Utility of healthcare-worker-targeted antimicrobial stewardship interventions in hospitals of low- and lower-middle-income countries: a scoping review of systematic reviews

BACKGROUND

Antimicrobial stewardship (AMS) initiatives in hospitals often include the implementation of clustered intervention components to improve the surveillance and targeting of antibiotics. However, impacts of the individual components of AMS interventions are not well known, especially in low- and lower-middle-income countries (LLMICs).

OBJECTIVE

A scoping review was conducted to summarize evidence from systematic reviews (SRs) on the impact of common hospital-implemented healthcare-worker-targeted components of AMS interventions that may be appropriate for LLMICs.

METHODS

Major databases were searched systematically for SRs of AMS interventions that were evaluated in hospitals. For SRs to be eligible, they had to report on at least one intervention that could be categorized according to the Effective Practice and Organisation of Care taxonomy. Clinical and process outcomes were considered. Primary studies from LLMICs were consulted for additional information.

RESULTS

Eighteen SRs of the evaluation of intervention components met the inclusion criteria. The evidence shows that audit and feedback, and clinical practice guidelines improved several clinical and process outcomes in hospitals. An unintended consequence of interventions was an increase in the use of antibiotics. There was a cumulative total of 547 unique studies, but only 2% (N=12) were conducted in hospitals in LLMICs. Two studies in LLMICs reported that guidelines and educational meetings were effective in hospitals.

CONCLUSION

Evidence from high- and upper-middle-income countries suggests that audit and feedback, and clinical practice guidelines have the potential to improve various clinical and process outcomes in hospitals. The lack of evidence in LLMIC settings prevents firm conclusions from being drawn, and highlights the need for further research.

Youth screen use in the ABCD® study

Adolescent screen usage is ubiquitous and influences development and behavior. Longitudinal screen usage data coupled with psychometrically valid constructs of problematic behaviors can provide insights into these relationships. We describe methods by which the screen usage questionnaire was developed in the Adolescent Brain Cognitive Development (ABCD) Study, demonstrate longitudinal changes in screen usage via child report and describe data harmonization baseline-year 2. We further include psychometric analyses of adapted social media and video game addiction scales completed by youth. Nearly 12,000 children ages 9-10 years at baseline and their parents were included in the analyses. The social media addiction questionnaire (SMAQ) showed similar factor structure and item loadings across sex and race/ethnicities, but that item intercepts varied across both sex and race/ethnicity. The videogame addiction questionnaire (VGAQ) demonstrated the same configural, metric and scalar invariance across racial and ethnic groups, however differed across sex. Video gaming and online social activity increased over ages 9/10-11/12 (p's < 0.001). Compared with boys, girls engaged in greater social media use (p < .001) and demonstrated higher ratings on the SMAQ (p < .001). Compared with girls, boys played more video games (p < .001) and demonstrated higher ratings on the VGAQ (p < .001). Time spent playing video games increased more steeply for boys than girls from age 9/10-11/12 years (p < .001). Black youth demonstrated significantly higher SMAQ and VGAQ scores compared to all other racial/ethnic groups. These data show the importance of considering different screen modalities beyond total screen use and point towards clear demographic differences in use patterns. With these comprehensive data, ABCD is poised to address critical questions about screen usage changes across adolescence.

Healthcare-associated infections and the prescribing of antibiotics in hospitalized patients of the Caribbean Community (CARICOM) states: a mixed-methods systematic review

BACKGROUND

Healthcare-associated infections (HCAIs) and variation in antibiotic prescribing pose a significant public health challenge in hospitals of low-resource countries.

AIM

To critically appraise and synthesize the evidence on HCAI and the prescribing of antibiotics in Caribbean Community (CARICOM) states.

METHODS

All primary qualitative and quantitative studies that addressed HCAI, and the prescribing of antibiotics in hospitalized patients of CARICOM states were included. Ovid Medline, Embase, Global Health, and regional databases were searched. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Findings were presented in narrative and table formats.

FINDINGS

Twenty-one studies met the inclusion criteria for this mixed-methods systematic review (MMSR). Studies were from four different CARICOM states: Trinidad and Tobago, Jamaica, Haiti, and Antigua and Barbuda. Intensive care units (ICUs) had the highest rate of infections (67% over four years). Surgical site infections were discussed by seven studies and ranged from 1.5% to 7.3%. For inpatients with contaminated or infected wounds, rates ranged from 29% to 83%. Empiric and prophylactic therapies were common and inappropriately prescribed. Resources and training for healthcare workers in infection control and antimicrobial stewardship were insufficient. Few qualitative studies existed, so it was not possible to integrate evidence from qualitative and quantitative paradigms.

