Family physicians and the mental health system. Report from the Mental Health Supplement to the Ontario Health Survey

OBJECTIVE

To determine family physicians' role in the mental health care system.

DESIGN

The Mental Health Supplement to the Ontario Health Survey is an epidemiologic, retrospective, home-interview survey. Results reported here are based on responses of a weighted sample of patients aged 15 to 64.

SETTING

Ontario, 1990 to 1991.

PARTICIPANTS

Random sample of 9953 household residents.

MAIN OUTCOME MEASURES

Standardized assessment of mental disorders, associated risk factors and disability, and patterns of use of mental health services.

RESULTS

More people seek mental health services from their family physicians (FPs) than from psychiatrists, social workers, or psychologists. Among patients who consulted for mental health purposes, more than 35.4% saw FPs only, 24.7% saw FPs and other mental health care providers (psychiatrists, psychologists, social workers, others), and 40% saw other mental health care providers only. There were few sociodemographic, diagnostic, or clinical severity differences between the FP-only group and the other two groups. Some evidence suggested FPs saw more recent onset cases, but they were also involved in joint care for more complex or disabled cases. More than 57% of those seeing FPs received medication; 43% received other forms of care. Those seeing FPs only made four visits per year; those who consulted other mental health professionals made 14 to 20.

CONCLUSIONS

Our study confirms FPs' important role in the current mental health care system.

Urine lipids in patients with a history of filariasis

The presence of lipids in postprandial urine was assessed in 116 patients with a history of filariasis and 70 normal individuals using a biochemical autoanalyzer. Urinary triglycerides (TGs) ranging from 10 to 1955 mg/dl were detected in 13 individuals with a history of chyluria, including 3 with TG levels ranging from 233 to 1955 mg/dl and cholesterol levels of 6-35 mg/dl. Three patients who had a filarial history but without chyluria were also found to have urinary TGs (13-15 mg/dl) without detectable cholesterol. Neither TGs nor cholesterol were detected in the urine of normal individuals. Fluctuations in postprandial urine lipid contents were measured by time course determinations of urinary TG and cholesterol in 17 patients with filariasis and a history of chyluria, 16 patients with filariasis and hydrocele and 16 normal individuals. The level of urine lipid excretion was found to increase within 1-4 h postprandially, with urinary TG levels ranging between 7.8 and 1284 mg/h in eight patients and urinary cholesterol levels between 1.2 and 138 mg/h in seven patients with a history of chyluria. To evaluate the origin of the urine lipids in hematochyluria, fish oil containing 360 mg eicosapentaenoic acid (EPA) and 240 mg docosahexaenoic acid (DHA) was prescribed to a patient with hematochyluria. The excretion of EPA and DHA in urine was increased postprandially in the patient, similar to the elevation of urinary TG and cholesterol. The profile of fatty acids from urine samples showed it was of dietary origin. Our results suggest that postprandial urine lipids, especially TG, might be used as markers for the clinical evaluation of chyluria.

Collaborative management to achieve depression treatment guidelines

Two models that integrate the psychiatrist into treatment of depression in primary care have been evaluated in randomized controlled trials. In the psychiatrist/primary care model, a psychiatrist alternated visits with a primary care physician to assist in the education and pharmacologic treatment of the patient. In the psychiatrist/psychologist team model, the psychiatrist worked with a team of psychologists to improve adherence to and effectiveness of antidepressant treatment, with psychologists also providing brief behavioral treatment in the primary care clinic. Findings with the psychiatry/primary care model are reported. It was found that the collaborative model was associated with improved adherence to treatment, increased patient satisfaction with depression care, and improved depression outcome compared with usual care by primary care physicians alone. Similar results were found in the study of the psychiatrist/psychologist collaborative care model. The success of these models indicates the appropriateness of a novel role for the psychiatrist and psychologist, i.e., that of collaboration with primary care physicians in care of the depressed patient in the primary care setting.

Outcome of treatment for distal bile duct cancer

All patients with distal bile duct tumours over a 10-year period (October 1983 to December 1993) were identified by means of a prospective database. The medical records of 104 patients were reviewed. Univariate and multivariate analysis for predictors of outcome was performed. Median age of the patients was 65 (range 30-89) years. Patients presented with a clinical picture indistinguishable from that of pancreatic ductal adenocarcinoma. Twenty patients had no surgical treatment and 23 had a diagnostic laparotomy only. Biliary bypass was performed in 16 patients and radical resection was performed in 45 (pancreaticoduodenectomy, 39; bile duct excision, six). Operative mortality occurred in two of 45 patients having radical resection and complications in 17. Resection provided significant survival benefit. By univariate and multivariate analysis, resectability and negative node status (P < 0.001) were the only predictors of favourable outcome. Sex, age, preoperative stenting, grade of tumour and bilirubin level did not predict outcome. The 5-year survival rate for radically resected, node-negative tumours was 54 per cent. Surgical resection is effective therapy for distal bile duct tumours. These patients have a better outlook than those having resection of pancreatic adenocarcinoma.

Microemulsion Formation and Phase Behavior of Anionic and Cationic Surfactants with Sodium Dodecyl Sulfate and Cetyltrimethylammonium Bromide

The phase behavior and solubilization of multiphase microemulsions in mixed anionic-cationic surfactant systems were studied for fixed ratios of water-to-oil and surfactant-to-alcohol. In the mixed surfactants (sodium dodecyl sulfate + cetyltrimethylammonium bromide)/heptane/alcohol/water systems, microemulsion and birefringent phases are formed by adjusting the surfactant ratio epsilon and the cationic weight fraction delta. The bicontinuous (or w/o microemulsion) --> birefringent o/w microemulsion transition takes place and microemulsion domain enlarges with increasing epsilon. The optimum surfactant concentration gamma increases and the corresponding optimum delta decreases with increasing epsilon and both of them decrease with increasing the alcohol chain length from butanol to hexanol. The birefringent region shrinks rapidly with increasing alcohol and/or CTAB weight fractions in total surfactant concentration. Conductivity measurements have been performed in the single-phase region of the system containing mixed surfactants and alcohols at 25&deg;C. The conductivity results indicate where a transition takes place and which of these different types of phase structures may be in the single-phase of the system containing anionic-cationic mixed surfactants.

