Indication, performance and outcomes of adrenal vein sampling in patients with primary hyperaldosteronism

Primary hyperaldosteronism (PAH) is an important cause of secondary hypertension (HTN). The study of the same requires a high clinical suspicion in addition to a hormonal study that confirms hormonal hypersecretion. It is important to start the appropriate treatment once the diagnosis is confirmed, and for this is necessary to demonstrate whether the hormonal hypersecretion is unilateral (patients who could be candidates for surgical treatment) or bilateral (patients who are candidates for pharmacological treatment only). At the Hospital del Mar since 2016 there has been a multidisciplinary work team in which Nephrologists, Endocrinologists, Radiologists and Surgeons participate to evaluate cases with suspected hyperaldosteronism and agree on the best diagnostic-therapeutic approach for these patients, including the need for adrenal vein sampling, which is a technique that in recent years has become the gold standard for the study of PAH. In the present study we collect the experience of our centre in performing AVC and its usefulness for the management of these patients.

Follow-up care of 12 months of patients with bladder cancer in Spain: A multicenter prospective cohort study

The therapeutic approach of bladder cancer strongly determines its prognosis. We describe the treatments and outcomes for a Spanish cohort of patients with bladder cancer for the first 12 months after diagnosis and identify the factors that influenced the decision to undergo the treatment received. We conducted a multicenter, prospective, cohort study including primary bladder cancer patients during the first 12 months after diagnosis. The clinical outcomes were performance status (ECOG), adverse events and any cause of mortality. We stratified the analysis by factors that might influence the treatments received. We conducted univariate and multivariable logistic regression models to assess which patient and tumor characteristics were associated with receiving adjuvant treatment in the subgroup of noninvasive bladder cancer patients. In total, 314 patients were included (85% men; 53.8% >70 years) in 7 tertiary Spanish hospitals; 82.2% had a noninvasive urothelial bladder cancer (NMIBC). Patients received mostly surgery plus adjuvant therapy (67.7%). BCG (32.8% patients) was the most frequently administered adjuvant therapy, followed by intravesical chemotherapy (17.8% patients) and radiotherapy (10.8%). The variability of administered treatments among hospitals was low. Patients with NMIBC were more likely to receive adjuvant therapy if they had a higher educational level, some comorbidities and a high-grade tumor. The number of fully active patients (ECOG 0) significantly decreased during the first year of follow-up from 58% to 36 % (OR: 2.41, 95%CI 1.82-3.20); at 12-month follow-up 10.8% patients had died from any cause. In conclusion, most of the patients had a NMIBC. Surgery alone or plus adjuvant therapy were the commonest curative options of bladder cancer. BCG therapy was the adjuvant therapy most frequently administered. Higher educational level, presence of comorbidities and a high-grade tumor were associated with adjuvant therapy. Patient performance status was worsening over time. Almost 1 of 10 patients died during the first year of follow-up.

Increased mortality after kidney transplantation in mildly frail recipients

Background

Physical Frailty Phenotype (PFP) is the most used frailty instrument among kidney transplant recipients, classifying patients as pre-frail if they have 1–2 criteria and as frail if they have ≥3. However, different definitions of robustness have been used among renal patients, including only those who have 0 criteria, or those with 0–1 criteria. Our aim was to determine the impact of one PFP criterion on transplant outcomes.

Methods

We undertook a retrospective study of 296 kidney transplant recipients who had been evaluated for frailty by PFP at the time of evaluating for transplantation.

Results

Only 30.4% of patients had 0 criteria, and an additional 42.9% showed one PFP criterion. As PFP score increased, a higher percentage of women and cerebrovascular disease were found. Recipients with 0–1 criteria had lower 1-year mortality after transplant than those with ≥2 (1.8% vs 10.1%), but this difference was already present when we only considered those who scored 0 (mortality 1.1%) and 1 (mortality 2.4%) separately. The multivariable analysis confirmed that one PFP criterion was associated to a higher risk of patient death after kidney transplantation [hazard ratio 3.52 (95% confidence interval 1.03–15.9)].

Conclusions

Listed kidney transplant candidates frequently show only one PFP frailty criterion. This has an independent impact on patient survival after transplantation.

Validation of the Regicor Short Physical Activity Questionnaire for the Adult Population

Objective

To develop and validate a short questionnaire to estimate physical activity (PA) practice and sedentary behavior for the adult population.

Methods

The short questionnaire was developed using data from a cross-sectional population-based survey (n = 6352) that included the Minnesota leisure-time PA questionnaire. Activities that explained a significant proportion of the variability of population PA practice were identified. Validation of the short questionnaire included a cross-sectional component to assess validity with respect to the data collected by accelerometers and a longitudinal component to assess reliability and sensitivity to detect changes (n = 114, aged 35 to 74 years).

Results

Six types of activities that accounted for 87% of population variability in PA estimated with the Minnesota questionnaire were selected. The short questionnaire estimates energy expenditure in total PA and by intensity (light, moderate, vigorous), and includes 2 questions about sedentary behavior and a question about occupational PA. The short questionnaire showed high reliability, with intraclass correlation coefficients ranging between 0.79 to 0.95. The Spearman correlation coefficients between estimated energy expenditure obtained with the questionnaire and the number of steps detected by the accelerometer were as follows: 0.36 for total PA, 0.40 for moderate intensity, and 0.26 for vigorous intensity. The questionnaire was sensitive to detect changes in moderate and vigorous PA (correlation coefficients ranging from 0.26 to 0.34).

Conclusion

The REGICOR short questionnaire is reliable, valid, and sensitive to detect changes in moderate and vigorous PA. This questionnaire could be used in daily clinical practice and epidemiological studies.

Risk of Cause-Specific Death in Individuals With Diabetes: A Competing Risks Analysis

OBJECTIVE

Diabetes is a common cause of shortened life expectancy. We aimed to assess the association between diabetes and cause-specific death.

