Teaching ethics in psychiatry: a one-day workshop for clinical students

In this paper we describe the objectives of teaching medical ethics to undergraduates and the teaching methods used. We describe a workshop used in the University of Liverpool Department of Psychiatry, designed to enhance ethical sensitivity in psychiatry. The workshop reviews significant historical and current errors in the ethical practice of psychiatry and doctors' defence mechanisms against accepting responsibility for deficiencies in ethical practice. The workshop explores the student doctors' own group ethos in response to ethical dilemmas, and demonstrates how the individual contributes to and is responsible for the group ethos through participation and also through nonparticipation. The student feedback about the workshop is reviewed. The Toronto Ethical Sensitivity Instrument was used to assess whether or not the workshop altered sensitivity. Compared to a control group the attenders' sensitivity was significantly increased (on Student's t-test p equals or is less than 0.002).

Preventing the nosocomial transmission of tuberculosis

OBJECTIVE

To study the efficacy of expanded tuberculosis infection control measures consisting primarily of administrative controls.

DESIGN

Descriptive case series.

SETTING

University-affiliated, inner-city hospital.

INTERVENTIONS

Introduction of expanded tuberculosis infection control measures (including an expanded respiratory isolation policy).

MEASUREMENTS

The number of tuberculosis exposure episodes and skin test conversion rates of health care workers were measured before and after implementation of expanded infection control measures. Tuberculosis exposure episodes (the number of patients who were not placed in respiratory isolation at admission but who subsequently had a diagnosis of acid-fast bacilli smear-positive pulmonary tuberculosis during that admission or within 2 weeks of discharge) were compared for two time periods: the 8 months before and the 28 months after implementation of infection control measures. Tuberculin skin test conversion rates among health care workers were evaluated during a 2.5-year period.

RESULTS

After expanded infection control measures were implemented, the number of tuberculosis exposure episodes decreased from 4.4 per month (35 episodes among 103 patient admissions for potentially infectious tuberculosis over 8 months) to 0.6 per month (18 episodes among 358 patient admissions for smear-positive pulmonary tuberculosis over 28 months) (odds ratio, 9.72; 95% CI, 4.99 to 19.25 [P < 0.001]). The cumulative number of days per month that potentially infectious patients with tuberculosis were not in isolation decreased from 35.4 to 3.3 (P < 0.001). A concomitant decrease in tuberculin skin test conversion rates in health care workers was seen; 6-month tuberculin skin test conversion rates decreased steadily from 3.3% (118 conversions in 3579 health care workers; 1/92 to 6/92), 1.7%, 1.4%, 0.6%, to 0.4% (23 conversions in 5153 workers [1/94 to 6/94]) (P < 0.001).

CONCLUSIONS

Infection control measures effectively prevented nosocomial transmission of tuberculosis to health care workers. Administrative controls appear to be the most important component of a tuberculosis infection control program and should be the first focus of such a program, especially at public hospitals, where resources are most likely to be limited.

MR of omental myelosynangiosis

PURPOSE

To describe MR findings in patients who have undergone omental transposition (omental myelosynangiosis) for spinal cord revascularization.

METHODS

Spin-echo MR images, without and with intravenous gadolinium, were obtained before and after surgery in three patients using a quadrature spine coil. Three-dimensional time-of-flight spinal MR angiography was also performed.

RESULTS

On routine MR, the transposed omentum is an irregular, lobulated fat-equivalent mass, containing serpiginous areas of flow void, which extends through the laminectomy site to lie directly adjacent to the cord surface. MR angiography demonstrated small omental vessels, some coursing to the omentum-cord interface; however, no definite extension into the cord was detected. In all patients, there was alteration in cord size and contour after transposition, but no change in cord signal. Clinical improvement was observed in one of the three patients. The signal characteristics of the transposed omentum changed, showing less homogeneity and a gradual loss of the signal over a period of 4 months.

CONCLUSIONS

MR delineates transposed omentum and associated postoperative changes in omental myelosynangiosis. MR angiography is useful as an adjunct to demonstrate the small vessels near the omentum-cord interface, but lacks sufficient resolution to demonstrate neoangiogenesis within the cord.