CONCLUSION

Evidence from CARICOM states shows high rates of HCAI and inappropriately prescribed antibiotics, primarily in ICUs. Disease surveillance, infection control, and antimicrobial stewardship programmes require urgent evidence-based improvements.

Baseline data for distribution of contaminants by natural disasters: results from a residential Houston neighborhood during Hurricane Harvey flooding

Hurricane Harvey made landfall in Texas August 25, 2017, bringing massive rains and flooding that impacted soils in a residential neighborhood in East Houston. Trace elements, organochlorine pesticides, polycyclic aromatic hydrocarbons (PAHs), polybrominated diphenyl ether fire retardants (PBDEs) and polychlorinated biphenyls (PCBs) were determined in 24 soil samples. The highest concentrations found in soils were total PAHs, which ranged from 1,310 μg/kg to 85,700 μg/kg with a mean of 12,600 μg/kg. Analysis of specific PAH ratios indicate the source of the PAHs were dominated by pyrogenic rather than petrogenic sources. Chlordanes were detectable in the area where the likely local source is for ant control. The trace metal concentrations were below any environmental health concern concentrations but As, Cd, Hg, Pb, Se, Ag, Zn were enriched over the crustal abundance. While Hurricane Harvey was responsible for the redistribution of many contaminants, the large volume of rain and floodwater likely transported contaminants from the land areas and into the Houston Ship Channel and Galveston Bay. The findings from this study will serve as baseline data for determining the mobilization of contaminants caused by natural disasters.

A randomised controlled trial of three psychological treatments for anorexia nervosa

BACKGROUND

There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy.

METHOD

A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment.

RESULTS

Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up.

CONCLUSION

The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.

A review of the nutritional challenges experienced by people living with severe mental illness: a role for dietitians in addressing physical health gaps

People experiencing a severe mental illness (SMI), such as schizophrenia, schizoaffective disorder, bipolar affective disorder or depression with psychotic features, have a 20-year mortality gap compared to the general population. This 'scandal of premature mortality' is primarily driven by preventable cardiometabolic disease, and recent research suggests that the mortality gap is widening. Multidisciplinary mental health teams often include psychiatrists, clinical psychologists, specialist mental health nurses, social workers and occupational therapists, offering a range of pharmacological and nonpharmacological treatments to enhance the recovery of clients who have experienced, or are experiencing a SMI. Until recently, lifestyle and life skills interventions targeting the poor physical health experienced by people living with SMI have not been offered in most routine clinical settings. Furthermore, there are calls to include dietary intervention as mainstream in psychiatry to enhance mental health recovery. With the integration of dietitians being a relatively new approach, it is important to review and assess the literature to inform practice. This review assesses the dietary challenges experienced by people with a SMI and discusses potential strategies for improving mental and physical health.

Neurosensory effects of chronic human exposure to arsenic associated with body burden and environmental measures

Exposure to arsenic in drinking water is known to produce a variety of health problems, including peripheral neuropathy. Auditory, visual and somatosensory impairment have been reported in Mongolian farmers living in the Yellow River Valley, where drinking water is contaminated by arsenic. In the present study, sensory tests, including pinprick and vibration thresholds, were administered to 320 residents with well-water arsenic levels, ranging from non-detectable to 690 μg/L. Vibration thresholds in the second and fifth fingers of both hands were measured using a vibrothesiometer. Drinking water, urine and toenail samples were obtained to assess arsenic exposure and body burden. Regression analyses indicated significant associations of pinprick scores and vibration thresholds with all arsenic measures. Vibration thresholds were more strongly associated with urinary than water or nail arsenic measures, but odds ratios for decreased pinprick sensitivity were highest for the water arsenic measure. Results of the current study indicate neurosensory effects of arsenic exposure at concentrations well below the 1000 μg/L drinking water level specified by NRC, and suggest that non-carcinogenic end-points, such as vibration thresholds, are useful in the risk assessment of exposure to arsenic in drinking water.

Magnetic Configurations in Co/Cu Multilayered Nanowires: Evidence of Structural and Magnetic Interplay

Off-axis electron holography experiments have been combined with micromagnetic simulations to study the remnant magnetic states of electrodeposited Co/Cu multilayered nanocylinders. Structural and chemical data obtained by transmission electron microscopy have been introduced in the simulations. Three different magnetic configurations such as an antiparallel coupling of the Co layers, coupled vortices, and a monodomain-like state have been quantitatively mapped and simulated. While most of the wires present the same remnant state whatever the direction of the saturation field, we show that some layers can present a change from an antiparallel coupling to vortices. Such a configuration can be of particular interest to design nano-oscillators with two different working frequencies.