Psychiatric disability in Ontario

OBJECTIVE

To describe the disability associated with psychiatric disorder in a community sample in order to refine estimates of service need and identify subgroups with greater priority for intervention.

METHOD

Disability is conceptualized broadly as performance difficulties, troubled relationships, and dissatisfaction in various life domains. Data from the Mental Health Supplement are used to compare disability between those with and without disorder and among various subtypes of disorder.

RESULTS

Although the majority of those with disorder do not report disability, their difficulties with functioning are far greater than for the rest of the population. Those with comorbid or affective disorders typically have more disability than those with anxiety or substance abuse disorders.

CONCLUSIONS

Society needs to recognize the high human and economic costs associated with the prevalence of psychiatric disorder. Assessments of service need and decisions about priorities should take both disorder and disability into consideration.

The use of mental health services in Ontario: epidemiologic findings

OBJECTIVE

To describe the distribution and predictors of mental health service use for a survey of Ontario household residents aged 15 to 64 years.

METHOD

Service use was defined as any past-year contact with formal or informal health care providers for mental health reasons. Data from the Mental Health Supplement (the Supplement) to the Ontario Mental Health Survey were used to compare the sociodemographic, geographic, and diagnostic status characteristics of service users with these characteristics among nonusers.

RESULTS

Mental health services were used by 7.8% of respondents in the past year. The majority (57.8%) had a past-year University of Michigan Composite International Diagnostic Interview (UM-CIDI) diagnosis, although 27.1% had never met diagnostic criteria. Other significant predictors were marital status, household public assistance, gender, age, and urban/rural residence.

CONCLUSION

Although diagnosis is the strongest predictor of use, the fit between "need" and "care" in Ontario is not perfect. Help seeking differs within specific sociodemographic and geographic groups. Furthermore, the association of marital disruption and economic disadvantage with utilization indicates that prevention and intervention should address needs beyond the medical or psychological.

Mental health supplement to the Ontario Health Survey: methodology

OBJECTIVE

To describe the methodology of a province-wide, cross-sectional, epidemiologic study of psychiatric disorder among those aged 15 years and over living in household dwellings in Ontario.

METHOD

Respondents for the survey were drawn from households (N = 13002) participating in a province-wide health survey. One person per household was selected, and 9953 (76.5%) participated.

RESULTS

Participants and nonparticipants were similar to each other. An extensive array of data, including measures of psychiatric disorder classified using a revised version of the Composite International Diagnostic Interview (CIDI), are available for all respondents.

CONCLUSIONS

The Ontario Health Supplement is contained in a public-use data file at the Ontario Ministry of Health and is available to investigators for study. A strong survey design, careful measurement, and acceptable levels of response provide the rationale for our inviting researchers to access and use the Ontario Health Supplement data base.

Purging and nonpurging forms of bulimia nervosa in a community sample

OBJECTIVE

Recent consensus on the subclassification of the eating disorder bulimia nervosa into purging and nonpurging forms is examined in the context of a large psychiatric epidemiological survey in Ontario, Canada.

METHOD

Among a sample of 8,116 individuals, 62 met criteria for bulimia nervosa. Of these, the 17 who were of the purging subtype could be distinguished from the nonpurging group on a variety of parameters of comorbidity, family history, and childhood environment.

RESULTS

The purging subtype was distinguishable on the basis of early age of onset, and high rates of affective disorders and anxiety and alcoholism, sexual abuse, and parental discord.

DISCUSSION

The data support the taxonomy and point to the need for better understanding of the meaning of purging behavior.

One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age

OBJECTIVE

To present the one-year prevalence of 14 psychiatric disorders in a community sample of Ontarians aged 15 to 64 years.

METHOD

Data on psychiatric disorders were collected on 9953 respondents using the University of Michigan revision of the Composite International Diagnostic Interview (UM-CIDI). DSM-III-R criteria were used to define the psychiatric disorders.

RESULTS

Almost 1 in 5 Ontarians (18.6%) had one or more of the disorders measured in the survey. Among 15-to 24-year-olds, 1 in 4 was affected. The distribution of individual disorders varied by sex and age.

CONCLUSION

Because of the immense burden of suffering associated with psychiatric disorders, clinical and research efforts in this area should receive high priority within the health budget.

A multifaceted intervention to improve treatment of depression in primary care

BACKGROUND

This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care.

METHODS

One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time.

RESULTS

At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients.

CONCLUSION

A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

Single-dose intrapulmonary pharmacokinetics of azithromycin, clarithromycin, ciprofloxacin, and cefuroxime in volunteer subjects

The intrapulmonary pharmacokinetics of azithromycin, clarithromycin, ciprofloxacin, and cefuroxime were studied in 68 volunteers who received single, oral doses of azithromycin (0.5 g), clarithormycin (0.5 g), ciprofloxacin (0.5 g), or cefuroxime (0.5 g). In subgroups of four subjects each, the subjects underwent bronchoscopy and bronchoalveolar lavage at timed intervals following drug administration. Drug concentrations, including those of 14-hydroxyclarithromycin (14H), were determined in serum, bronchoalveolar lavage fluid, and alveolar cells (ACs) by high-pressure liquid chromatography. Concentrations in epithelial lining fluid (ELF) were calculated by the urea diffusion method. The maximum observed concentrations (mean +/- standard deviation) of azithromycin, clarithromycin, 14H, ciprofloxacin, and cefuroxime in serum were 0.13 +/- 0.07, 1.0 +/- 0.6, 0.60 +/- 0.41, 0.95 +/- 0.32, and 1.1 +/- 0.3 microgram/ml, respectively (all at 6 h). None of the antibiotics except clarithromycin (39.6 +/- 41.1 micrograms/ml) was detectable in ELF at the 6-h bronchoscopy. The movement into and persistence in cells was different for azithromycin and clarithromycin. In ACs azithromycin was not detectable at 6 h, reached its highest concentration at 120 h, and exhibited the greatest area under the curve (7,403 micrograms.hr ml-1). The peak concentration of clarithromycin (181 +/- 94.1 micrograms/ml) was greater and occurred earlier (6 h), but the area under the curve (2,006 micrograms.hr ml-1) was less than that observed for azithromycin. 14H was detectable in ACs at 6 h (40.3 +/- 5.2 micrograms/ml) and 12 h (32.8 +/- 57.2 micrograms/ml). The peak concentration of ciprofloxacin occurred at 6 h (4.3 +/- 5.2 micrograms/ml), and the area under the curve was 35.0 micrograms.hr ml-1. The data indicate that after the administration of a single dose, azithromycin, clarithromycin, and ciprofloxacin penetrated into ACs in therapeutic concentrations and that only clarithromycin was present in ELF. The correlation of these kinetic observations with clinical efficacy or toxicity was not investigated and is unclear, but the data provide a basis for further kinetic and clinical studies.

