Psychosocial interest, medical interviews, and the recognition of depression

OBJECTIVES

To measure primary care physicians' attitudes toward psychosocial issues, determine their relationship to the style of the medical interview, and assess whether attitudes and interview behaviors lead to correct diagnosis in patients with depression.

DESIGN

Physicians were videotaped while interviewing four patients standardized with criteria symptoms of major depression. Physicians were unaware of the mental health focus of the study.

SETTING

Patient examining rooms.

PARTICIPANTS

Physicians were eligible for recruitment if they were board certified or eligible in family practice or internal medicine, practiced primary care medicine, and were listed in regional directories. Standardized patients were recruited from the community.

MAIN OUTCOME MEASURES

Attitudes toward psychosocial issues (measured by the Physician Belief Scale), interview content (measured by review of the videotaped encounters), interview behaviors (measured by the Interaction Analysis System for Interview Evaluation), and a listing of depression in the differential diagnosis (determined by physician debriefing interviews).

RESULTS

Forty-seven community-based practitioners participated. Forty-eight percent of interviews resulted in a diagnosis of depression. Physician Belief Scale scores were not significantly correlated with patient-centered interviewing, psychosocial questions, inquiry about depression symptoms, or a depression diagnosis. Longer interviews were more likely to result in a depression diagnosis.

CONCLUSIONS

High interest in psychosocial issues was not associated with patient-centered interviewing behaviors, questions about psychosocial or depression symptoms, or depression diagnoses. However, certain patient-centered interviewing behaviors, particularly those defined as "affective," did lead to the recognition of depression.

Relationship between lung biopersistence and biological effects of man-made vitreous fibers after chronic inhalation in rats

This article describes the relationship between fiber biopersistence and the chronic toxicity of different chemical compositions of man-made vitreous fibers (MMVF) in the lung. Rats were exposed in "nose-only" inhalation chambers, 6 hr/day, 5 days/week, for 24 months to aerosol concentrations of 30 mg/m3 containing comparable fiber numbers and similar dimensions of fibrous glass (FG) or refractory ceramic fiber (RCF). Interim sacrifices were performed periodically to monitor fiber number and dimensions in the lung and the progression of pulmonary alterations. At each interim sacrifice, three to six recovery animals were removed from each exposure group and held until two years to determine the biopersistence of fibers after different exposure times. Fibers were recovered from the ashed lungs, counted, and measured using optical and scanning electron microscopy (SEM). Fiber chemistry was assessed in 91-week recovery lungs using energy dispersive spectroscopy (EDS) analysis. RCF induced lung fibrosis and an elevation in lung tumors and pleural mesotheliomas. FG exposure resulted in no lung fibrosis, no statistically significant increase in the lung tumor incidence, and no mesotheliomas. After two years of continuous exposure, the number of World Health Organization fibers per milligram dry lung recovered from RCF and FG exposed lungs was comparable. EDS analysis of recovery lungs showed that most of the alkalis and alkaline earths had leached from the FG fibers over time. A slight change in RCF chemistry was observed. These findings indicate that the change in the chemical composition of fibers may be an important determinant of the chronic toxicity of MMVFs.

Characterization of exposure and dose of man made vitreous fiber in experimental studies

The use of fibrous test materials in in vivo experiments introduces a number of significant problems not associated with nonfibrous particulates. The key to all aspects of the experiment is the accurate characterization of the test material in terms of fiber length, diameter, particulate content, and chemistry. All data related to fiber properties must be collected in a statistically sound manner to eliminate potential bias. Procedures similar to those outlined by the National Institute of Occupational Safety and Health (NIOSH) or the World Health Organization (WHO) must be the basis of any fiber characterization. The test material to which the animal is exposed must be processed to maximize the amount of respirable fiber and to minimize particulate content. The complex relationship among the characteristics of the test material, the properties of the delivery system, and the actual dose that reaches the target tissue in the lung makes verification of dose essential. In the case of man-made vitreous fibers (MMVF), dose verification through recovery of fiber from exposed animals is a complex task. The potential for high fiber solubility makes many of the conventional techniques for tissue preservation and digestion inappropriate. Processes based on the minimum use of aggressive chemicals, such as cold storage and low temperature ashing, are potentially useful for a wide range of inorganic fibers. Any processes used to assess fiber exposure and dose must be carefully validated to establish that the chemical and physical characteristics of the fibers have not been changed and that the dose to the target tissue is completely and accurately described.