Reflective case study on end of life care in post anaesthesia

Operating department practitioners (ODPs) are well known for their technical abilities within the perioperative environment and are passionate about the care they deliver. This article will critically reflect on the post anaesthetic care of a dying patient, the challenges of having relatives present, the importance of having a good student/mentor relationship, and will show that student ODPs can deliver compassionate and personalised care.

Case management approaches for in-home care

Restructuring healthcare delivery systems within limited budgets presents multiple management challenges. As hospitals have downsized, the demand for in-home services has increased. The involvement of multiple provider agencies and professionals has heightened duplication and fragmentation of services and has complicated the need to develop client-focused, evidence-based approaches. In response to these challenges, community-based case management has burgeoned.

Presentation of ovalbumin internalized via the immunoglobulin-A Fc receptor is enhanced through Fc receptor gamma-chain signaling

The mechanism of enhanced presentation of ovalbumin (OVA) internalized as immunoglobulin A (IgA)-OVA via the IgA Fc receptor (FcalphaR) was analyzed by focusing on the role of the FcalphaR-associated gamma chain. Comparison of B-cell transfectants expressing FcalphaR plus wild-type (WT) gamma chain or gamma chain in which the immunoreceptor tyrosine-based activation motif (ITAM) was altered by tyrosine mutation or substitution with the ITAM of FcgammaRIIA showed that signaling-competent ITAM was not required for endocytosis of IgA-OVA. However, antigen presentation was impaired by ITAM changes. Signaling-competent gamma-chain ITAM appeared necessary for transport of ligated FcalphaR to a lamp-1(+) late endocytic compartment for remodeling and/or activation of that compartment and also for efficient degradation of IgA complexes. Moreover, FcalphaR ligation also activated efficient processing of nonreceptor-targeted antigen. The results suggest that gamma-chain signaling activates the antigen processing compartment.

Cloning and functional expression of two families of beta-subunits of the large conductance calcium-activated K+ channel

We report here a characterization of two families of calcium-activated K(+) channel beta-subunits, beta2 and beta3, which are encoded by distinct genes that map to 3q26.2-27. A single beta2 family member and four alternatively spliced variants of beta3 were investigated. These subunits have predicted molecular masses of 27. 1-31.6 kDa, share approximately 30-44% amino acid identity with beta1, and exhibit distinct but overlapping expression patterns. Coexpression of the beta2 or beta3a-c subunits with a BK alpha-subunit altered the functional properties of the current expressed by the alpha-subunit alone. The beta2 subunit rapidly and completely inactivated the current and shifted the voltage dependence for activation to more polarized membrane potentials. In contrast, coexpression of the beta3a-c subunits resulted in only partial inactivation of the current, and the beta3b subunit conferred an apparent inward rectification. Furthermore, unlike the beta1 and beta2 subunits, none of the beta3 subunits increased channel sensitivity to calcium or voltage. The tissue-specific expression of these beta-subunits may allow for the assembly of a large number of distinct BK channels in vivo, contributing to the functional diversity of native BK currents.

Changes in striatal dopamine D(2) receptors in relation to expression of and recovery from experimental parkinsonism

Changes in dopamine D(2) receptor number in 1-methyl-4-phenyl-1,2,3, 6-tetrahydropyridine (MPTP)-treated cats during various stages of experimental parkinsonism were examined. In the normal adult cat, D(2) receptors were expressed throughout the striatum. In symptomatic cats (assessed 7 days after the last MPTP administration), there was a slight elevation of D(2) receptors in all striatal regions. At 2 weeks after MPTP (animals still grossly symptomatic), D(2) receptor number was increased 60-75% above normal. At 3 weeks after MPTP (partial functional recovery), D(2) receptor number remained elevated at a level slightly less than that observed at 2 weeks. At 6 weeks after MPTP (full functional recovery), D(2) receptor levels were back to normal. Changes in D(2) receptor mRNA expression in the striatum essentially mirrored the changes in receptor number. Increases in D(2) receptor number and mRNA expression did not coincide with the onset of parkinsonian signs and peaked after the parkinsonism was established. Permanent reduction of parkinsonian signs corresponded to normalization of D(2) receptor number.

Assessing the relevance of the hopelessness theory of depression to women with disordered eating

OBJECTIVE

The aim of this study was to investigate the relevance of the hopelessness theory of depression to women with partial-syndrome eating disorders.