RESEARCH DESIGN AND METHODS

We used the pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79 years old. Diabetes status was self-reported or defined as glycemia >125 mg/dL at baseline. Vital status and causes of death were ascertained by medical records review and linkage with the official death registry. The hazard ratios and cumulative mortality function were assessed with two approaches, with and without competing risks: proportional subdistribution hazard (PSH) and cause-specific hazard (CSH), respectively. Multivariate analyses were fitted for cardiovascular, cancer, and noncardiovascular noncancer deaths.

RESULTS

We included 55,292 individuals (15.6% with diabetes and overall mortality of 9.1%). The adjusted hazard ratios showed that diabetes increased mortality risk: 1) cardiovascular death, CSH = 2.03 (95% CI 1.63-2.52) and PSH = 1.99 (1.60-2.49) in men; and CSH = 2.28 (1.75-2.97) and PSH = 2.23 (1.70-2.91) in women; 2) cancer death, CSH = 1.37 (1.13-1.67) and PSH = 1.35 (1.10-1.65) in men; and CSH = 1.68 (1.29-2.20) and PSH = 1.66 (1.25-2.19) in women; and 3) noncardiovascular noncancer death, CSH = 1.53 (1.23-1.91) and PSH = 1.50 (1.20-1.89) in men; and CSH = 1.89 (1.43-2.48) and PSH = 1.84 (1.39-2.45) in women. In all instances, the cumulative mortality function was significantly higher in individuals with diabetes.

CONCLUSIONS

Diabetes is associated with premature death from cardiovascular disease, cancer, and noncardiovascular noncancer causes. The use of CSH and PSH provides a comprehensive view of mortality dynamics in a population with diabetes.

Disappointed Love and Suicide: A Randomized Controlled Trial of "Abandonment Psychotherapy" Among Borderline Patients

To determine whether ambulatory psychotherapy targeted to abandonment experiences and fears can reduce suicidality and improve outcome in borderline patients referred to the emergency room with major depressive disorder and self-destructive behavior severe enough to require medical/surgical treatment and a brief psychiatric hospitalization. A total of 170 subjects were randomized at hospital discharge into three treatment groups: treatment as usual (TAU), abandonment psychotherapy delivered by certified psychotherapists, and abandonment psychotherapy delivered by nurses. Assessments were performed before randomization and at 3-month follow-up. Continued suicidality and other outcome measures were significantly worse in the treatment-as-usual as compared to both abandonment psychotherapy groups, but there were no differences between the two psychotherapy groups. These results suggest the efficacy of manualized psychotherapy that specifically targets the abandonment fears and experiences that are so common as precipitants to suicidal and self-destructive acts in borderline patients. It does not appear that formal psychotherapy training is associated with better outcomes.

Bladder cancer index: cross-cultural adaptation into Spanish and psychometric evaluation

BACKGROUND

The Bladder Cancer Index (BCI) is so far the only instrument applicable across all bladder cancer patients, independent of tumor infiltration or treatment applied. We developed a Spanish version of the BCI, and assessed its acceptability and metric properties.

METHODS

For the adaptation into Spanish we used the forward and back-translation method, expert panels, and cognitive debriefing patient interviews. For the assessment of metric properties we used data from 197 bladder cancer patients from a multi-center prospective study. The Spanish BCI and the SF-36 Health Survey were self-administered before and 12 months after treatment. Reliability was estimated by Cronbach's alpha. Construct validity was assessed through the multi-trait multi-method matrix. The magnitude of change was quantified by effect sizes to assess responsiveness.

RESULTS

Reliability coefficients ranged 0.75-0.97. The validity analysis confirmed moderate associations between the BCI function and bother subscales for urinary (r = 0.61) and bowel (r = 0.53) domains; conceptual independence among all BCI domains (r ≤ 0.3); and low correlation coefficients with the SF-36 scores, ranging 0.14-0.48. Among patients reporting global improvement at follow-up, pre-post treatment changes were statistically significant for the urinary domain and urinary bother subscale, with effect sizes of 0.38 and 0.53.

CONCLUSIONS

The Spanish BCI is well accepted, reliable, valid, responsive, and similar in performance compared to the original instrument. These findings support its use, both in Spanish and international studies, as a valuable and comprehensive tool for assessing quality of life across a wide range of bladder cancer patients.

Bladder transitional cell carcinoma and BK virus in a young kidney transplant recipient

Kidney transplant recipients have a heightened risk of developing neoplasms. Immunosuppressive treatments decrease the incidence of transplant rejection but increase the risk of infections, including BK virus (BKV). This infection is acquired in childhood and remains latent in the renal and urinary epithelium. In cases of immunodeficiency, BKV has been implicated as a tumor virus, but the role of BKV in cancer is a controversial topic and is difficult to determine. In the tumor cells, it is possible to detect fragments of the viral genome that could alter the control mechanisms of the cell cycle and DNA repair. We report the case of a kidney transplant recipient who developed BKV nephropathy and carcinoma of the bladder, supporting a possible role for BKV in the oncogenic pathway in this clinical setting, but the role of BKV in cancer remains a controversial topic and difficult to determine.

[Critical evaluation of the first draft of DSM-V]

Critical evaluation of DSM-V first draft This is an evaluation of the first DSM-V (Diagnostic and Statistical Manual of Mental Disorders-V) draft from the DSM-IV chairman. First, a brief history of DSM is reported. Then, major reasons for present controversies and the threat they raise to APA leadership in the field are discussed. Third point is careful recollection of the several conflicting aspects of the DSM-V draft, paying attention to drawbacks and their implications for future clinical practice, research and forensic activity. Comment is finally provided about APA (American Psychiatric Association) decisions aimed at reaching more consensus about this basic instrument of American psychiatry.

High-flow priapism as a complication of a veno-occlusive priapism: two case reports

The presentation of two cases of veno-occlusive priapism, in patients of 36 and 58 years, in whom the different medical and surgical techniques employed, failed. The suspicion that high-flow priapism had been provoked by said surgical intervention was confirmed by bilateral arteriographs of the pudendal artery. The treatment, selective embolisation of the affected cavernosal artery with reabsorbable material, led to a rapid return of penile detumescence.

