Using in vitro data to derive acceptable exposure levels: A case study on PBDE developmental neurotoxicity

BACKGROUND

Current acceptable chemical exposure levels (e.g., tolerable daily intake) are mainly based on animal experiments, which are costly, time-consuming, considered non-ethical by many, and may poorly predict adverse outcomes in humans.

OBJECTIVE

To evaluate a method using human in vitro data and biological modeling to calculate an acceptable exposure level through a case study on 2,2',4,4'-tetrabromodiphenyl ether (BDE-47) developmental neurotoxicity (DNT).

METHODS

We reviewed the literature on in vitro assays studying BDE-47-induced DNT. Using the most sensitive endpoint, we derived a point of departure using a mass-balance in vitro disposition model and benchmark dose modeling for a 5% response (BMC05) in cells. We subsequently used a pharmacokinetic model of gestation and lactation to estimate administered equivalent doses leading to four different metrics of child brain concentration (i.e., average prenatal, average postnatal, average overall, and maximum concentration) equal to the point of departure. The administered equivalent doses were translated into tolerable daily intakes using uncertainty factors. Finally, we calculated biomonitoring equivalents for maternal serum and compared them to published epidemiological studies of DNT.

RESULTS

We calculated a BMC05 of 164 μg/kg of cells for BDE-47 induced alteration of differentiation in neural progenitor cells. We estimated administered equivalent doses of 0.925-3.767 μg/kg/day in mothers, and tolerable daily intakes of 0.009-0.038 μg/kg/day (composite uncertainty factor: 100). The lowest derived biomonitoring equivalent was 19.75 ng/g lipids, which was consistent with reported median (0.9-23 ng/g lipids) and geometric mean (7.02-26.9 ng/g lipids) maternal serum concentrations from epidemiological studies.

CONCLUSION

This case study supports using in vitro data and biological modeling as a viable alternative to animal testing to derive acceptable exposure levels.

Dynamic Mass Balance Modeling for Chemical Distribution Over Time in In Vitro Systems With Repeated Dosing

As toxicologists and risk assessors move away from animal testing and more toward using in vitro models and biological modeling, it is necessary to produce tools to quantify the chemical distribution within the in vitro environment prior to extrapolating in vitro concentrations to human equivalent doses. Although models predicting chemical distribution in vitro have been developed, very little has been done for repeated dosing scenarios, which are common in prolonged experiments where the medium needs to be refreshed. Failure to account for repeated dosing may lead to inaccurate estimations of exposure and introduce bias into subsequent in vitro to in vivo extrapolations. Our objectives were to develop a dynamic mass balance model for repeated dosing in in vitro systems; to evaluate model accuracy against experimental data; and to perform illustrative simulations to assess the impact of repeated doses on predicted cellular concentrations. A novel dynamic in vitro partitioning mass balance model (IV-MBM DP v1.0) was created based on the well-established fugacity approach. We parameterized and applied the dynamic mass balance model to single dose and repeat dosing scenarios, and evaluated the predicted medium and cellular concentrations against available empirical data. We also simulated repeated dosing scenarios for organic chemicals with a range of partitioning properties and compared the in vitro distributions over time. In single dose scenarios, for which only medium concentrations were available, simulated concentrations predicted measured concentrations with coefficients of determination (R2) of 0.85–0.89, mean absolute error within a factor of two and model bias of nearly one. Repeat dose scenario simulations displayed model bias <2 within the cell lysate, and ∼1.5-3 in the medium. The concordance between simulated and available experimental data supports the predictive capacity of the IV-MBM DP v1.0 tool, but further evaluation as empirical data becomes available is warranted, especially for cellular concentrations.

Multifunctional Thio-Stabilized Gold Nanoparticles for Near-Infrared Fluorescence Detection and Imaging of Activated Caspase-3

Background

Gold nanoparticles (AuNPs) are commonly used in nanomedicine because of their unique spectral properties, chemical and biological stability, and ability to quench the fluorescence of organic dyes attached to their surfaces. However, the utility of spherical AuNPs for activatable fluorescence sensing of molecular processes have been confined to resonance-matched fluorophores in the 500 nm to 600 nm spectral range to maximize dye fluorescence quenching efficiency. Expanding the repertoire of fluorophore systems into the NIR fluorescence regimen with emission >800 nm will facilitate the analysis of multiple biological events with high detection sensitivity.

Objective

The primary goal of this study is to determine if spherical AuNP-induced radiative rate suppression of non-resonant near-infrared (NIR) fluorescent probes can serve as a versatile nanoconstruct for highly sensitive detection and imaging of activated caspase-3 in aqueous media and cancer cells. This required the development of activatable NIR fluorescence sensors of caspase-3 designed to overcome the nonspecific degradation and release of the surface coatings in aqueous media.