Seasonal-Variation in Water Flux, Field Metabolic-Rate and Food-Consumption of Free-Ranging Koalas (Phascolarctos-Cinereus)

Mass-corrected field metabolic rates of free-ranging male koalas in central Queensland, Australia, varied between 0.329 MJ kg0.75 day-1 in summer and 0.382 MJ kg0.75 day-1 in winter. Field water influx measured 50.8 mL kg-0.8 day-1 in winter, increasing to 59.9 mL kg0.8 day-1 in summer for the same koalas, and was positively correlated with values for leaf moisture of food. Winter rates of water influx for koalas from Springsure were lower than those recorded for koalas from Victoria for the same period of the year. Mass-corrected feeding rates were lower in summer than winter; wet food intake was significantly lower than reported for similar sized female koalas from Victoria. The preferred browse was Eucalyptus crebra in winter and E. tereticornis in summer. Our study indicates that in central Queensland seasonal changes in diet selection by male koalas reflect increased energy requirements in winter and increased water requirements in summer.

Energy allocation for reproduction in a marsupial arboreal folivore, the common ringtail possum (Pseudocheirus peregrinus)

This study examines the annual energetics of a small folivorous marsupial, Pseudocheirus peregrinus. Particular attention was given to the energy and time allocated to reproduction by the females. Daily energy expenditure was measured directly using the doubly labelled water technique. Energy transferred to the young via the milk was estimated from information on milk composition and production. There was no significant seasonal variation in the energy expenditure or water influx of males or females. The mean daily energy expenditure of a 1-kg non-lactating adult ringtail possum was 615 kJ day^-1 or 2.2 times standard metabolic rate. Females showed significant changes in daily energy expenditure according to their reproductive status. Without the burden of lactation the total annual energy expenditure of an adult female was estimated as 212.4 MJ kg^-1 year^-1. The total annual energy expenditure of a female rearing two young was 247.5 MJ kg^-1 year^-1, with the late stage of lactation constituting the most energetically expensive period accounting for 30% of the total yearly energy expenditure during 24% of the time. Total metabolisable energy allocation during reproduction (22 MJ kg) was similar to estimates available for other herbivores, although, the peak metabolisable energy allocation during lactation (759 kJ day^-1) was lower than values available for other herbivores. The total energy requirement for reproduction (metabolisable energy plus potential energy exported to young via milk) suggests that the ringtail possum also has a relatively low overall energy investment in reproduction. It is suggested that the lactational strategy of the ringtail possum has been selected in order to spread the energy demands of reproduction over time due to constraints on the rate of energy intake imposed by a leaf diet and/or to prolong the mother-young bond. The strategies a female ringtail possum may employ to achieve energy balance when faced with the energy demands of reproduction are discussed.

Genetic ablation of IGFBP-2 suggests functional redundancy in the IGFBP family

Gene targeting allows mutations to be introduced selectively into any mouse locus of interest. This approach has already been used to demonstrate that insulin-like growth factor (IGF) peptides and receptors are required in vivo for normal prenatal growth. One of the IGFBP genes, IGFBP-2, has also been disrupted using gene targeting, and homozgyous null BP-2 mice are characterized by a decreased spleen size most apparent during early postnatal stages and increased adult circulating levels of several other IGFBPs. These alterations are considered less dramatic than the phenotypes initially predicted based on the fetal IGFBP-2 expression pattern, although several physiological paradigms can be envisioned that will provide additional tests for specific aspects of IGFBP function. Since all six IGFBP genes are expressed during prenatal rodent development, as well as in adult tissues, the IGFBP-2 null phenotype must also be compared with genetic ablations involving members of other gene families and in the context of the other IGFBP expression patterns in rodent embryonic, extraembryonic, and uterine tissues.