Practitioner versus medication-expert opinion on psychiatric pharmacotherapy of mentally retarded patients with mental disorders

The agreement of practicing psychiatrists with medication experts regarding how psychotropic drugs should be used to treat behavioral and psychiatric problems in patients with mental retardation was studied. The medication survey used in developing guidelines on the treatment of behavioral and psychiatric problems in mental retardation was sent to 85 psychiatrists who had been identified as caring for the mentally retarded in the Texas public mental health system. The comparison of these practitioners with the medication experts included first-line and second-line treatment choices. Survey analysis was based on using 95% confidence intervals (CIs) to determine the type of rating. If the 95% CIs for the practitioners' responses overlapped the 95% CIs for experts, the two groups were judged to be in agreement. Thirty-seven practitioners (43.5%) completed and returned the survey. Few differences between the practitioners and the medication experts were found with respect to treatments for specific mental illness diagnoses. However, the practitioners rated venlafaxine and mirtazapine higher than the medication experts. Lithium augmentation of therapy with selective serotonin-reuptake inhibitors for nonpsychotic depression was rated first-line by the practitioners and second-line by the medication experts. Practicing psychiatrists and medication experts generally agreed about the use of psychotropic drugs for mental illness in patients with mental retardation.

Comparison of immunologic restoration and virologic response in plasma, tonsillar tissue, and cerebrospinal fluid in HIV-1-infected patients treated with double versus triple antiretroviral therapy in very early stages: The Spanish EARTH-2 Study. Early Anti-Retroviral Therapy Study

The objective of antiretroviral therapy is to obtain an almost complete and durable suppression of viral replication in all compartments to facilitate recovery of the immune system. We assessed the virologic effect in plasma, tonsillar tissue, and cerebrospinal fluid (CSF) in 94 HIV-1-infected patients with CD4 counts >500 x 106 cells per liter and viral load >5000 copies/ml randomly assigned to triple antiretroviral therapy (two nucleoside reverse transcriptase inhibitors (NRTIs) plus one protease inhibitor) versus double therapy (two NRTIs). We also analyzed the immunologic recovery in this cohort of patients. Lymphoid tissue and cerebrospinal fluid viral load, development of genotypic resistance, proliferative responses to HIV-1 specific antigens, and other immunophenotypic markers were analyzed. The proportion of patients who achieved a decrease in HIV RNA levels to <200 copies/ml was significantly greater in the triple therapy group than in the two drug groups (p =.0002 for each pair-wise difference). At week 52, tonsillar tissue HIV RNA from 5 patients treated with triple therapy was lower than the limit of detection, whereas the mean +/- standard error in patients with double therapy (n = 5) was 5.03 +/- 0.34 copies/mg/tissue. In all 10 patients, CSF viral load (VL) was <20 HIV-1 RNA copies/ml at week 52. CSF cell counts and protein levels tended to decrease after 52 weeks of antiretroviral therapy. After 1 year of therapy, 13 of 21 patients (62%) in the double-therapy groups (zidovudine plus lamivudine [n = 9] and stavudine plus lamivudine [n = 12]) had evidence of M184V mutation. None of the 10 samples of patients receiving triple therapy could be amplified because of low HIV RNA levels. The mean increase in CD4 cells at week 52 was greater in the stavudine and lamivudine and indinavir group than in the double-treatment arms (186 versus 67 and 102, respectively; p =.03). In patients treated with triple therapy, the increase in naive T cells (CD4 and CD8) was greater than in patients treated with double therapy. Markers of activation decreased further in patients treated with the regimen that included protease inhibitors. Proliferative responses to HIV-1 p24 antigen were never recovered after double or triple therapy. Our study suggests that even in very early stages of HIV-1 disease only therapy with two NRTIs and one protease inhibitor reduces plasma, lymphoid tissue, and CSF VL to undetectable levels. HIV-1-related immune system abnormalities improved but were still defective after 1 year of antiretroviral therapy.

A new method of developing expert consensus practice guidelines

To improve the quality of medical care while reducing costs, it is necessary to standardize best practice habits at the most crucial clinical decision points. Because many pertinent questions encountered in everyday practice are not well answered by the available research, expert consensus is a valuable bridge between clinical research and clinical practice. Previous methods of developing expert consensus have been limited by their relative lack of quantification, specificity, representativeness, and implementation. This article describes a new method of developing, documenting, and disseminating expert consensus guidelines that meets these concerns. This method has already been applied to four disorders in psychiatry and could be equally useful for other medical conditions. Leading clinical researchers studying a given disorder complete a survey soliciting their opinions on its most important disease management questions that are not covered well by definitive research. The survey response rates among the experts for the four different psychiatric disorders have each exceeded 85%. The views of the clinical researchers are validated by surveying separately a large group of practicing clinicians to ensure that the guideline recommendations are widely generalizable. All of the suggestions made in the guideline are derived from, and referenced to, the experts' survey responses using criteria that were established a priori for defining first-, second-, and third-line choices. Analysis of survey results suggests that this method of quantifying expert responses achieves a high level of reliability and reproducibility. This survey method is probably the best available means for standardizing practice for decisions points not well covered by research.

Consensus methods in practice guideline development: a review and description of a new method

Practice guidelines are an increasingly important means of conveying to practitioners and administrators the most appropriate methods of treating patients. Although the development of practice guidelines relies on scientific evidence, the consensus of expert opinion is an important ingredient, particularly in many key areas of clinical decision making that are insufficiently informed by experimental data. The authors review current methods in the assessment of expert opinion for practice guideline development and the problem of the lack of quantification. A new method is presented for quantification of expert opinion on surveys, and the development of expert consensus practice guidelines from the resulting data.

Relapse and rehospitalization during maintenance treatment of schizophrenia. The effects of dose reduction and family treatment

BACKGROUND

Previous studies have examined dose reduction and family treatment in schizophrenia, but none has examined their interaction. This study assessed the impact of dose reduction of antipsychotic medication and family treatment on relapse and rehospitalization during maintenance treatment.

