Letter to the Editor Regarding: Evolving Business Models in Orthotics by Schneider, N

The purpose of this letter is to continue the dialogue regarding the paper "Evolving business models in Orthotics" in the Canadian Prosthetics & Orthotics Journal Volume 4, Issue2, No.3, 2021. In it we present the perspective of the current Alberta Association of Orthotists and Prosthetists (AAOP) and provide additional context and information on historical events. Finally, we provide additional clarity on how costing is approached in the Province of Alberta (Canada) and the purported inequity in compensation between the two disciplines.

Analysis of porcine body size variation using re-sequencing data of miniature and large pigs

Background

Domestication has led to substantial phenotypic and genetic variation in domestic animals. In pigs, the size of so called minipigs differs by one order of magnitude compared to breeds of large body size. We used biallelic SNPs identified from re-sequencing data to compare various publicly available wild and domestic populations against two minipig breeds to gain better understanding of the genetic background of the extensive body size variation. We combined two complementary measures, expected heterozygosity and the composite likelihood ratio test implemented in “SweepFinder”, to identify signatures of selection in Minipigs. We intersected these sweep regions with a measure of differentiation, namely F_ST, to remove regions of low variation across pigs. An extraordinary large sweep between 52 and 61 Mb on chromosome X was separately analyzed based on SNP-array data of F₂ individuals from a cross of Goettingen Minipigs and large pigs.

Results

Selective sweep analysis identified putative sweep regions for growth and subsequent gene annotation provided a comprehensive set of putative candidate genes. A long swept haplotype on chromosome X, descending from the Goettingen Minipig founders was associated with a reduction of adult body length by 3% in F₂ cross-breds.

Conclusion

The resulting set of genes in putative sweep regions implies that the genetic background of body size variation in pigs is polygenic rather than mono- or oligogenic. Identified genes suggest alterations in metabolic functions and a possible insulin resistance to contribute to miniaturization. A size QTL located within the sweep on chromosome X, with an estimated effect of 3% on body length, is comparable to the largest known in pigs or other species. The androgen receptor AR, previously known to influence pig performance and carcass traits, is the most obvious potential candidate gene within this region.

Electronic supplementary material

The online version of this article (10.1186/s12864-018-5009-y) contains supplementary material, which is available to authorized users.

Low medical morbidity and mortality after acute courses of electroconvulsive therapy in a population-based sample

BACKGROUND

To determine event rates for specific medical events and mortality among individuals receiving electroconvulsive therapy (ECT).

METHOD

Population-based cohort study using health administrative data of acute ECT treatments delivered in Ontario, Canada, from 2003 to 2011. We measured the following medical event rates, per 10 000 ECT treatments, up to 7 and 30 days post-treatment: stroke, seizure, acute myocardial infarction, arrhythmia, pneumonia, pulmonary embolus, deep vein thrombosis, gastrointestinal bleeding, falls, hip fracture, and mortality.

RESULTS

A total of 135 831 ECT treatments were delivered to 8810 unique patients. Overall medical event rates were 9.1 and 16.8 per 10 000 ECT treatments respectively. The most common medical events were falls (2.7 and 5.5 per 10 000 ECT treatments) and pneumonia (1.8 and 3.8 per 10 000 ECT treatments). Fewer than six deaths occurred on the day of an ECT treatment. This corresponded to a mortality rate of less than 0.4 per 10 000 treatments. Deaths within 7 and 30 days of an ECT treatment, excluding deaths due to external causes (e.g., accidental and intentional causes of death), were 1.0 and 2.4 per 10 000 ECT treatments respectively.

CONCLUSION

Morbidity and mortality events after ECT treatments were relatively low, supporting ECT as a low-risk medical procedure.

Randomised clinical trial: alginate (Gaviscon Advance) vs. placebo as add-on therapy in reflux patients with inadequate response to a once daily proton pump inhibitor

BACKGROUND

Many reflux patients remain symptomatic on a standard dose of proton pump inhibitor (PPI). Alginates decrease the number of reflux events by forming a raft on top of the stomach content and thus offer a supplemental mechanism of action to acid suppression.

