Multicentric investigations of the role in the disease severity of accelerated phospholipid changes in COVID-19 patient airway

CONTEXT

The changes in host membrane phospholipids are crucial in airway infection pathogenesis. Phospholipase A2 hydrolyzes host cell membranes, producing lyso-phospholipids and free fatty acids, including arachidonic acid (AA), which contributes significantly to lung inflammation.

AIM

Follow these changes and their evolution from day 1, day 3 to day 7 in airway aspirates of 89 patients with COVID-19-associated acute respiratory distress syndrome and examine whether they correlate with the severity of the disease. The patients were recruited in three French intensive care units. The analysis was conducted from admission to the intensive care unit until the end of the first week of mechanical ventilation.

RESULTS

In the airway aspirates, we found significant increases in the levels of host cell phospholipids, including phosphatidyl-serine and phosphatidyl-ethanolamine, and their corresponding lyso-phospholipids. This was accompanied by increased levels of AA and its inflammatory metabolite prostaglandin E2 (PGE2). Additionally, enhanced levels of ceramides, sphingomyelin, and free cholesterol were observed in these aspirates. These lipids are known to be involved in cell death and/or apoptosis, whereas free cholesterol plays a role in virus entry and replication in host cells. However, there were no significant changes in the levels of dipalmitoyl-phosphatidylcholine, the major surfactant phospholipid. A correlation analysis revealed an association between mortality risk and levels of AA and PGE2, as well as host cell phospholipids.

CONCLUSION

Our findings indicate a correlation between heightened cellular phospholipid modifications and variations in AA and PGE2 with the severity of the disease in patients. Nevertheless, there is no indication of surfactant alteration in the initial phases of the illness.

Peer Support Activities for Veterans, Serving Members, and Their Families: Results of a Scoping Review

For many, including military veterans and their families, support between individuals with shared lived experiences, or peer support, has long been utilized as a way to support each other through many different challenges. Building on other reviews and guided by the seven domains of well-being in the Canadian veteran well-being framework, the objective of this paper is to describe and catalogue the nature of peer support activities and related outcomes in the veteran, serving member, and family member populations. A scoping review following the five stages outlined by Arksey and O'Malley was conducted; it was guided by the question: What is currently known about peer support activities for veterans, serving members, and their families that has been evaluated in the literature? In total, 101 publications from 6 different countries were included in this review and catalogued based on publication characteristics, participant information, peer support activity information, and peer information. Peer support activities have the potential to positively influence the well-being of veterans, serving members, and their families on a holistic level across multiple domains. This scoping review highlights the existing gaps in the literature and provides an important foundation for future research on peer support for these populations, specifically in the Canadian context.

Well-being of Canadian Armed Forces Veterans and Spouses of Veterans During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Survey

BACKGROUND

The COVID-19 pandemic has resulted in significant changes to everyday life, including social distancing mandates, changes to health care, and a heightened risk of infection. Previous research has shown that Canadian Armed Forces (CAF) veterans are at higher risk of developing mental and physical health conditions. Veterans and their families may face unique social challenges that can compound with pandemic-related disruptions to negatively impact well-being.

OBJECTIVE

This study aims to longitudinally characterize the mental health of CAF veterans and spouses of CAF veterans throughout the pandemic and to understand the dynamic influences of pandemic-related stressors on psychological health over time.

METHODS

We employed a prospective longitudinal panel design using an online data collection platform. Study participation was open to all CAF veterans and spouses of CAF veterans residing in Canada. Participants were asked to complete a comprehensive battery of assessments representing psychological well-being, chronic pain, health care access patterns, physical environment, employment, social integration, and adjustment to pandemic-related lifestyle changes. Follow-up assessments were conducted every 3 months over an 18-month period. This study was approved by the Western University Health Sciences and Lawson Health Research Institute Research Ethics Boards.

RESULTS

Baseline data were collected between July 2020 and February 2021. There were 3 population segments that participated in the study: 1047 veterans, 366 spouses of veterans, and 125 veterans who are also spouses of veterans completed baseline data collection. As of November 2021, data collection is ongoing, with participants completing the 9- or 12-month follow-up surveys depending on their date of self-enrollment. Data collection across all time points will be complete in September 2022.

CONCLUSIONS

This longitudinal survey is unique in its comprehensive assessment of domains relevant to veterans and spouses of veterans during the COVID-19 pandemic, ranging from occupational, demographic, social, mental, and physical domains, to perceptions and experiences with health care treatments and access. The results of this study will be used to inform policy for veteran and veteran family support, and to best prepare for similar emergencies should they occur in the future.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34984.

Well-being of Canadian Veterans during the COVID-19 pandemic: cross-sectional results from the COVID-19 Veteran well-being study

BACKGROUND

The impacts of the COVID-19 pandemic have disproportionally affected different population groups. Veterans are more likely to have pre-existing mental health conditions compared to the general Canadian population, experience compounded stressors resulting from disruptions to familial, social, and occupational domains, and were faced with changes in health-care delivery (e.g. telehealth). The objectives of this study are to assess (a) the mental health impact of COVID-19 and related life changes on the well-being of Veterans and (b) perceptions of and satisfaction with changes in health-care treatments and delivery during the pandemic.

METHODS

A total of 1136 Canadian Veterans participated in an online survey. Participants completed questions pertaining to their mental health and well-being, lifestyle changes, and concerns relating to the COVID-19 pandemic, as well as experiences and satisfaction with health-care treatments during the pandemic.

RESULTS

Results showed that 55.9% of respondents reported worse mental health functioning compared to before the pandemic. The frequency of probable posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, alcohol use disorder, and suicidal ideation were 34.2%, 35.3%, 26.8%, 13.0%, and 22.0%, respectively. Between 38.6% and 53.1% of respondents attributed their symptoms as either directly related to or exacerbated by the pandemic. Approximately 18% of respondents reported using telehealth for mental health services during the pandemic, and among those, 72.8% indicated a choice to use telehealth even after the pandemic.

CONCLUSIONS

This study found that Veterans experienced worsening mental health as a result of the COVID-19 pandemic. The use of telehealth services was widely endorsed by mental health treatment-seeking Veterans who transitioned to virtual care during the pandemic. Our findings have important clinical and programmeadministrator implications, emphasizing the need to reach out to support veterans, especially those with pre-existing mental health conditions and to enhance and maintain virtual care even post-pandemic.

Bactericidal effects and stability of LL-37 and CAMA in the presence of human lung epithelial cells

Cationic antimicrobial peptides (CAMPs) are important actors in host innate immunity and represent a promising alternative to combat antibiotic resistance. Here, the bactericidal activity of two CAMPs (LL-37, and CAMA) was evaluated against Pseudomonas aeruginosa (PA) in the presence of IB3-1 cells, a cell line derived from patients with cystic fibrosis. The two CAMPs exerted different effects on PA survival depending on the timing of their administration. We observed a greater bactericidal effect when IB3-1 cells were pretreated with sub-minimum bactericidal concentrations (Sub-MBCs) of the CAMPs prior to infection. These findings suggest that CAMPs induce the production of factors by IB3-1 cells that improve their bactericidal action. However, we observed no bactericidal effect when supra-minimum bactericidal concentrations (Supra-MBCs) of the CAMPs were added to IB3-1 cells at the same time or after infection. Western-blot analysis showed a large decrease in LL-37 levels in supernatants of infected IB3-1 cells and an increase in LL-37 binding to these cells after LL-37 administration. LL-37 induced a weak inflammatory response in the cells without being toxic. In conclusion, our findings suggest a potential prophylactic action of CAMPs. The bactericidal effects were low when the CAMPs were added after cell infection, likely due to degradation of CAMPs by bacterial or epithelial cell proteases and/or due to adherence of CAMPs to cells becoming less available for direct bacterial killing.

Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy

BACKGROUND

Over 85% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations.

OBJECTIVE

This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD.

METHODS

This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation & Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes.

RESULTS

The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021.

CONCLUSIONS

This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations.

TRIAL REGISTRATION

PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33151.

Exploring the Well-being of Health Care Workers During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Study

BACKGROUND

Health care workers (HCWs) have experienced several stressors associated with the COVID-19 pandemic. Structural stressors, including extended work hours, redeployment, and changes in organizational mandates, often intersect with interpersonal and personal stressors, such as caring for those with COVID-19 infections; worrying about infection of self, family, and loved ones; working despite shortages of personal protective equipment; and encountering various difficult moral-ethical dilemmas.