Should amenorrhoea be necessary for the diagnosis of anorexia nervosa? Evidence from a Canadian community sample

BACKGROUND

This study compares the characteristics of women with anorexia nervosa with those of women who have all the diagnostic features of that disorder except amenorrhoea.

METHOD

The study uses data from a large community epidemiological survey of the mental health status of household residents in Ontario, Canada. A multi-stage stratified sampling design generated a sample of 4285 females aged 15-64. DSM-III-R diagnoses were made using the Composite International Diagnostic interview.

RESULTS

Eighty-four out of 4285 female respondents met full or partial-syndrome criteria for anorexia nervosa. Comparison of these two groups revealed few statistically significant differences in terms of demographics, psychiatric comorbidity, family history or early experiences.

CONCLUSIONS

Amenorrhoea did not discriminate between women with anorexia nervosa and women with all the features except amenorrhoea across a number of relevant variables. The authors question the utility of amenorrhoea as a diagnostic criterion.

Evaluation of enzyme immunoassay for detection of salivary antibody to Helicobacter pylori

The Helisal test is a quantitative enzyme immunoassay for the measurement of Helicobacter pylori-specific immunoglobulin G antibodies in saliva. This test was evaluated in comparison with culture and histopathologic examination of gastric biopsy specimens obtained from 195 patients who underwent 200 endoscopic procedures for the investigation of gastrointestinal symptoms. Forty-one (21%) patients were found to have peptic ulcer disease, and one other patient had a gastric carcinoma. H. pylori was detected in gastric biopsy specimens obtained from 98 (49%) of the procedures. The sensitivity, specificity, and positive and negative predictive values of the Helisal test were 81, 75, 76, and 80%, respectively. The test was negative for 16 (38%) of the 42 patients with peptic ulcer disease or a gastric malignancy diagnosed at endoscopy. These results suggest that the Helisal assay is only moderately accurate for the detection of H. pylori infection in symptomatic patients.

The guanine nucleoside analog penciclovir is active against chronic duck hepatitis B virus infection in vivo

Ducks congenitally infected with duck hepatitis B virus (HBV) were treated with the antiviral guanine nucleoside analog penciclovir for 4 weeks at a dose of 10 mg/kg of body weight per day. The effects of treatment on viremia and intrahepatic viral genome replication, transcription, and translation were examined. In seven of eight penciclovir-treated ducks, viremia was barely detectable after a week of treatment. After 4 weeks of treatment, molecular hybridization studies showed that intrahepatic viral DNA, RNA, and protein levels were significantly reduced compared with those in placebo-treated controls. Synthesis of all viral replicative intermediates, including the normally persistent viral supercoiled DNA species, was inhibited by penciclovir treatment. Examination of liver tissue sections after in situ DNA hybridization or immunohistochemical staining confirmed that viral DNA and protein synthesis had been profoundly inhibited in most hepatic parenchymal cells. However, small subpopulations of cells, in particular the small bile duct epithelial cells, remained strongly positive for duck HBV antigens and DNA despite treatment. There was no evidence of toxicity associated with penciclovir therapy. This study confirms the safety and potent antihepadnaviral activity of penciclovir in vivo but indicates that further improvements in antiviral therapy will be required to completely eliminate HBV infection.

Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups

OBJECTIVE

Previous epidemiological studies of bulimia nervosa have generated differing estimates of the incidence and prevalence of the disorder. These differences are attributable, in part, to varying definitions of the illness and a range of methodologies. The authors sought to define the prevalence of bulimia nervosa in a nonclinical community sample, examine the clinical significance of DSM-III-R threshold criteria, and examine comorbidity.

METHOD

Subjects across Ontario (N = 8,116) were assessed with a structured interview, the World Health Organization Composite International Diagnostic Interview, with specific questions added for bulimia nervosa. Subjects who met DSM-III-R criteria for bulimia nervosa were compared with those who were missing only the frequency criterion (two or more binge-eating episodes per week for 3 months).

RESULTS

In this sample, the lifetime prevalence of bulimia nervosa was 1.1% for female subjects and 0.1% for male subjects. The subjects with full- and partial-syndrome bulimia nervosa showed significant vulnerability for mood and anxiety disorders. Lifetime rates of alcohol dependence were high in the full-syndrome group. Rates of parental psychopathologies were high in both bulimic groups but tended to be higher in the subjects with full-syndrome bulimia nervosa. Both bulimic groups were significantly more likely to experience childhood sexual abuse than a normal female comparison group.

CONCLUSIONS

This study confirms other prevalence estimates of bulimia nervosa and its comorbid diagnoses from studies that were based on sound methodologies. It also points to the arbitrary aspects of the frequency of binge eating as a diagnostic threshold criterion for the disorder.

Primary care physician use of cognitive behavioral techniques with depressed patients

BACKGROUND

Although researchers are paying more attention to the treatment of depression in the primary care setting, little is known about the nature of psychotherapeutic interactions that occur between primary care physicians and their patients in the context of a visit for depression. In recent years, brief cognitive behavioral therapy has been demonstrated to be efficacious, and the public has become more familiar with these techniques through media exposure and self-help books.

METHODS

Depressed primary care patients were surveyed regarding the extent to which cognitive behavioral (CB) techniques were suggested during the primary care visit in which antidepressant medication was initially prescribed. One hundred fifty-five patients completed responses to phone surveys 1 month and 4 months after the visit. Patients were also surveyed regarding the recommendation of counseling by the primary care physician.