AIM

To assess the efficacy of an alginate (Gaviscon Advance, Reckitt Benckiser, Slough, UK) on reflux symptoms in patients with persistent symptoms despite once daily PPI.

METHODS

This was a multicentre, randomised, placebo-controlled, 7-day double-blind trial preceded by a 7-day run-in period. Reflux symptoms were assessed using the Heartburn Reflux Dyspepsia Questionnaire (HRDQ). Based on symptom score during run-in, eligible patients were randomised to Gaviscon Advance 10 mL four times a day or placebo in addition to a once daily PPI. The primary endpoint was change in HRDQ score post-treatment compared to baseline.

RESULTS

One hundred and thirty-six patients were randomised. Change in HRDQ reflux score was significantly greater for Gaviscon Advance (mean: -5.0, s.d.: 4.7) than for placebo (mean: -3.5, s.d.: 5.5) with an LS mean difference of 1.6 [95% CI -3.1 to -0.1], P = 0.03. A decrease in the mean (s.d.) number of nights with symptoms was observed from 3.6 (2.8) to 3.0 (3.0) in the placebo group and from 3.9 (2.8) to 2.2 (2.7) for the Gaviscon Advance group. This reduction was significantly greater in the Gaviscon Advance group than in the placebo group [LS mean difference = -0.9, 95% CI (-1.6 to -0.2), P < 0.01].

CONCLUSION

In patients with residual reflux symptoms despite PPI treatment, adding an alginate offers additional decrease in the burden of reflux symptoms (EudraCT/IND Number: 2011-005486-21).

Activity of the antiseptic polyhexanide against meticillin-susceptible and meticillin-resistant Staphylococcus aureus

Staphylococcus aureus is one of the most important pathogens, with increasing emergence of meticillin-resistant S. aureus (MRSA) strains. This is associated not only with multiresistance to antibiotics but also with increasing resistance to topical antibiotics and antiseptics. As the antiseptic polyhexanide has only a low risk of emergence of resistant strains, the aim of the study was to obtain data on the sensitivity of S. aureus towards polyhexanide. The effect of polyhexanide was tested against 80 meticillin-susceptible S. aureus (MSSA) and 80 MRSA strains from sporadic cases as well as against 6 MRSA outbreak strains. The clonal diversity of the 166 strains was proven by pulsed-field gel electrophoresis (PFGE). Minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) were determined by the serial broth microdilution technique according to DIN 58940. Time-kill studies were performed for reference strains MSSA ATCC 29213 and MRSA ATCC 33591. MICs and MBCs in the range of 0.5-2mg/L were found. According to a created epidemiological cut-off (ECOFF) value of 4mg/L, all strains were regarded as susceptible to polyhexanide, including MRSA epidemic strains and MSSA and MRSA sporadic strains with various antibiotic susceptibility patterns. Addition of up to 4% albumin to the test medium did not change the MICs and MBCs. Time-kill studies showed reduction rates of 4log₁₀CFU/mL for 200mg/L and 5log₁₀CFU/mL for 400mg/L polyhexanide within 5-30min. It is concluded that polyhexanide is suitable for topical eradication of S. aureus.

Clinical trial: long-term use of proton pump inhibitors in primary care patients - a cross sectional analysis of 901 patients

BACKGROUND

The use of proton pump inhibitors (PPIs) is extensive. While the incidence of new treatments remains stable, the prevalence of long-term treatment is rising. Studies have shown that up to 70% of patients on chronic acid suppression lack a verified indication for treatment.

AIMS

To investigate primary care patient characteristics associated with long-term use of PPIs.

METHODS

A cross-sectional analysis of 42,634 patients registered with 22 general practitioners was performed. Patients with prescriptions of > or =120 tablets/year were defined as long-term users. A survey of a subgroup of patients without verified indication was performed.