OBJECTIVE

The paper describes the protocol for a longitudinal study seeking to capture the unique experiences, challenges, and changes faced by HCWs during the COVID-19 pandemic. The study seeks to explore the impact of COVID-19 on the mental well-being of HCWs with a particular focus on moral distress, perceptions of and satisfaction with delivery of care, and how changes in work structure are tolerated among HCWs providing clinical services.

METHODS

A prospective longitudinal design is employed to assess HCWs' experiences across domains of mental health (depression, anxiety, posttraumatic stress, and well-being), moral distress and moral reasoning, work-related changes and telehealth, organizational responses to COVID-19 concerns, and experiences with COVID-19 infections to self and to others. We recruited HCWs from across Canada through convenience snowball sampling to participate in either a short-form or long-form web-based survey at baseline. Respondents to the baseline survey are invited to complete a follow-up survey every 3 months, for a total of 18 months.

RESULTS

A total of 1926 participants completed baseline surveys between June 26 and December 31, 2020, and 1859 participants provided their emails to contact them to participate in follow-up surveys. As of July 2021, data collection is ongoing, with participants nearing the 6- or 9-month follow-up periods depending on their initial time of self-enrollment.

CONCLUSIONS

This protocol describes a study that will provide unique insights into the immediate and longitudinal impact of the COVID-19 pandemic on the dimensions of mental health, moral distress, health care delivery, and workplace environment of HCWs. The feasibility and acceptability of implementing a short-form and long-form survey on participant engagement and data retention will also be discussed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32663.

Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic

BACKGROUND

Research is urgently needed to understand health care workers' (HCWs') experiences of moral-ethical dilemmas encountered throughout the COVID-19 pandemic, and their associations with organizational perceptions and personal well-being. This research is important to prevent long-term moral and psychological distress and to ensure that workers can optimally provide health services.

OBJECTIVE

Evaluate associations between workplace experiences during COVID-19, moral distress, and the psychological well-being of Canadian HCWs.

METHOD

A total of 1362 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in an online survey. Participants completed measures reflecting moral distress, perceptions of organizational response to the pandemic, burnout, and symptoms of psychological disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD).

RESULTS

Structural equation modelling showed that when organizational predictors were considered together, resource adequacy, positive work life impact, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress also significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout.

CONCLUSIONS

Our findings highlight an urgent need for HCW organizations to implement strategies designed to prevent long-term moral and psychological distress within the workplace. Ensuring availability of adequate resources, reducing HCW risk of contracting COVID-19, providing organizational support regarding individual priorities, and upholding ethical considerations are crucial to reducing severity of moral distress in HCWs.

Adult mental health outcomes of adolescent depression: A systematic review

BACKGROUND

Adolescent depression may increase risk for poor mental health outcomes in adulthood. The objective of this study was to systematically review the literature on the association between adolescent depression and adult anxiety and depressive disorders as well as suicidality.

METHODS

EMBASE, MEDLINE, and PSYCinfo databases were searched and longitudinal cohort studies in which depression was measured in adolescence (age 10-19) and outcomes of depressive disorders, anxiety disorders, or suicidality were measured in adulthood (age 21+), were selected. Meta-analysis using inverse variance and random effects modeling, along with sensitivity analyses, were used to synthesize article estimates.

RESULTS

Twenty articles were identified, representing 15 unique cohorts. Seventeen of 18 articles showed adolescent depression increased risk for adult depression; eleven pooled cohorts estimated that adolescents with depression had 2.78 (1.97, 3.93) times increased odds of depression in adulthood. Seven of eight articles that investigated the association between adolescent depression and any adult anxiety found a significant association. Three of five articles showed a significant association between adolescent depression and adult suicidality.

CONCLUSION

This review shows that adolescent depression increases the risk for subsequent depression later in life. Articles consistently found that adolescent depression increases the risk for anxiety disorders in adulthood, but evidence was mixed on whether or not a significant association existed between adolescent depression and suicidality in adulthood. Early intervention in adolescent depression may reduce long-term burden of disease.

Associations between fruit and vegetable consumption and depressive symptoms: evidence from a national Canadian longitudinal survey

BACKGROUND

Several cross-sectional studies have demonstrated associations between diet quality, including fruit and vegetable consumption, and mental health. However, research examining these associations longitudinally, while accounting for related lifestyle factors (eg, smoking, physical activity) is scarce.

METHODS

This study used data from the National Population Health Survey (NPHS), a large, national longitudinal survey of Canadians. The sample included 8353 participants aged 18 and older. Every 2 years from 2002/2003 to 2010/2011, participants completed self-reports of daily fruit and vegetable consumption, physical activity, smoking and symptoms of depression and psychological distress. Using generalised estimating equations, we modelled the associations between fruit and vegetable consumption at each timepoint and depression at the next timepoint, adjusting for relevant covariates.

RESULTS

Fruit and vegetable consumption at each cycle was inversely associated with next-cycle depression (β=-0.03, 95% CI -0.05 to -0.01, p<0.01) and psychological distress (β=-0.03, 95% CI -0.05 to -0.02, p<0.0001). However, once models were adjusted for other health-related factors, these associations were attenuated (β=-0.01, 95% CI -0.04 to 0.02, p=0.55; β=-0.00, 95% CI -0.03 to 0.02, p=0.78 for models predicting depression and distress, respectively).

CONCLUSIONS

These findings suggest that relations between fruit and vegetable intake, other health-related behaviours and depression are complex. Behaviours such as smoking and physical activity may have a more important impact on depression than fruit and vegetable intake. Randomised control trials of diet are necessary to disentangle the effects of multiple health behaviours on mental health.

Quality of work life in doctors working with cancer patients

BACKGROUND

Although studies have shown that medical residents experience poor psychological health and poor organizational conditions, their quality of work life (QWL) had not been measured. A new tool, the Quality of Work Life Systemic Inventory (QWLSI), proposes to fill the gap in the definition and assessment of this concept.

AIMS

To confirm the convergent validity of the QWLSI, analyse Belgian medical residents' QWL with the QWLSI and discuss an intervention methodology based on the analysis of the QWLSI.

METHODS

One hundred and thirteen medical residents participated between 2002 and 2006. They completed the QWLSI, the Maslach Burnout Inventory and the Job Stress Survey to confirm the correspondence between these three tools.

RESULTS

Residents' low QWL predicted high emotional exhaustion (β = 0.282; P < 0.01) and job stress (β = 0.370; P < 0.001) levels, confirming the convergent validity. This sample of medical residents had an average QWL (μ = 5.8; SD = 3.1). However, their QWL was very low for three subscales: arrangement of work schedule (μ = 9; SD = 6.3), support offered to employee (μ = 7.6; SD = 6.1) and working relationship with superiors (μ = 6.9; SD = 5.3).

CONCLUSIONS

The results confirm that the QWLSI can provide an indication of workers' health well-being and of organizational performance in different areas of work life. The problem factors found among Belgian medical residents suggest that prevention should focus on reduction of work hours, development of support and change in leadership style.

[Catatonia in a 14 year-old girl: treatment with clorazepam and carbamazepine, a 10-year follow-up]

INTRODUCTION

Child and adolescent catatonia has been poorly investigated. Moreover, diagnosis criteria only exist for adult psychiatry, and there are no therapeutic guidelines. The aim of this paper is to describe the case of a 14-year-old girl presenting an overlap between psychogenic and neuroleptic induced catatonia, acute treatment and ten year's follow-up.