METHODS

Subjects were 313 male and female outpatients at 5 centers with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder. In a 3 x 2 design, subjects were randomized to 1 of 3 medication strategies using fluphenazine decanoate under double-blind conditions: continuous moderate dose (standard) (12.5-50 mg every 2 weeks); continuous low dose (2.5-10 mg every 2 weeks); or targeted, early intervention (fluphenazine only when symptomatic). Subjects also were randomized to 1 of 2 family treatment strategies (supportive or applied). Supportive family management involved monthly group meetings. The more intensive applied family management involved monthly group meetings and home visits where communication and problem-solving skills were taught. Patients and families were treated and assessed for 2 years.

RESULTS

Both continuous low-dose and targeted treatment increased use of rescue medication and relapse; only targeted treatment increased rehospitalization. This pattern was consistent across both family treatments; there were no differences between family treatments.

CONCLUSIONS

These findings reaffirm the value of antipsychotic medication in preventing relapse and rehospitalization. The absence of family treatment differences may be because both conditions engaged families.

Hormonal regulation of serum and endometrial IL-1 alpha, IL-1 beta and IL-1ra: IL-1 endometrial microenvironment of the human embryo at the apposition phase under physiological and supraphysiological steroid level conditions

We have investigated serum and intracavitary levels of IL-1 alpha, IL-1 beta and IL-1ra from agonadal women undergoing mock cycles (n = 20) of oocyte donation as a clinical model of controlled hormonal stimulation. Further, we compared the intracavitary IL-1 alpha, IL-1 beta and IL-1ra levels in the microenvironment of the human embryo at the apposition phase, day 5 after progesterone (P) administration using two different clinical models: oocyte donation (n = 20) which provides physiological steroid levels and a higher implantation rate per embryo, and in vitro fertilization (n = 6) with supraphysiological hormonal levels and a lower implantation rate.

DSM-IV antisocial personality disorder field trial

The development of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) included 12 field trials to assess proposed revisions. This article provides results from the antisocial personality disorder (APD) field trial that was conducted to obtain data of relevance to the proposals for simplification and for the inclusion of more traditional traits of psychopathy. Provided herein are the results from 4 sites that had sampled from populations of particular relevance to the diagnosis of APD (i.e., prison inmates, psychiatric inpatients, outpatients with substance use disorders, and homeless persons). The results indicated that some items from the 3rd revised Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) could be deleted without affecting the diagnosis. The field trial provided mixed support for the proposal to include more traditional traits of psychopathy.

Nosology of chronic mood disorders

In attempting to assess the complex relationship of chronic depression with other conditions to which it may be a predisposition, an accompaniment, or a consequence of, a few concluding caveats may be useful. It must be recognized that chronic depression has a wide variety of different presentations and causes. Current definitions of major depressive disorder and dysthymic disorder may create a misleading distinction of what may be two aspects of the overall course of a depressive disorder. Furthermore, much of what is considered to be comorbidity of other disorders with chronic depression actually may be a complex syndrome with a common pathogenesis.

DSM-IV antisocial personality disorder field trial

The development of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) included 12 field trials to assess proposed revisions. This article provides results from the antisocial personality disorder (APD) field trial that was conducted to obtain data of relevance to the proposals for simplification and for the inclusion of more traditional traits of psychopathy. Provided herein are the results from 4 sites that had sampled from populations of particular relevance to the diagnosis of APD (i.e., prison inmates, psychiatric inpatients, outpatients with substance use disorders, and homeless persons). The results indicated that some items from the 3rd revised Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) could be deleted without affecting the diagnosis. The field trial provided mixed support for the proposal to include more traditional traits of psychopathy.

Diagnostic agreement between the SCID-II screening questionnaire and the Personality Disorder Examination

Instruments to assess personality disorders offer reliability, but at the cost of large amounts of a skilled clinician's time to make assessments. The Structured Clinical Interview for DSM-III Axis II (SCID-II; Spitzer, Williams, Gibbon, & First, 1990), incorporates a self-report screening questionnaire, reducing the number of items needing evaluation by the interviewer. However, false negative responses may cause clinically important areas to be overlooked. To establish the rate of false negative responses, we compared participant self-report on the SCID-II with Axis II diagnostic assessment done by clinicians using the Personality Disorder Examination (Loranger, Susman, Oldham, & Russakoff, 1987). The false negative rate was low for every diagnosis, supporting validity of following up with clinician questioning only those diagnostic elements endorsed in the self-report. Avoidant and dependent personality disorders were accurately self-reported. This, an efficient assessment instrument for personality disorders might combine self-report of those disorders where self-report is reliable, with clinician assessment where needed.

Role of embryonic factors in human implantation

Implantation biology is now at a stage where experimental science will be very productive in answering basic questions about the ability of an embryo to implant. The advancement of our knowledge of cytokines and growth factors has been critically important in fuelling the recent new understanding of embryo implantation. Specifically, our increased knowledge of the interleukin (IL)-1 system, as well as leukaemia-inhibiting factor (LIF), epidermal growth factor and colony-stimulating factor-1, and the availability of recombinant protein, specific antibodies and knockout mice, have led to a more detailed outline of implantation events. LIF and IL-1 are the two systems where recent advances have suggested their importance in implantation events. Recently, LIF has been shown in mice to be an endometrial requirement for implantation and embryo development. Although LIF is a pleiotropic molecule, with many interactions in multiple body tissues, in the uterus, concentrations are elevated on day 4 of pregnancy. Experiments with knockout mice have shown the requirement for endometrial LIF for successful implantation. The IL-1 system, consisting of two agonists (IL-1 alpha and IL-1 beta), two receptors (IL-1R types I and II) and the homologous IL-1 receptor antagonist (ra), has also been studied. Knowledge that the embryo secretes IL-1 suggested the interaction between embryonic IL-1 and endometrial receptor, which has been shown to occur. IL-1R type I is plentiful on endometrial epithelial cells and appears to interact with embryonically secreted IL-1 beta to favour implantation. Such implantation events in vivo in mice are blocked by the introduction of large quantities of IL-1ra, consistent with the hypothesis that appropriate interactions between agonist and receptor at the level of the endometrial surface are a requisite for successful implantation. As more specific information on each cytokine or growth factor system comes to light, more complete information on the multiple molecular steps of implantation will become apparent. However, it is clear that no single cytokine or growth factor will be able to explain the complicated events of embryo implantation. Such an important necessary phenomenon has multiple redundancies. The interactions between cytokines and growth factors are becoming increasingly apparent and will need more experimental evidence before a full understanding of implantation is available.