RESULTS

In all, 901 (2.1%) patients were long-term treated. Verified indications for treatment were identified for 247/901 (27%). An upper GI endoscopy had been performed in 418 patients (46%). Of the 194/654 without verified indication who participated in the survey, 71% reported heartburn/acid regurgitation as the reason for therapy. On-demand therapy was reported by 43/194 (22%) and previous attempts to withdraw by 119/194 (61%).

CONCLUSIONS

The prevalence of PPI long-term treatment among primary care patients is 2.1%. The main reason for treatment is reflux symptoms or verified GERD. Rationalization of use of PPIs is possible as daily treatment without attempts to discontinue is frequently observed.

[Health-related quality of life in dermatologists compared to other physicians]

BACKGROUND

According to recent studies, there may be differences in quality of life for physicians depending on gender and field of medicine. Presently, there are hardly any data with respect to health-related quality of life in dermatologists.

METHODS

Using the SF-36 Health Survey, 112 dermatologists and 113 physicians in other fields of medicine were studied in a cross-sectional study.

RESULTS

Dermatologists' mental health level averaged lower than their physical health level (chi2=28.49; p<.001). The mental and physical health level were higher in female dermatologists than in their male colleagues (e.g., GH: chi2=6.15; p<.05 and MH: chi2=6.83; p<.05). These findings are the opposite of results in other medical specialists. The differences between mental and physical health dimensions on the one hand, and between women and men on the other hand, were found in all age groups.

CONCLUSIONS

In comparison to other medical specialists, dermatologists differ only slightly in their health-related quality of life. Therefore, it may be advisable to implement preventive measures concerning their comparatively low mental health status.

Extracellular matrix-derived peptide binds to alpha(v)beta(3) integrin and inhibits angiogenesis

Angiogenesis is associated with several pathological disorders as well as with normal physiological maintenance. Components of vascular basement membrane are speculated to regulate angiogenesis in both positive and negative manner. Recently, we reported that tumstatin (the NC1 domain of alpha 3 chain of type IV collagen) and its deletion mutant tum-5 possess anti-angiogenic activity. In the present study, we confirm that the anti-angiogenic activity of tumstatin and tum-5 is independent of disulfide bond requirement. This property of tum-5 allowed us to use overlapping synthetic peptide strategy to identify peptide sequence(s) which possess anti-angiogenic activity. Among these peptides, only the T3 peptide (69-88 amino acids) and T7 peptide (74-98 amino acids) inhibited proliferation and induced apoptosis specifically in endothelial cells. The peptides, similar to tumstatin and the tum-5 domain, bind and function via alpha(v)beta(3) in an RGD-independent manner. Restoration of a disulfide bond between two cysteines within the peptide did not alter the anti-angiogenic activity. Additionally, these studies show that tumstatin peptides can inhibit proliferation of endothelial cells in the presence of vitronectin, fibronectin, and collagen I. Anti-angiogenic effect of the peptides was further confirmed in vivo using a Matrigel plug assay in C57BL/6 mice. Collectively, these experiments suggest that the anti-angiogenic activity of tumstatin is localized to a 25-amino acid region of tumstatin and it is independent of disulfide bond linkage. Structural features and potency of the tumstatin peptide make it highly feasible as a potential anti-cancer drug.