CASE REPORT

A 14-year-old Caucasian French girl, Elsa, was admitted in February 1998 to a University adolescent mental health center with an acute psychotic disorder. She showed agitation, impulsivity (sudden engagement in inappropriate behaviour), paranoid delusions, visual and auditory hallucinations, diurnal and nocturnal urinary incontinence, lack of self-care, inadequate food intake because of fear of poisoning, and vomiting after meals leading to rapid weight loss of 5 kg. Clinical examination, laboratory tests, EEG and RMI were normal. Toxicological tests were negative. Her IQ, assessed six months before admission, was in the dull average range (70-75). Elsa was treated with loxapine 150 mg per day for one week without improvement and this was then replaced by haloperidol 30 mg per day. One week after the start of haloperidol her agitation, impulsivity, and hallucinatory symptoms decreased. Twenty four days after loxapine introduction and 17 days after the haloperidol, her condition deteriorated rapidly over less than 48 hours. She exhibited immobility, minimal response to stimuli, staring and catalepsy with waxy flexibility. The diagnosis of catatonia was established. Examination revealed tremulous extremities, tachychardia (110 pm) and apyrexia. Creatine phosphokinase levels were 106 UI/l (normal range 0-250). Human immunodeficiency virus, hepatitis, listeria and Lyme serology were negative. Cerebrospinal fluid analysis was normal. Haloperidol was stopped and intravenous clonazepam 5mg/kg was begun. It was not possible to obtain signed consent from the two parents for Electroconvulsive therapy. The patient was transferred to a pediatric intensive care unit. The treatment was standard parenteral nutrition, nursing, intravenous clonazepam 0.05 mg/kg, with regular attendance by a child psychiatrist. Elsa stayed three weeks in this condition. She then began to notice the child psychiatrist, and a few days later she was able to carry out simple requests. Elsa was transferred to an adolescent psychiatric unit. As soon as she could eat by herself again, carbamazepine 400mg per day was begun. Her agitation reduced at a carbamazepine level of 7 mg/l. One month later her condition was stable. However, language difficulties persisted for a further six months. One year after the episode she scored 66 on a repeat IQ test and her RMI was normal. She exhibited no significant residual symptoms except some cognitive impairment. She integrated into a special education facility. These attempts to stop the carbamazepine were followed by depressed mood, aggressiveness and impulsivity; carbamazepine was finally stopped successfully after seven years. Ten years later, Elsa is the mother of two young children and is able to take care of them. She has never had a relapse of her psychotic disorder or catatonic state.

DISCUSSION

The etiopathogenic diagnosis is problematic. Some indices in the familial history may suggest a traumatic event. But one to the total residual amnesia it was never confirmed, and traumatic catatonia are extremely rare. Normal CPK levels, with autonomic disturbance limited to tachycardia and the lack of resolution after discontinuance of medication, argues against a diagnosis of neuroleptic malignant syndrome (NMS). But CPK levels are non specific, and NMS without pyrexia has been described. The occurrence of the catatonic syndrome 21 days after the first dose of a neuroleptic could be diagnostic. This case involved a non organic catatonic psychosis followed by neuroleptic induced catatonia. Catatonia is described as a risk factor for the development of NMS and some consider NMS to be a variant of malignant catatonia. The interest of this report is (1) it reinforces the need to be cautious before prescribing neuroleptics in adolescents presenting with symptoms of catatonia; (2) the complete recovery from catatonia after treatment with intensive care and more than three weeks of intravenous clonazepam without the use of ECT and (3) the effectiveness of carbamazepine over a long period of follow-up. Although trials on carbamazepine in catatonia are published, there are no data available for the control of residual symptoms or the long term prognosis, especially in child and adolescent psychiatry.

`I'm Cured But….'

The current qualitative research studied representations of illness posttreatment from a heart transplant group, a panic disorder group, and a tic disorder group. All three groups were preoccupied with perceptions about the impact of the illness, perception of self and the perception of how others view the ill person. The heart transplant group seem to adopt an active style of coping compared to the panic disorder group who presented a more passive, anticipatory mode of coping, and the tic group who were preoccupied with control over the perceptions of others. This qualitative information could help optimize adaptation strategies.

Colonic Drug Delivery: Influence of Cross-linking Agent on Pectin Beads Properties and Role of the Shell Capsule type

For colonic delivery, pectin beads obtained by ionotropic gelation method have been already reported as an interesting approach. This study investigated the influence of the cross-linking agent (calcium or zinc) and the type of shell capsule used (classical or enteric capsules) on pectin beads properties and on their performance to target the colon (in vitro dissolution studies with subsequent pH change to mimic overall gastro-intestinal tract). Zinc pectinate beads seemed to be relatively similar to calcium's ones in morphological point, except on the surface aspect. When beads were introduced in classical hard capsules, ketoprofen release was not significantly different between CPG and ZPG beads, and it was too premature and too quick due to a chemical erosion of the pectinate matrix (acid + basic attacks). However, zinc pectinate beads showed slower ketoprofen release compared with calcium pectinate beads when enteric hard capsules were used. This interesting finding could be due to the strength of the network formed during the process between the zinc cations and the LM-pectin following the "egg-box" model. This network was stronger and induced a reduction of swelling and hydration when contact with dissolution medium, then subsequently a decrease of drug release. Thus, the zinc pectinate beads could protect sufficiently drug entrapped from the upper gastro-intestinal conditions and drug release will be controlled by pectin degradation with colonic microflora. Finally, these zinc pectinate beads in enteric hard capsules are promising as a carrier for specific colonic delivery of drugs after oral administration.

Colon-specific drug delivery: Influence of solution reticulation properties upon pectin beads performance

In this study, pectinate gel beads were produced by ionotropic gelation method with different solutions of cross-linking agents and ketoprofen was entrapped as model drug. The influence of these formulation parameters was investigated upon bead properties and upon their performance to target the colon. Zinc pectinate beads obtained with 10% of counter-ions solution at pH 1.6 exhibited the strongest gel network due to "egg-box" dimmer formation helped by hydrogen bonding. Furthermore the gel network formed at low pH was arranged in a compact three-fold conformation. Thus, this matrix structure in enteric capsules induced the lowest drug release in the upper gastro-intestinal tract (pH 1.2 following by pH 7.4). However ketoprofen release occurred specifically in the colon thanks to the presence of pectinolytic enzymes and the release rate can be modulated by the counter-ion concentration during the reticulation process. Therefore this approach using pectinate beads is very promising as efficient carrier for specific delivery of drug into the colon, after oral administration.

Measurement properties of a new quality of life measure for patients with work disability associated with musculoskeletal pain

INTRODUCTION

The Quality of Life Systemic Inventory (QLSI) measures patients' goal attainment based on the system control theory. It quantifies the perceived impact of the disorder and the gap between the present and aspired states.

PURPOSE

To evaluate concurrent validity and responsiveness of the QLSI among workers on sick leave due to musculoskeletal disorders (MSDs).

METHODS

Participants (10 women; 29 men) were recruited at a work rehabilitation centre and had more than 4 weeks of absence from work due to MSDs compensated by the Workers' Compensation Board. Concurrent validity and external responsiveness were based on baseline and post-treatment measures of external criteria. Criteria and related instruments were the following: perception of disability (Roland-Morris Disability Questionnaire); health-related quality of life (SF-12); stress (Psychological Stress Measure) and distress (Psychological Distress Index).

RESULTS

Regression analyses revealed significant correlations between QLSI scores and the Psychological Distress Index (r2 = .11 to .19 and .66; p < .001), with either the SF-12 mental component scale (r2 = .18 and .11; p < .01) or the Roland-Morris Disability Questionnaire (r2 = .04 and .10; p < .05). All measures showed highly significant change over time.

CONCLUSION

Results support the concurrent validity and responsiveness of the QLSI, with an MSD population.

SIGNIFICANCE

This instrument could serve in future research as an outcome measurement instrument in the evaluation of more long-term effects of rehabilitation programs.

The impact of cholesterol lowering on patients' mood

This study compared mood changes in 212 patients treated for hypercholesterolemia, as a function of their level of adherence to dietary recommendations. Assessments of mood (anxiety, depression, and hostility), measured by the Profile of Mood States, were obtained at baseline and 3-, 6-, and 12-month follow-up. Adherence to diet was categorized as low, medium, or high based on the Food Record Rating. Repeated-measures ANOVAs showed a significant decrease over time for anxiety, total cholesterol (TC), and low-density lipoproteins (LDL). A multiple regression was performed to determine if reductions in TC or LDL were associated with the anxiety decrease. The model for anxiety change was highly significant and included gender, baseline anxiety, number of stressful events, psychological stress, baseline level of adherence to diet, gender x adherence interaction, and change in TC x adherence interaction. In conclusion, cholesterol lowering did not negatively affect patients' moods. However, those who adhered poorly but nonetheless showed stable or reduced TC exhibited a greater decrease in anxiety.