METHOD

Three groups of women, one meeting criteria for eating disorders not otherwise specified (EDNOS), one with major depression, and a control group, completed the Balanced Attributional Style Questionnaire, the Eating Disorders Examination Questionnaire, and the Beck Depression Inventory.

RESULTS

Once levels of depression were controlled, all three groups differed significantly with respect to their attributional style for bad events, with the depressed group showing the greatest tendency to attribute the causes of negative life events to internal factors. However, with respect to the attributional style for good events, the depressed and control group displayed similar styles of attribution, whereas the EDNOS group showed a significantly more dysfunctional style, being more likely to attribute positive events to external factors.

DISCUSSION

These findings are discussed in terms of their implications for specific therapeutic interventions with disordered eating.

Differential regulation of striatal dopamine D(1) and D(2) receptors in acute and chronic parkinsonian monkeys

The contribution of the duration of the striatal dopamine (DA) depletion and the expression of parkinsonian signs to changes in D(1) and D(2) receptor number was investigated in the present study. Some animals (N=4) received large doses of 1-methyl-4-phenyl-1,2,3, 6-tetrahydropyridine (MPTP) over short periods of time and were symptomatic for a short period of time (1-3 months; acute parkinsonian group). Other animals (N8 months; chronic parkinsonian group). Despite similar symptomatology and similar degrees of striatal DA denervation, only acute parkinsonian animals had significantly increased numbers of D(1) receptors in most striatal regions. Striatal D(2) receptor binding was elevated in acute parkinsonian monkeys but only in some lateral striatal subregions at mid and caudal levels. These findings further suggest that the duration of parkinsonism is a critical factor in modulating changes in striatal neurochemistry.

Pasteurella multocida meningitis in infancy - (a lick may be as bad as a bite)

Pasteurella multocida is the commonest cause of local infection after an animal bite, but is an unusual cause of meningitis. We report a case of P. multocida meningitis occurring in a 7-week-old infant which was contracted after non-traumatic contact with a household pet, that is, without any animal bite or scratch. The organism may be easily confused with more common Gram-negative pathogens. In this case, it was initially incorrectly diagnosed as Haemophilus influenzae type b (Hib); a possibility which has important implications in the era of routine use of Hib vaccine in infant immunisation programs.

CONCLUSION

Pasteurella multocida is an unusual, but serious cause of meningitis in infancy. It is potentially preventable by the avoidance of contact between young infants and the saliva of household pets, in particular by assiduous hand hygiene.

Striatal preproenkephalin gene expression is upregulated in acute but not chronic parkinsonian monkeys: implications for the contribution of the indirect striatopallidal circuit to parkinsonian symptomatology

This study examined the extent of striatal dopamine (DA) denervation and coincident expression of preproenkephalin (PPE) mRNA in monkeys made parkinsonian by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) administration. Some animals (n = 4) became moderately parkinsonian after receiving large doses of MPTP over short periods of time and were symptomatic for only a short period of time (1-3 months; acute parkinsonian group). Other animals became moderately parkinsonian after receiving either escalating doses of MPTP over long periods (4-6 months; n = 5) or a high dose of MPTP over a short period (<1 month; n = 1) and remained symptomatic for an extended period (>8 months; chronic parkinsonian group). Despite similar symptomatology and similar degrees of striatal DA denervation at the time of their deaths, only acute parkinsonian animals had significantly increased PPE expression in sensorimotor striatal regions. PPE expression in chronic parkinsonian animals was either not changed or significantly decreased in most striatal regions. These findings suggest that the duration and not the extent of striatal DA denervation is a critical factor in modulating changes in striatal PPE expression. Furthermore, these results question the role of increased activity in the enkephalin-containing indirect striatopallidal pathway in the expression of parkinsonian symptoms.