[A patient with Gulf war syndrome. On discussion of an uncertain disease picture]

The Gulf War syndrome represents neurological and neuropsychological disorders in veterans of the Persian Gulf war. Until today, the various symptoms observed could not be attributed to any defined disease. As a possible cause, exposure to neurotoxic agents such as the organophosphates used during the war has been suggested by many authors. We report on a 29-year-old man who suffered from dysmnesia, disturbance of orientation, cognitive impairment, and double vision. His history revealed several front-line operations in 1990 and 1991 during the Gulf War. Physical examinations showed a complex eye-movement disturbance and a horizontal nystagmus, which was neuro-ophthalmologically confirmed. The early auditory potentials referred to a brainstem dysfunction and the cognitive disturbances correlated to changes in the late-appearing component of event-related potentials (P 300). Brain imaging with CCT, MRI, SPECT, PET, and EEG and CSF showed no pathologies. Neuropsychological tests disclosed severe cognitive impairment especially concerning memory. Three-month follow-up studies in a department of psychosomatic medicine excluded a dissociative disorder as a feature of a post-traumatic stress or a conversion disorder. This is the first case of Gulf War syndrome in Germany. We focus on an unfamiliar complication after the war. The recent literature is reviewed.

[Psychosocial predictors of metabolic instability in brittle diabetes--a multivariate time series analysis]

The term "brittle diabetes" denotes the unstable course of an insulin-dependent diabetes characterised by frequent hypo- or hyperglycaemic crises. The aim of this study is to demonstrate empirically how psychosocial parameters interact with metabolic instability in a paradigmatic case of juvenile brittle diabetes. By means of a structured diary study, blood sugar values, moods (SAM), body symptoms (GBB), the daily hustle and hassle, helping therapeutic alliance (HAQ) and the aspects of setting were registered. Resulting time series (112 days each) were ARIMA-analysed by a multivariate approach. It could be shown that the mean variance of daily blood sugar values as an indicator of brittleness was predicted by moods, body complaints and by a family session as setting factor (p < 0.05, for corresponding predictors). Feelings of dominance preceded an increase of blood sugar variance, whereas depressive moods, anger and body symptoms were associated with metabolic instability. A family therapy session also resulted in an increase of the mean blood sugar variance. The model accounted for almost 30% of the total variance of the dependent variable (R-square-adjusted, p < 0.0001). The potential of multivariate time-series as a means to demonstrate psychosomatic interrelations is discussed. We believe that the results may also contribute to an empirically rooted understanding of psychodynamic processes in psychosomatoses.

Identification of the anti-angiogenic site within vascular basement membrane-derived tumstatin

Components of vascular basement membrane are involved in regulating angiogenesis. Recently, tumstatin (the NC1 domain of alpha3 chain of type IV collagen) was identified as possessing anti-angiogenic activity. In the present study, the anti-angiogenic activity of tumstatin was localized to the putative 54-132-amino acid Tum-5 domain, and the activity mediated by alpha(v)beta(3) integrin interaction in an RGD-independent manner. The recombinant Tum-5 produced in Escherichia coli and Pichia Pastoris specifically inhibited proliferation and caused apoptosis of endothelial cells with no significant effect on nonendothelial cells. Tum-5 also inhibited tube formation of endothelial cells on Matrigel and induced G1 endothelial cell cycle arrest. Moreover, anti-angiogenic effect of Tum-5 was also examined in vivo using both a Matrigel plug assay in C57BL/6 mice and human prostate cancer (PC-3) xenografts in nude mice. The in vivo results demonstrate that Tum-5 at 1 mg/kg significantly inhibited growth of PC-3 tumors in association with a decrease in CD31 positive vasculature. These in vivo studies also show that, at molar equivalents, human Tum-5 is at least 10-fold more active than human endostatin. In addition, these studies for the first time suggest that through the action of endogenous inhibitors, alpha(v)beta(3) integrin may also function as a negative regulator of angiogenesis. Taken together, these findings demonstrate that Tum-5, a domain derived from tumstatin, is an effective inhibitor of tumor-associated angiogenesis and a promising candidate for the treatment of cancer.