Patients' perceptions of cardiac anesthesia services: a pilot study

PURPOSE

To develop an instrument to measure patients' perceptions of the services provided by anesthesiologists, an important indicator of quality for which little information is available.

METHODS

The scale of patients' perceptions of cardiac anesthesia services (SOPPCAS) is composed of 17 Likert-type and sociodemographic questions. Data collection was conducted on T-1 (fourth postoperative day) and T-2 (15 days postoperatively). In addition, we employed the Marlow-Crowne scale and a short form of the Psychological Symptoms Index to verify the influence of social desirability and psychological distress respectively. Data analysis included a principal component analysis (PCA).

RESULTS

One hundred seventy patients answered the questionnaires at T-1 and 133 patients at T-2. Cronbach alpha of the SOPPCAS was 0.58. PCA revealed four perioperative factors: patient/anesthesiologist interactions, preoccupations related to anesthesia, experience with anesthesia and pain management. Global mean satisfaction was 4.45 +/- 0.64 (maximum score 6.0). Main items related to satisfaction were: satisfaction with premedication, empathy from anesthesiologists, pain management. Main items related to dissatisfaction were: lack of information on blood transfusion and recall of endotracheal intubation. A score of 14/20 was obtained for social desirability. Social desirability did not influence the construct of the SOPPCAS.

CONCLUSION

We developed, using rigorous methods, an instrument to measure patients' perceptions of the quality of cardiac anesthesia services. Global mean satisfaction with anesthesia services was moderately high contrary to previous studies where it was high. Finally, the SOPPCAS should allow anesthesiologists to improve the quality of the care they provide.

High efficiency transient transfection of genes in human umbilical vein endothelial cells by electroporation

Endothelial cells derived from the human umbilical vein (HUVEC) are used to study the mechanisms involved in EC response to various stimuli as well as to investigate the basis of pathological conditions of the vascular system such as altered endothelium permeability, tumor-induced angiogenesis, atherosclerosis and leukocyte extravasation in chronic inflammatory responses. However, investigations of gene involvement related to these conditions have progressed slowly because of the difficulty of transfecting HUVEC with high efficiency. Whereas several technical approaches have been described, they usually result in low levels of transfected cells or they require several steps or sophisticated instrumentation. We describe here a straightforward protocol of transfection of freshly isolated HUVEC that is based on the simple technique of electroporation. Efficiencies of gene transfection greater than 40% were routinely obtained by using a combination of optimized conditions of HUVEC isolation, composition of the electroporation medium and homogeneity of the plasmids. The protocol has been applied to the functional transient transfection of functional genes in HUVEC as illustrated in the case of the cDNA encoding GFP, protein kinase C (alpha and epsilon isotypes) and beta-galactosidase.

Cyclodextrin modulation of T lymphocyte signal transduction with aging

There is an alteration of the immune response in aging that leads to the increased incidence of infections, cancers and autoimmune disorders. The aim of the present study was to investigate whether there exists changes in signal transduction under the IL-2 receptor stimulation and the role of plasma membrane cholesterol in the activation of T cells with aging. We report age-related changes in the JAK-STAT signalling pathway that results in decreased tyrosine phosphorylation of STAT5. We present evidence for the importance of cholesterol content in regulating signalling pathways in T cells and in modulating their proliferation by using the plasma membrane cholesterol-depleting agent methyl-beta-cyclodexrin (MBCD). MBCD treatment (0.5 mM) induced a significant decrease in the cholesterol content of T cells of elderly subjects whereas it was increased in T cells of young subjects. MBCD induced changes in the phosphorylation of p56(lck), especially in T cells of elderly subjects. The proliferation of MBCD-treated T cells decreased in lymphocytes of young subjects but did not change in T cells of elderly subjects. These results suggest a role for plasma membrane cholesterol in the regulation of the TcR signalling pathways with differential effects related to aging. However, the data suggest that modulation of the plasma membrane cholesterol content alone may not be enough to restore signal transduction changes with aging.

Monocytes influence the fate of T cells challenged with oxidised low density lipoproteins towards apoptosis or MHC-restricted proliferation

Atherosclerosis has been implicated in myocardial infarction, stroke and a host of cardiovascular diseases. The presence of activated T lymphocytes and macrophages, and the increased expression of HLA-DR antigen are consistent with the notion of immune activity in the atherosclerotic plaque. The nature of the causative antigen has not been established although oxidised low density lipoproteins (oxLDL) that accumulate in atherosclerotic plaques could fulfil this role. Here, we report that monocytes play a key role in influencing the fate of purified peripheral human T lymphocytes from healthy donors when the cells are exposed to LDL oxidised under the controlled conditions of water radiolysis. Our data showed that oxLDL generated under these conditions were chemoattractants for T cells. However, they induced a state of apoptosis in T lymphocytes cultured in the absence of monocytes. The extent of apoptosis was related to the degree of oxidation of LDL and the time of T cell exposure to oxLDL. OxLDL-dependent apoptosis did not involve a scavenger-like receptor. CD4(+) cells were more sensitive to the apoptotic effect of oxLDL than CD8(+) cells. OxLDL-primed (12 h) autologous monocytes triggered a robust proliferation of T lymphocytes cultured in the absence of oxLDL. The strength of T cell stimulation was related to the degree of oxidation of the LDL used in priming. Heterologous monocytes exposed to oxLDL under similar conditions induced a response that was not different than monocytes exposed to untreated LDL (natLDL) which did not induce T cell proliferation. Fucoidan did not modify the oxLDL-, monocyte-dependent T cell response to proliferation, suggesting that a scavenger-like receptor was not involved. The expression of the HLA-DR marker and the B7.2 protein were up-regulated in monocytes exposed to oxLDL but not to natLDL. The levels of B7.1 were unchanged. Our data are consistent with the notion that monocytes are critical for T cell survival in the presence of oxLDL and MHC-restricted T cell proliferative response to oxLDL.

Impact of waiting time on the quality of life of patients awaiting coronary artery bypass grafting

BACKGROUND

A lack of resources has created waiting lists for many elective surgical procedures within Canada's universal health care system. Coronary artery bypass grafting (CABG) for the treatment of atherosclerotic ischemic heart disease is one of these affected surgical procedures. We studied the impact of waiting times on the quality of life of patients awaiting CABG.

METHODS

A prospective cohort of 266 patients from 3 hospitals in Montreal was used. Patients who gave informed consent were followed from the time they were registered for CABG until 6 months after surgery; recruitment began in November 1993, and the last follow-up was completed in July 1995. Patient groups were classified according to the duration of the wait for CABG (< or = 97 days or > 97 days). We measured the following outcomes: quality of life (using the Medical Outcomes Study 36-item Short Form [SF-36]), incidence of chest pain (using the New York Heart Association angina classification), frequency of symptoms (using the Cardiac Symptom Inventory) and rates of complications and death before and after surgery.

RESULTS

There were no differences in quality of life at baseline between the 2 groups. Immediately before surgery, compared with patients who waited 97 days or less, those who waited longer had significantly reduced physical functioning (change from baseline SF-36 score 0 v. -4 respectively, p = 0.001), vitality (change from baseline score -0.1 v. -1.3, p = 0.01), social functioning (change from baseline score 0.4 v. -0.4, p = 0.03) and general health (change from baseline score 1.1 v. -1.7, p = 0.001). At 6 months after surgery, compared with patients who waited 97 days or less for CABG, those who waited longer had reduced physical functioning (change from baseline SF-36 score 4.0 v. -0.1 respectively, p = 0.001), physical role (change from baseline score 0.8 v. 0.0, p = 0.001), vitality (change from baseline score 2.2 v. 0.9, p = 0.001), mental health (change from baseline score 1.2 v. 0.0, p = 0.001) and general health (change from baseline score 1.8 v. -0.3, p = 0.001). The incidence of postoperative adverse events was significantly greater among the patients with longer waits for CABG than among those with shorter waits (32 v. 14 events respectively, p = 0.005). Longer waits before CABG were associated with an increased likelihood of not returning to work after surgery (p = 0.08): 10 (53%) of the 19 patients with longer waiting times remained employed after CABG, as compared with 17 (85%) of the 20 with shorter waiting times.

INTERPRETATION

The significant decrease in physical and social functioning, both before and after surgery, for patients waiting more than 3 months for CABG is an important observation. Longer waiting times were also associated with increased postoperative adverse events. By decreasing waiting times for CABG, we may improve patients' quality of life and decrease the psychological morbidity associated with CABG.