Dichotomy between naïve and memory CD4(+) T cell responses to Fas engagement

Engagement of Fas (APO-1, CD95), a member of the tumor necrosis factor receptor superfamily, can induce apoptotic cell death. However, Fas engagement also can costimulate lymphocyte proliferation. The physiologic regulation of these two outcomes is poorly understood. Here, we have used two systems, the first in vitro and the second in vivo, to demonstrate that naïve and memory CD4(+) T cells display dichotomous responses to Fas ligation. Naïve CD4(+) T cells (CD44(lo), CD45RB+, CD62L+) die as a consequence of Fas ligation in the presence of anti-CD3 antibody, whereas memory T cells (CD44(hi), CD45RB-, CD62L-), freshly isolated from the same starting population and subjected to the same stimulation conditions, are costimulated to proliferate by Fas ligation. In vitro, we demonstrate that CD28-mediated signals or T helper 1 and T helper 2 differentiation cytokines alter the response of naïve T cells, but not of memory T cells, to Fas ligation. In vivo experiments in hen egg lysozyme (HEL) T cell receptor transgenic mice show that CD4(+) T cells from HEL-naïve mice are killed by Fas ligation, but CD4(+) T cells from long-term HEL-exposed mice are costimulated by Fas ligation. Thus, the physiological outcome of Fas ligation in CD4(+) T cells is determined primarily by the antigenic history of the T cell.

The structure of genetic and environmental risk factors for three measures of disordered eating

BACKGROUND

The study explored the genetic and environmental risk factors for both the behaviours and attitudes characteristic of disordered eating.

METHODS

In three waves of data collection, information was collected from female twins regarding their eating and attitudes towards eating, weight and shape. The first assessment consisted of a self-report questionnaire (1988-9) with 1682 women. The second assessment consisted of a semi-structured psychiatric interview schedule (1992-3), completed by 1852 women, many of whom had completed Wave 1 assessment. The third assessment, with 325 women chosen from Waves 1 and 2 (1995-6), consisted of a semi-structured interview (the Eating Disorder Examination).

RESULTS

As only one twin pair was concordant for lifetime bulimia nervosa at Wave 3 assessment, ordinal measures of all assessments were used in a multivariate genetic analysis. Results indicated that additive genetic and non-shared environmental influences best explained variance in liability to disordered eating, with about 60% (95% CI 50-68) of the variance explained by genetic factors. Comparison with a model allowing for the effects of shared environment indicated genetic factors accounted for a similar degree of variance (59%, 95% CI 36-68).

CONCLUSION

Liability to the development of the behaviours and attitudes characteristic of eating disorders is best explained by both environmental and genetic factors, with covariation between the three measures best explained by a single latent phenotype of disordered eating which has a heritability of 60%.

The role of body dissatisfaction and bingeing in the self-esteem of women with type II diabetes

This study investigated the impact of body dissatisfaction and binge eating on self-esteem in women with Type II diabetes. The relationship of body dissatisfaction and bingeing to perceived blood glucose control was also assessed. Questionnaires were completed by a total of 215 women: 125 women with Type II diabetes and 90 comparison women, who were roughly matched for age, education, and ethnicity. When actual weight (BMI) was statistically controlled, there was no difference between the groups in body dissatisfaction or bingeing behavior. The women with diabetes, however, had significantly lower self-esteem. Further, bingeing made a significant contribution to their self-esteem, in contrast to the women without diabetes. For the women with diabetes, body dissatisfaction and bingeing were also related to perceived blood glucose control, although only bingeing remained significant when both variables were entered into the regression equation. It was concluded that diabetes broadens the domains of body dissatisfaction which are related to self-esteem.

A genetic analysis of the eating and attitudes associated with bulimia nervosa: dealing with the problem of ascertainment in twin studies

Little is known about the etiology of bulimia nervosa and the attitudes associated with it. We have undertaken a study of selected (45 pairs) and unselected (106 pairs) female twins to elucidate the broad causes of individual differences in these behaviours and attitudes. The selected sample was chosen on the basis of at least one of the twin pair having a lifetime incidence of bulimia nervosa. Biometrical model fitting, which corrected for the biased twin correlations of the ascertained group, was used to investigate the genetic and environmental risk factors contributing to the development of bulimia nervosa. The best-fitting model showed that individual variation was best explained by additive genetic influences (62%) and nonshared environmental influences (38%). The proportion of genetic variance affecting individual variation in the ascertained group and the random group was not found to be significantly different. In summary, it is suggested that it may not be necessary to supplement a randomly selected sample with an ascertained sample when investigating the liability to a low-prevalence psychiatric disorder if a continuous measure of that disorder is available.

Genetic and environmental risk factors for the weight and shape concerns characteristic of bulimia nervosa

BACKGROUND

This study seeks to identify the genetic and environmental risk factors for the overvalued ideas that are characteristic of bulimia nervosa, using a biometrical model fitting approach with twin data.

METHODS

The Eating Disorder Examination (EDE), which can be used to gain continuous measures of dietary restraint, eating concern, weight concern and shape concern, was administered to 325 female twins, both monozygotic (MZ) and dizygotic (DZ). For each subscale, questions were asked concerning the month prior to interview and lifetime prevalence ('ever').