RESULTS

The majority of patients (61%) reported that their physician advised them to identify activities they were already doing that helped them feel better. Physician recommendations regarding planning pleasurable activities, problem solving, challenging depressive thoughts, and planning activities that boost confidence were reported by 22% to 40% of study patients. Older patients reported fewer interactions about CB strategies. Primary care physicians' suggestion of CB strategies was associated with both patient use of CB strategies in the months following the visit and better adherence to recommended medication therapy during the first month of treatment.

CONCLUSIONS

Many patients seem to recognize the occurrence of psychotherapeutic interactions during visits to their primary care physician in which an antidepressant medication was prescribed, and patients' recognition of these interactions is associated with increased adherence to the recommended course of antidepressant prescriptions.

Neuroendocrine effects of light therapy in late luteal phase dysphoric disorder

In 20 late luteal phase dysphoric disorder (LLPDD) and in 11 normal control (NC) subjects, circadian profiles of cortisol, prolactin, thyrotropin-stimulating hormone (TSH), and core body temperature were measured during midfollicular (MF) and late luteal (LL) menstrual cycle phases and after 1 week of light therapy either with (1) bright (tau 2500 lux) white morning (6:30 AM to 8:30 AM), (2) bright white evening (7 PM to 9 PM) or (3) dim (< 10 lux) red evening light, randomly administered in three separate luteal phases. In NC but not PMDD subjects, the cortisol peak significantly delayed in the LL compared with the MF phase. In PMDD, prolactin peak and amplitude were higher, prolactin acrophase earlier, and temperature amplitude higher during both the MF and LL phases. After light treatment, prolactin amplitude remained higher in LLPDD than in controls. In both groups, bright light shifted the cortisol acrophase, and AM light increased the prolactin nadir. Bright PM light increased the TSH nadir in LLPDD, but decreased it in controls. Thus, menstrual cycle phase, diagnosis, and light therapy may differentially affect neuroendocrine systems.

The predictors of persistence of depression in primary care

164 patients in primary care who were recognized as depressed by their physicians and started on antidepressants were interviewed at 1 and 4 months after initiation of treatment. Ten factors hypothesized to be related to persistence of depressive symptoms were entered into a multivariate analysis to determine predictors of persistence of affective symptoms. Patients with minor depression were significantly older, more likely to be married or cohabitating, more likely to have serious medical illness, and had significantly less comorbid panic disorder, recurrent depression and lower neuroticism scores compared to patients with major depression. Approximately half of the patients in this primary care sample with major depression and one-third of those with minor depression were still distressed at 4 months, although few met criteria for major depression. Severity of depression and high neuroticism scores were the best predictors of persistent depressive symptoms.

Methodologic issues in randomized trials of liaison psychiatry in primary care

Most anxiety, depressive, and substance abuse disorders are treated exclusively in the primary care health system. However, recognition and treatment of these disorders in primary care is deficient. Psychopharmacologic and psychotherapeutic interventions have been developed and proven effective in randomized trials in specialty care. However, the results of successful trials of mental health interventions in specialty settings may not generalize to primary care settings because of epidemiologic differences in patients, differences in skills of providers, as well as differences in the very structure of care. The importance of the development of innovative randomized trials to improve recognition and treatment of mental illness in primary care is emphasized, as well as the methodologic problems inherent in carrying out these trials.

Evaluation of the PAPNET cytologic screening system for quality control of cervical smears

The PAPNET system is an automated interactive instrument for analysis of conventional (Papanicolaou) cervical smears. The instrument, described in this paper, introduces several important innovations to cytology automation. The cell selection system is composed of two stages: an algorithmic classifier, followed by a trained neural network allowing for great flexibility and precision in recognition of abnormal cell images. Contrary to other attempts at cytology automation, this machine does not attempt to diagnose cell abnormalities. Instead, it is interactive, leaving the assessment of the cells displayed on a high-resolution video screen to trained human observers. The slides judged to contain abnormal cells or to be inadequate are referred for a second microscopic review. Two versions of the instrument (Alpha and Beta) were evaluated in several modes. Initial testing was performed on archival smears with known, histologically confirmed neoplastic lesions of the uterine cervix. These lesions comprised the entire spectrum of abnormalities, from low-grade lesions to invasive cancers of several types. The Alpha machine displayed recognizable abnormal cells in 97% of the 201 cases, and the Beta machine displayed such cells in 97.2% of 176 cases. The Beta instrument was subsequently tested on 500 sequential archival cervical smears that had been previously subjected to a rigorous quality control. One hundred forty smears (28%), which either displayed atypical cells or were considered "inadequate," were referred for further rescreening. Fifteen of 16 previously diagnosed neoplastic smears were appropriately identified with the help of the machine. The one missed case contained a single cluster of vacuolated cancer cells from an endometrial carcinoma. As a result of PAPNET-triggered review, three new cases of low-grade squamous intraepithelial lesions view, three new cases of low-grade squamous intraepithelial lesions (SIL) came to light in previously negative smears; three additional cases, previously classified as atypical, were also reclassified as SIL, for a net gain of six neoplastic abnormalities. In two additional atypical cases, colposcopic follow-up was recommended, even though the diagnosis was not modified. Two cases of cervical intraepithelial neoplasia, represented by tiny single clusters of abnormal cells missed on original screening, quality control, and on machine rescreening, came to light on second review of the residual 360 cases. The initial experience with the PAPNET system suggests that the instrument may be valuable in quality control and may assist in significantly reducing false-negative cervical smears in an efficient and timely manner. Further testing of the instrument on a much larger number of cervical smears is in progress.

Fruit developmental regulation of the kiwifruit actinidin promoter is conserved in transgenic petunia plants

We have examined the expression of actinidin, a cysteine protease found in kiwifruit, over the course of fruit development. Protease activity was first seen in fruit that had reached about half their final weight, and rose to high levels at harvest. The 5'-flanking region (nucleotides -1301 to +58) of a kiwifruit actinidin gene was fused to the beta-glucuronidase (GUS)-coding region, and the chimaeric gene was introduced into transgenic petunia plants. Induction of the GUS gene was observed during the later stages of seed pod development, closely resembling the pattern of actinidin induction in fruit tissues of kiwifruit. Some GUS expression was also detected in the vascular system of the receptacle, leaves, stems and roots. A shorter promoter fragment consisting of nucleotides -115 to +58 conferred similar spatial and temporal regulation in some of the transgenic plants.