Method

We harnessed the fluorescence-quenching properties and multivalency of spherical AuNPs to develop AuNP-templated activatable NIR fluorescent probes to detect activated caspase-3, an intracellular reporter of early cell death. Freshly AuNPs were coated with a multifunctional NIR fluorescent dye-labeled peptide (LS422) consisting of an RGD peptide sequence that targets α_vβ₃-integrin protein (α_vβ₃) on the surface of cancer cells to mediate the uptake and internalization of the sensors in tumor cells; a DEVD peptide sequence for reporting the induction of cell death through caspase-3 mediated NIR fluorescence enhancement; and a multidentate hexacysteine sequence for enhancing self-assembly and stabilizing the multifunctional construct on AuNPs. The integrin binding affinity of LS422 and caspase-3 kinetics were determined by a radioligand competitive binding and fluorogenic peptide assays, respectively. Detection of intracellular caspase-3, cell viability, and the internalization of LS422 in cancer cells were determined by confocal NIR fluorescence spectroscopy and microscopy.

Results

Narrow size AuNPs (13 nm) were prepared and characterized by transmission electron microscopy and dynamic light scattering. When assembled on the AuNPs, the binding constant of LS422 for α_vβ₃ improved 11-fold from 13.2 nM to 1.2 nM. Whereas the catalytic turnover of caspase-3 by LS422-AuNPs was similar to the reference fluorogenic peptide, the binding affinity for the enzyme increased by a factor of 2. Unlike the α_vβ₃ positive, but caspase-3 negative breast cancer MCF-7 cells, treatment of the α_vβ₃ and caspase-3 positive lung cancer A549 cells with Paclitaxel showed significant fluorescence enhancement within 30 minutes, which correlated with caspase-3 specific activation of LS422-AuNPs fluorescence. Incorporation of a 3.5 mW NIR laser source into our spectrofluorometer increased the detection sensitivity by an order of magnitude (limit of detection ~0.1 nM of cypate) and significantly decreased the signal noise relative to a xenon lamp. This gain in sensitivity enabled the detection of substrate hydrolysis at a broad range of inhibitor concentrations without photobleaching the cypate dye.

Conclusion

The multifunctional AuNPs demonstrate the use of a non-resonant quenching strategy to design activatable NIR fluorescence molecular probes. The nanoconstruct offers a selective reporting method for detecting activated caspase-3, imaging of cell viability, identifying dying cells, and visualizing the functional status of intracellular enzymes. Performing these tasks with NIR fluorescent probes creates an opportunity to translate the in vitro and cellular analysis of enzymes into in vivo interrogation of their functional status using deep tissue penetrating NIR fluorescence analytical methods.

Grey matter structural differences in alcohol-dependent individuals with and without comorbid depression/anxiety-an MRI study

Although depression and anxiety disorders are common comorbid conditions in alcohol dependence, few structural brain imaging studies have compared alcohol-dependent subjects with and without such comorbidity. In the current study, brain scans of 35 alcohol-dependent with and 40 individuals without diagnosis of a comorbid ICD-10 depressive or anxiety disorder receiving detoxification inpatient treatment were evaluated. Thickness and volumes of automatically segmented neuroanatomical structures were measured in FreeSurfer. Furthermore, associations of brain structure with biological markers and clinical severity markers of alcohol dependence were assessed. Despite comparable addiction severity, the non-comorbid group had evidence of higher cytotoxic effects of alcohol use on hepatic and haematological markers, and showed significantly smaller volumes of total cerebral, and cerebellar grey matter. Similarly, they showed unexpected smaller hippocampal and nucleus accumbens volumes, and thinner frontal, temporal and occipital cortices. Smaller brain volumes correlated with increased markers of hepatic and haematological dysfunction, and with longer duration of alcohol dependence in the non-comorbid group. Evidence of higher biomarkers of alcohol use may be indicative of more severe alcohol dependence or higher vulnerability to ethanol toxicity in this group. Furthermore, psychopathology-related drug treatment, which occurred in 53% of the comorbid group over the recent years, or tissue inflammation may have a moderate effect on the grade of cerebral atrophy in alcohol-dependent patients. Longitudinal studies are needed to investigate this issue more fully.

Immune response profiling of primary monocytes and oral keratinocytes to different Tannerella forsythia strains and their cell surface mutants

The oral pathogen Tannerella forsythia possesses a unique surface (S-) layer with a complex O-glycan containing a bacterial sialic acid mimic in the form of either pseudaminic acid or legionaminic acid at its terminal position. We hypothesize that different T. forsythia strains employ these stereoisomeric sugar acids for interacting with the immune system and resident host tissues in the periodontium. Here, we show how T. forsythia strains ATCC 43037 and UB4 displaying pseudaminic acid and legionaminic acid, respectively, and selected cell surface mutants of these strains modulate the immune response in monocytes and human oral keratinocytes (HOK) using a multiplex immunoassay. When challenged with T. forsythia, monocytes secrete proinflammatory cytokines, chemokines and vascular endothelial growth factor (VEGF) with the release of interleukin-1β (IL-1β) and IL-7 being differentially regulated by the two T. forsythia wild-type strains. Truncation of the bacteria's O-glycan leads to significant reduction of IL-1β and regulates macrophage inflammatory protein-1. HOK infected with T. forsythia produce IL-1Ra, chemokines and VEGF. Although the two wild-type strains elicit preferential immune responses for IL-8, both truncation of the O-glycan and deletion of the S-layer result in significantly increased release of IL-8, granulocyte-macrophage colony-stimulating factor and monocyte chemoattractant protein-1. Through immunofluorescence and confocal laser scanning microscopy of infected HOK we additionally show that T. forsythia is highly invasive and tends to localize to the perinuclear region. This indicates, that the T. forsythia S-layer and attached sugars, particularly pseudaminic acid in ATCC 43037, contribute to dampening the response of epithelial tissues to initial infection and hence play a pivotal role in orchestrating the bacterium's virulence.