RESULTS

Model fitting indicated that there is a powerful role of the environment in shaping women's attitude towards weight, shape, eating and food, ranging from 38% to 100% of the variance. For all subscales, with the exception of weight concern, the best explanation for individual variation was one that incorporated additive genetic and non-shared environmental influences. In contrast, model fitting indicated that non-shared and shared environmental influences best explained the variance of weight concern.

CONCLUSIONS

With the exception of the Shape Concern subscale, environmental factors make a greater contribution than genetic factors to the development of the overvalued ideas that are seen to be one of the triggers for the development of bulimia nervosa. Given this substantial role of the environment influences, it seems likely that environmental manipulation can be effective in the prevention of bulimia nervosa.

Chronic neuroleptic treatment alters expression of glial glutamate transporter GLT-1 mRNA in the striatum

Recent reports have shown that typical neuroleptics may enhance glutamatergic neurotransmission and that these effects might in part underlie motor side effects of chronic neuroleptic treatment. Since glutamate reuptake is the primary mechanism for controlling extracellular glutamate levels, the present study was conducted to examine whether chronic neuroleptic exposure alters gene expression for the glutamate transporter GLT-1 in the striatum. Although both haloperidol and clozapine treatment for 30 days significantly decreased GLT-1 expression from normal, the effects of haloperidol treatment were consistently, and in the dorsal striatum, significantly greater than those of clozapine. These findings suggest that a deficiency in glutamate transport may underlie the pathogenesis of neuroleptic-induced movement disorders.

Anorexia nervosa following gastric reduction surgery for morbid obesity

Anorexia nervosa and morbid obesity are popularly considered to be opposite ends of the eating disorder spectrum. Research and clinical experience, however, suggest common psychological factors in a subgroup of obese people. This paper details case reports of two subjects who developed anorexia nervosa following gastric reduction surgery for morbid obesity. Clinical profiles, treatment, and outcome are reported. Psychological similarities between morbid obesity and anorexia nervosa in these subjects are explored. Implications for the selection of subjects for gastric reduction surgery and management after surgery are discussed.

A comparison of the Eating Disorder Examination and a general psychiatric schedule

OBJECTIVE

The aim of this study is to investigate the adequacy of a general interview schedule for the purpose of assessing bulimia nervosa.

METHOD

In two waves of data collection 18-24 months apart, 250 women were assessed for disordered eating. The first interview was typical of that included in many psychiatric interview schedules and was used to screen women for selection in a subsequent interview. This latter interview, using the Eating Disorder Examination, represents the 'gold standard' for the assessment of disordered eating.

RESULTS

While the psychiatric interview satisfactorily assessed disturbed eating in general, it seemed less capable of accurately assessing cases of bulimia nervosa in particular, the major weakness being the overestimation of binge-eating.

CONCLUSIONS

Structured psychiatric interviews are suitable for screening purposes to identify women with disordered eating, but identification of bulimia nervosa requires further assessment with a suitable instrument.

Comparison of cognitive style in bulimia nervosa and depression

This study investigated the global and specific cognitive style associated with bulimia nervosa. Three groups of women (women with bulimia nervosa, women with major depression, and controls) completed measures of eating disorder severity, depression, dysfunctional cognitions and irrational beliefs. The control group was found to report significantly lower levels of cognitive distortions and irrational beliefs overall than both women with bulimia nervosa and women with depression. However, no difference was found between the latter two groups. Furthermore, the pattern of individual cognitions and beliefs was exactly the same. When depression was statistically controlled, cognitive style no longer differentiated between the control group and two clinical groups. These results have implications for improving the effectiveness of cognitive behaviour therapy for bulimia nervosa.

Differences between treatment seekers in an obese population: medical intervention vs. dietary restriction

This study examined two groups of people who were pursuing treatment for obesity: either medical intervention (a hospital group; N = 20) or support for dietary restriction (a community group; N = 18). This study addressed four questions: (1) Were there differences between the two groups in terms of their psychological distress (as measured by the Symptom Checklist)? (2) Does binge eating moderate psychological distress? (3) Do feelings of ineffectiveness moderate psychological distress? and (4) Which variables best accounted for group membership (i.e., type of treatment sought)? Results suggested that the hospital group was significantly more distressed than the community group. However, there were no differences between the two groups with respect to binge eating or feelings of ineffectiveness. These findings suggest that it is the effects of morbid obesity that are most likely to moderate psychological distress.