Basement membrane formation during wound healing is dependent on epidermal transplants

The purpose of the study was to compare directly the effect of healing and the formation of the basement membrane during wound healing from two autologous primary keratinocyte cultures in the liquid environment in full-thickness wounds in pigs. Wounds were either transplanted with cultured epidermal autografts (n = 26) or autologous keratinocyte suspensions (n = 24) or treated with saline alone (n = 40) and covered with a chamber. All wounds transplanted with cultured epidermal autografts and keratinocyte cell suspensions had positive "take" after transplantation. Healing times were significantly shorter for wounds treated with either cultured epidermal autografts or keratinocyte suspensions (p = 0.0001) compared with saline-treated wounds but were not different from each other (p = 0.1835). There were no differences in cytokeratin and laminin expression; however, staining with monoclonal antibody against collagen type VII showed a lower signal for cultured epidermal autografts only on days 8 and 16 compared with keratinocyte suspensions. Electron microscope evaluation showed a higher incidence of anchoring fibrils and a more mature dermal-epidermal junction in wounds treated with keratinocyte cell suspensions at day 8. These findings may be due to the single, noncontact-inhibited cells and the early formation of an in vivo neodermis to the wet wound environment. These data suggest that wounds transplanted with autologous keratinocyte suspensions in a wet environment may be an alternative method in the treatment of wounds.

NM-3, an isocoumarin, increases the antitumor effects of radiotherapy without toxicity

We examined the effects of a new antiangiogenic isocoumarin, NM-3, as a radiation modifier in vitro and in vivo. The present studies demonstrate that NM-3 is cytotoxic to human umbilical vein endothelial cells (HUVECs) but not to Lewis lung carcinoma (LLC) cells nor Seg-1, esophageal adenocarcinoma cells, in clonogenic survival assays. When HUVEC cultures are treated with NM-3 combined with ionizing radiation (IR), additive cytotoxicity is observed. In addition, the combination of NM-3 and IR inhibits HUVEC migration to a greater extent than either treatment alone. The effects of treatment with NM-3 and IR were also evaluated in tumor model systems. C57BL/6 female mice bearing LLC tumors were given injections for 4 consecutive days with NM-3 (25 mg/kg/day) and treated with IR (20 Gy) for 2 consecutive days. Combined treatment with NM-3 and IR significantly reduced mean tumor volume compared with either treatment alone. An increase in local tumor control was also observed in LLC tumors in mice receiving NM-3/IR therapy. When athymic nude mice bearing Seg-1 tumor xenografts were treated with NM-3 (100 mg/kg/day for 4 days) and 20 Gy (four 5 Gy fractions), significant tumor regression was observed after combined treatment (NM-3 and IR) compared with IR alone. Importantly, no increase in systemic or local tissue toxicity was observed after combined treatment (NM-3 and IR) when compared with IR alone. The bioavailability and nontoxic profile of NM-3 suggests that the efficacy of this agent should be tested in clinical radiotherapy.

[Expectations and attitudes of medical students concerning work stress and consequences of their future medical profession]

In the following cross-sectional study 245 medical students from two different terms (three years apart) were being questioned about work stress and the consequences of their future medical profession. Attitudes and expectations regarding future work stress, work satisfaction, coping strategies, gender specific problems, effects on private life and future quality of life were studied. As expected, students in the upper term were able to judge their professional and private future more realistically. The expectations of the advanced students are more realistic and as a consequence it is likely that a disillusioning process is taking place. The results contribute to a better understanding of the present study situation and well-being of medical students concerning their professional and private future which is also important for teaching and the teaching professionals.

Criteria for gene identification and features of genome organization: analysis of 6.5 Mb of DNA sequence from human chromosome 21

To establish criteria for and the limitations of novel gene identification, to identify novel genes of potential relevance to Down Syndrome and to investigate features of genome organization, 6. 550kb. In total, 41 novel gene models were predicted, and for a subset of these, RT-PCR experiments helped to verify and refine the models, and were used to assess expression in early development and in adult brain regions of potential relevance to Down syndrome. Results suggest generally low and/or restricted patterns of expression, and also reveal examples of complex alternative processing, especially in brain, that may have important implications for regulation of protein function. Analysis of complete gene structures of the known genes identified a number of very large introns, a number of very short intergenic distances, and at least one potentially bi-directional promoter. At least 3/4 of known genes and 1/2 of predicted genes are associated with CpG islands. For novel genes, three cases of overlapping genes are predicted. Results of these analyses illustrate some of the complexities inherent in mammalian genome organization and some of the limitations of current sequence analysis technologies. They also doubled the number of potential genes within the region.