Effect of chronic theophylline therapy on brain blood flow and function in adult asthmatics

The impact of theophylline therapy on neuropsychological (NP) function in adult asthmatics is unclear. Additionally, whether the previously demonstrated acute reduction in cerebral blood flow (CBF) persists with continued administration of theophylline, or whether accommodation develops, has not been previously reported. We examined the effects of chronic theophylline administration on CBF and NP function in adults with mild to moderate asthma. Sixty adult patients with mild to moderate asthma were entered into this double-blind, placebo-controlled, crossover, random sequence study. Subjects received theophylline or placebo for 6 wk interposed with a 2-wk washout period. At the conclusion of Week 1 and Week 6 of each drug phase, patients received NP testing, and CBF was determined using the 133Xenon washout method. Forty-three patients completed the study. Theophylline administration was associated with small (6%), but statistically significant, reductions in CBF after both 1 and 6 wk of treatment. No differences consequent to theophylline administration were observed in any of the tests of NP function after 1 or 6 wk of therapy. While CBF was decreased after theophylline, the changes were small compared with previously reported decrements in CBF immediately after theophylline administration.

An experimental approach to the evaluation of the biopersistence of respirable synthetic fibers and minerals

The biopersistence of fibers and minerals in the respiratory tract is an important parameter in the toxicity of those materials. The biopersistence of respirable synthetic fibers and minerals in man can be most closely evaluated in an animal model. While acellular and in vitro systems are important for initial evaluation of solubility and durability, they cannot simulate the dynamics of inhalation deposition and clearance and the subsequent systemic reaction to fibers and minerals that occurs in the animal. To evaluate the biopersistence of synthetic fibers, male rats were exposed to a well defined rat respirable aerosol of man-made vitreous fibers (MMVF), 6 hr/day for 5 days. Following exposure, subgroups were sacrificed at intervals ranging from 1 hr to 52 weeks. Following sacrifice, the lungs were removed, weighed, and immediately frozen at 20 degrees C for subsequent digestion by low temperature plasma ashing. The number, size distribution, and chemical composition of the fibers in the aerosol and lung were determined. With this animal model the role of biopersistence in altering the geometry and clearance of fibers can be systematically evaluated. The model also can be applied for the evaluation of the biopersistence of nonfibrous minerals.

Chronic inhalation and biopersistence of refractory ceramic fiber in rats and hamsters

Lifetime "nose-only" inhalation studies were conducted in rats using four types of refractory ceramic fibers (FCF), 1 micron in diameter x 22 to 26 microns length: High Purity, Kaolin, Zirconia, and After-Service; and on hamsters using Kaolin RCF. For comparison, animals also were exposed to chrysotile fibers. Rats were exposed 6 hr/day, 5 days/week for 24 months to concentrations ranging between 3 and 30 mg/m3. Time- and dose-dependent lesions in the rat included the development of interstitial fibrosis, pleural fibrosis, pulmonary tumors, and mesothelioma. Exposure to 3, 9 or 16 mg/m3 produced no excess lung tumors; no fibrosis was seen at 3 mg/m3. A significant increase in lung tumors and interstitial fibrosis was observed at 30 mg/m3. A single mesothelioma was observed in rats exposed to 9 mg/m3, while two occurred at 30 mg/m3. Hamsters were similarly exposed to 30 mg/m3 Kaolin RCF for 18 months; no lung tumors were induced, but pulmonary and pleural fibrosis were observed and there was a 42% incidence of mesothelioma. Multiple interim sacrifices together with recovery animals allowed detailed assessment of the lung burden of RCF, which was found to be dose related and, at the high doses, exceeded 10(5) fibers/mg of dry lung. During the various recovery periods there was a clear reduction in fiber burden. Mathematical modeling of these data for deposition, clearance, and retention and for species is currently underway.