Characteristics of interview refusers: women who decline to participate in interviews relating to eating

OBJECTIVES

The aim of this study was to compare the eating habits and weight ranges of 27 women who refused to participate in a semistructured interview on eating with 25 women who agreed to participate, to determine if there were any systematic differences between the two groups.

METHOD

The women had previously completed a general psychiatric interview that also included a lifetime DSM-III-R diagnosis of eating disorders. About 2 years after this interview, the women were asked to participate in an interview that would specifically examine eating behaviors.

RESULTS

In contrast to the results of previous studies, this study found that there was no difference between women who refused or agreed to participate in an interview about eating, in terms of their eating problems or weight ranges.

CONCLUSIONS

It seems that eating or weight problems need not be overrepresented in groups who refuse to participate in surveys about eating, thereby undermining the accuracy of prevalence rates in the general population. Suggestions for achieving this representation are discussed.

Interpretive bias for benign sensations in panic disorder with agoraphobia

The present study further examines the cognitive model of panic disorder by investigating two questions. The first is whether panic patients misinterpret bodily sensations which are symptoms of either nonanxious states or harmless events. The second is whether panic patients are able to provide benign subsequent explanations for bodily sensations which have initially been interpreted in an anxiety-related manner. Two groups of subjects were used, 15 panic disorder patients with agoraphobia and 15 controls, matched on verbal fluency, age and gender. Compared to controls, patients failed to identify overt explanations for bodily sensations which are due to nonanxious states or harmless events. Patients also misinterpreted bodily sensations in ambiguous scenarios by providing more anxiety-related initial interpretations than controls. Furthermore, compared to controls, patients provided significantly more anxiety-related initial interpretations which they were unable to subsequently reinterpret in a benign manner. These results provide support for the cognitive theory of panic disorder as authored by Clark and his colleagues.

The Beck Anxiety Inventory: reexamination of factor structure and psychometric properties

Several exploratory factor-analytic studies of the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) have reported two, four, and five factors. This study evaluated the fit of four competing models to data provided by a sample of 350 undergraduates. Results of the initial confirmatory factor analyses (CFA) provided strong support for the fit of the four-factor oblique model. Next, we respecified the four-factor model as a single second-order BAI. Results showed that the second-order model also provided adequate fit to the data. Evidence also supported the psychometric indices of reliability and convergent validity. Finally, we examined the relation of the BAI to several demographic variables. Limitations of the study are discussed.

The Beck Anxiety Inventory: reexamination of factor structure and psychometric properties

Several exploratory factor-analytic studies of the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988) have reported two, four, and five factors. This study evaluated the fit of four competing models to data provided by a sample of 350 undergraduates. Results of the initial confirmatory factor analyses (CFA) provided strong support for the fit of the four-factor oblique model. Next, we respecified the four-factor model as a single second-order BAI. Results showed that the second-order model also provided adequate fit to the data. Evidence also supported the psychometric indices of reliability and convergent validity. Finally, we examined the relation of the BAI to several demographic variables. Limitations of the study are discussed.

Assessing the prevalence of eating disorders in an Australian twin population

OBJECTIVE

This paper examines the prevalence of disordered eating in a female Australian twin population aged between 28 and 90 years in 1993.

METHOD

In two waves of data collection, the eating behaviour of 3869 female twins was first assessed in 1988-1989 by self-report questionnaire and then in 1992-1993 with a telephone interview, using the Semi-Structured Assessment for the Genetics of Alcoholism interview.

RESULTS

It was found that about 0.4% of the women have a lifetime prevalence of anorexia nervosa and 1.8% of the group have suffered from bulimia nervosa. The incidence of bulimia nervosa but not anorexia nervosa was markedly higher for those women under 45 (2.3% bulimia nervosa) than for those women 45 years or older. Furthermore, one in three women have at some stage in their life used some extreme method of weight control.

CONCLUSIONS

The levels of bulimia nervosa and anorexia nervosa found are commensurate with those found in smaller studies in Australia and other parts of the world. The finding of widespread use of extreme weight control methods is of concern as this behaviour is a well-recognised precursor to more serious eating disorders.

Structure of disordered eating in a twin community sample

OBJECTIVE

To describe the types of eating problems experienced by women in an Australian twin population.

METHOD

Questions assessing preoccupation with weight or shape, use of various methods of weight control, difficulties with weight control, disordered eating, or binging, were administered to a group of 3,869 female twins. Exploratory and confirmatory factor analyses were used to summarize and describe problematic eating behaviors.