Attitudes toward psychotherapists, psychologists, psychiatrists, and psychoanalysts. A meta-content analysis of 60 studies published between 1948 and 1995

Sixty studies, published between 1948 and 1995, on attitudes toward mental health professionals, particularly psychotherapists, were systematically content analyzed. Descriptive results concerning the topics status, expertise, personality attributes, physical appearance, sex/gender, psychotherapeutic settings, and interactions between therapists and clients are presented. Public-image problems of psychotherapists, research deficits, methodological problems, and sex/gender issues are critically discussed.

Postdischarge telephone follow-up program for breastfeeding preterm infants discharged from a special care nursery

There is little research about mothers' concerns and management strategies for breastfeeding preterm infants in the postdischarge period. However, preterm infants have unique needs, and their mothers often face overwhelming challenges when trying to breastfeed in the early postdischarge period. The purpose of this project was to provide support to breastfeeding mothers whose babies had been recently discharged and to help the SCN team to develop a discharge plan. A telephone follow-up form was developed to help identify real or potential problems, plan realistic interventions, and evaluate the effectiveness of the plan. The first part of the form includes information about the baby's stay in the hospital. The second part of the form is used postdischarge. Space is provided to document any identified problems and suggested interventions. Feedback from the mothers who have received the telephone follow-up has been very favorable.

[Epicutaneous breast prosthesis after breast ablation]

INTRODUCTION

Restoration of body symmetry is a very important aspect after mastectomy to help patients coping with daily life. There are basically two possibilities for patients who do not wish breast reconstruction: either using breast forms that are suspended in a brassière or a new system in which the breast form is attached on an adhesive strip to the thorax wall. With burr crushers the breast form is attached to the strip. Brassières are not necessarily needed. The influence of improved prosthetics on the patients' self-concept and well-being was investigated.

MATERIALS AND METHOD

67 patients in postoperative care at the Universitätsfrauenklinik Giessen were randomized in control group using customary breast forms and the study group changing to self adhesive breast forms. Using the "Frankfurter Selbstkonzeptionsskalen" (Frankfurt Self-Concept Scales), plus additional questions concerning problems after mastectomy, self-concept was assessed before study and after 3 months.

RESULTS

Significant differences with regard to the scale "Social Contact and Relations" (FSKU) were seen. Most patients were better satisfied with epicutaneous self-adhesive breast forms. Weight and movement behaviour of the self-adhesive breast form was considered natural and almost like a part of the body by 92%. 80% considered adhesive strips to be well tolerable. Thoughts about operative breast reconstruction became less important for 62%. 78% were happy to be able to wear more fashionable clothing.

CONCLUSION

The new concept of self-adhesive breast forms is an improvement with respect to social and psychological rehabilitation.

Breast forms after mastectomy--patient's issues

After mastectomy restoration of body symmetry, a very important aspect of coping with daily life, may be achieved either using breast forms that are suspended in a brassière or by a new system in which breast forms are attached by adhesive strips to the thorax walls. The system promises free and easy movement, favourable effects on lymphoedema, and improvements with respect to dressing. Brassières are not necessarily needed. The influence of improved prosthetics on patients' self concept and well-being was investigated. A group of 67 patients after unilateral mastectomy tested custom breast forms and self-adhesive breast forms. Using the Frankfurter Selbstkonzeptionsskalen (Frankfurt Self-Concept Scales), plus additional questions concerning problems after mastectomy, self-concept was assessed before study and after 3 months. Analysis of variance with repeated measures revealed significant differences with respect to the scale Social Contact and Relations (FSKU). Most patients were better satisfied with epicutaneous self-adhesive breast forms. The weight and type of movement of the self-adhesive breast forms were considered natural, and adhesive strips were well tolerated. A total of 78% were able to wear more fashionable clothing. Breast reconstruction became less important for 62%. The new concept of self-adhesive breast forms is an improvement with respect to social and pyschological rehabilitation.

