Psychotherapy 2000. Some predictions for the coming decade

The purpose of this paper is prediction. It is bound to be proved wrong. Like long range weather forecasters and economists, psychotherapists are in an “impossible profession” (Freud, 1937), dealing with non-linear and therefore inherently unstable systems, unable to make accurate predictions about the future. But psychotherapists are familiar with uncertainty, and indeed perhaps actively cultivate it in order to work more creatively. Also, the development of chaos theory (Gleick, 1988) has now made vagueness a respectable topic for scientific inquiry.

Factors influencing choice of specialty and location of residency

Students recently graduating from the University of Oklahoma College of Medicine are leaving the state for their postgraduate training and entering nonprimary care fields in increasing numbers. This study identifies the major determinants for training location as having to do with the anticipated quality of the program, and for specialty as having to do with positive experiences on clerkship and the perceived characteristics of the field, including potential controllability of practice. Other factors of significance include lifestyle, standard of living and opinions of others. A striking finding was the negative view of Oklahoma held by our graduates.

Traumatic hyphaema in a haemophiliac

A case is presented of a 9-year-old haemophiliac boy who sustained a traumatic hyphaema with secondary haemorrhage. Conservative management was successful in preventing complications, and normal vision was retained.

Strand-specific mismatch correction in nuclear extracts of human and Drosophila melanogaster cell lines

Nuclear extracts derived from HeLa and Drosophila melanogaster KC cell lines have been found to correct single base-base mispairs within open circular DNA heteroduplexes containing a strand-specific, site-specific incision located 808 base pairs from the mismatch. Correction in both extract systems is strand specific, being highly biased to the incised DNA strand. Different mispairs within a homologous set of heteroduplexes were processed with different efficiencies (G.T greater than G.G approximately equal to A.C greater than C.C), and correction was accompanied by mismatch-dependent DNA synthesis localized to the region spanning the mispair and the strand break, thus demonstrating that mismatch recognition is associated with the repair reaction. Correction of each of these heteroduplexes was abolished by aphidicolin but was relatively insensitive to the presence of high concentrations of ddTTP, indicating probable involvement of alpha and/or delta class DNA polymerase(s). These findings suggest that higher eukaryotic cells possess a general, strand-specific mismatch repair system analogous to the Escherichia coli mutHLS and the Streptococcus pneumoniae hexAB pathways, systems that contribute in a major way to the genetic stability of these bacterial species.

Glutathione-s-transferase pi expression in leukaemia: a comparative analysis with mdr-1 data

Drug resistance in haemopoietic cells may be partly related to the expression of the glutathione-s-transferase (GST) pi and mdr-1 genes. We have used RNA slot blotting techniques to investigate the expression of GST pi in peripheral blood and bone marrow of eleven normal subjects, nine patients with myelodysplastic syndrome (MDS), eighteen patients with acute myeloblastic leukaemia (AML), and thirty-two patients with chronic lymphocyte leukaemia (CLL). We found increased expression of GST pi in 8 of 9 MDS, (7 peripheral blood, 1 bone marrow) 12 of 18 AML (5 peripheral blood, 7 bone marrow; 4 of 5 untreated, 1 of 5 secondary, 7 of 11 relapse or refractory) and in the peripheral blood of 24 of 32 CLL (3 of 7 untreated, 21 of 25 treated) relative to normal controls. Increased expression of GST pi can occur at any stage of disease and shows no clear relation to mdr-1 expression except, possibly, in CLL. In 3 AML patients GST pi transcript levels were the same or lower on relapse compared to presentation. Upregulation of the GST pi gene could not be demonstrated in 2 CLL patients in response to treatment with intermittent chlorambucil.

Discoid lupus erythematosus associated with hereditary angioneurotic oedema

A female patient developed discoid lupus erythematosus 6 years after the onset of hereditary angioneurotic oedema. Treatment with danazol for 18 months cleared both conditions and was well tolerated.

Lymphokine control of in vivo immunoglobulin isotype selection

Several specific conclusions can be drawn from these studies: 1. IL-4 is required for the generation of both primary polyclonal and secondary antigen-specific IgE responses in vivo. 2. IL-4 is required to maintain established, ongoing, antigen-specific and polyclonal IgE responses. 3. Most, but not all, polyclonal IgE production during a secondary immune response is IL-4-dependent. Memory B cells that have already switched to IgE at the DNA level may no longer require stimulation with IL-4 to be induced to secrete IgE. 4. The generation of a secondary IgE response is not dependent upon the presence of IL-4 during primary immunization. However, if IL-4 is not present during primary immunization, it is required during secondary immunization for the generation of an IgE response. 5. IL-4 does not appear to be required for the generation of in vivo IgG1 responses, and in at least some instances, does not contribute significantly to the generation of IgG1 responses in vivo. 6. A late-acting form of T-cell help other than IL-4 appears to be required for the generation of an IgE, but not an IgG1 response. 7. An antibody that inhibits IL-4 binding to IL-4 receptors affects Ig isotype selection in the same way as an antibody that neutralizes IL-4. 8. IFN-gamma can act in both spontaneous and induced immune responses to suppress IgE production. 9. IFN-gamma can also suppress IgG1 production and stimulate IgG2a production. However, IFN-gamma appears to suppress polyclonal IgG1 responses more than antigen-specific IgG1 responses, and it enhances, but is not required for, the generation of IgG2a responses. 10. IFN-alpha appears to resemble IFN-gamma in its ability to inhibit IgE and enhance IgG2a responses in GaM delta-injected mice, but it requires the presence of IFN-gamma to suppress IgG1 production in these mice. 11. Both IFN-alpha and IFN-gamma appear to be able to decrease IgE production in some human patients. 12. There is no direct evidence that IL-5 contributes to the generation of in vivo antibody responses. Two general conclusions may also be drawn.(ABSTRACT TRUNCATED AT 400 WORDS)