Postdischarge medication compliance of inpatients converted from an oral to a depot neuroleptic regimen

OBJECTIVE

This preliminary study assessed the effects on outpatient medication compliance of converting inpatients with schizophrenia from oral to depot neuroleptic medication.

METHODS

Subjects consisted of 93 neuroleptic-responsive inpatients with schizophrenia from three New York City hospitals who were part of a one-year prospective longitudinal study of medication compliance. Forty patients were converted to depot neuroleptic medication while hospitalized; the other 53 remained on oral medication. Symptoms, side effects, and medication compliance of the two groups were compared at one, six, and 12 months postdischarge.

RESULTS

Inpatients converted to depot medication had significantly better compliance at one month postdischarge. Differences in demographic characteristics, symptoms, hospital site, and baseline attitudes toward medication did not account for this finding. The initial positive effect on compliance waned, and no significant between-group differences in compliance were found at six and 12 months postdischarge.

CONCLUSIONS

Conversion to depot medication before hospital discharge may facilitate medication compliance during transition to outpatient treatment, but other interventions are needed to maintain compliance over time.

Immunohistochemical localization, identification and regulation of the interleukin-1 receptor antagonist in the human endometrium

There is evidence suggesting the importance of the interleukin-1 receptor type I (IL-1Rtl) and interleukin-1 beta (IL-1 beta) as mediator in local intercellular interactions in endometrial tissue and embryonic implantation. To complete our understanding of the entire endometrial IL-1 system in humans, we have investigated the immunohistochemical distribution of IL-1 receptor antagonist (IL-1ra) in the human endometrium throughout the menstrual cycle. We have also identified the forms of IL-1ra present in human endometrial cells. Immunoreactive IL-1ra was found in both cryostat and paraffin-embedded sections of human endometrium using the alkaline phosphatase-peroxidase (A-P) method with two different IL-1ra antibodies. IL-1ra was present throughout the entire menstrual cycle, located primarily in the endometrial epithelium. However, IL-1ra staining was significantly higher during follicular phase in comparison with early and mid-late luteal phases. Reverse transcriptase polymerase chain reaction of cultured stromal and glandular cells showed that these cells express the intracellular form of IL-1ra mRNA (icIL-1ra). Our results demonstrate the regulated presence of the icIL-1ra in the human endometrium. This finding supports a possible autocrine-paracrine role for the IL-1 system in the human endometrium and embryonic implantation.

Axis II diagnoses among volunteers for HIV testing and counseling

OBJECTIVE

The authors' goal was to investigate the rate of personality disorders (axis II diagnoses in DSM-III-R) among adults at risk for AIDS.

METHOD

The Personality Disorder Examination was administered to 260 volunteers for HIV testing and counseling.

RESULTS

Thirty-seven percent of the subjects who subsequently tested seropositive for HIV and 20% of those who tested seronegative were given DSM-III-R axis II diagnoses on the Personality Disorder Examination. Thirty percent of the HIV-positive subjects who knew their serostatus before they were tested were given DSM-III-R axis II diagnoses.

CONCLUSIONS

The meaningful rates of axis II diagnoses that preexisted determination of HIV status and the relation of these diagnoses to subsequently determined serostatus underscore the importance of adequately assessing the occurrence of personality disorder in individuals at risk for HIV infection.

Gene regulation of interleukin-1 beta, interleukin-1 receptor type I, and plasminogen activator inhibitor-1 and -2 in human granulosa-luteal cells

OBJECTIVE

To investigate the regulation of messenger ribonucleic acid (mRNA) levels of interleukin-1 beta (IL-1 beta), interleukin-1 (IL-1) receptor type 1, and plasminogen activator (PA) inhibitor-1 and -2 in cumulus cells, granulosa-luteal cells, and macrophage-depleted granulosa-luteal cells obtained from human preovulatory follicles.

DESIGN

Prospective longitudinal study.

SETTING, PATIENTS

Patients undergoing assisted reproductive technologies (ART) in the Department of Gynecology and Obstetrics, Stanford University, Stanford, California.

INTERVENTIONS

Cumulus cells and granulosa-luteal cells were collected by ultrasound-guided transvaginal aspiration at the time of ART.

MAIN OUTCOME MEASURES

Northern blot analysis of mRNA levels of IL-1 beta, IL-1 receptor type 1, PA inhibitor-1 and -2 in cumulus cells, granulosa-luteal cells and macrophage-depleted granulosa-luteal cells, and indirect immunocytochemical analysis of the IL-1 system and macrophages in granulosa-luteal cell preparations were performed.

RESULTS

Interleukin-1 beta mRNA levels in uncultured cumulus cells were less than those of uncultured granulosa-luteal cells with no differences in IL-1 receptor type 1 mRNA levels between these two cell types. Granulosa-luteal cell IL-1 receptor type 1 mRNA levels were expressed constitutively throughout 24 hours of culture with no effect by hCG, whereas IL-1 beta mRNA levels increased within 6 hours, and then remained elevated for 24 hours with no effect by hCG. Interleukin-1 beta significantly increased granulosa-luteal cell mRNA levels of IL-1 beta (over twofold), IL-1 receptor type 1 (over twofold), PA inhibitor-1 (approximately 1.4-fold), and PA inhibitor-2 (approximately 1.6-fold). In contrast, IL-1 beta had no effect on IL-1 beta and IL-1 receptor type 1 mRNA levels in macrophage-depleted granulosa-luteal cells. Granulosa-luteal cells, not macrophages, account for the majority of the immunocytochemical staining for IL-1 beta and IL-1 receptor type 1 in follicular aspirates.