Angiotensin and neurovascular coupling: beyond hypertension

Brain homeostasis is dependent upon the constant perfusion of oxygen and nutrients through CBF. The mechanism responsible to couple CBF to neuronal activity is termed NVC. Ang II, a key player in hypertension, impairs NVC and has been found to be of significant importance in neurodegenerative diseases, such as AD. The presence of Ang II and its metabolites, as well as their receptors have been detected in many areas of the brain. Findings indicate that disruption of NVC by Ang II is mediated by its AT1R and NADPH oxidase (NOX)-dependent ROS production independently of its effect on blood pressure. Although the process causing ROS to interfere with NVC has yet to be elucidated, data label peroxynitrite as the leading ROS to do so. The same common pathway is involved in NVC impairment in AD experimental models. This review investigates recent data concerning the effects of Ang II on NVC with the intent of exploring new treatment perspectives for neurodegenerative diseases such as AD.

Group music therapy for severe mental illness: a randomized embedded-experimental mixed methods study

OBJECTIVE

Music therapy is an innovative approach to support people with severe mental illness (SMI). The aim of the study was to determine whether group music therapy (GMT) positively impacted on quality of life (QoL), social enrichment, self-esteem, spirituality and psychiatric symptoms of participants with SMI and how they experienced the intervention.

METHOD

The primary outcome was QoL; secondary measures assessed social enrichment, self-esteem, spirituality and psychiatric symptoms. The 13-week intervention comprised singing familiar songs and composing original songs recorded in a professional studio. Qualitative data were generated from focus group interviews and song lyric analysis.

RESULTS

Ninety-nine adults (57 female) were recruited, with an initial cohort (n = 75) randomized to either: weekly GMT followed by standard care (SC) or SC followed by GMT. Crossover occurred after 13 weeks. Measures were conducted at baseline, 13, 26 and 39 weeks. A second cohort (n = 24) could not be randomized and were assigned to GMT followed by SC. Intention-to-treat analysis showed a significant difference between GMT and SC on QoL and spirituality. This was robust to different assumptions about missing data (listwise deletion, last observation carried forward or multiple imputation). Per-protocol analysis suggested greater benefit for those receiving more sessions. Focus group interview and song lyric analyses suggested that GMT was enjoyable; self-esteem was enhanced; participants appreciated therapists and peers; and although challenges were experienced, the programme was recommended to others.

CONCLUSION

Group music therapy may enhance QoL and spirituality of persons with SMI.

Clinical consequences of aspirin and clopidogrel resistance: an overview

The aim of this review is to introduce the concept of personalized medicine in secondary stroke prevention with antiplatelet medication. In the last years, many studies have been conducted regarding aspirin resistance and genotyping of clopidogrel metabolism. A review of the currently published data on this issue emphasizes the importance of focusing on the individualizing approach in antiplatelet therapy to achieve maximal therapeutic beneficial effect. However, many authors suggest that, before new information from ongoing trials become available, good clinical practice should dictate the use of low dose of aspirin that was shown to be effective in the prevention of stroke and death in patients with ischemic cerebrovascular disease, because higher doses do not have significantly better efficacy than lower doses in secondary stroke prevention, but lower-dose aspirin is associated with less side effects. On the other hand, many factors are associated with clopidogrel resistance, and recent genetic studies showed that the CYP2C19*2 genotype (loss-of-function allele) is related to poor metabolism of clopidogrel, but larger studies are needed to definitively confirm or rule out the clinical significance of this genetic effect. The aim of personalized approach in secondary stroke prevention is to take the most appropriate medicine in the right dose in accordance with the clinical condition of the patient and associated risk factors.

Paradoxical reactions in non-HIV tuberculosis presenting as endobronchial obstruction

Paradoxical reaction (PR) in tuberculosis (TB) is common and may affect up to 25% of patients. PR has the potential to cause significant morbidity and, on occasion, death. Although PR has been recognised for some time, the pathophysiology, especially in HIV-negative patients, is not well understood. We present two cases of PR in HIV-negative patients with TB presenting as significant airway obstruction secondary to a florid endobronchial component. These cases demonstrate that PR should be considered in all patients presenting with airway symptoms who have started TB treatment. The outcomes of the cases illustrate the need for wider recognition of this condition and more research to characterise patients who may be at risk, in order to gain a greater understanding of the mechanisms involved and to make or predict this diagnosis earlier.

The ethical imperative to scale up health care services for people with severe mental disorders in low and middle income countries

Most mentally ill people in low and middle income countries, where clinical services are typically scarce and mental health legal provisions often inadequate, do not receive requisite evidence based treatment. The unfortunate consequence is compromised health and well-being and lack of social integration in the community. Recent initiatives, such as the Movement for Global Mental Health, aim to improve the situation and, in so doing, take into account ethical factors that play a role in the face of inadequate care and mental health legislative frameworks. Two composite case vignettes based on the narratives of actual patients living in India are used to show how family carers resort to measures like deception, coercion and physical restraint in order to deal with challenging behaviours stemming from severe and enduring mental disorders. These actions, while violating patients' fundamental human rights, are also the consequence of the utter frustration and despair experienced by families. Scaling up mental health care based on the principle of cost effectiveness is not only a clinical imperative, but also a pivotal means to ensure that the severely mentally ill are accorded the same universal rights as those enjoyed by others.