Patterns of attendance of child psychiatry out-patients with special reference to Asian families

Asian and non-Asian referrals to the department of child psychiatry at the London Hospital in 1987 were analysed. Asian referrals were under-represented with respect to the local population but, contrary to our expectations, there were no significant differences between the groups with regard to demographic data, the nature of the presenting problem, and attrition rates.

Driving safety after brain damage: follow-up of twenty-two patients with matched controls

Driving after brain damage is a vital issue, considering the large number of patients who suffer from cerebrovascular and traumatic encephalopathy. The ability to operate a motor vehicle is an integral part of independence for most adults and so should be preserved whenever possible. The physician may estimate a patient's ability to drive safely based on his own examination, the evaluation of a neuropsychologist, and a comprehensive driving evaluation--testing, driving simulation, behind-the-wheel observation--with a driving specialist. This study sought to evaluate the ability of brain-damaged individuals to operate a motor vehicle safely at follow-up. These patients had been evaluated (by a physician, a neuropsychologist, and a driving specialist) and were judged able to operate a motor vehicle safely after their cognitive insult. Twenty-two brain-damaged patients who were evaluated at our institution were successfully followed up to five years (mean interval of 2.67 years). Patients were interviewed by telephone. Their driving safely was compared with a control group consisting of a close friend or spouse of each patient. Statistical analysis revealed no difference between patient and control groups in the type of driving, the incidence of speeding tickets, near accidents, and accidents, and the cost of vehicle damage when accidents occurred. The patient group was further divided into those who had, and those who had not experienced driving difficulties so that initial neuropsychologic testing could be compared. No significant differences were noted in any aspect of the neuropsychologic test battery. We conclude that selected brain-damaged patients who have passed a comprehensive driving assessment as outlined were as fit to drive as were their normal matched controls.(ABSTRACT TRUNCATED AT 250 WORDS)

A family study of congenital X linked sideroblastic anaemia

We report on the cytogenetic findings in a family study of pyridoxine responsive, X linked sideroblastic anaemia. An increase in the number of X chromosomes was observed in a small proportion of metaphases prepared from five female members, but these findings did not strictly correlate with the carrier status of the condition. No consistent cytogenetic abnormality could be identified or associated with this rare familial condition. The diagnosis and counselling of carriers of this condition is discussed.

Changes in seasonal mortalities with improvement in home heating in England and Wales from 1964 to 1984

Changes in summer (July-September) and winter (January-March) mortalities of people aged 70-74 in England and Wales from 1964 to 1984 were compared with possible causal factors. Summer mortalities were little affected by annual temperature or influenza epidemics and fell from 1972-1975 for all causes, coronary and respiratory causes, while cerebrovascular mortality fell more rapidly from that time. Cigarette consumption also fell from 1972-1975; falling consumptions of total fat from 1970 and saturated fat from 1972-1975 probably also contributed to the fall in arterial deaths, and likewise falls in prescription rates for tranquillisers and sedatives from 1976-1978 to the fall in respiratory deaths. From 1964 to 1984 use of central heating increased from 13% to 69% of households, domestic fuel consumption increased, and excess mortality in winter from respiratory disease declined by 69%, even relative to summer mortality and when adjusted for varying coldness of winters. The improvement was partly explained by a decline in influenza epidemics. By contrast, excess mortalities in winter from coronary and cerebrovascular disease, although rising in some early influenza epidemics, did not fall significantly as home heating improved. These thrombotic deaths together accounted for 56% of the total excess winter mortality by 1984. The findings support other indications that most of the excess mortality from arterial thrombosis in winter in England and Wales is due to brief excursions outdoors rather than to low indoor temperatures.