CONCLUSIONS

These studies suggest that the IL-1 system is regulated in human granulosa-luteal cells during the periovulatory period. Furthermore, the augmentation of PA inhibitor-1 and -2 mRNA levels by IL-1 beta suggests a potential role for IL-1 beta in remodeling of the human ovary during the periovulatory period.

Dysthymic disorder: a comparison of DSM-IV and ICD-10 and issues in differential diagnosis

Dysthymic disorders are a major category among the mood disorders but the concept is not widely understood in many parts of the world, where it is often considered as a new name for familiar categories, such as neurotic depression, depressive personality or even neurasthenia (which is still a frequent diagnosis in many Far East countries). The purpose of this chapter is to compare the definitions of Dysthymic Disorder that are contained in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) with the definitions in the International Classification of diseases Tenth Edition (ICD-10). The two systems are in fact quite congruent both in their overall approach and their specific contents; this has resulted from the fact that many of the DSM-IV Task Force and Work Group members have participated in the ICD-10 expert committees and many of the ICD-10 experts have been advisors to the DSM-IV revision process.

A brief history of psychiatric classification. From the ancients to DSM-IV

We are now at an interesting crossroads in the history of psychiatric nosology. There have been many oscillations over time between etiologic and descriptive models, between lumping and splitting, and between categorical and dimensional systems. It is unfortunate, but inevitable, that most of the etiologic models of the past have been based on unproven and unprovable theories. Like its predecessors, DSM-IV is a descriptive system, and it too gradually will be replaced by an etiologic model--one, it is hoped, that is more scientifically valid than previous attempts at etiologic explanation. This will be an important step for the profession, for scientific understanding, and for the patient.

DMS-IV meets philosophy

The authors discuss some of the conceptual issues that must be considered in using and understanding psychiatric classification. DMS-IV is a practical and common sense nosology of psychiatric disorders that is intended to improve communication in clinical practice and in research studies. DSM-IV has no philosophic pretensions but does raise many philosophical questions. This paper describes the development of DSM-IV and the way in which it addresses a number of philosophic issues: nominalism vs. realism, epistemology in science, the mind/body dichotomy, the definition of mental disorders, and dimensional vs. categorical classification.

Interleukin-1 system in the materno-trophoblast unit in human implantation: immunohistochemical evidence for autocrine/paracrine function

Interleukin-1 receptor type I, IL-1 beta, IL-1 receptor antagonist, and human macrophages were immunohistochemically localized in the villous trophoblast, maternal-trophoblast interphase, and maternal decidua during early human implantation. Immunostaining for IL-1 receptor type I was present in the syncytiotrophoblast and hyperplastic endometrial glands in the maternal decidua. Immunoreactive IL-1 beta was present in the villous cytotrophoblast, syncytiotrophoblast, intermediate trophoblast, and maternal stromal decidual cells. IL-1 receptor antagonist staining was observed in the glandular endometrium of the maternal decidua and in isolated cells located inside the chorionic villi, intervillous space, and maternal decidua. Mature human macrophages, as defined by both CD/68+ and HAM56+, were present in the chorionic villi, maternal blood of intervillous space, and maternal decidua. Co-localization studies demonstrated that macrophages in all of the reported locations also stained for immunoreactive IL-1 beta. Our results show the shared presence in maternal and embryonic tissues of this receptor-agonist-antagonist system during early human implantation. This finding supports an autocrine/paracrine role for the IL-1 system in human implantation.

The effect of interleukin-1 beta (IL-1 beta) on the regulation of IL-1 receptor type I messenger ribonucleic acid and protein levels in cultured human endometrial stromal and glandular cells

Because we hypothesize that the interleukin-1 (IL-1) system may be important in the dialogue between mother and embryo during the implantation process, we have analyzed the effect of IL-1 beta, a secretory product of the human embryo and human endometrium, on the mRNA and protein levels of IL-1 receptor type I (IL-1R tI) in the human endometrium. For this purpose, endometrial epithelial cells (EEC) and stromal cells (ESC) were isolated and cultured with progesterone (3.18 micrograms/mL) and epidermal growth factor (20 ng/mL) for 8 days in the presence or absence of hrIL-1 beta (20 pg/mL). EEC from proliferative and secretory endometrium expressed high levels of IL-1R tI mRNA compared to ESC, and these levels were not modulated by IL-1 beta. However, prostaglandin E2 levels peaked on day 4 in EEC treated with progesterone, epidermal growth factor, and IL-1 beta (208.7 +/- 92 ng/10(7) cells), whereas no prostaglandin E2 was detectable in cells not treated with IL-1 beta, indicating that these cells responded to IL-1 beta. With regard to ESC from secretory endometrium, IL-1 beta increased its own receptor mRNA levels (4 +/- 0.5-fold increase) after 8 days in culture. However, when ESC were isolated from proliferative endometrium, an up-regulation of IL-1R tI (3.5 +/- 0.5-fold increase) was observed on days 6 and 8 of culture regardless of the presence or absence of IL-1 beta. Immunoreactive IL-1R tI was identified in cultured EEC and ESC, and patterns similar to those of mRNA were observed. The constitutive presence of IL-1R tI in EEC, which was not affected by IL-1 beta, and the up-regulation of IL-1R tI mRNA by its ligand IL-1 beta in ESC isolated during the luteal phase suggest a role for the IL-1 system in human implantation.