Psychosocial adaptation in female partners of men with prostate cancer

The objective was to explore the psychosocial adaptation of female partners living with men with a diagnosis of either localized or metastatic prostate cancer. Semi-structured qualitative interviews were conducted with 50 women at two time points (baseline and 6 months later). The interviews examined emotions, experiences, attitudes to sexual and continence issues and treatment decision making. As part of a larger prospective observational study, demographic data and scores for depression and anxiety were collected. Initial analysis demonstrated that the group of 11 women assessed as distressed on the anxiety and depression measures described reduced coping skills and poorer adaptation after 6 months. In contrast, the 39 women in the non-distressed group reported emotional adaptation that fitted the Lazarus and Folkman pattern of coping through appraisal of the impact of the diagnosis on their partner and themselves, appraisal of coping strategies and reappraisal of the situation. A surprise finding was the high level of resilience displayed by majority of these women. Results suggest that a psychosocial intervention could strengthen healthy adaptation and provide better coping skills for distressed couples.

Substance abuse among medical practitioners

This paper reviews the literature relating to the prevalence, causes and treatment of substance abuse and psychiatric illness among doctors. Possible aetiological and pathogenic factors influencing drug-dependent doctors are discussed and some problems which arise in the management of these doctors are raised. Local studies in relation to certain personality factors in medical students, to cause of death in a medical cohort, and preliminary impressions from a study of substance-abusing doctors are reported.

Peritoneal mucinous cystadenocarcinoma of probable urachal origin: a challenging diagnosis

This report describes the case of a mucinous cystadenocarcinoma of probable urachal origin that presented with mass effect, precipitating deep venous thrombosis and pulmonary embolism. The patient presented with acute symptoms of leg swelling, pain and dyspnoea, and a vague awareness of lower abdominal distension. Computer tomography showed a cystic mass closely related to the anterior abdominal wall and the superior aspect of the bladder. A 1500 cm(3) cyst adherent to the dome of the urinary bladder was resected on laparotomy. Partial cystectomy was not carried out in the belief that the cyst represented a benign lesion. Subsequent imaging has shown cystic changes in the anterior bladder wall, and the patient has been referred for partial cystectomy.

The Impact Factor: time for change

OBJECTIVE

The Impact Factor (IF) has received virtually no attention in the psychiat ric literature, despite its long-term use, expanding influence and evidence of misapplication. We examine the IF's validity as a measure of a paper's scientific worth, and consider alternative ways to conduct such an appraisal.

METHOD

We explored medical databases and websites, and conferred with acknowledged experts on the subject.

RESULTS

Irremediable problems, both conceptual and technical, make the IF a flawed measure. The notion that citations vouch for the quality of an article is questionable. Moreover, the IF's vulnerability to misuse in domains such as academic promotion and research grant assessment is a serious development.

CONCLUSION

The IF (and all measures derived from it) should be abandoned. A "return to basics" in evaluating published work is overdue. As seductive as a simple formula is to assess quality, shortcuts are unavailable and unlikely to be useful. Publishing a short-list of papers annually, judged as objectively as possible by peers to merit special attention, may be a more meaningful option. Conceivably, every psychiatric journal could participate in this cyclical exercise, leading to a "grand short-list". This could be made readily available to all professionals, both researchers and clinicians, by being posted on a suitable website. Since peer review has a long-standing role in scientific publishing, our proposal is essentially an extension of that process.

Working in a flawed mental health care system: an ethical challenge

OBJECTIVE

Psychiatrists are under immense ethical pressure when practicing in circumstances that reasonable, informed colleagues would regard as not "good enough" in that they do not adequately meet the needs of patients and patients' families. This article is an examination of the ethical quandaries that ensue and options for response.

METHOD

The authors explore the ways in which mental health systems may become flawed and compare philosophical arguments that deal with the predicament of working in such systems.

RESULTS

The principle of fidelity to the patient is compromised in flawed systems, thus threatening professional integrity. Arguments for efficiency or the greater good in the provision of mental health care fail as remedies since they both lead to harms for particular clinical groups, as well as downgrading of a psychiatrist's integrity.

CONCLUSIONS

Psychiatrists should submit to the principle of fidelity in working with patients. Since flawed systems undermine fidelity, threatening the patient's interests, psychiatrists are morally responsible for working to improve such systems.

Publishing ethics in psychiatry

OBJECTIVE

The ethics of publishing in psychiatry has gained only limited attention. We examine, in a historical context, pertinent ethical problems and offer a series of recommendations for dealing with them.

METHOD

The study was conducted by exploration of medical databases and websites, and systematic discussion with ethicists, legal experts, publishers and researchers.

RESULTS

Serious 'publishing misconduct' appears to have been rare in the psychiatric literature, but any occurrence of redundant publication, plagiarism and publication of fraudulent or inhumane research is disturbing and should be prevented. Difficulties around authorship, sensitive use of language, conflict of interest and bias in the publishing process are additional issues claiming our attention.