NADPH-oxidase activity of stimulated neutrophils is markedly increased by serum

In this study we have investigated the effects of serum (10, 20, and 40% final concentrations) on the activity of NADPH-oxidase and energy metabolism of activated human neutrophils in vitro. Neutrophils were stimulated with FMLP, PMA, or opsonized zymosan in the presence and absence of serum, and generation of reactive oxidants by intact cells was measured using lucigenin-enhanced chemiluminescence (LECL). This method was also used to measure NADPH-oxidase activity in purified membrane preparations from neutrophils activated with PMA in the presence or absence of serum. Cellular ATP levels and activities of the various glycolytic enzymes were assayed using CL and spectrophotometric procedures, respectively. Inclusion of serum with neutrophils during exposure to the various stimuli of membrane-associated oxidative metabolism caused significant enhancement of the LECL responses of intact cells as well as of the activity of NADPH-oxidase in purified membranes prepared from PMA-activated neutrophils. In the absence of serum, the ATP levels and activity of glyceraldehyde-3-phosphate dehydrogenase (G3PDH), but not the other glycolytic enzymes, were decreased in activated neutrophils, while inclusion of serum preserved neutrophil ATP levels and activity of G3PDH. Serum supplementation of the cell-suspending medium appears to promote optimum activity of NADPH-oxidase in stimulated neutrophils by preventing premature, oxidative inactivation of cellular energy metabolism.

The riminophenazine agents clofazimine and B669 reverse acquired multidrug resistance in a human lung cancer cell line

The potential of the riminophenazine agents clofazimine and B669, at therapeutically relevant concentrations, to reverse P-glycoprotein-mediated multidrug-resistance (MDR) in a human lung cancer cell line (H69/LX4) has been investigated in vitro. Cyclosporin A, a well-documented MDR-modifying agent, was included for comparison. Clofazimine, B669 and cyclosporin A at minimally cytotoxic concentrations of 1, 0.5 and 5 micrograms/ml, respectively, were equally effective in restoring sensitivity to vinblastine, doxorubicin, daunorubicin and mitomycin C in the H69/LX4 cell line. All three chemosensitizing agents also increased the accumulation of [14C]vinblastine by H69/LX4 cells. Riminophenazines, which are relatively non-toxic, non-carcinogenic and non-myelosuppressive agents, are promising contenders for evaluation in experimental and clinical oncology as modulators of acquired MDR.

First trimester biochemical screening for trisomy 21: the role of free beta hCG, alpha fetoprotein and pregnancy associated plasma protein A

The potential efficacy of screening for trisomy 21 in the first trimester, using maternal serum markers alpha fetoprotein, free beta human chorionic gonadotropin, unconjugated oestriol and pregnancy associated plasma protein A, was studied in an unselected population of women between the seventh and fourteenth week of gestation. Using a combination of alpha fetoprotein and free beta human chorionic gonadotropin, 53% of affected pregnancies could be identified at a false positive rate of 5%. Unconjugated oestriol and pregnancy associated plasma protein A levels were lower in cases of trisomy 21, but their inclusion with other markers did not significantly improve detection rate. Monitoring the same pregnancies also in the second trimester showed that screening in the first trimester identified the same cases as in the second. We conclude that first trimester screening using free beta human chorionic gonadotropin and alpha fetoprotein, is a viable possibility and will lead to detection rates in excess of 50%. Prospective studies are needed to confirm these observations.

What influences public perceptions of silicone breast implants?

In an effort to determine public attitude regarding breast implants in the wake of what many might consider biased media publicity, surveys of women and men in Milwaukee were made. Questionnaires appropriate to each of four groups [patients with reconstructions (n = 54), mastectomy without reconstruction (n = 14), those with augmentation mammaplasty (n = 26), and the general public (n = 60)] were administered. Some of the findings included the following: Over 98 percent had heard of the controversy; most had received their information from the media, with less than 10 percent referring to a medical journal; only 6 percent felt that the media coverage was objective, while 88 percent felt that the media were biased; almost two-thirds of those in the general population were not aware of any other method of reconstruction; and almost half that same group would have significant hesitancy in having the procedure on themselves or a family member were it indicated. In summary, our findings would substantiate the fact that the media do exert a very significant influence on the public's perception of silicone breast implants. Though most people surveyed generally consider the media biased, they still use them as the primary source for their negative conclusions on the matter. Though the media cannot be viewed as our ally in this matter, we, as a group, might be better served by minimizing conflict, which makes the whole issue less newsworthy.