The impact of social cognitive variables on the initial level of depression and recovery

Thirty-seven patients who fulfilled DSM-III-R criteria for Major Depressive Disorder were recruited for a double-blind controlled trial of Desipramine and placebo for 6 weeks. Data about social cognitive variables, including social adversities, investment in roles and goals, general social support and crisis support were collected. Crisis support had a moderating effect on the initial level of depression: the more crisis support the subjects had, the less depressed they were on recruitment. Initial level of depression, the experience of adversity and drugs all contributed significantly to recovery defined as Hamilton Rating for Depression less than 10 at week 6. When recovery was defined as Hamilton score halved or more than halved between week 2 and week 6, subjects' level of ideal emotional support, and whether they had experienced adversity in their most invested domains, contributed significantly to recovery, independent of any drug effects or the initial level of depression. The higher their level of ideal emotional support, the less was the chance of these subjects recovering. The findings of this study pointed to the importance of controlling for psycho-social variables in studies of response to treatment.

The Children's Global Assessment Scale in clinical practice: an empirical evaluation

OBJECTIVE

The purpose of this study was to examine characteristics of the Children's Global Assessment Scale (CGAS) in the context of clinical practice.

METHOD

Ninety-five children admitted to a psychiatric inpatient unit were rated by their attending psychiatrist and by milieu staff on the CGAS. Measures of severity and type of symptomatology; social, behavioral, and school competence; intellectual level; social relatedness; and family stress were completed by parents and staff raters.

RESULTS

Results indicated that there was significant convergence in CGAS ratings by independent raters. CGAS ratings were unrelated to measures of symptomatology but were significantly related to indices of children's competence.

CONCLUSIONS

This pattern of results diverged from findings from highly controlled research settings and indicated that CGAS ratings obtained in clinical contexts may reflect evaluations of functional competence rather than severity of symptomatology.

Synthesis of steroidal D-ring fused pyrazolines: study of regiochemistry of addition

The addition of diphenylnitrilimine and C-o-chlorodiphenylnitrilimine to 3 beta-hydroxyandrost-5,16-diene (3b) produced a 1/1 ratio of regioisomeric, 1,3-diaryl-2-pyrazolines (6a, 7a and 6b, 7b), whereas the addition of N-o-chlorodiphenylnitrilimine gave a 5/1 ratio in favor of the [17 alpha, 16 alpha-d] regioisomer (7c). To further delineate the factors governing the regiochemistry of addition of diphenylnitrilimines to steroid 16-enes, additions were carried out on 16-acetyl-5 alpha-androst-16-ene (5b) and 1-acetylcyclopentene (10).

The relationship between serum p53 autoantibodies and characteristics of human breast cancer

Sera from 182 newly diagnosed breast cancer patients were assayed for antibodies to p53 using an enzyme-linked immunosorbent assay (ELISA) method, and antibodies were detected in 48 (26%) compared with 1 out of 76 (1.3%) normal control volunteers (P = 0.0001). In breast cancer patients, autoantibodies were found in all stages of disease progression: carcinoma in situ, primary invasive breast cancer and in metastatic disease. In the subset of patients in whom sequential sera were assessed over a 6 month period, changes in the p53 antibody titres were observed. The presence of antibodies to p53 correlated positively with high histological grade (P = 0.0012) and a history of second primary cancer (six positive out of eight cases). The incidence of autoantibodies was lower in those patients with a first-degree relative with breast cancer (P = 0.046). Out of 68 patients, there was a significant correlation between positive p53 autoantibody status and the detection of p53 protein in the tissue sections by immunocytochemistry (P = 0.002). In the seronegative patients, positive p53 tumour staining was strongly associated with a family history of breast cancer (P = 0.009). The p53 protein overexpressed in heritable breast cancers may therefore be less immunogenic. The presence of p53 autoantibodies provides important additional information to immunochemistry and may identify patients with aggressive histological types of breast cancer.

Comparative expression of fibroblast growth factor mRNAs in benign and malignant breast disease

The messenger RNAs for the angiogenic acidic and basic fibroblast growth factors are expressed at a significantly higher level in samples of human benign neoplastic and hyperplastic tissue than in samples from breast cancers. However, approximately one in four malignant breast cancer samples contain basic fibroblast growth factor mRNA at the same level as in the benign lesions when basic fibroblast growth factor mRNA levels are corrected with respect to levels of expression of glyceraldehyde-3-phosphate dehydrogenase mRNA. A similar proportion of human malignant breast cancer cell lines express a high level of basic fibroblast growth factor mRNA. The results suggest that some malignant breast cancers and their constitutive carcinoma cells express abundant levels of basic fibroblast growth factor mRNA. The resultant production of basic fibroblast growth factor by breast cancer cells within some tumours may contribute to their development.