CONCLUSIONS

A clearly articulated publishing ethos is desirable. Potential strategies to achieve this include devising guidelines on publishing ethics, teaching the subject to new writers, journals committing themselves to the ethical dimension of their operations, and penalising colleagues who violate agreed principles of good conduct.

Influence of protein composition on total urinary protein determined by pyrocatechol-violet (UPRO vitros) and pyrogallol red dye binding methods

Influence of protein composition on total urinary protein assays was evaluated for pyrogallol red-molybdate both with and without sodium dodecyl sulfate (SDS) and pyrocatechol violet-molybdate complex (UPRO) techniques. Using mixtures of albumin and gamma-globulins (n = 8; albumin/globulin ratio, 0 to 10), mean recoveries were 79, 77, and 81% for pyrogallol red, pyrogallol red-SDS, and UPRO, respectively. Using diluted myeloma sera (n = 26; A/G ratio, 0.39 to 2.35), mean recovery by the UPRO method was 115% (vs. 63% for pyrogallol red and 83% pyrogallol red-SDS). Results positively correlated with A/G ratio for UPRO (r = 0.69; P < 0.001), pyrogallol red (r = 0.48; P < 0.05), but not pyrogallol red-SDS (r = 0.191; NS). The difference between UPRO and pyrogallol red assays correlated with the A/G ratio (r = 0.82; P < 0.001). In light chain proteinuria (n = 10), no significant difference (< 15%) was observed between techniques, whereas in glomerular selective proteinuria (n = 10), values were significantly higher with the UPRO assay (2.20 +/- 1.61 vs. 1.43 +/- 1.10 g/L; P < 0.02). Our results support the idea that screening for renal diseases can be performed with UPRO or pyrogallol red assays. However, since A/G ratios may vary with renal disease evolution, follow-up of patients with positive proteinuria should be performed using the same assay, preferably the pyrogallol red-SDS.

Psychotherapies in psycho-oncology. An exciting new challenge

BACKGROUND

There is ample scope to devise forms of psychotherapy in consultation-liaison psychiatry, including the newly evolving area of psycho-oncology.

AIMS

To highlight the development of psychotherapy in psycho-oncology, providing two illustrations.

METHOD

We report on conceptual and clinical research in the context of oncology and palliative care, focusing on (a) an approach for families at risk of maladaptive bereavement; and (b) a group programme for women newly diagnosed with early-stage breast cancer.

RESULTS

We were able to introduce new forms of psychological treatment for specific clinical groups, and anecdotal evidence points to useful benefits for participants.

CONCLUSIONS

Psychotherapists should grasp the opportunity to bring their skills to the medical arena, but need to subject newly devised interventions to well-designed and methodologically rigorous research.

Cancer education among primary care physicians in an underserved community

INTRODUCTION

Urban minority groups, such as those living in north Manhattan, are generally underserved with regard to cancer prevention and screening practices. Primary care physicians are in a critical position to counsel their patients on these subjects and to order screening tests for their patients.

METHODS

Eighty-four primary care physicians in two intervention communities who received educational visits about cancer screening and prevention were compared with 38 physicians in a nearby community who received no intervention. With pre- and post-test interviews over an 18-month period, the physicians were asked about their attitudes toward, knowledge of (relative to American Cancer Society guidelines), and likelihood of counseling and screening for breast, cervical, colorectal, and prostate cancers.

RESULTS

Comparison of the two surveys of physicians indicated no statistically significant differences in knowledge of cancer prevention or screening. At post-test, however, intervention group physicians identified significantly fewer barriers to practice than control physicians (p<0.05). While overall, the educational visits to inner-city primary care physicians did not appear to significantly alter cancer prevention practices, there was a positive dose-response relationship among the subgroup of participants who received three or more project contacts.

CONCLUSIONS

We uncovered significant changes in attitude due to academic detailing among urban primary care physicians practicing in north Manhattan. A significant pre-test sensitization effect and small numbers may have masked overall changes in cancer prevention and screening behaviors among physicians due to the intervention.

Cancer screening and prevention practices of inner-city physicians

INTRODUCTION

Effective preventive services are needed most in underserved, inner-city settings that suffer disproportionately from morbidity and mortality. Primary care physicians can play an important role in the provision of efficacious cancer prevention and screening services to patients in these communities.

METHOD

We surveyed 122 primary care physicians about their cancer prevention and screening knowledge, attitudes, and practices.

RESULTS

Relative to the findings from national and local surveys, sample physicians were not as knowledgeable about national guidelines for preventive care, were less likely to counsel on smoking cessation, and were less likely to advise diet modification. Although physician practices reflected national cancer prevention and screening guidelines in general, a significant proportion of physicians suggested lung and prostate cancer screening tests that were inconsistent with national recommendations.

CONCLUSIONS

Systematic efforts are needed to increase the knowledge and practices of inner-city physicians concerning cancer prevention and screening.

Health and well-being of women family carers: a comparative study with a generic focus

OBJECTIVE

To examine differences between women family carers of people with chronic illnesses or disabilities and a group of women 'non-carers' in self-reported physical health, psychological well-being, life satisfaction, social support and feelings of overload.

METHOD

Using a computer-assisted telephone interviewing system, a random survey of more than 26,000 households was conducted in Victoria to identify and then interview a representative sample of family carers of people with disabilities or chronic illnesses. The women in the sample (n = 857) were then compared with a sample of women with 'usual family responsibilities' (n = 219) in terms of physical and emotional states.