Investigation of the relative contributions of cigarette smoking and mineral dust exposure to activation of circulating phagocytes, alterations in plasma concentrations of vitamin C, vitamin E, and beta carotene, and pulmonary dysfunction in South African gold miners

OBJECTIVES

To determine the relative effects of cigarette smoking and mineral dust exposure on numbers and activity of circulating phagocytes, plasma nutritional antioxidant state, and pulmonary function in South African gold miners.

METHODS

Pulmonary function was assessed spirometrically, whereas reactive oxidant generation by circulating phagocytes, and plasma concentrations of the nutritional antioxidative nutrients vitamin C and vitamin E and beta carotene were measured with chemiluminescence, spectrophotometry, or high performance liquid chromatography respectively.

RESULTS

Cigarette smoking, but not mineral dust exposure, was associated with increased numbers and pro-oxidative activity of circulating neutrophils and monocytes, decreased plasma concentrations of vitamin C, and pulmonary dysfunction.

DISCUSSION

In this study group occupational exposure to mineral dust has not been found to promote increases in the numbers or reactivity of circulating phagocytes or to be a significant cause of pulmonary dysfunction, the changes found being due primarily to cigarette smoking.

Catalytically important domains of rat carnitine palmitoyltransferase II as determined by site-directed mutagenesis and chemical modification. Evidence for a critical histidine residue

Rat carnitine palmitoyltransferase (CPT) II was expressed in Saccharomyces cerevisiae. Mitochondrial fractions prepared from the cells displayed high CPT activity and reacted with an antibody to the rat protein on immunoblots, whereas no activity or immunoreactive protein was observed in control cells. The recombinant enzyme was largely membrane associated. Treatment of the expressed protein with diethyl pyrocarbonate, a reagent that modifies histidine residues, abolished CPT activity, but this was completely restored by reversal of the modification with hydroxylamine. It is inferred that a histidine residue plays a critical role in CPT function. Expression and analysis of site-directed mutants of CPT II showed that histidine 372, as well as aspartates 376 and 464 (all conserved throughout the carnitine/choline acyltransferase family), are essential for catalytic activity. The data suggest that the mechanism by which CPT II effects transesterification between palmitoyl-CoA and carnitine possibly involves histidine 372 and one of these aspartate residues, interacting with the carnitine hydroxyl group, in a reaction analogous to that carried out by a histidine/aspartate/serine catalytic triad in certain other enzyme systems. Mutagenic analysis of a region of CPT II that is highly conserved among the carnitine and choline acyltransferases, and which is homologous to the "adenine binding loop" of citrate synthase, implies that it has no similar function in CPT II.

Oxidant-mediated ciliary dysfunction in human respiratory epithelium

Exposure of human nasal ciliated epithelium to reactive oxidants generated by the enzymatic xanthine-xanthine oxidase superoxide/hydrogen peroxide (H2O2) and glucose-glucose oxidase H2O2-generating systems, or to reagent H2O2 or hypochlorous acid (HOCl) resulted in significant alterations in ciliary beating. The earliest change noted was the presence of ciliary slowing, progressing eventually to complete ciliary stasis in some areas. Ciliary dyskinesia was seen within the first hour, often from as early as 15 min after exposure of the cells to reactive oxidants. Using peroxidases, various antioxidant enzymes, and oxidant scavengers, we confirmed that these detrimental effects on ciliary function were mediated primarily by H2O2 and HOCl. Moreover, 3-aminobenzamide (3-ABA), an inhibitor of the DNA repair enzyme poly ADP ribose polymerase, prevented H2O2-mediated inhibition of ciliary function, indicating that oxidant-mediated damage to DNA may well be the basis of the effects of H2O2 on ciliated epithelium. Acute and chronic inflammatory responses may therefore present the possible threat of H2O2- or HOCl-inflicted injury on bystander respiratory epithelium, leading to ciliary dyskinesia and slowing.