Verification of the Acute Physiology and Chronic Health Evaluation scoring system in a Hong Kong intensive care unit

OBJECTIVES

To validate the Acute Physiology and Chronic Health Evaluation (APACHE II) severity of illness scoring system in Chinese patients in a multidisciplinary intensive care unit (ICU) in Hong Kong. To audit the service and utilization of an ICU with a low ICU to hospital bed ratio.

DESIGN

Prospective data collection and review.

SETTING

A 12-bed multidisciplinary ICU within a 1,430-bed tertiary care university hospital.

PATIENTS

Data from 1,573 of 1,814 consecutive patients admitted to the ICU from May 1988 to November 1990 were studied. The patients were all Chinese.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The patients' clinical details and APACHE II scores were recorded on day 2 of admission and reviewed at hospital discharge or after death. The APACHE II scores, risk of death values, age, and length of ICU stay between survivors and nonsurvivors were compared by two-sample t-tests. Relationships between mortality and APACHE II score, risk of death, and results from previous studies were investigated using the Pearson product-moment coefficient and regression analysis. Predictive capacity of risk of death was assessed by receiver operating characteristic curve analysis. The hospital mortality rate for study patients was 36%. Survivors were younger, had shorter ICU stays, lower APACHE scores, and lower risk of death values than nonsurvivors (p < .001). There was close correlation (r2 = .81, .77, and .76 for all patients, operative group, nonoperative group, respectively) between APACHE II scores and predicted risk of death values. Risk of death was an accurate group predictor of death in all patients and in separate operative and nonoperative groups. Areas under the receiver operating characteristic curves were 0.89 (all patients), 0.85 (operative), and 0.88 (nonoperative). Neither the Apache II scores nor risk of death scores were sufficiently accurate to predict outcome of individual patients. There was close concordance between observed and predicted mortality of patient groups. Mortality ratio was 0.97 (all patients), 0.89 (operative group), and 1.02 (nonoperative group). Chronological age, per se, was not a good predictor of mortality. The audit of the ICU service showed a short length (4.2 days) of ICU stay and high bed occupancy (80%). Subgroups of low-risk, postoperative patients with good outcomes and poor-risk patients admitted after cardiopulmonary arrest with a high mortality rate were identified.

CONCLUSIONS

The APACHE II scoring system was an accurate predictor of group outcome in a Chinese population, making it suitable for comparisons between countries. Application of the APACHE II scoring system in a clinical audit facilitates critical appraisal of an ICU service. Problems identified by the study were a shortage of ICU beds and delayed referrals of patients.

A single transcription factor binds to two divergent sequence elements with a common function in cardiac myosin light chain-2 promoter

The cardiac myosin light chain-2 (MLC-2) gene promoter contains several positive and negative cis-acting sequences that are involved in the regulation of its expression. We describe here the properties of two activator sequences, elements A and P, and their DNA-binding factors (ABFs). Element A (CCAAAAGTGG), located at -61, has homology with the evolutionarily conserved sequence CC(A/T)6GG, present in the genes of many contractile proteins. Element P (TAACCTTGAAAGC), located 114 bp upstream of element A, is conserved in both chicken and rat cardiac MLC-2 gene promoters. Deletion mutagenesis demonstrated that these two elements are involved in the positive regulation of MLC-2 gene transcription. At least two sequence-specific element A-binding proteins, ABF-1 and ABF-2, were identified by gel shift analysis of the fractionated cardiac nuclear proteins. ABF-1 binds to element A with strict dependence on the internal element A sequence AAAAGT. In contrast, ABF-2 exhibits a relaxed sequence requirement, as it recognizes the consensus CArG and CCAAT box sequences as well. ABF-2 also recognizes the distal element P despite the fact that the sequences of elements A and P are divergent. DNase I footprinting, methylation interference, and gel shift analyses demonstrated unequivocally that the element A-DNA affinity-purified protein ABF-2 binds to element P with sequence specificity. Since both elements A and P play a positive regulatory role in MLC-2 gene transcription and bind to a single protein (ABF-2), it would appear that ABF-2 is a key transcription factor with the ability to recognize divergent sequence elements involved in a common regulatory pathway during myogenesis.

A randomized trial of psychiatric consultation with distressed high utilizers

This study reports the results of a randomized trial of a psychiatric consultation intervention with distressed, high utilizing patients of 18 physicians in two primary care clinics. Psychiatric consultation was associated with a significant increase in the use of antidepressants in intervention patients compared with controls in the first 6 months after intervention. Intervention patients were also significantly more likely to continue antidepressant treatment than control patients. The primary care physicians receiving psychiatric consultations increased the rate of prescribing antidepressant medications in their practice from 32 prescriptions filled per 1,000 visits before their participation in four consultations to 44 new prescriptions per 1,000 visits in the 12-month period after. There were no significant differences between intervention patients and controls at 6 and 12 months after randomization in psychiatric distress, functional disability, or utilization of health care (ambulatory visits, radiographic and laboratory testing services, admissions to inpatient medical care).