RESULTS

We found higher rates of self-reported ill-health and use of medication, more negative effect, and less life satisfaction and perceived social support, among carers than among women in the comparison group. Even though the latter were more likely to be caring for one or more children, compared with the carers they reported less overload. Irrespective of carers status, women without partners expressed less life satisfaction, and more social isolation and negative effect.

CONCLUSIONS AND IMPLICATIONS

The poorer health status and emotional well-being of carers compared with non-carers among women, and associations between overload, social isolation, negative effect and health problems within carers, point to a number of practical interventions such as promoting an awareness in GPs and other health professionals of the impact of caregiving on the health of their patients; informing them about relevant community services; and encouraging appropriate referrals.

Effect of high-intensity focused ultrasound on whole blood with and without microbubble contrast agent

Using human whole blood samples with and without contrast agent (CA), we evaluated the effect of exposures to focused, continuous wave (CW) 1.1-MHz ultrasound for durations of 10 ms to 1 s at spatial average intensities of 560 to 2360 W/cm2. Cavitation was monitored with a passive cavitation detector and hemolysis was determined with spectroscopy. In whole blood alone, no significant cavitation, heating or hemolysis was detected at any exposure condition. Conversely, cavitation and hemolysis, but not heating, were detected in whole blood with CA. A CA concentration as low as 0.28 microL CA per mL whole blood at an intensity of 2360 W/cm2 for 1 s resulted in measurable cavitation and a 6-fold increase in hemolysis compared to shams. Cavitation and hemolysis increased proportional to the concentration of CA and duration of exposure. In samples containing 4.2 microL CA per mL whole blood exposed for 1 s, a threshold was seen at 1750 W/cm2 where cavitation and hemolysis increased 10-fold compared to exposures at lower intensities. HIFU exposure of whole blood containing CA leads to significant hemolysis in vitro and may lead to clinically significant hemolysis in vivo.

[Apolipoprotein B and LDL cholesterol: which parameter(s) should be included in the assessment of cardiovascular risk?]

High level of plasma apo B lipoproteins is a risk factor for coronary artery disease. However, which lipid parameters should be routinely assayed is a question still in debate. For this purpose, the authors have studied issues since 1992 comparing predictive and discriminative values of LDL-cholesterol and apo B in order to assess coronary artery disease. Indeed the respective advantages of these markers were still being discussed after an exhaustive review had been completed in 1992. Despite the number of the debates, none of the few studies about this topic rise any decisive arguments. In conclusion it is proposed that a true comparison of the predictive values of LDL-cholesterol and apo B should be carried out before making definitive recommendations concerning their clinical utility.

Psychological morbidity and quality of life in Australian women with early-stage breast cancer: a cross-sectional survey

OBJECTIVE

To determine the prevalence of psychological morbidity and describe quality of life in women with early-stage breast cancer.

DESIGN

Cross-sectional descriptive study (3 months after conservative breast surgery or mastectomy) of patients from nine general hospitals in Melbourne, Victoria, October 1994 to March 1997.

PARTICIPANTS

303 women with early-stage breast cancer entering a randomised trial of adjuvant psychological group therapy; mean age, 46 years (SD, 8).

MAIN OUTCOME MEASURES

Diagnostic and Statistical Manual of Mental Health (DSM)-IV psychiatric diagnoses generated by the Monash Interview for Liaison Psychiatry; quality-of-life data based on the the European Organization for Research and Treatment of Cancer quality-of-life questionnaire (QLQ)-C30 (core) and QLQ-BR23 (breast module) instruments.

RESULTS

45% of the women (135/303) had a psychiatric disorder; 42% (127) of the sample had depression or anxiety, or both; there was minor depression in 82 (27.1%), an anxiety disorder in 26 (8.6%), major depression in 29 (9.6%) and a phobic disorder in 21 (6.9%). 20% of women (61) had more than one disorder. On quality-of-life measures nearly one-third of the women felt less attractive and most had lost interest in sexual activity. There was substantial distress about hair loss. Symptoms of lymphoedema were described by 13 women (4.3%). Breast conservation surgery was associated with a better body image (P<0.01).

CONCLUSION

Women recently diagnosed with early-stage breast cancer have high rates of psychiatric and psychological disturbance. Quality of life is substantially affected. Clinicians should actively explore their patients' psychological adjustment to enable early recognition and treatment of these disorders.

Family grief therapy: a preliminary account of a new model to promote healthy family functioning during palliative care and bereavement

The family is usually the primary provider of care for the terminally ill patient with cancer or other serious progressive illness. The way in which such a family functions is a major determinant of psychological well-being for its members. Through screening with the Family Relationships Index (FRI) (Moos and Moos, 1981), dysfunctional families and those at risk can be identified, and then helped to achieve better family functioning, thus improving psychosocial outcome of their grief. In this paper, we describe the techniques and themes involved in the application of our empirically developed model of family grief therapy, designed as a preventive intervention for use in the setting of palliative care and bereavement.