Implementing clinical paths in a managed care environment

The survival of health care institutions depends upon a delivery system focusing on appropriate use of resources and controlling length of stay while monitoring clinical progress toward identified outcomes. Using a clinical path as a tool for managing resources, research activities, continuous quality improvement, and increased collaborative practice can enhance the professional practice environment and benefit patient care.

Conversion of anterior limb bud cells to ZPA signaling cells in vitro and in vivo

Following a graft of posterior (zone of polarizing activity or ZPA) cells into the anterior margin of the developing chick wing bud, anterior cells are induced to alter their developmental fate and form structures that are normally composed of posterior cells. When anterior cells are cultured under microdissociation conditions they develop ZPA signaling ability within 24 hr. ZPA signaling in these cultures is transient and once established the level of ZPA signaling declines with time in culture. ZPA signaling in anterior cells is sensitive to treatment with fibroblast growth factor-2 (FGF-2); the development of ZPA signaling is inhibited when nonsignaling anterior cells are cultured in the presence of FGF-2. Conversely, when anterior cells that have developed ZPA signaling are treated with FGF-2, ZPA signaling levels are maintained. Thus, our results suggest that FGF-2 maintains or stabilizes the positional character of anterior (nonsignaling) cells, as well as anterior ZPA signaling converted cells, and posterior (ZPA signaling) limb bud cells in vitro (R. Anderson, M. Landry, and K. Muneoka (1993) Development 117, 1421-1433). In addition, anterior cells will convert to ZPA signaling cells in vivo following apical ectodermal ridge (AER) removal, suggesting that a factor(s) localized to the AER prevents anterior cells from developing ZPA signaling capability during limb outgrowth. These findings indicate that nonsignaling anterior limb bud cells have the potential to become ZPA signaling cells and that FGF-2, or a related factor, functions in the maintenance of positional states in the developing limb.

In vitro activity of readily available household materials against HIV-1: is bleach enough?

This report describes experiments assessing the effectiveness against HIV of potential disinfecting agents that are commonly available to IDU when they are sharing syringes. We exposed cell-free HIV, HIV-infected cells, and HIV-infected blood containing known quantities of HIV to household cleaning agents, alcohols, peroxide, and highly acidic materials for 1 min, in order to examine the effects of these materials on the infectivity of the HIV. Undiluted liquid laundry bleach and dilute liquid dish detergent reduced the number of culturable HIV to an undetectable level under the experimental conditions used. Diluted bleach was not completely effective. Other potential disinfecting agents, including ethanol, isopropyl alcohol, and hydrogen peroxide, were unable to disinfect high numbers of HIV-infected cells or infected blood. Liquid dish detergent warrants further study as a possible acceptable alternative to bleach. Our data provide support for recommendations to IDU that they disinfect shared syringes every time between users with full-strength liquid laundry bleach to reduce their risk of acquiring or transmitting HIV. When bleach is not available, liquid dish detergent or other available disinfecting agents such as rubbing alcohol, hydrogen peroxide, or high alcohol content beverages are more effective than water at disinfecting HIV, recognizing that these materials are less effective than bleach. Although these materials are effective, they should not be viewed as a substitute for decreased sharing of injection equipment by IDU, or increased availability of sterile needles and syringes.

