types. The relative contribution of the three receptors to spectral-sensitivity curves was estimated by fitting theoretical curves based on the absorption spectra of the three rhodopsins. This analysis indicated that the dorsal retina is green and ultraviolet dichromatic, with green-sensitive cells greatly predominating. The ventral retina is trichromatic with a substantial population of blue- and ultraviolet-sensitive receptors. We previously showed that flower visitation for nectar feeding is mediated mainly by blue-sensitive cells. Their localization in the ventral retina seems an appropriate adaptation of the receptor mosaic, since the moths hover above flowers as they feed.

Women and HIV infection: investigation of its psychosocial consequences

HIV infection is associated with substantial psychological and social morbidity, although there is a dearth of studies of women with the infection. In recent years, developed countries have reported an increase in the prevalence of HIV infection in women, a fact that makes it all the more important to address the study of their psychological and social status. The study is a controlled investigation of HIV seropositive (n = 49) and seronegative women (n = 43), including study of psychological status and history, social functioning and perceived supports, coping style, life events, and sexual difficulties. The results show that about a third of women were psychiatric cases, regardless of HIV status, although more than half of symptomatic women were psychiatric cases. Seropositive women were less likely to use instrumental social supports and more likely to use mental disengagement as ways of coping. Regarding perceived social supports, positive women had lower scores on social integration and guidance. Positive women were more likely to experience sexual difficulties and not to be in a relationship. Negative women reported more adverse life events in the last 6 months. Psychiatric morbidity was associated with poorer social adjustment and more adverse life events, but not with serostatus. HIV positive women and those at risk of HIV infection have substantial levels of psychological and social morbidity that require recognition by those involved in their care and provision of adequate mental health intervention.

The application of shear and extensional viscosity measurements to assess the potential of hylan in viscosupplementation

The shear and extensional viscosity characteristics have been compared for hyaluronan and two samples of a cross-linked derivative, hylan, of different molecular weights. While shear thinning behavior was observed for all systems in shear flow, strain thickening was observed in extensional flow for the relatively dilute systems. However, there was a progressive transition to shear thinning behavior as the polymer concentration was increased. It is evident from the results that the shear flow techniques alone provide an incomplete picture of the rheological properties of these materials and that extensional flow characteristics are potentially dominant. For example, at relatively high deformation rates of 500 s-1 and above, our results show that the extensional viscosities of aqueous solutions of the various polymers are at least two orders of magnitude greater than their corresponding shear flow viscosities. The incremental differences in viscosity with concentration increased with increasing molecular mass of the polymers and were greater in extensional flow than shear flow. These results demonstrate that the dynamic network structure formed by the higher molecular mass hylans offer potentially better physical and mechanical properties for viscosupplementation of diseased osteoarthritis joints compared with the parent hyaluronan.

Preoperative HIV antibody testing: the views of surgeons and patients

Fifty surgeons and 72 preoperative patients in 2 central London hospitals were asked their views on preoperative HIV antibody testing, who is at risk of HIV infection and HIV test counseling. A substantial proportion of both surgeons and preoperative patients, 48% and 54% respectively, supported compulsory HIV antibody testing without patient consent. They believed this should occur as a routine practice prior to surgery. However, surgeons and patients differed in the preoperative patients to be considered for such testing. All surgeons advocating compulsory testing believed that it was only necessary for those patients belonging to high risk groups whilst preoperative patients believed that all patients should be HIV tested prior to surgery. Surgeons and patients also differed in their views on who was at risk of HIV infection. Surgeons believed those at risk to be members of identifiable risk groups whilst patients believed everyone was at risk, especially those engaging in high risk behaviours. Finally, when asked which health professionals they thought should be involved in HIV test counselling, both surgeons and patients agreed that hospital doctors, including surgeons themselves, should take on the responsibility of test counselling. The implications of this and routine HIV antibody testing are discussed.

Testing patients for HIV before surgery: the views of doctors performing surgery

The aim of this study was to investigate the attitudes of doctors performing surgery to the HIV antibody testing of surgical patients. Fifty of eighty (62.5%) doctors performing surgery who are working in two London teaching hospitals returned completed anonymous postal questionnaires. Sixty-six per cent of the sample would like some form of compulsory testing of pre-operative patients, although most of them feel that this is only necessary for patients considered to be in 'high-risk groups'. Eighty-four per cent believe that this would ensure their safety from infection during surgery. Forty-eight per cent agreed with testing patients without their consent. Results suggest that most of the doctors performing surgery in this study agree with compulsory HIV antibody testing of pre-operative patients in the belief that this would protect them from infection during surgery. The problems associated with compulsory testing and relying on such testing in order to protect doctors from infection during surgery are discussed.

Why do antenatal attenders decide to have the HIV antibody test?

The aim of the study was to investigate factors influencing the parturient woman's decision to accept or decline the HIV antibody test in the antenatal clinic. Eighty-eight women attending an antenatal clinic, in a central London hospital, for an appointment at 28-32 weeks of pregnancy were given a structured face to face interview. Results indicated that 36% (n = 32) had elected to be tested. Reasons for declining included assumption of no risk, being in a stable relationship, not wanting to think about HIV when pregnant and not wanting to know if HIV positive. Reasons for accepting included fears for health of the baby and fears for own health. 52% (n = 46) had discussed the test with their partner, most of whom had agreed with the woman's decision or left the decision to her. Only 31% of the women were aware they had been automatically tested for syphilis. Knowledge about vertical transmission was poor. Anxiety levels of those tested and those not tested were not significantly different nor did either group differ over time. The groups did not differ on demographic variables, transmission knowledge or perceived likelihood of infection. Most women elected not to be tested and reasons around the decision are very individualistic and varied. HIV testing does not appear to cause anxiety when it is offered on a voluntary basis. Knowledge of routine testing and of vertical transmission is poor and should be the focus of health education intervention.

Who chooses to have the HIV antibody test in the antenatal clinic?

With the increase in human immunodeficiency virus (HIV) seroprevalence amongst antenatal clinic attenders, and given that current medical opinion considers it desirable that a woman is aware of her serostatus, it has been recommended that the HIV test is offered to all women in the antenatal clinic and that its uptake is monitored. This paper reports on the uptake rate during the 12 months to February 1990 at a central London hospital, which was 17%, and the characteristics of the women who agreed to be tested for HIV. Using information collected by the midwife on an interactive computer during the 'booking' interview, it was found that women who were single and not in a stable relationship (p < 0.001) and those who described themselves as Mediterranean (p < 0.01) were more likely to accept the test. Caucasian women (p < 0.05) and married women (p < 0.05) were less likely to accept the test. Accepters did not differ from decliners in any other variable examined. Possible reasons for these differences are discussed.