The role of general practitioners and pharmacists in information exchange with family carers

As a trial of the provision of community-service information to family carers, general practitioners and pharmacists from the Western region of Melbourne were supplied with tear-off pads listing suburb-specific community services, and were encouraged to discuss service needs with carers of people with disabilities and distribute the lists to carers accordingly. One hundred and nine general practitioners and 58 pharmacists participated in pretrial and post-trial interviews assessing their knowledge of community services and frequency of discussion with carers. Before the trial, general practitioners had significantly higher self-rated knowledge of community services and reportedly discussed these with carers more often than did pharmacists. After the five-month trial period, pharmacists showed a significant increase in self-rated knowledge and frequency of discussion. General practitioners' knowledge and discussion showed a nonsignificant increase. After the trial, the two did not differ in knowledge of services; however, general practitioners maintained a higher reported frequency of discussion about services with carers. General practitioners and pharmacists appear to be well placed to act as a service link for family carers. However, additional high-intensity strategies are needed to assist them in this role.

The bereavement phenomenology questionnaire: a single factor only

OBJECTIVE

To review the psychometric properties and factor structure of the Bereavement Phenomenology Questionnaire (BPQ).

METHOD

Continuous data were compared using two tailed t-tests and analysis of variance. A confirmatory factor analysis was carried out.

RESULTS

Good internal consistency (Cronbach's alpha = 0.93) with a single factor has been found. The BPQ discriminates the intensity of grief between widows and widowers, spouses and offspring, and temporally between acute and later phases of bereavement.

CONCLUSION

Although on the BPQ items are highly correlated and only a single factor has emerged, it remains nonetheless a valid and reliable scale for the measurement of grief.

Family coping and bereavement outcome

Using a three-phase longitudinal design, the bereavement of 115 adult Australian families following the death of a parent from cancer was studied. The cohort comprised 115 spouses and 153 offspring: 670 individual responses were obtained. A range of psychosocial variables was studied through a semistructured interview covering the experience of the deceased's illness, death and funeral, spousal health, family coping, sources of support, use of ritual and completion of estate duties. Bereavement outcome was measured by standardized questionnaires of the intensity of grief (Bereavement Phenomenology Questionnaire), depression (Beck Depression Inventory), psychological distress (Brief Symptom Inventory) and social adjustment (Social Adjustment Scale). Those psychosocial variables found to be significantly correlated with bereavement outcome were entered into best sub-set regression analyses. Family coping was the most consistent correlate of bereavement outcome in these regression analyses, which accounted for up to 38% of the variance in grief, 64% in distress, 53% in depression and 46% in social adjustment. The nature of family functioning is a key aspect of social support in influencing the outcome of bereavement.

Family caregiving: measurement of emotional well-being and various aspects of the caregiving role

BACKGROUND

Past research and instrument development in caregiving have focused on specific aspects of caregiving or specific disability groups. This paper reports the scale characteristics of a new generic instrument developed to assess the experience of caregiving, and the social and emotional well-being of caregivers and a comparison group of 'non-caregivers'.

METHODS

Using computer-assisted telephone technology, a random survey of 26000 households was conducted in Victoria, Australia to identify and interview 976 caregivers of people who were aged or had a long-term illness or disability of any kind, and 219 non-caregivers. Both groups were re-interviewed after 15 months. Scales administered on each occasion to caregivers and non-caregivers included life satisfaction, positive and negative affect, social support and overload; and to caregivers, caring role satisfaction, resentment and anger, and, in relation to the care recipient, measures of help provided and needed, severity of disability and behaviour problems.

RESULTS

On each occasion and with each sample all scales demonstrated a satisfactory reliability. With a subsample of caregiver-care-recipient dyads (N = 67), caregiver reports of severity of disability, level of helped needed and provided were validated externally by clinician assessments.

CONCLUSIONS

A comprehensive instrument to assess the experience of caregiving was developed. It is relevant to a broad range of ages, levels and types of disability and care provided; and, in assessing health and well-being, to both caregivers and non-caregivers. Scales, including both positive and negative dimensions, have demonstrated good internal consistency on two occasions. The instrument is potentially useful in a range of research and practical settings.

Psychiatry: an impossible profession?

OBJECTIVE

To examine the disconcerting question as to whether psychiatry is a fully-fledged profession or not.

METHOD

A review of pertinent literature regarding the criteria of a profession, the vulnerability of psychiatry to abuse, and potential models for the proper practice of psychiatry.

RESULTS

Psychiatry lost its professional anchorage entirely with its misuse to suppress dissent in the former Soviet Union and in the so-called euthanasia program in Nazi Germany. It remains vulnerable to abuse unless psychiatrists recognise the professional criteria they must satisfy. A new symbol, a humble stool, is proposed. Its, three legs represent the three equally significant dimensions of psychiatric practice: science, art and ethics.

CONCLUSION

Psychiatry just 'scrapes home' in constituting a profession but only subject to three provisos:namely (i) that psychiatrists appreciate the need to achieve a coherent body of special knowledge through a genuine creative process which necessarily results in uncomfortable tension from time to time; (ii) that we promote the art of psychiatry by cultivating an ethos of caring and sensitivity; and (iii) that we function within an articulated ethical framework with respect for codes of ethics as guidelines.