Embryonic implantation in mice is blocked by interleukin-1 receptor antagonist

We have investigated the relevance of interleukin-1 receptor type I (IL-1R tI) in the implantation process in vivo in a murine model. Indirect immunofluorescence experiments demonstrate that IL-1R tI is located in mouse endometrial lumenal epithelium with increased intensity in the periimplantation period, whereas IL-1 beta staining is located in the mouse placenta. PMSG/human CG (hCG)-stimulated and mated 12-week-old B6C3F-1 female mice were randomly allocated to three groups: A, control noninjected; B, buffer-injected animals; and C, animals injected ip with 20 micrograms recombinant human IL-1 receptor antagonist (rhIL-1ra) every 12 h beginning on pregnancy day 3. Injections were continued until day 9, and animals were killed 12 h after the last injection. Pregnancy rates in the three groups were: noninjected, 58.8% (10 of 17); buffer-injected, 73.7% (14 of 19); rhIL-1ra-injected, 6.7% (1 of 15), P = 0.0001155, Fisher exact test. To rule out the possibility that pregnancy failure was due to an embryotoxic effect of rhIL-1ra, 2-cell mouse embryos (n = 276) were flushed from the same group of animals used for in vivo experiments and cultured with increasing concentrations of rhIL-1ra: 0 microgram/ml (n = 91), 1 microgram/ml (n = 36), 50 micrograms/ml (n = 36), 100 micrograms/ml (n = 52), and 200 micrograms/ml (n = 61) rhIL-1ra. The percentages of 2-cell mouse embryos reaching the blastocyst stage after 72 h in culture were 85.7%, 91.6%, 94.4%, 96%, and 85.2%, respectively. We further cultured these blastocysts for 5 days on fibronectin-coated plates with or without 200 micrograms/ml rhIL-1ra. In both groups, hatching, attachment to fibronectin, outgrowth, and migration were documented to be similar. Furthermore, our longitudinal morphological study of embryonic implantation in control and rhIL-1ra-injected mice shows that the blockade of IL-1R tI interferes with the attachment of mouse blastocysts to maternal endometrium in vivo. In summary, we demonstrate that blockade of maternal endometrial IL-1R tI with IL-1ra prevents implantation in the mouse by interfering with embryonic attachment, without adverse effects on blastocyst formation, hatching, fibronectin attachment, outgrowth, and migration in vitro.

Immunohistochemical localization of the interleukin-1 system in the mouse ovary during follicular growth, ovulation, and luteinization

The distribution of immunoreactive interleukin-1 receptor type I (IL-1R tI), IL-1 alpha, and IL-1 beta, and of macrophages, was investigated immunohistochemically in the mouse ovary during follicular growth, ovulation, and luteinization. For this purpose, an indirect immunofluorescence technique, using specific monoclonal antibodies against mouse IL-1R tI, mouse IL-1 alpha, IL-1 beta, and macrophage antigens (CD11b/CD18) was used with sections of paraffin-embedded ovaries from eCG and eCG/hCG-treated 12-wk-old B6C3F-1 female mice. During follicular development, IL-1 alpha, IL-1 beta, and IL-1R tI staining were confined to the theca-interstitial layer of growing follicles with one remarkable exception. Intense IL-1R tI still staining was present in the cytoplasm and plasma membrane of the murine oocyte. During ovulation, IL-1 alpha and IL-1 beta were still confined to the theca layer, but faint IL-1R tI staining was initiated in cumulus cells and in granulosa cells just before follicle rupture. Immediately after follicle rupture, granulosa cells stained positive for IL-1R tI, IL-1 alpha, and IL-1 beta. During luteinization, granulosa-luteal cells of the corpus luteum demonstrated strong IL-1R tI, IL-1 alpha, and IL-1 beta staining. Macrophages were detected in the theca layer and stroma, but never within the follicle before ovulation. Immediately after ovulation, there was a rapid entry of macrophages into the follicle, and macrophages were also present inside the corpus luteum. Our morphological results support a possible autocrine-paracrine role of the mouse ovarian IL-1 system in ovulation and luteinization.

Rating of medication influences (ROMI) scale in schizophrenia

Noncompliance with neuroleptic treatment is a major barrier to delivery of effective treatment for schizophrenia outpatients. This article describes the development of a standardized measure for the assessment of attitudinal and behavioral factors influencing patient compliance with neuroleptic treatment. The Rating of Medication Influences (ROMI) scale was developed as part of a longitudinal study of neuroleptic noncompliance in schizophrenia and administered to 115 discharged schizophrenia outpatients. Analyses of the following were conducted to assess the scale's psychometric properties: (1) interrater reliability, (2) internal consistency, (3) principal components, (4) correlation with other subjective measures, and (5) correlation with independent family reports. Most (95%) of the ROMI patient-report items were reliable, whereas rater-judgment items were not reliable. The rater section was dropped. A principal components analysis of the reliable patient-report items yielded three subscales related to compliance (Prevention, Influence of Others, and Medication Affinity) and five subscales related to noncompliance (Denial/Dysphoria, Logistical Problems, Rejection of Label, Family Influence, and Negative Therapeutic Alliance). There were significant correlations between these subscales, and independently obtained family-report ROMI items were significant. The Denial/Dysphoria subscale correlated strongly with two other published measures of dysphoric response to neuroleptics, whereas the other noncompliance subscales did not. The ROMI is a reliable and valid instrument that can be used to assess the patient's subjective reasons for medication compliance and non-compliance. The subscale findings suggest that the ROMI provides a more comprehensive data base for patient-reported compliance attitudes than the other available subjective measures. Indications for use of the ROMI and other subjective measures of neuroleptic response are reviewed.

Crisis intervention in depressed patients with and without DSM-III-R personality disorders

We compared the relationships between response to a crisis intervention program and long-term outcome in 31 depressed outpatients with and without DSM-III-R personality disorders (PD). The presence of PD predicted a poorer 2-year outcome. PD subjects with better working alliance and increased insight at termination of crisis intervention had increased compliance with long-term psychiatric treatment (p < .005) and better 2-year outcome (p < .005). Increased compliance with long-term psychiatric treatment predicted better long-term outcome in PD patients (p < .005). None of these significant relationships was observed in the comparison group without PD, suggesting that establishing an effective treatment process may be especially important for outcome in PD patients.

Immunocytochemical localization of transforming growth factor-alpha and epidermal growth factor receptor in human fallopian tubes and cumulus cells

PROBLEM

Transforming growth factor-alpha (TGF-alpha) has been shown to be a potent stimulant of oocyte maturation and embryonic development. The role of maternal growth factors and their mechanism of action in early mammalian development is not well understood.