Primary amyloidosis of the external auditory canal: case report

A case of primary amyloidosis of the external auditory canal is described. To the best of our knowledge this is the first case described in the literature.

Serum p53 auto-antibodies: incidence in familial breast cancer

Inactivation of the p53 gene, which codes for a tumour suppressor protein, is known to occur in the majority of human malignancies. An ELISA technique has been developed which has detected auto-antibodies to p53 in the serum of 25.6% of 176 women with breast cancer, considerably higher than previously reported with an immunoblotting technique. The incidence of auto-antibodies in those cases with a family history of breast cancer was 9.1%, compared to 29.4% in those with no family history (P = 0.029). In women without clinical breast cancer, 4 out of 36 (11.1%) of those with a positive family history were seropositive, compared to 1 out of 73 control women. Auto-antibodies were more frequently seen in the serum of breast cancer patients whose biopsies demonstrated overexpression of p53 protein. We conclude that auto-antibodies to p53 may have a role in the molecular characterisation of familial breast cancer.

Case-control study of congenital anomalies in children of cancer patients

OBJECTIVES

To determine whether the offspring of cancer survivors are at an increased risk of congenital anomalies and whether cancer therapy before conception is associated with such an increase.

DESIGN

Case-control study using computerised record linkage.

SETTING

Ontario, Canada.

SUBJECTS

Parents of children born during April 1979 to December 1986 who had a congenital anomaly diagnosed within the first year of life (45,200 mothers and 41,158 fathers) and a matched sample of parents whose children did not have a congenital anomaly (45,200 mothers and 41,158 fathers).

MAIN OUTCOME MEASURES

Cancer diagnosed in either parent before conception and radiotherapy to the pelvis or abdomen or chemotherapy with an alkylating agent.

RESULTS

Among the mothers, 54 cases and 52 controls were identified as having had cancer diagnosed in Ontario (relative risk = 1.04, 95% confidence interval 0.7 to 1.5) and among the fathers, 61 cases and 65 controls were identified (0.9, 0.7 to 1.4). No significant associations were found between congenital anomalies in the offspring and any type of cancer treatment in either the mothers or the fathers.

CONCLUSIONS

The risk of congenital anomalies among liveborn offspring whose parents have had cancer or been treated for cancer is not higher than that in the general population.

Conserved sequence and functional domains in satellite 2 from three families of salamanders

Thirteen satellite 2 elements from Ambystoma talpoideum and 16 from Amphiuma tridactylum were cloned, sequenced, and compared with the satellite 2 consensus from Notophthalmus viridescens. These elements have maintained a high degree of similarity during the 65-200 Myr that the salamander families, represented by the three species, have been separated. The DNA sequences of the consensus elements from A. talpoideum and A. tridactylum are 81% similar, and both are approximately 65% similar to the N. viridescens consensus. In addition to its DNA sequence, the functional properties of satellite 2 have also been conserved. By selecting and analyzing clones that closely mimicked the consensus of each species, we were able to demonstrate that satellite 2 from each species was capable of promoting transcription after injection into Xenopus laevis oocytes and that synthetic transcripts of satellite 2 from each species were capable of catalyzing their own site-specific cleavage. These properties may be related to the process of retroposition, which was previously proposed to be responsible for the genomic proliferation of satellite 2. Each of these functional properties also has general biological interest.