Multidrug resistance in haemopoietic cell lines, myelodysplastic syndromes and acute myeloblastic leukaemia

Resistance to cytotoxic agents is a common clinical problem encountered in the treatment of human myelodysplastic syndromes (MDS) and acute myeloblastic leukaemia (AML). Cellular acquisition of the multidrug resistance (MDR) phenotype confers loss of sensitivity to a wide range of structurally dissimilar anti-neoplastic agents. This state can arise through increased expression of the mdrl (P-glycoprotein) gene. We have used the mdrl gene probe to investigate adriamycin resistant (HL60/AR) and vinblastine resistant (CEM/VLB100) human leukaemic cell lines. In addition, peripheral blood or bone marrow cells from 66 patients with MDS and AML have been screened for gene amplification and 40 cases for increased mRNA expression. P-glycoprotein gene amplification was observed only in the (CEM/VLB100) and not in the HL60/AR on any other leukaemic cell line. Gene amplification was not found in any patient's cells. Eighteen out of 40 patients showed an increase (2----20) of mdrl mRNA expression. These results are not only of significance in understanding the biology of human drug resistance but have practical importance in the design of anti-leukaemic therapy.

T help requirements for the generation of an in vivo IgE response: a late acting form of T cell help other than IL-4 is required for IgE but not for IgG1 production

To further define requirements for T cell help in the stimulation of an in vivo IgE response, we studied a system in which the injection of mice with a goat antibody to mouse IgD (GaMD) stimulates large polyclonal IgG1 and IgE responses. In this system, both responses are blocked by anti-CD4 antibody, but only the IgE response is blocked by (anti-IL-4) antibody. Anti-CD4 antibody, if injected 5 days after GaMD, was found to inhibit the GaMD-induced IgE response to a much greater extent than the IgG1 response, even though both responses occur simultaneously and are inhibited to an equal extent by optimal or suboptimal doses of anti-CD4 antibody administered 2 days after GaMD. Even a suboptimal, 50-micrograms dose of anti-CD4 antibody, when injected 5 days after GaMD, inhibited the IgE response to a much greater extent than did an optimal 10-mg dose of anti-IL-4 antibody injected at the same time, even though 10 mg of anti-IL-4 antibody more completely inhibited GaMD-induced IgE production than did 50 micrograms of anti-CD4 antibody when injected 2 days after GaMD. These observations provide evidence that a late acting form of T cell help other than IL-4 is important for the generation of an IgE response but not an IgG1 response in GaMD-immunized mice.

T help requirements for the generation of an in vivo IgE response: a late acting form of T cell help other than IL-4 is required for IgE but not for IgG1 production

To further define requirements for T cell help in the stimulation of an in vivo IgE response, we studied a system in which the injection of mice with a goat antibody to mouse IgD (GaMD) stimulates large polyclonal IgG1 and IgE responses. In this system, both responses are blocked by anti-CD4 antibody, but only the IgE response is blocked by (anti-IL-4) antibody. Anti-CD4 antibody, if injected 5 days after GaMD, was found to inhibit the GaMD-induced IgE response to a much greater extent than the IgG1 response, even though both responses occur simultaneously and are inhibited to an equal extent by optimal or suboptimal doses of anti-CD4 antibody administered 2 days after GaMD. Even a suboptimal, 50-micrograms dose of anti-CD4 antibody, when injected 5 days after GaMD, inhibited the IgE response to a much greater extent than did an optimal 10-mg dose of anti-IL-4 antibody injected at the same time, even though 10 mg of anti-IL-4 antibody more completely inhibited GaMD-induced IgE production than did 50 micrograms of anti-CD4 antibody when injected 2 days after GaMD. These observations provide evidence that a late acting form of T cell help other than IL-4 is important for the generation of an IgE response but not an IgG1 response in GaMD-immunized mice.

IL-4 is required to generate and sustain in vivo IgE responses

Antibodies of the IgE isotype play a predominant role in immediate hypersensitivity reactions. IL-4, a T cell-derived lymphokine that stimulates increased Ia expression by resting B cells and increased IgG1 secretion by LPS-activated B cells in vitro, has also been shown to regulate in vitro and in vivo polyclonal IgE responses. We report that large quantities of a purified anti-IL-4 mAb inhibit primary in vivo polyclonal IgE responses by 99% in mice infected with Nippostrongylus brasiliensis or injected with anti-IgD antibodies, and totally inhibit secondary Ag-specific IgE responses to TNP-keyhole limpet hemocyanin without effect on either IgG1 or IgG2a responses to these stimuli. The lack of effect of anti-IL-4 antibody on IgG1 secretion cannot be explained simply by inadequate neutralization of IL-4, inasmuch as the doses of anti-IL-4 antibody used blocked an N. brasiliensis-induced increase in B cell Ia expression by more than 85%, whereas in vitro studies indicate that enhancement of B cell Ia expression requires less IL-4 than induction of IgG1 secretion. In addition to demonstrating that IL-4 plays a necessary role in the generation of an in vivo IgE response, we show that IL-4 has an important role in sustaining established IgE responses, because anti-IL-4 antibody, when given at the peak of an N. brasiliensis- or TNP-keyhole limpet hemocyanin-induced IgE response, accelerates the declines in total serum IgE and in IgE anti-TNP antibody levels, respectively. These observations suggest that the effects of IL-4 on in vivo immune responses may be more specific than might have been predicted from in vitro observations, and that regulation of IL-4 production or action may be useful for the prevention or therapy of immediate hypersensitivity disorders.