Control of CYP11B2 gene expression through differential regulation of its promoter by atypical and conventional protein kinase C isoforms

We reported previously that the protein kinase C (PKC) inhibitor GF109203X stimulated the hamster CYP11B2 promoter activity in transfected NCI-H295 cells. PKCalpha, -epsilon, and -zeta were detected in hamster adrenal zona glomerulosa and NCI-H295 cells, and PKCtheta in NCI-H295 cells. 12-O-Tetradecanoylphorbol-13-acetate (TPA) inhibited basal and stimulated cytochrome P450 aldosterone synthase mRNA expression by angiotensin (AII), dibutyryl cyclic adenosine 3':5'-monophosphate (Bt2cAMP), or KCl in NCI-H295 cells. Basal CYP11B2 promoter activity was inhibited in cells cotransfected with constitutively active (CA) PKCalpha, -epsilon, and -theta mutants, whereas it was increased with CA-PKCzeta. Dominant negative (DN) PKCalpha, -theta, -epsilon, and -zeta mutants stimulated the promoter activity. AII-, KCl-, and Bt2cAMP-stimulatory effects were abolished in cells cotransfected with CA-PKCalpha, -epsilon, or -theta. The effect of Bt2cAMP was abolished by CA-PKCzeta but AII and KCl were still able to enhance the promoter activity. DN-PKCalpha, -epsilon, -theta, or -zeta did not inhibit these effects. Gö6976 enhanced promoter activity, providing further evidence that PKCalpha was involved. Various CYP11B2 promoter constructs were used to identify the area associated with TPA and PKC inhibition. TPA and CA-PKCalpha, -epsilon, or -theta abolished the effects of AII, KCl, and Bt2cAMP on the activity of -102 and longer constructs. In summary, our findings suggest that the hamster CYP11B2 gene is under differential control by conventional (alpha) and atypical (zeta) PKC.

Patient satisfaction with anesthesia services

PURPOSE

The evaluation of services by patients is an essential component of continuous quality improvement in anesthesiology. Little is known, however, about how to achieve this objective. Our goal was to conduct a systematic review of all available studies on patient satisfaction with anesthesia services, thereby ascertaining the present level of knowledge in this field and suggesting ways of improving current measurement methodologies.

SOURCE

We reviewed relevant major data banks--Medline, Dissertation Abstract, Psyclit and Cochrane--between 1980 and 2000 and bibliographies from primary sources. We used the following keywords for our search: quality improvement, anesthesia, quality, patient perceptions, consumer satisfaction, continuous quality improvement, outcome measures.

PRINCIPAL FINDINGS

The review yielded 14 pertinent studies. Studies were divided into two groups (A & B), according to the quality of the psychometric evaluation (tests performed to verify the reliability and validity of an instrument). While all studies reported high levels of patient satisfaction with anesthesia services, many used methods of questionable value. None of the 14 studies controlled for any confounding variables, such as social desirability. Four studies had seriously biased their data collection and the majority of the studies lacked rigour in the development of the instrument used to measure patient satisfaction. Only one study presented a definition of the concept measured, and none provided a conceptual model of patients' satisfaction with anesthesia services.

CONCLUSION

The currently available studies of patient satisfaction are of questionable value. Only rigorous methods and reliable instruments will yield valid and clinically relevant findings of this important issue in anesthesiology.

Regulation of CYP11B2 gene expression by protein kinase C

Bisindolylmaleimide, a protein kinase C (PKC) inhibitor, was shown to stimulate the hamster CYP11B2 promoter activity in transfected NCI-H295 cells. In this study we have found that TPA, an activator of PKC, also inhibited the hamster CYP11B2 promoter activity. DAG-dependent PKC alpha and PKC epsilon, and atypical PKC zeta were detected in hamster adrenal zona glomerulosa, whereas the isoforms alpha, epsilon, zeta and theta were found in NCI-H295 cells. CYP11B2 promoter activity was inhibited in cells co-transfected with constitutively active PKC alpha and epsilon mutants, whereas it was increased with the constitutively active PKC zeta mutant. Dominant negative PKC alpha, epsilon and zeta mutants stimulated the promoter activity. Gö6976, a specific inhibitor of classical PKCs, enhanced promoter activity, providing further evidence that PKC alpha, the only classical PKC revealed in hamster adrenal and NCI-H295 cells, was involved in the promoter inhibition.

Chronic PMA treatment of Jurkat T lymphocytes results in decreased protein tyrosine phosphorylation and inhibition of CD3- but not Ti-dependent antibody-triggered Ca2+ signaling

We have treated Jurkat T lymphocytes with a concentration (160 nM) of phorbol myristyl acetate (PMA) that down-regulates conventional and novel protein kinase C (PKC) isozymes and we have investigated the effects on Ca2+ signaling and protein tyrosine phosphorylation using mAb (C305) directed against the beta-subunit of the Ti heterodimer or the epsilon/delta-component of the CD3 complex (mAb Leu 4 or OKT 3). The levels of expression of PKC alpha, betaI, betaII, and delta were reduced by 90% or more in PMA-treated cells, whereas the expression of PKCtheta decreased by approximately 30%. In contrast, the chronic treatment with PMA increased the expression of PKCepsilon and PKCzeta. There was a lack of Ca2+ response and myo-inositol trisphosphate (IP3) production in PMA-treated cells when they were exposed to mAb Leu 4 but the cells responded to mAb C305. The treatment with PMA did not affect the surface expression of Ti or CD3. The overall levels of tyrosine-phosphorylated proteins were markedly reduced in PMA-treated cells. We investigated whether these observations were related to defects in signal transduction related to protein tyrosine kinase (PTK) of the src and syk families. The electrophoretic mobilities of p59(fyn) or ZAP-70 were not changed in PMA-treated cells but p56(Ick) migrated as a large band of M(r) 60-62 kDa. The decreased mobility of p56(Ick) was related to a state of hyperphosphorylation. The activity of modified p56(Ick) was not up-regulated in activated Jurkat cells. Our data suggest that clonotypic Ti can trigger Ca2+ mobilization independently of conventional PKC isoforms. Our observations further suggest that conventional PKC isoforms are involved early in the cascade of events associated with Jurkat T lymphocyte activation.

Non-fearful panic disorder: a variant of panic in medical patients?

Is it possible to have panic attacks without fear? Beitman et al. reported that 32%-41% of panic disorder (PD) patients seeking treatment for chest pain have non-fearful panic disorder (NFPD). To replicate and extend this work on NFPD, the authors compared NFPD patients (N = 48), PD patients (N = 60), and No-PD patients (N = 333) at the time of an emergency department visit and follow-up approximately 2 years later. The authors compared comorbid Axis I diagnoses, panic attack symptoms, and scores on self-report measures. A significantly greater proportion of PD patients had comorbid generalized anxiety disorder and agoraphobia than NFPD patients. NFPD patients had self-report scores that were between no-PD and PD patients or similar to no-PD patients, with the exception of the Beck Depression Inventory. At follow-up, NFPD patients, like PD patients, were still symptomatic and had either not improved or had worsened according to scores on all self-report measures. NFPD should be recognized as a variant of PD, both because of its high prevalence in medical settings and its poor prognosis.

Clinimetric scale to measure surgeons' satisfaction with anesthesia services

PURPOSE

Continuous quality improvement is of increasing interest to anesthesiologists. Since surgeons are coworkers and important clients of anesthesiologists, the level of satisfaction of surgeons with anesthesia services should be explored to optimize quality. The purpose of this study was, first, to introduce the concept of surgeons as clients of anesthesiologists and second, to develop and test an instrument to measure surgeons' satisfaction, the Surgeon Satisfaction with Anesthesia Services (SSAS) scale.

METHODS

A conceptual model of surgeon satisfaction with anesthesia services was created before the development of the SSAS scale. The scale, composed of socio-demographic, Likert-type and open-ended questions was sent to a sample of 250 surgeons selected randomly by the Collège des Médecins du Québec. Exploratory factorial analysis were performed on the results.