The role of the cell-cell adhesion molecule E-cadherin in large bowel tumour cell invasion and metastasis

It has been suggested that the selective loss of E-cadherin expression can generate invasiveness in human carcinoma cells and might be a predictor of metastasis. Frozen sections of samples from 44 patients, 43 with suspected large bowel cancer and one with a liver recurrence were examined for E-cadherin expression using the antibody 6F9 specific for the human E-cadherin molecule. Twelve of the 40 patients with carcinoma already had lymph node involvement at the time of surgery. Samples from the primary carcinomas of only nine of these 12 patients showed reduced E-cadherin expression. However, the one lymph node with metastatic spread examined did show reduced E-cadherin expression. Four of the 40 carcinoma patients had liver involvement at the time of surgery. The primary carcinoma samples from only three of these four patients showed reduced E-cadherin expression. In addition only two out of the three liver metastases examined showed reduced expression. The primary carcinoma samples from seven patients with no evidence of tumour spread also exhibited reduced expression. Overall, analysis of the data suggests that there is no absolute correlation between reduced E-cadherin expression and tumour spread in carcinomas of the large bowel.

Immunocytochemical identification of cell types in benign and malignant breast diseases: variations in cell markers accompany the malignant state

We performed immunocytochemical staining of benign, in situ, and malignant breast disease to identify antigens related to the presence of the major parenchymal cell types of the normal breast. Markers for the epithelial cells, antiserum to epithelial membrane antigen, and three monoclonal antibodies (MAb) to milk-fat globule membranes stained most of the inner cells in benign breast lesions, carcinoma in situ, and invasive carcinomas, but the peripheral cells in benign lesions, as well as in carcinoma in situ, were unstained. MAb to epithelium-specific keratin 18 stained the majority of inner cells in benign breast lesions but comparatively fewer such cells in carcinoma in situ and invasive carcinoma. Markers for the myoepithelial cells, antisera, and MAb to smooth muscle actin and vimentin stained most of the peripheral cells in benign breast lesions and in carcinoma in situ but failed to stain virtually any neoplastic cells in invasive carcinomas. Markers for the basement membrane adjacent to the myoepithelial cells, antiserum, and MAb to laminin and Type IV collagen delineated an intact basement membrane around benign lesions and carcinoma in situ, and fragmented structures in 5-10% of invasive carcinomas; the remaining carcinomas were largely unstained. Markers for both myoepithelial and epithelial cells, keratin MAb PKK2 and LP34, stained most of the inner cells in benign lesions but usually only relatively few malignant cells in carcinoma in situ and invasive carcinomas. Markers for the secretory alveolar cell, MAb to beta- and kappa-casein, stained a few isolated cells in benign lesions, many more inner cells in two such lesions in pregnant females, and none in invasive carcinomas. In conclusion, the myoepithelial cell and, under suitable hormonal conditions, the secretory alveolar cell, are retained in most benign lesions, but they are largely lost in invasive carcinomas.

Properties of FNR proteins substituted at each of the five cysteine residues

FNR is a transcriptional regulator controlling the expression of a number of Escherichia coli genes in response to anoxia. It is structurally-related to CRP (the cyclic AMP receptor protein) except for the presence of a cysteine-rich N-terminal extension, which may form part of an iron-binding, redox-sensing domain in FNR. Site-directed substitution has previously shown that four of the cysteine residues (C20, C23, C29 and C122) are essential for FNR function, whereas the fifth (C16) is not. The FNR protein exists in two forms separable by non-reducing SDS-PAGE, and in studies with altered FNR proteins containing single substitutions at each of the five cysteine residues it was concluded that the faster-migrating form (FNR(27)), possesses an intramolecular disulphide bond linking C122 to one of the cysteines near the N-terminus. FNR(27) was more abundant in aerobic cells but the physiological significance of this was not established. Footprint studies indicated that FNR proteins lacking essential cysteine residues are impaired in their ability to protect FNR sites in the ndh promoter. The non-essential cysteine residue (C16) was identified as the source of the most reactive sulphydryl group and all of the inactive proteins exhibited different sulphydryl reactivities. The iron content of the C122A-substituted protein was much reduced but those of the other proteins were less affected. Electrospray mass spectrometry confirmed the accuracy of the gene-derived amino acid composition of FNR with a mutant protein and it showed that a fraction of the wild-type protein may carry a 78 Da substituent which could not be removed with dithiothreitol or beta-mercaptoethanol.