Panic disorder: relationship to high medical utilization

The purpose of this review is to describe the relationship between panic disorder, somatization, functional disability, and high medical utilization. Data from community, primary-care, and specialty studies were reviewed to determine the prevalence of anxiety and panic disorder in these populations. Data from the Epidemiologic Catchment Area Study were reviewed to emphasize the effect of panic disorder on health-care utilization and health perception in a community population. Data on the prevalence of panic disorder in primary care and mode of presentation of primary-care patients with panic disorder were also reviewed. Finally, the epidemiologic psychiatric findings from our recent study of distressed high utilizers of primary care were presented. Panic disorder was found to occur in 1-3% of people in the study community and 1.4-8% of primary-care patients. Of people with or without psychiatric disorder, people with panic disorder in the community had the highest risk of having multiple medically unexplained symptoms and of being high utilizers of medical ambulatory services. People with panic disorder in the community compared to both community psychiatric and nonpsychiatric controls tend to perceive themselves as having poor physical health and to be high users of emergency and hospital inpatient services, as well as ambulatory services. Most patients with panic disorder present to their primary-care physician with somatic complaints, especially cardiac (tachycardia, chest pain), gastrointestinal (epigastric pain or irritable bowel syndrome), or neurologic complaints (headaches, dizziness, or presyncope). Patients who were distressed high utilizers of primary care had an extremely high prevalence of current panic disorder (12%) and lifetime panic disorder (30%), which supported the association between panic disorder and high medical utilization found in the Epidemiologic Catchment Area (ECA) Study.

Adequacy and duration of antidepressant treatment in primary care

Among a sample of 119 distressed high-utilizers of primary care, 45% of patients evaluated by a psychiatrist as needing antidepressant treatment had been treated in the year before the examination. However, only 11% of the patients needing antidepressants had received adequate dosage and duration of pharmacotherapy. In the year following the intervention, study patients whose physicians were advised regarding treatment during a psychiatric consultation were more likely to receive antidepressant medications (52.7%) relative to a randomized control group (36.1%). However, the intervention did not significantly increase the provision of adequate antidepressant therapy (37.1% vs 27.9%). Among study patients using antidepressants, patient characteristics did not differentiate patients who received adequate dosage and duration of antidepressant medications from those who did not. Analysis of data on the duration of antidepressant therapy for all health maintenance organization enrollees initiating use of antidepressants showed that only 20% of patients who had been given prescriptions for first-generation antidepressants (amitriptyline, imipramine, or doxepin) filled four or more prescriptions in the following six months, compared to 34% of patients who had prescriptions for newer antidepressants (nortriptyline, desipramine, trazodone and fluoxetine). Experimental research evaluating whether these newer medications (with more favorable side effect profiles) improve adherence, and thereby patient outcome, is needed.

Spectroscopic imaging display and analysis

A system for display of magnetic resonance (MR) spectroscopic imaging (SI) data is described which provides for efficient review and analysis of the multidimensional spectroscopic and spatial data format of this technique. Features include the rapid display of spectra from selected image voxels, formation of spectroscopic images, spectral and image data processing operations, methods for correlating spectroscopic image data with high resolution 1H MR images, and hardcopy facilities. Examples are shown for 31P and 1H spectroscopic imaging studies obtained in human and rat brain.

Enhanced biliary iron excretion with amphiphilic diethylenetriaminepentaacetic acid

The elimination of toxic metal ions metabolically accumulated by patients remains a difficult clinical problem and a target of drug development. DTPA (diethylenetriaminepentaacetic acid) is a hydrophilic chelating agent with high affinity for divalent and trivalent metal ions including iron but with a limited ability to cross cell membranes for access to iron stores. In this study we have synthesized an amphiphilic form of this chelator-DTPA covalently linked to the phospholipid phosphatidylethanolamine (PE)--to produce a chelator that incorporates completely and stably into liposome membranes for efficient delivery to the liver and reticuloendothelial system. Biliary and urinary excretion of iron were studied in iron-loaded rats (n = 15) in association with a 2-hr intravenous infusion of sonicated liposomes of 1:1 amphiphilic phosphatidylethanolamine-DTPA/egg phosphatidylcholine (L-PE-DTPA) and compared with excretion obtained using equivalent amounts of water-soluble DTPA (alone or mixed with egg phosphatidylcholine liposomes [L-DTPA] as controls). For a 6-hr period, the administration of L-PE-DTPA resulted in approximately a 20-fold increase in biliary iron excretion (480 +/- 160 micrograms/6 hr, mean +/- S.D.) compared with that seen with DTPA (21.2 +/- 4.0 micrograms/6 hr) and L-DTPA (23.1 +/- 5.0 micrograms/6 hr) (p less than 0.05, analysis of variance). Urinary iron excretion was significantly decreased with L-PE-DTPA (41.5 +/- 38 micrograms/6 hr) compared with DTPA (154 +/- 110 micrograms/6 hr) and L-DTPA (86 +/- 17 micrograms/6 hr) (p less than 0.05). Combined biliary and urinary excretion of iron was three to four times greater with L-PE-DTPA.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory failure as presentation of achalasia of the oesophagus

A 68-year-old woman with a history of hiatus hernia developed aspiration pneumonia after operation for fractured neck of femur. After 8 days, acute respiratory failure was caused by massive retention of air and food in the oesophagus. This was relieved by aspiration, and treated by balloon dilation of the gastric cardia.

The effect of human recombinant erythropoietin on iron absorption and hepatic iron in a rat model

In order to ascertain whether recombinant human erythropoietin (EPO) therapy would result in further intestinal iron absorption in the setting of systemic iron loading, iron absorption was measured in iron-loaded rats receiving EPO therapy and a control group of iron-loaded rats. Parenteral iron dextran (100 mg) resulted in hepatic siderosis with predominantly a reticuloendothelial distribution. EPO was given by intraperitoneal injection (100 U/kg) for 10 days. Radioiron absorption was measured by total body counting. Iron absorption in EPO-treated rats was 4.8 +/- 2.0% (n = 12) and 4.5 +/- 2.2% (n = 10) in the control rats (p greater than 0.05). Mean hemoglobin in the EPO rats was 201 +/- 12.5 g/L and 140 +/- 18.2 g/L in the control rats (p less than 0.001). Mean hepatic iron concentration was 73 +/- 16 mumol/g in the control rats and 34 +/- 9.1 mumol/g in the EPO-treated rats (p less than 0.001). This study suggests that iron-loaded rats do not demonstrate an increase in intestinal iron absorption with EPO therapy despite a significant erythropoiesis. The reduction in hepatic iron concentration suggests that reticuloendothelial iron is accessible and mobilized to produce new red blood cells.