RESULTS

A Cronbach's alpha of 0.84 was obtained for internal consistency. Exploratory factorial analysis yielded two subscale factors: a) clinical expertise and b) attitudes and behaviour Global mean of surgeons'satisfaction was moderately high (3.11/4.0). Satisfaction was not related to sociodemographic variables. Very high scores were obtained for items related to clinical expertise. Items related to attitudes and behaviour obtained lower scores. A significant difference was obtained between both factors (t = -5.732, P = 0.0001).

CONCLUSION

The SSAS scale is a new instrument to evaluate surgeon satisfaction. Overall, surgeons seem satisfied with anesthesia services, but many areas of dissatisfaction persist. Further discussions with surgeons should be encouraged, in view of improving the perceptions of the quality of anesthesia services and interprofessional relationships.

Long term vascular complications of Coxiella burnetii infection in Switzerland: cohort study

OBJECTIVE

To evaluate the range of long term vascular manifestations of Coxiella burnetii infection.

DESIGN

Cohort study in Switzerland of people affected in 1983 by the largest reported outbreak of Q fever and who were followed up 12 years later. Follow up information about possible vascular disease and endocarditis was obtained through a mailed questionnaire and death certificates.

SETTING

Val de Bagnes, a rural Alpine valley in Switzerland.

PARTICIPANTS

2044 (87%) of 2355 people who had serum testing for Coxiella burnetii infection in 1983: 1247 were classed as not having been infected, 411 were classed as having been acutely infected, and 386 were classed as having been infected before 1983.

MAIN OUTCOME MEASURES

Relative risk controlled for age and sex and 12 year risk of vascular diseases and endocarditis among infected participants as compared with those who had never been infected.

RESULTS

The 12 year risk of endocarditis or venous thromboembolic disease was not increased among those who had been acutely infected. The 12 year risk of arterial disease was significantly higher among those who had been acutely infected (7%) as compared with those who had never been infected (4%) (relative risk 2.2, 95% confidence interval 1.4 to 3.6). Specifically, there was an increased risk of developing a cerebrovascular accident (relative risk 3.7, 1.6 to 8.4) and cardiac ischaemia (relative risk 1.9, 1.04 to 3.4). 12 year mortality was significantly higher among the 411 people who had been acutely infected in 1983 (9.7%; age adjusted relative risk 1.8, 1.2 to 2.6) when compared with the 1247 participants who had remained serologically negative in 1983 (7.0%).

CONCLUSIONS

Coxiella burnetii infection may cause long term complications including vascular disease.

Psychological distress and adaptational problems associated with discontinuation of benzodiazepines

This study compared subjects who had received standard tapered withdrawal of benzodiazepine (BZD) (group 1) with a group with comparable diagnosis still receiving BZD (group 2) and a control group of comparable diagnosis not yet receiving treatment (group 3). Sixty subjects aged 21-65 years with a diagnosis of nonpsychotic anxiety or insomnia were included. The assessment of psychological distress and quality of life was timed to coincide with the maximum immediate effect of BZD discontinuation, as calculated according to drug half-life. Subjects diagnosed with insomnia reported lower distress in all three groups. The pattern of distress experienced by group 1 was closer to group 3 than to group 2, indicating the potential importance of re-emergence of anxiety. High neuroticism, lower education level, and lower quality of life were associated with higher levels of distress during withdrawal.

Age-related impairment of p56lck and ZAP-70 activities in human T lymphocytes activated through the TcR/CD3 complex

Cellular immune responses decrease with aging. Lymphocytes of aged individuals do not perform as well as cells from young subjects in a number of in vitro assays including cell proliferation, cytokine production, and protection against apoptosis. Here, we have tested the hypothesis that a decrease in T cell responses in tymphocytes from elderly subjects could parallel a decrease in the activity of protein tyrosine kinases (PTK) associated with signal transduction in T lymphocytes. We report that anti-CD3-triggered T lymphocyte proliferation was significantly decreased in T lymphocytes from elderly subjects, but the decrease was not due to an alteration of the percentage or mean fluorescence intensities of CD3, CD4, and CD45. Of significance, the activities of p56lck and ZAP-70 in vitro were significantly decreased in T lymphocytes from elderly subjects compared to young individuals. However, the level of expression of the two kinases did not change with aging. The activity of p59fyn did not show changes with aging, suggesting that p59fyn did not compensate for the decreased activity of p56lck. We also found that the extent of tyrosine phosphorylation of the adaptor protein p95vav was similar in activated T lymphocytes from elderly and young subjects. Our results suggest that the altered cellular immune responses observed in T lymphocytes with aging may be the result, at least in part, of an alteration in early events associated with signal transduction through the TcR/CD3 complex that translates into decreased activities of p56lck and ZAP-70. Impairment in the activities of these twokey components of T cell signaling may contribute to reduced immune functions associated with aging.

Comparing emergency department and psychiatric setting patients with panic disorder

In a recent study, the authors reported that 25% (108/441) of consecutive emergency department (ED) chest pain patients had panic disorder (PD). As part of this study, the authors sought to answer the question: How do ED patients with PD compare with patients with PD who seek treatment in a psychiatric setting? PD patients from an ED (n = 108) and psychiatric clinic (n = 137) were compared with respect to comorbid Axis I diagnoses, self-report scores, and recent suicidal ideation. The group of psychiatric patients was younger (36.5 vs. 52.3 years) (P < 0.0001) and consisted of proportionally more women (63% vs. 39%) (P = 0.0001) than the ED patients. The psychiatric patients had significantly higher rates of comorbid agoraphobia (100% vs. 15%) (P < 0.0001), social phobia (23% vs. 3%) (P = 0.0001), specific phobia (12.3% vs. 4.6%) (P = 0.03), and posttraumatic stress disorder (16.9% vs. 5.6%) (P = 0.006), compared with the ED patients, and displayed significantly higher scores on all of the self-report panic measures. However, the patients in both groups had similar rates of comorbid generalized anxiety disorder (41.2% vs. 33.3%) (P = 0.17), major depression (8.8% vs. 11.1%) (P = 0.54), and obsessive-compulsive disorder (1.5% vs. 2.8%) (P = 0.7). Both groups also did not differ on the Beck Depression Inventory and in their rate of report of recent suicidal ideation (32% vs. 25%) (P = 0.23). Both psychiatric and ED patients with PD appear to be highly distressed patients who require treatment. Early intervention for ED patients may prevent both chronic patient distress and development of the significant phobic avoidance observed in psychiatric patients.

Clinical features in panic disorder with agoraphobia: a comparison of men and women

This study compared 96 women and 58 men suffering from panic disorder with agoraphobia. Participants completed questionnaires assessing various clinical features associated with panic disorder with agoraphobia (PDA), general adjustment, and drug/alcohol use. Results showed that PDA is a more severe condition in women. Women reported more severe agoraphobic avoidance when facing situations or places alone, more catastrophic thoughts, more body sensations, and higher scores on the Fear Survey Schedule. Also, women more often had a comorbid social phobia or posttraumatic stress disorder. The lower agoraphobic avoidance of men was associated with their alcohol use. However, there were no differences between genders in other dimensions, including depression, situational and trait anxiety, stressful life events, social self-esteem, marital adjustment, and drug use.

Detecting panic disorder in emergency department chest pain patients: a validated model to improve recognition

OBJECTIVE

To develop and validate a detection model to improve the probability of recognizing panic disorder in patients consulting the emergency department for chest pain.

METHODS

Through logistic regression analysis, demographic, self-report psychological, and pain variables were explored as factors predictive of the presence of panic disorder in 180 consecutive patients consulting an emergency department with a chief complaint of chest pain. The detection model was then prospectively validated on a sample of 212 patients recruited following the same procedure.

RESULTS

Panic-agoraphobia (Agoraphobia Cognitions Questionnaire, Mobility Inventory for Agoraphobia), chest pain quality (Short Form McGill Pain Questionnaire), pain loci, and gender variables were the best predictors of the presence of panic disorder. These variables correctly classified 84% of chest pain subjects in panic and non-panic disorder categories. Model properties: sensitivity 59%; specificity 93%; positive predictive power 75%; negative predictive power 87% at a panic disorder sample prevalence of 26%. The model correctly classified 73% of subjects in the validation phase.

CONCLUSION

The scales in this model take approximately ten minutes to complete and score. It may improve upon current physician recognition of panic disorder in patients consulting for chest pain.