[Psychosomatic aspects of menopause: review of the literature 1988-1992]

Based on an analysis of medical and psychological studies published in 1988-1992 a review about psychosomatic aspects of the menopause is presented. While more than 1000 studies on medical/gynecological aspects of the menopause and especially "hormone replacement therapy" were published in English or German, psychological aspects seemed to have been neglected in about 90% of those articles. Only in the abstracts of 58 studies on menopause the keywords psychosom*, psychology or quality of life were mentioned. The methods of those psychosomatic studies are summarized, and central results concerning the description of menopausal experiences, psychosocial influences, prevention and interventions are referred. Research deficits and implications for prevention and therapy are discussed critically.

Enumeration of human peripheral blood lymphocytes secreting immunoglobulins of major classes and subclasses in healthy children and adults

The reverse enzyme-linked immunospot assay was modified to enumerate peripheral blood mononuclear cells (PBMC) secreting IgG1-4, IgA1-2, and IgM. Anti-human IgG F(ab')2 and mouse monoclonal antibodies specific to each of the isotypes were used as solid-phase capture antibodies and developing antibodies, respectively. Although attempts were also made to detect IgD- and IgE-secreting cells (SC), their numbers in the peripheral blood were too few to be reliably estimated. The assay was applied to study healthy subjects including 21 neonates within 3 days of birth, 44 1- to 48-month-old children, and 32 adults. Sixty percent of these neonates had IgM SC in small numbers (less than 20 per 10(6) PBMC), but only three neonates had IgSC of other isotypes. In contrast, by 1-2 months of age children had IgSC of all isotypes, including IgA2 and IgG4, often in higher numbers than adults. The relative frequencies of IgSC were IgA1 greater than IgG1 greater than IgM greater than IgG2 greater than IgG3 greater than IgG4 greater than IgA2 in the children and IgA1 greater than IgG1 greater than IgA2 greater than IgM greater than IgG4 greater than IgG2 greater than IgG3 in the adults. The order of the serum concentrations in the adults was IgG1 greater than IgG2 greater than IgA greater than IgM greater than IgG4 greater than IgG3. No correlation was found between the serum level and the IgSC number of individual isotypes (except for serum IgA and IgA1-SC). This new methodology should facilitate investigating the current status of immunoglobulin synthesis and the Ig repertoire in adults and children, in health and in disease.

[Problems in dealing with difficult patients]

There are difficult patients, but there are difficult therapists too. The problems on either side may encumber and disturb the relationship between the doctor and his patient. Based on the author's experience in the field of clinical psychiatry, of clinical as well as of out-patient psychotherapy, typical problems of interaction with so called difficult patients are presented. At first these groups of patients are characterized, which are frequently experienced by doctors as being particularly difficult. Doctors describe and explain certain features of those patient's character and behaviour. Furtheron problematic doctor-patient interactions may also be induced by problematic sides of the therapist. Typical problems of therapists are dealt with in the last part of the article.

Serum immunoglobulin G subclasses in children infected with human immunodeficiency virus type 1

We studied serum concentrations of IgG subclasses in 47 human immunodeficiency virus 1-infected (17 asymptomatic and 30 symptomatic) children. Thirty-nine of 47 (83%) had an abnormality of at least 1 subclass. Sixteen had only elevated IgG1, 6 had only elevated IgG3 and 12 had elevated IgG1 and IgG3 concentrations. IgG2, IgG4 and combined IgG2-IgG4 deficiency was found in 3, 4 and 4 patients, respectively. IgG2 concentrations did not differ between patients with (n = 23) or without (n = 24) bacterial infections. Additionally the number of bacterial infections was similar between the patients with normal or low IgG2 and/or low IgG4. These data indicate that IgG subclass abnormalities are found in most children with human immunodeficiency virus 1 infection, but quantitative deficiencies of specific subclasses do not appear to explain the high frequency of bacterial infections occurring in these patients.