[Selective vascular occlusion by repetitive short laser pulse]

The occlusion of arterioles and venules (30 microns in diameter) by means of repeated dye laser pulses (577 nm, 160 microseconds, 0.5 Hz) was studied in the hamster cheek pouch model. Microscopically visible changes during and after irradiation were recorded and monitored by a video system. The energy necessary per pulse for vessel occlusion with a single pulse (arterioles 5 J/cm2, venules 3.5 J/cm2) can be lowered more than 50% with 100 pulses (1.8 J/cm2, 1.2 J/cm2). Rupture of vessels, which regularly occurs with a single pulse, can be totally avoided with 100 repetitive laser pulses. Investigations of the temperature dependence of the occlusion rate of arterioles showed different interaction mechanisms with one pulse and 100 pulses (mechanical and thermal respectively). Light and electron microscopic investigations supported this concept of selective occlusion using repeated short laser pulses. Possible clinical applications are portwine stains of the eyelid, neovascularisation on the cornea and subretinal neovascularisation.

Trial of labor following cesarean delivery

OBJECTIVE

To examine several variables that may affect the success rate for a trial of labor after previous cesarean delivery, as well as those affecting the rate of uterine rupture.

METHODS

Between June 1, 1990 and December 31, 1991, we performed a consecutive, prospective study of 593 pregnant women who had had at least one abdominal delivery in the past, and attempted a trial of labor in each. Particular attention was given to the success rate of vaginal delivery, the type of previous uterine incision, use of oxytocin, estimated maternal blood loss, 5-minute Apgar scores, and reason for the previous cesarean operation.

RESULTS

Four hundred seventy-eight patients (81%) had a successful vaginal delivery. Oxytocin induction or augmentation was successful in 46 of 67 (69%) and 117 of 167 cases (70%), respectively. Estimated maternal blood loss was less than 500 mL in 453 cases (95%). Five patients (0.8%) experienced true uterine rupture, resulting in severe neurologic sequelae in one infant. The only consistent indication of uterine rupture was an abrupt and prolonged fetal bradycardia. The majority (463; 97%) of infants who were delivered vaginally had 5-minute Apgar scores of 8 or greater.

CONCLUSION

Our success rate of 81% suggests that a trial of labor after previous cesarean delivery is a safe and desirable option, but only after thorough patient counseling. An abrupt and persistent fetal bradycardia may be the only indication that uterine rupture has occurred.

Dietary cholesterol and downregulation of cholesterol 7 alpha-hydroxylase and cholesterol absorption in African green monkeys

In this study, hepatic production of bile acid was considered together with intestinal cholesterol absorption as potential regulatory sites responsive to dietary cholesterol. Sequential liver biopsies were taken from 45 feral African green monkeys studied during three different diet periods. Low-fat Monkey Chow was fed during the baseline period, a cholesterol and fat-enriched diet was then fed for 12 wk during period 2, and finally, after a washout period of 10 wk, three subgroups were fed low-, moderate-, and high-cholesterol diets for 12 mo during period 3. The percentage of cholesterol absorbed in the intestine was significantly lower when higher levels of cholesterol were fed; however, this percentage was significantly and positively correlated to plasma cholesterol concentration at each dietary cholesterol level. Hepatic free and esterified cholesterol content were significantly elevated by dietary cholesterol challenge and remained elevated even after 20 wk of low-cholesterol diets. Hepatic mRNA abundance for cholesterol 7 alpha-hydroxylase (C7H) was significantly lower (approximately 60%) when the high-cholesterol diet was fed, with the decrease being greater than that seen for low density lipoprotein (LDL) receptor mRNA. At the same time, hepatic mRNA abundance for apolipoprotein B and hepatic lipase were not diet sensitive. C7H activity was decreased to a similar extent by diet as was C7H mRNA, although the correlation between enzyme activity and mRNA abundance was only r = 0.5, suggesting that dietary regulation includes factors in addition to transcriptional regulation. Activity and mRNA abundance of C7H remained decreased when liver esterified cholesterol content was reduced to only a two- to three-fold elevation over baseline, at a time when plasma cholesterol and hepatic LDL receptor mRNA abundance had returned to baseline levels. These data on liver C7H, obtained in one of the few primate species predisposed to cholesterol gallstone formation, support the hypothesis that the liver may attempt to downregulate intestinal cholesterol absorption by decreasing bile acid production when increased amounts of absorbed dietary cholesterol reach the liver. Presumably this represents attempted downregulation of intestinal cholesterol absorption by limiting bile acid availability as a means to maintain hepatic cholesterol balance.