Biochemical liver profile in hemochromatosis. A survey of 100 patients

To determine the frequency of liver profile abnormalities in hereditary hemochromatosis, we under took a retrospective survey in 100 patients, all of whom had undergone liver biopsy. Liver histology was compared with the biochemical profile, which included aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin and albumin determinations. Mild abnormalities in the AST and ALT levels were seen in more than 65% of patients. Patients with cirrhosis had significantly greater elevations in AST, ALT, and alkaline phosphatase, and a significant decrease in albumin (p less than 0.05). Proband cases had more frequent abnormalities than discovered cases within families. Accordingly, we find that mild abnormalities in the biochemical liver profile are common in hemochromatosis and suggest that patients with an unexplained abnormality in the liver profile should be screened for hemochromatosis with a serum ferritin and transferrin saturation.

Patent ductus arteriosus, indomethacin, and intestinal distension: effects on intestinal blood flow and oxygen consumption

To determine the relative importance of patent ductus arteriosus, indomethacin, and intestinal distension as factors that promote terminal ileum ischemia, eight near-term fetal lambs were surgically prepared by in situ cannulation of the proximal and distal ends of a loop of terminal ileum, formalin infiltration of the ductus arteriosus, and placement of a snare around the ductus arteriosus to control its patency. The incisions were closed; the lambs were delivered and mechanically ventilated. Terminal ileum blood flow and oxygen consumption were measured after the loop of ileum had been distended with 0.9% NaCl to luminal pressures of 1-2, 7, and 18 mm Hg (0.13-0.26, 0.93, and 2.38 kPa) (pressures observed in the intestinal lumen after feeding and during pathologic conditions). The effect of these pressures on terminal ileum blood flow and oxygen consumption was examined: 1) with ductus closed, 2) with ductus open, and 3) 1 h after administration of indomethacin (0.3 mg/kg; 0.8 mumol/kg) with ductus closed. Both open ductus and indomethacin produced a significant decrease in intestinal blood flow. This occurred over the entire range of luminal pressures examined. In all three study conditions, terminal ileum blood flow fell commensurate with a fall in perfusion pressure. Despite this absence of pressure-flow autoregulation, oxygen consumption was maintained when the ductus was closed or open. In contrast, indomethacin inhibited the ability of the terminal ileum to autoregulate its oxygen consumption. These findings suggest that both open ductus and indomethacin present an increased risk of intestinal ischemia. We hypothesize that indomethacin's beneficial effect on ductus closure may be counterbalanced by its negative effect on intestinal perfusion and metabolism.

Somatization: a spectrum of severity

OBJECTIVE

The DSM-III-R diagnosis of somatization disorder requires that a patient have a specific number of medically unexplained somatic symptoms. This number of symptoms was developed by committee consensus, and it is not clear whether patients with this specific number of symptoms can be differentiated from patients with lower but still substantial numbers of somatic symptoms.

METHOD

Fifty-one percent of 767 high utilizers of two primary care clinics were identified as distressed by an elevated SCL anxiety, depression, or somatization scale score or by their primary care physician. The Diagnostic Interview Schedule (DIS) was completed on 119 distressed high utilizers who were randomly assigned to an intervention group in a controlled trial of psychiatric consultation. The 119 distressed high utilizers were separated into four categories according to the number of unexplained somatic symptoms found on the DIS and were compared on demographic, psychiatric distress, disability, medical, and health utilization variables.

RESULTS

The data suggest that many clinical and behavioral features of somatization are significantly more common in patients with four to 12 medically unexplained somatic symptoms rather than changing dramatically at the diagnostic threshold for somatization disorder. The data also showed that patients who meet the DSM-III-R criteria for somatization disorder are severely ill and have a high burden of psychiatric illness and disability.

CONCLUSIONS

The results suggest that the DSM-IV somatoform disorders section should include somatization disorder, an abridged definition of somatization disorder often associated with anxiety and depression, as well as a type of somatization associated with an adjustment disorder.

Biodistribution, tissue reaction, and lung retention of pentamidine aerosolized as three different salts

Aerosolized pentamidine isoethionate is retained in the lung and appears to prevent Pneumocystis carinii pneumonia (PCP) in many AIDS patients. We evaluated alternative formulations of pentamidine that might reduce the airway irritation associated with aerosolized pentamidine isoethionate. Specifically, we assessed the biodistribution, histologic response, and lung retention of the isoethionate, gluconate, and lactate salts of pentamidine after aerosol administration to mice. For each of the three aerosolized salts tested, greater than 50% of the pentamidine initially recovered from the lungs after one dose was still retained there 14 days later. Thus, significant levels of pentamidine, aerosolized as three different salts, are retained in the lung for at least 2 wk after a single dose. The three salts of pentamidine each produced high lung to extrapulmonary drug ratios, the converse of that produced by intravenous injection of pentamidine isoethionate. At very high aerosol doses, the ability of the lung to retain pentamidine appeared saturable. Even aerosolized daily for 2 wk at very high doses, none of the three pentamidine salts produced histologic evidence of organ toxicity. A Phase 1 trial of aerosolized pentamidine gluconate in AIDS-PCP patients is now in progress to determine if this approach can reduce airway irritation.

Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs

Among a sample of 767 high utilizers of health care, 51% were identified as distressed by an elevated score on the SCL anxiety and depression scales, the SCL somatization scale, or by their primary-care physician. These distressed high utilizers were found to have a high prevalence of chronic medical problems and significant limitation of activities caused by illness. In the prior year, they made an average of 15 medical visits and 15 telephone calls to the clinic. The Diagnostic Interview Schedule was completed on 119 distressed high utilizers randomly assigned to an intervention group in a controlled trial of psychiatric consultation. The following DSM-III-R disorders were most common: major depression 23.5%, dysthymic disorder 16.8%, generalized anxiety disorder 21.8%, and somatization disorder 20.2%. Two thirds had a lifetime history of major depression. The examination resulted in an improved diagnostic assessment for 40% of intervention patients and a revised treatment plan for 67%.

Polymorphic N-acetylation of sulfamethazine and benzidine by human liver: implication for cancer risk?