Clinical and immunologic responses to Haemophilus influenzae type b-tetanus toxoid conjugate vaccine in infants injected at 3, 5, 7, and 18 months of age

The safety and immunogenicity of Haemophilus influenzae type b-tetanus toxoid conjugate vaccine (Hib-TT) were evaluated in 77 healthy infants receiving injections at 3, 5, 7, and 18 months of age. No serious local or systemic reactions were noted. After the first injection the geometric mean Hib antibody level rose to 0.55 micrograms/ml, and each subsequent injection elicited a statistically significant rise in the geometric mean. The percentage of vaccinees with Hib antibody levels greater than 0.15 micrograms/ml serum was 75.5% after the first, 97.4% after the second, and 100% after the third Hib-TT injection. This percentage fell to 90.9% at 18 months of age but rose again to 100% after the fourth injection. Control infants (n = 10) injected with diphtheria-tetanus toxoid-pertussis vaccine only had nondetectable levels after the second injection. Hib-TT elicited increases of Hib antibody in all isotypes: IgG greater than IgM greater than IgA. Among IgG subclasses the highest increases were of IgG1. All vaccinated subjects had greater than 0.01 U/ml of TT antibody (estimated protective level) throughout the study. We conclude that Hib-TT, injected at 3, 5, 7, and 18 months, is safe and induces protective levels of antibodies during the age of highest incidence of meningitis caused by Hib.

[Indications and prerequisites for psychotherapy]

A list of psychoreactive and neurotic disorders is given, which are often seen in general practice and which are suitable for psychotherapy. These disorders are shortly discussed. Subsequently, a survey of the most important psychotherapeutic methods is given and conditions for a positive outcome are described. Finally, the authors suggest further information on this subject for general practitioners, among others in Balint groups.

A monoclonal antibody may show cross-reactivities in Ouchterlony assays but not in other assays

A monoclonal antibody to human IgG was tested with myeloma proteins of the four IgG subclasses. When tested by immunofluorometric assay, enzyme-linked immunosorbent assay, hemagglutination and hemagglutination inhibition assays, the antibody reacted with IgG3 but not with the other three IgG subclasses. When tested by Ouchterlony assays in the presence of polyethylene glycol, the antibody formed lines with all four IgG proteins. The line with IgG3 was sharp and stable, but the lines with the other three IgG subclasses tended to blur with time and with the lower PEG concentrations. These findings show that Ouchterlony assays can reveal cross-reactions of a monoclonal antibody that can be missed by more sensitive assays.

[The dependence of psychiatric diagnosis on the function of the diagnostician in relation to his patient (author's transl)]

At the admittance of patients to a psychiatric clinic, the diagnostic judgement of physicians with different functions was investigated. There was a great variability of statements on the severity, the consequences of the disease, and the social behaviour of the patients, dependent on the functions of the respective physicians who always tended to observe and judge first of all those sides of the disease that concerned their special fields of responsibility.

A rapid gas-chromatographic method for the quantitative determination of clomethiazole in human serum

A rapid method without elaborate instrumentation for the determination of clomethiazole serum concentrations is described. This method is suitable for a routine clinical laboratory, and the results, from 37 patients investigated by this method which are presented, are comparable to results described by other authors. A relationship between dose ingested and serum concentration can be established. The determination of clomethiazole serum concentrations is useful as an adjunct to overall clinical assessment, and helpful in establishing a suitable dosage regimen of clomethiazole for the individual patient; it can also be used to verify suspected clomethiazole abuse or overdose.