Cognitive-existential group therapy for patients with primary breast cancer--techniques and themes

We describe a model of cognitive-existential group therapy designed to be integrated over 6 months with regimens of adjuvant chemotherapy given as conventional medical treatment to breast cancer patients with stage 1 and 2 disease. Our broad therapy goals are for members to develop a supportive network, work through grief over losses, improve problem solving and develop cognitive strategies to maximise coping, enhance a sense of mastery over life and re-evaluate priorities for the future. Specific group themes include death anxiety, fear of recurrence, living with uncertainty, understanding treatment with chemotherapy, radiotherapy and hormone regimens, the collaborative doctor-patient relationship, body and self image, sexuality, relationships with partner, friends and family, surgical reconstruction, life style effects and future goals. Active coping skills are developed through teaching formal problem solving and cognitive restructuring of automatic negative thoughts. Technical aspects of the therapy are discussed.

The ethics committee of a psychiatric college: its procedures and themes

OBJECTIVE

Ethics committees (ECs) of medical colleges and other medical associations have become part of their professional experience only in recent years. This is probably attributable to such factors as greater professional accountability and informed consumerism. Relatively little is known about the procedures and agendas of such committees. The aim of the present study was to examine the EC of the Royal Australian and New Zealand College of Psychiatrists, with respect to its practices, in order to learn how a medical college grapples with ethical concerns.

METHODS

Two members of the College's EC, including its foundation chairman, assembled relevant documents, and subjected them to detailed scrutiny. Consensus was used, preceded by independent attempts at categorising these issues covering the period from the EC's inception in 1978 to June, 1995.

RESULTS

Three hundred and sixty-seven issues were dealt with by the EC over a 17 year period, covering clinical practice, financial aspects, forensic psychiatry, teaching and research, liaison with other organisations and preparation of guidelines and a code of ethics.

CONCLUSIONS

An EC can play a vital role in advising its parent body and members in the ethics of day-to-day professional life as well as formulating (and revising) a code of ethics and supplementary ethical guidelines.

Home-based assessment for family carers: a preventative strategy to identify and meet service needs

OBJECTIVE

To identify unmet need for services among family carers and their frail or disabled relatives and to facilitate links to services.

DESIGN

Intervention study with a subgroup of carer dyads from a random statewide survey of family carers, followed by telephone 2 months post intervention.

SETTING

Carer dyads in general community; urban and rural Victoria.

PARTICIPANTS

All 186 identified carers were approached. One-third of the dyads were ineligible; of the remainder, 67 (53%) participated, matching refusals on sociodemographic characteristics. Carers were typically married, middle-aged women looking after parents or spouses. Almost half of the care recipients were aged > or = 80; most had multiple disorders and impairments. Follow-up rate was 94%.

INTERVENTION

One off, multidisciplinary home-based assessment of dyad by research team and regional aged care assessment service (ACAT).

MAIN OUTCOME MEASURES

"Unmet need': % dyads recommended new services; number services per dyad via ACAT; increases in service range; extension of pre-existing services. Service linkage: % dyads linked to new services; perceived usefulness of linkages.

MAIN RESULTS

Dyads recommended a new service (93%); increased range (73%); extensions (41%). Average two services requiring ACAT implementation; commonly respite care, aids and paramedical services. Recommendations related to impairment severity and carer stress. ACAT implemented recommendations (90% relevant dyads); links rated useful (75% relevant dyads). Three-quarters of the carers rated intervention as helpful.

CONCLUSION

A preventative programme of needs assessment for carer dyads has considerable potential; (a) identifying needs and engaging new services; (b) providing emotional support.

A profile of Australian family caregivers: diversity of roles and circumstances

Research on family caregiving has been based largely on small samples, often drawn from support organisations or services, and has tended to focus on particular disability groups. Our study was population-based and included all ages and disabilities. As the first stage in a longitudinal research and health promotion program for informal caregivers, a statewide random survey of over 26,000 households was conducted by telephone: 78 per cent of self-identified carers (N = 976) agreed to participate in a one-hour interview. This paper presents a sociodemographic profile of Australian caregivers. Four types of relationship between carers and care recipients (adult offspring, spouses, parents and other relatives and friends) provide the framework for results. Group differences were observed on most characteristics: for example, age, living arrangements, work status and duration of care. Care recipient characteristics, including difficult behaviours and need for assistance, are also reported, as well as use of and need for community services. What the findings reflected most was the heterogeneity of both caregivers and care recipients and the diversity of caregiving roles and circumstances.

Increased immunogenicity of oral poliovirus vaccine administered in mass vaccination campaigns compared with the routine vaccination program in Jordan

To compare the immunogenicity of routine versus mass campaign doses of oral poliovirus vaccine (OPV), serum neutralizing antibodies were measured in 254 children before and after two mass vaccination campaigns in Jordan. Precampaign seroprevalences to poliovirus types 1, 2, and 3 in children who had received three, four, or five routine doses of OPV were compared with postcampaign seroprevalences in children who had received one, two, or three routine doses plus two mass campaign doses. Seroprevalences were consistently higher in subgroups that received two doses through mass campaigns than in subgroups that received all doses through the routine program, especially for poliovirus type 3. Geometric mean titers were also consistently higher for mass campaign subgroups, particularly for poliovirus type 3. The findings suggest that adding further doses of OPV to the routine schedule is unlikely to have as great an impact on the immune state of children as administering the same number of doses during mass campaigns.