Extensive epidemiologic studies have indicated a relationship between bladder cancer in populations exposed to arylamines and the slow phenotype for acetylation of arylamines (e.g., sulfamethazine) and aryl hydrazides (e.g., isoniazid). In human liver preparations, we have examined the association between the capability for sulfamethazine acetylation and that for the human bladder arylamine carcinogen, benzidine. By the usual criteria for polymorphic acetylation, we classified the 10 donor subjects as four rapid and six slow acetylators of sulfamethazine. Concurrent tests of benzidine acetylation in the same liver preparations yielded capacities to acetylate benzidine that were directly and significantly correlated with those for sulfamethazine acetylation (r = 0.672; P less than 0.05). We suggest that acetylation of these two compounds is directly related and knowledge of the human acetylator phenotype may be a useful indicator of possible risk for bladder cancer due to exposure of certain arylamines and, perhaps for other cancers in man.

Bilateral Baker's cyst as the presenting symptom of paraneoplastic syndrome

Paraneoplastic syndrome is defined as a systemic malignancy producing prostaglandins or other substances that lead to various manifestations, syndromes or diseases. In the following report we present a case of a young patient complaining of bilateral Baker's cysts who ultimately was diagnosed as suffering from gastric lymphoma. Following subtotal gastrectomy the Baker's cysts disappeared with no specific treatment.

Regulation of alpha 2(I), alpha 1(III), and alpha 2(V) collagen mRNAs by estradiol in the immature rat uterus

We show that mRNAs for alpha 2(I), alpha 1(III), and alpha 2(V) collagens are regulated by estradiol in the immature rat uterus. Clones for alpha 2(I) and alpha 1(III) collagen were induced in a cDNA library prepared from estradiol-stimulated rat uterine mRNA. Alpha 2(I) collagen cDNA was identified by its characteristic hybridization pattern on Northern blots and hybridization to known probes. The sequence of alpha 1(III) collagen cDNA showed 91% amino acid sequence homology with the corresponding 525-nucleotide segment of human alpha 1(III) procollagen cDNA. Type I and type III collagen mRNAs were coordinately regulated, and showed peaks of induction at 4 and 24 hr. Three injections of estradiol, 24 hr apart, produced induction maxima 24 hr apart. The third induction, however, was suppressed relative to the first, suggesting that estrogen-stimulated factors may act to negatively regulate the uterine response to estrogen.

Percutaneous discectomy of the lumbar spine

Ten patients with clinical and radiological evidence of herniated discs at lower lumbar levels were treated with partial discectomy by a lateral percutaneous approach. Eight patients had complete relief from radicular pain and were discharged within four days. They returned to normal daily activity within one month.

Effects of zinc and thyroxine treatment on dietary-obese mice

Altered thyroid hormone metabolism is known to be an important factor contributing to the defective expression of thermogenesis in the obese mouse, and the action of zinc on thyroid hormone conversion may be an important factor in the energy metabolism of obesity. The effects of zinc and thyroxine treatment on dietary-obese mice were examined. The dietary-obese mice were successfully induced by high-fat diet (80% fat), and every mouse was administered daily 1.25 mg zinc sulfate and/or 5 micrograms thyroxine. After 8 weeks of treatment, serum zinc, serum triacylglycerols and body fat composition were determined. On high-fat diets, fat deposition was found in male mice treated with zinc sulfate. However, when mice were treated with zinc and thyroxine at the same time, serum triacylglycerols and body fat composition decreased significantly on both basal and high-fat diets. When mice were treated with thyroxine alone, body fat composition decreased significantly, but there was no significant effect on serum triacylglycerols on either diet. Obesity was significantly correlated with dietary fat, zinc and thyroid hormone. It is suggested that zinc may play an important role, through its action on thyroid hormone conversion and via insulin action, in the energy metabolism of dietary-obese mice.

Transient bilateral peroneal palsy in a painter's model

Peripheral neuropathies caused by pressure are common. The most common causes are pressure of the ulnar nerve at the elbow and of the median nerve at the wrist. Pressure neuropathy of the peroneal nerve at the level of the fibular neck is a rare syndrome. The literature describes well-defined etiologies of that syndrome: external pressure, tumors, ganglion, or stretching of the limb. A case of bilateral peroneal palsy in a painter's model caused by prolonged sitting in a specific position is described. Review of the literature revealed no such case described previously.

Osteoblastoma of the sternum

Osteoblastoma has become a well defined bone tumor since its first description by Jaffe and Mayer in 1932. This tumor was considered to occur in almost any bone of the skeleton. Only one previous case of sternal osteoblastoma was described in the literature. Herein we report, as far as we know, the second reported case of osteoblastoma in the sternum, as an isolated tumor.

Treatment of avulsed clavicle and recurrent subluxations of the ipsilateral shoulder by dynamic fixation

A new operative approach is presented for treatment of fractured distal end of clavicle associated with recurrent anterior shoulder subluxations. One case is presented in which open reduction of the fractured clavicle and stabilizing the anterior shoulder joint were accomplished by transfer of the coracoid process with its attached muscles under the subcapularis muscle onto the clavicle. The operation was followed by complete reduction of the fracture and a stable shoulder joint.

Successful treatment with aerosolized pentamidine of Pneumocystis carinii pneumonia in rats

We examined both the therapeutic efficacy and tissue distribution of aerosolized pentamidine in immunosuppressed rats with Pneumocystis carinii pneumonia. In rats immunosuppressed by 5 weeks of pretreatment with dexamethasone, a 2-week course of 5 mg of aerosolized pentamidine per kg per day, administered free or encapsulated in the drug carrier system (liposomes), eradicated P. carinii pneumonia in 75% of treated animals. At this dose, extrapulmonary drug uptake as measured by a sensitive high-pressure liquid chromatography assay was negligible. No significant differences in tissue distribution were noted between aerosolized free and liposome-encapsulated pentamidine. In rats receiving dexamethasone for 6 weeks prior to treatment with pentamidine, both lung uptake and therapeutic efficacy of aerosolized pentamidine (5 mg/kg per day) were substantially reduced. Aerosolized pentamidine appears to be an effective therapy for P. carinii pneumonia in rats and produces significantly lower extrapulmonary drug deposition than parenteral administration. The severity of P. carinii involvement at the time of treatment influences both the level of drug delivery to the lung and the response to aerosolized pentamidine therapy.