VCAM-1 is internalized by a clathrin-related pathway in human endothelial cells but its alpha 4 beta 1 integrin counter-receptor remains associated with the plasma membrane in human T lymphocytes

Lymphocyte extravasation involves a step(s) of de-adhesion to allow trans- and subendothelial migration in response to inflammatory signals. We show here that ligated VCAM-1 was rapidly internalized (t1/2 14.5 min) in ECV 304 endothelial cells and in TNF-alpha-primed human umbilical vein-derived endothelial cells (t1/2 11.2 min). The process required energy (ATP), intracellular Ca2+, an intact cytoskeletal network and active protein kinases. The internalization of VCAM-1 involved a clathrin-dependent pathway based on the observations that 1) it was inhibited in cells treated with lysosomotropic agents or with a hypertonic concentration of sucrose, and 2) internalized VCAM-1 colocalized with clathrin. In contrast, the cross-linked alpha 4 beta 1 integrin counter-receptor of VCAM-1 remained associated with the plasma membrane of purified peripheral T and Jurkat cells. Our results suggest a model where VCAM-1 would initially participate in the retention of T cells to the endothelium by binding alpha 4 beta 1 integrin. Lymphocyte de-adhesion would be facilitated as a result of the internalization of VCAM-1. The persistent cell surface expression of alpha 4 beta 1 integrin would allow the migrating T cells to interact with and receive signal(s) from its fibronectin ligand of the extracellular matrix.

The sensitivity of the human Kv1.3 (hKv1.3) lymphocyte K+ channel to regulation by PKA and PKC is partially lost in HEK 293 host cells

cDNA encoding the full-length hKv1.3 lymphocyte channel and a C-terminal truncated (delta 459-523) form that lacks the putative PKA Ser468 phosphorylation site were stably transfected in human embryonic kidney (HEK) 293 cells. Immunostaining of the transfected cells revealed a distribution at the plasma membrane that was uniform in the case of the full-length channel whereas clustering was observed in the case of the truncated channel. Some straining within the cell cytoplasm was found in both instances, suggesting an active process of biosynthesis. Analyses of the K+ current by the patch-clamp technique in the whole cell configuration showed that depolarizing steps to 40 mV from a holding potential (HP) of -80 mV elicited an outward current of 2 to 10 nA. The current threshold was positive to -40 mV and the current amplitude increased in a voltage-dependent manner. The parameters of activation were -5.7 and -9.9 mV (slope factor) and -35 mV (half activation, V0.5) in the case of the full-length and truncated channels, respectively. The characteristics of the inactivation were 14.2 and 24.6 mV (slope factor) and -17.3 and -39.0 mV (V0.5) for the full-length and truncated channels, respectively. The activation time constant of the full-length channel for potentials ranging from -30 to 40 mV decreased from 18 to 12 msec whereas the inactivation time constant decreased from 6600 msec at -30 mV to 1800 msec at 40 mV. The unit current amplitude measured in cells bathing in 140 mM KCl was 1.3 +/- 0.1 pA at 40 mV, the unit conductance, 34.5 pS and the zero current voltage, 0 mV. Both forms of the channels were inhibited by TEA, 4-AP, Ni2+ and charybdotoxin. In contrast to the native (Jurkat) lymphocyte Kv1.3 channel that is fully inhibited by PKA and PKC, the addition of TPA resulted in 34.6 +/- 7.3% and 38.7 +/- 9.4% inhibition of the full-length and the truncated channels, respectively, 8-BrcAMP induced a 39.4 +/- 5.4% inhibition of the full-length channel but had no effect (8.6 +/- 8.3%) on the truncated channel. Cell dialysis with alkaline phosphatase had no effects, suggesting that the decreased sensitivity of the transfected channels to PKA and PKC was not due to an already phosphorylated channel. Patch extract experiments suggested that the hKv1.3 channel was partially sensitive to PKA and PKC. Cotransfecting the Kv beta 1.2 subunit resulted in a decrease in the value of the time constant of inactivation of the full-length channel but did not modify its sensitivity to PKA and PKC. The cotransfected Kv beta 2 subunit had no effects. Our results indicate that the hKv1.3 lymphocyte channel retains its electrophysiological characteristics when transfected in the Kv beta-negative HEK 293 cell line but its sensitivity to modulation by PKA and PKC is significantly reduced.

Panic disorder in coronary artery disease patients with noncardiac chest pain

In this study we address the following questions: (1) What percentage of coronary artery disease (CAD) patients that present with chest pain, but whose symptoms cannot be fully explained by their cardiac status, suffer from panic disorder (PD)? (2) How do patients with both CAD and PD compare to patients without CAD and to patients without either PD or CAD in terms of psychological distress? Four hundred forty-one consecutive walk-in emergency department patients with chest pain underwent a structured psychiatric interview (ADIS-R) and completed psychological scales. Fifty-seven percent (250 of 441) of these patients were diagnosed as having noncardiac chest pain and constituted this study's sample. A total of 30% (74 of 250) of noncardiac chest pain patients had a documented history of CAD. Thirty-four percent (25 of 74) of CAD patients met criteria for PD. Patients with both PD and CAD displayed significantly more psychological distress than CAD patients without PD and patients with neither CAD nor PD. However, they did not differ from non-CAD patients with PD. PD is highly prevalent in patients with CAD that are discharged with noncardiac diagnoses. The psychological distress in these patients appears to be related to the panic syndrome and not to the presence of the cardiac condition.

Signal transduction in Jurkat T lymphocytes. Evidence for early Ca2+ movements between the cytoplasm and the nucleoplasm in activated cells

Spatial analyses of the distribution of Ca2+ in resting and activated T and B lymphocytes have shown that the bulk of increased [Ca2+]i appears to be associated with the nuclear region. These observations suggest that Ca2+ is released from the perinuclear space or that it diffuses to the nucleoplasm, or both. We have used laser scanning confocal microscopy to assess whether cytoplasmic diffusion of Ca2+ could contribute to the rise in nuclear Ca2+. We found that the activation of individual Jurkat cells by use of an anti-Ti (beta-subunit) mAb induced a nucleus-associated increase in [Ca2+]i. In cells loaded with the InsP3 receptor antagonist heparin, the nuclear Ca2+ response was abolished but not the response to thapsigargin. Evidence for a cytoplasmic Ca2+ response was obtained by loading Jurkat cells with a cytoplasm-restricted Ca2+ probe (Calcium Green-1-Dextran). These observations suggested that a process of diffusion of cytoplasmic Ca2+ contributed to the rise of nuclear Ca2+ in Jurkat T cells. This interpretation was supported by the findings (1) that rapid scanning of thapsigargin-released Ca2+ showed an inverse relationship between the levels of cytoplasmic and nuclear Ca2+ and (2) that modulation of the external concentration of Ca2+ in thapsigargin-treated Jurkat cells showed a time-dependent decrease of fluorescence from the nucleoplasm that was reversed by raising the concentration of external Ca2+. We conclude that Ca2+ can rapidly diffuse between the cytoplasm and the nucleoplasm in activated Jurkat T lymphocytes and that hydrophilic Ca2+ probes largely partition to the nucleoplasm, thus giving rise to distorted nucleus-to-cytoplasm fluorescence ratios.

The MDR1 (P-glycoprotein) and MRP (P-190) transporters do not play a major role in the intrinsic multiple drug resistance of Jurkat T lymphocytes

The response of T cells in relation to the cell cycle has not been extensively studied. We have attempted to address this question using Jurkat T cells treated with cytostatic drugs known to arrest cells at various transition points of their cycle. We tested several concentrations of drugs that act at G1/S (hydroxyurea, lovastatin, thymidine), early S (aphidicolin, cyclosporin A, rapamycin) or G2+M (colchicine, nocodazole) in 24 h cultures. Cytofluorimetric analyses showed that cycling Jurkat cells were equally distributed between the G1 (44.9 +/- 6.5%) and S (42.3 +/- 8.0%) phases. Cell distribution in G2+M was 12.7 +/- 2.8%. Hydroxyurea but not lovastatin increased the percentage of cells in S phase to approximately 60-70% and both drugs decreased it to approximately 30% in G1. Thymidine had no effects. Aphidicolin increased the distribution in S phase to approximately 70% with a decrease in G1 to approximately 30%. Cyclosporin A and rapamycin increased the percentage of the cells in G1 to approximately 70% and decreased it to approximately 25% in S phase. Nocodazole increased cell distribution in G2+M to approximately 60% and induced a decrease in G1 to approximately 10%. The effects of the drugs were not related to their toxicity and their limited efficiency raised the possibility that Jurkat cells possessed an intrinsic resistance to these xenobiotics. Time-course analysis showed (scanning electron microscopy) that the early morphological changes induced by colchicine were reversible. Drug efflux experiments (vinblastine) suggested that an ATP-dependent process could be involved. However, Northern blot analyses showed a weak signal for MDR1 (P-glycoprotein). In contrast, a probe for MRP (P-190) showed a strong signal in Jurkat and peripheral lymphocytes. The presence of drugs (cyclosporin A, nocodazole, thymidine) (24 h) did not upregulate its message and cell treatment with DL-butathione (S,R)-sulfoximine only moderately affected the efficiency of the glutathione S-conjugate MRP transporter. Our data suggest that the intrinsic multidrug resistance of leukemic Jurkat T cells does not appear to involve the MDR1 and MRP members of the ABC family of reverse drug transporters and these observations raise the possibility of the involvement of multifaceted mechanisms.