METHOD

In this study, the presence of TGF-alpha and epidermal growth factor receptor (EGF-R) in human cumulus cells and fallopian tubes was investigated by immunocytochemical techniques.

RESULTS

The fallopian tube showed intense staining for TGF-alpha in the apical region of the epithelial cells, and the cumulus cells showed intense staining for EGF-R on cell membranes.

CONCLUSION

The presence of TGF-alpha in the fallopian tube epithelium and its receptor on cumulus cells suggest a paracrine mechanism between maternal growth factors and the developing embryo.

Localization of interleukin-1 type I receptor and interleukin-1 beta in human endometrium throughout the menstrual cycle

Previous studies in the human suggest that the interleukin-1 (IL-1) system, may be an important paracrine/autocrine mediator in local intercellular interaction in endometrial tissue. In this study we have determined that IL-1 receptor type I (IL-1R tI) is expressed at the messenger RNA (mRNA) and protein levels in glandular cells and its ligand, IL-1 beta has been localized by immunohistochemical methods in endothelial cells and isolated stromal cells in the human endometrium throughout the menstrual cycle. IL-1R tI mRNA was detected in glandular epithelium using both specific complementary DNA and complementary RNA 32P-labeled probes. Human glandular epithelium contains a 5.1-kilobase mRNA transcript throughout the complete menstrual cycle. Quantitative densitometric analysis of slot blot hybridization signals shows an increase of IL-1R tI mRNA in both early and mid-late secretory phases in comparison with the proliferative phase (P < 0.05). IL-1R tI protein was localized in endometrial glandular epithelial cells using both indirect immunofluorescence and avidin-biotin-peroxidase methods. However, more intense staining for IL-1R tI was observed in lumenal epithelial cells compared with the staining present deep in the endometrial glands. Using the same methods, IL-1 beta was detected in endothelial cells of spiral vessels and isolated stromal cells throughout the menstrual cycle, and an increased staining from proliferative to secretory phase was observed. The detection of IL-1R tI in the human endometrial epithelium and its ligand, IL-1 beta, in isolated stromal cells and endothelial cells, is another example of possible communication between the immune and reproductive systems with special relevance to human implantation.

Severity of psychiatric symptoms after HIV testing

OBJECTIVE

The authors were interested in the psychiatric effects of serological testing for HIV and what information feasibly available at intake might predict more severe psychiatric symptoms 1 year later.

METHOD

HIV testing in a private office setting was offered to adults at perceived risk for HIV infection but without AIDS. At entry, then 6 and 12 months later, subjects were counseled by psychiatric nurses and assessed by the Hamilton Rating Scale for Depression, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory, and Brief Symptom Inventory.

RESULTS

Mean scores on all measures of psychiatric symptoms were lower at follow-up among both 106 HIV-positive and 222 HIV-negative adults. One year after HIV testing, 121 (37%) of the 328 subjects had scores associated with psychopathology. These elevated scores were not predicted by serostatus but by initial psychopathological scores (N = 150), annual income less than +15,000 (N = 114), being female (N = 46), and history of injection drug use (N = 32) and heterosexual risk factors (N = 60) as compared to males having sex with males (N = 236).

CONCLUSIONS

Before the development of more severe physical symptoms, on average, knowledge of HIV infection does not increase psychiatric morbidity; however, regardless of serostatus, a notable percentage of at-risk adults have sustained high levels of psychiatric symptoms. Counseling during the HIV testing process provides an opportunity to identify these individuals for closer study and indicated psychiatric treatment.

Development of diagnostic criteria for headache syndromes: lessons from psychiatry

This paper reviews the development of diagnostic criteria for the psychiatric disorders in order to provide a model for the development of classification of headache. The strengths and weaknesses of the current psychiatric classification system, and procedures that have been instituted to strengthen the next version of the classification are described. The problems that characterized the successive versions of the criteria are highlighted in order to stimulate future developments of diagnostic criteria for headache syndromes. Recommendations for application of these principles to headache classification are presented.

Interleukin-1 type I receptor messenger ribonucleic acid expression in human endometrium throughout the menstrual cycle

OBJECTIVE

To investigate the messenger ribonucleic acid (mRNA) expression of interleukin-1 (IL-1) type I receptor in the endometrial tissue of normal patients during the menstrual cycle.

DESIGN

Prospective longitudinal study.

SETTING

Department of Obstetrics and Gynecology, Stanford University Medical Center, Stanford, California.

PATIENTS

Twenty fertile women between 19 and 41 years of age underwent hysterectomy for benign reasons (n = 9) and laparoscopy for tubal ligation (n = 11). In all cases, endometriosis was not visualized.

INTERVENTIONS

Endometrial biopsy using the Novak curette was obtained at the time of surgery.

MAIN OUTCOME MEASURE

Total RNA extracted from unfractioned endometrial tissue was analyzed on Northern blots by using specific complementary deoxyribonucleic acid probes.

RESULTS

We found IL-1 type I receptor mRNA expression in endometrial tissue throughout the entire menstrual cycle. However, IL-1 type I receptor mRNA levels were significantly higher during both early and late luteal phases than follicular and midluteal phases.

CONCLUSIONS

Our results demonstrate the presence of the IL-1 system in the human endometrium and that the receptor is regulated throughout the menstrual cycle with a 4.1-fold increased expression of the IL-1 receptor gene in the early luteal phase compared with preovulatory endometrium.

Panniculitis and fever in children

We describe three children with panniculitis and associated systemic manifestations including fever. Histopathologic features, such as the presence of lobular or septal inflammation, presence of vasculitis, character of the cellular infiltrate, and presence of erythrophagocytosis, were useful in classifying this group of panniculitides. In one patient with subcutaneous polyarteritis nodosa, corticosteroid therapy was effective; in two other patients with histiocytic cytophagic panniculitis, there were poor responses to steroids, intravenously administered immune globulin, dapsone, or antimalarial drugs; cyclosporine was very effective and appeared to be the drug of choice.