RESULTS

For those women experiencing problems with eating, five groups could be identified. These were overweight women who were dissatisfied with their weight and shape, underweight women struggling with anorexic behaviors, women who were having problems with binging, women who were using more extreme methods of weight control such as vomiting, laxatives, and starvation, and overweight women who were using slimming and fluid tablets for weight control. Confirmatory factor analysis suggested that this factor model is an acceptable fit to the data and that the factor structure generalizes well across two groups viz, the first-born and second-born twins.

DISCUSSION

It was concluded that future studies aiming to develop a general description of eating problems in the community should specifically assess the purging behaviors used by women.

Patients with bulimia nervosa who fail to engage in cognitive behavior therapy

Although cognitive behavioral treatment is the treatment of choice in bulimia nervosa, patients' response is variable. A minority of patients do not respond at all and some never engage in treatment. This paper concerns the latter group. A case series of six such patients with whom treatment could not be initiated is compared with a group who received a full course of treatment. The group with whom treatment could not begin were found to have a longer history of disorder, to report excessive laxative abuse, to have more severe depressed mood and a greater dissatisfaction with their body weight. In addition, they were more likely to have abused psychoactive substances, engaged in episodes of self-harm, and have a lower self-esteem. They were also more likely to be diagnosed as having borderline personality disorder. Patients presenting with the wide range of difficulties characteristic of this group require a more intensive form of treatment than standard outpatient cognitive behavior therapy.

Analysis of class II MHC structure in thymic nurse cells

During the course of thymocyte maturation, the processes of positive selection and tolerance induction are mediated by interactions between thymocyte T-cell receptors and MHC molecules on thymic stromal cells. The means by which these seemingly contrary processes can be mediated by interactions between the same molecules has long been a source of controversy. One idea which has been put forward is that the MHC molecules in different microenvironments of the thymus are not the same. We have tested this hypothesis by examining class II transcripts derived from thymic cortical epithelial cells known as thymic nurse cells, reasoning that alternative splicing of primary transcripts might give rise to a positively selecting MHC molecule. However, we found no evidence for alternative splicing of these transcripts. These results are presented and discussed with regard to implications for possible mechanisms of positive selection.

Residues of the variable region of the T-cell-receptor beta-chain that interact with S. aureus toxin superantigens

The alpha beta T-cell antigen receptor (TCR) recognizes antigenic peptides in the context of self major histocompatibility complex (MHC) molecules. The specificity of recognition of MHC plus antigen is generally determined by a combination of the variable elements of alpha- and beta-chains of the TCR. Several types of antigen, however, have been identified that, when bound to MHC molecules, stimulate T cells bearing particular variable-region beta-chain (V beta) elements irrespective of the other variable components of the TCR. These have been termed 'superantigens', and here we are concerned with one type of superantigen, the toxins produced by Staphylococcus aureus. T cells have been found that bear closely related members of the same V beta family but respond differently to S. aureus toxins; in particular, cells bearing the human V beta 13.2 element respond to toxin SEC2, whereas cells bearing human V beta 13.1 do not. We have now defined the residues of the V beta element responsible for this difference, and find that they reside in a region thought to lie on the side of the TCR molecule, away from the conventional antigen/MHC-binding site. The evolutionary conservation of this site may be due to its having an important role in some function of the TCR other than the binding of conventional antigen plus MHC.

Identification of the region of T cell receptor beta chain that interacts with the self-superantigen MIs-1a

Superantigen-MHC complexes are known to stimulate T cells primarily via the V beta element of the T cell receptor. In this paper we identify a number of amino acid residues that define the region of a particular V beta element interacting with one of the self-superantigens, MIs-1a. These residues are predicted to lie on a beta-pleated sheet of the T cell receptor, away from the complementarity determining regions of the receptor, which are thought to interact with complexes of conventional peptide antigens and MHC. In support of this prediction, mutations affecting MIs-1a activity have no effect on the response to conventional antigen and MHC.

Molecular basis for the nonexpression of V beta 17 in some strains of mice

The TCR alpha/beta variable element V beta 17a is expressed in all strains of mice carrying the V beta a complex in which about half of the V beta elements have been lost due to a large deletion. The mAb KJ23a detects V beta 17a containing alpha/beta receptors in these mice. Mouse strains with the V beta b complex carry a full complement of V beta genes including a structural gene for V beta 17 (V beta 17b), but no T cells reactive with KJ23a are present in these mice. Among random peripheral T cell hybridomas prepared from V beta b mice, occasional V beta 17b transcripts are found. The sequence of one of these transcripts reveals a single base difference from V beta 17a which results in a termination codon within the coding region inactivating the gene.