The MRD1 (P-glycoprotein) and MRP (P-190) transporters do not play a major role in the intrinsic multiple drug resistance of Jurkat T lymphocytes

The response of T cells in relation to the cell cycle has not been extensively studied. We have attempted to address this question using Jurkat T cells treated with cytostatic drugs known to arrest cells at various transition points of their cycle. We tested various concentrations of drugs that act at G1/S (hydroxyurea, lovastatin, thymidine), early S [aphidicolin, cyclosporin A (CsA), rapamycin] or G2 + M (colchicine, nocodazole) in 24 h cultures. Cytofluorimetric analyses showed that cycling Jurkat cells were equally distributed between the G1 (44.9 +/- 6.5%) and S (42.3 +/- 8.0%) phases. Cell distribution in G2 + M was 12.7 +/- 2.8%. Hydroxyurea but not lovastatin increased the percentage of cells in S phase to ca 60-70% and both drugs decreased it to ca 30% in G1. Thymidine had no effects. Aphidicolin increased the distribution in S phase to ca 70% with a decrease in G1 to ca 30%. CsA and rapamycin increased the percentage of the cells in G1 to ca 70% and decreased it to ca 25% in S phase. Nocodazole increased cell distribution in G2 + M to ca 60% and induced a decrease in G1 to ca 10%. The effects of the drugs were not related to their toxicity and their limited efficiency raised the possibility that Jurkat cells possessed an intrinsic resistance to these xenobiotics. Time-course analysis showed (scanning electron microscopy) that the early morphological changes induced by colchicine were reversible. Drug efflux experiments (vinblastine) suggested that an ATP-dependent process could be involved. However, Northern blot analyses showed a weak signal for MDR1 (MDR, multiple drug resistance). In contrast, a probe for multidrug resistance-associated protein (P-190; MRP) showed a strong signal in Jurkat and peripheral lymphocytes. The presence of drugs (CsA, nocodazole, thymidine) (24 h) did not up-regulate its message and cell treatment with BSO only moderately affected the efficiency of the glutathione S-conjugate MRP transporter. Our data suggest that the intrinsic multidrug resistance of leukemic Jurkat T cells does not appear to involve the MDR1 and MRP members of the ABC family of reverse drug transporters and these observations raise the possibility of the involvement of multi-faceted mechanisms.

Suicidal ideation in emergency department chest pain patients: panic disorder a risk factor

Most patients who present to the emergency department (ED) for chest pain do not have a cardiac disorder. Approximately 30% of noncardiac chest pain patients suffer from panic disorder (PD), a disabling, treatable, yet rarely detected psychiatric condition. Although still controversial, PD may be a risk factor for suicidal ideation and attempts. The prevalence of recent suicidal ideation (ie, past week) was studied in 441 consecutive ED chest pain patients who underwent a structured psychiatric interview. To examine the controversial link between panic and suicidal behavior, logistic regression analyses were conducted in which current psychiatric diagnoses (Axis I) as well as pertinent medical and demographic information were assessed as risk factors for suicidal ideation. Participants were interviewed with the Anxiety Disorders Interview Schedule-Revised to establish psychiatric diagnoses. Recent suicidal ideation (ie, past week) was assessed with question 9 of the Beck Depression Inventory. Ten percent of patients had recent suicidal ideation. Sixty percent of patients with suicidal thoughts met criteria for PD. In the patients with PD, suicidal ideation could not be explained by the presence of comorbid psychiatric or medical conditions or medication. In the total sample, only diagnoses of PD (odds ratio [OR] = 4.3; 95%, confidence interval [CI], 2.09-8.82; P = .0001) and dysthymia (OR = 9.98; 95% CI, 4.00-24.8; P = .00001) were significant and independent risk factors for suicidal ideation. PD, the most common psychiatric condition in ED chest pain patients, may be an independent risk factor for suicidal ideation, further supporting the need for recognition and treatment of these patients.

Changes in apoptosis of human polymorphonuclear granulocytes with aging

Many alterations with aging occur at the cellular and organic levels in the immune system ultimately leading to a decrease in the immune response. Our aim in the present work was to study apoptosis of polymorphonuclear granulocytes (PMN) with aging under various stimulations since apoptosis might play an important role in several pathologies encountered with aging. The PMN of healthy young (20-25 years) and elderly (65-85 years) subjects were examined after 24 h of sterile culture with and without stimulation. The stimulating agents included: phorbol myristate acetate (PMA), hydrogen peroxide (H2O2), N-formyl-methionyl-leucyl phenylalanine (FMLP), granulocyte-macrophage colony stimulating factor (GM-CSF), reduced glutathione (GSH), lipopolysaccharide (LPS) and interleukin 2 (IL-2). Apoptosis was assessed by traditional staining of the plates, by flow cytometric staining and DNA gel electrophoresis. It was found that without stimulation the susceptibility of PMN to apoptosis was slightly increased with aging. Under various stimulations, such as PMA. H2O2, apoptosis was almost 100%, while the treatment by FMLP, oxLDL and GSH did not change its extent in PMN obtained either from young or elderly subjects. Marked age-related changes were observed in the extent of apoptosis under stimulation with GM-CSF, IL-2 and LPS. These agents were able to significantly prevent apoptosis in PMN of young subjects, while only the GM-CSF was able to slightly modulate it in neutrophils of elderly subjects. From these results, we suggest that changes in apoptosis of PMN with aging could play a role in the increased incidence of certain immune system related pathologies of aging, such as cancer, infections and autoimmune disorders.

Clustering the adhesion molecules VLA-4 (CD49d/CD29) in Jurkat T cells or VCAM-1 (CD106) in endothelial (ECV 304) cells activates the phosphoinositide pathway and triggers Ca2+ mobilization

Ligation of very late antigen (VLA)-4 (alpha 4 beta 1 integrin) with a cross-linked anti-alpha 4 subunit monoclonal antibody (mAb) triggered a biphasic Ca2+ response in Jurkat cell populations and in peripheral human lymphocytes. Cross-linking vascular cell adhesion molecule (VCAM)-1 (the counter-receptor of VLA-4) in ECV 304 endothelial cells generated a biphasic Ca2+ response. Tumor necrosis factor-alpha-primed human umbilical cord vascular endothelial cells also responded to the cross-linked mAb with a biphasic Ca2+ profile. Ligated VLA-4 (Jurkat cells) or VCAM-1 (ECV 304) stimulated the production of myo-inositol 1,4,5-trisphosphate. ECV 304 cells induced a biphasic Ca2+ response in Fura2-loaded Jurkat cells, whereas a transient response was observed when Jurkat cells were added to Fura2-loaded ECV 304 cells. The Ca2+ responses in these experiments involved VLA-4/VCAM-1 interactions since they were significantly reduced (approximately 80%) by prior treatment of the target cells with the relevant noncross-linked mAb. Close contact between the cells triggered mutual Ca2+ signaling as shown by spectrofluorimetric and confocal microscopy time-dependent recordings. Fibronectin and its CS-1 fragment (V25) triggered a sustained Ca2+ response in Jurkat cells (confocal microscopy). Our results suggest that the VLA-4 and VCAM-1 adhesion molecules can transduce a signal that involves activation of the phosphoinositide pathway and the mobilization of Ca2+.