Initial reliability and validity of a new retrospective measure of child abuse and neglect

OBJECTIVE

This report presents initial findings on the reliability and validity of a new retrospective measure of child abuse and neglect, the Childhood Trauma Questionnaire.

METHOD

Two hundred eighty-six drug- or alcohol-dependent patients were given the Childhood Trauma Questionnaire as part of a larger test battery, and 40 of these patients were given the questionnaire again after an interval of 2 to 6 months. Sixty-eight of the patients were also given a structured interview for child abuse and neglect, the Childhood Trauma Interview, that was developed by the authors.

RESULTS

Principal-components analysis of responses on the Childhood Trauma Questionnaire yielded four rotated orthogonal factors: physical and emotional abuse, emotional neglect, sexual abuse, and physical neglect. Cronbach's alpha for the factors ranged from 0.79 to 0.94, indicating high internal consistency. The Childhood Trauma Questionnaire also demonstrated good test-retest reliability over a 2- to 6-month interval (intraclass correlation = 0.88), as well as convergence with the Childhood Trauma Interview, indicating that patients' reports of child abuse and neglect based on the Childhood Trauma Questionnaire were highly stable, both over time and across type of instruments.

CONCLUSIONS

These findings provide strong initial support for the reliability and validity of the Childhood Trauma Questionnaire.

Replacing the complementarity-determining regions in a human antibody with those from a mouse

The variable domains of an antibody consist of a beta-sheet framework with hypervariable regions (or complementarity-determining regions--CDRs) which fashion the antigen-binding site. Here we attempted to determine whether the antigen-binding site could be transplanted from one framework to another by grafting the CDRs. We substituted the CDRs from the heavy-chain variable region of mouse antibody B1-8, which binds the hapten NP-cap (4-hydroxy-3-nitrophenacetyl caproic acid; KNP-cap = 1.2 microM), for the corresponding CDRs of a human myeloma protein. We report that in combination with the B1-8 mouse light chain, the new antibody has acquired the hapten affinity of the B1-8 antibody (KNP-cap = 1.9 microM). Such 'CDR replacement' may offer a means of constructing human monoclonal antibodies from the corresponding mouse monoclonal antibodies.

Antibody framework residues affecting the conformation of the hypervariable loops

Rodent monoclonal antibodies have been "humanized" or "reshaped" for therapy by transplanting the antigen-binding loops from their variable domains onto the beta-sheet framework regions of human antibodies. However, additional substitutions in the human framework regions are sometimes required for high affinity antigen binding. Here we describe antigen binding by a reshaped antibody derived from the mouse anti-lysozyme antibody D1.3, and several variants in which point mutations had been introduced into framework positions to improve its affinity. The affinities were determined from the relaxation kinetics of reactant mixtures using quenching of fluorescence that occurs upon formation of the antibody-antigen complex. The dissociation constant of lysozyme ranged from 3.7 nM (for D1.3) to 260 nM. Measurement of antibody-antigen association kinetics using stopped-flow showed that D1.3 and most of the reshaped antibodies had bimolecular rate constants of 1.4 x 10(6) s-1 M-1, indicating that differences in equilibrium constant were predominantly due to different rates of dissociation of lysozyme from immune complexes. Mutations in a triad of heavy chain residues, 27, 29 and 71, contributed 0.9 kcal/mol in antigen binding free energy, and a Phe to Tyr substitution of light chain residue 71 contributed an additional 0.8 kcal/mol. The combined effect of all these mutations brought the affinity of the reshaped antibody to within a factor of 4 of D1.3. All of these substitutions were in the beta-sheet framework closely underlying the complementarity-determining regions, and do not participate in a direct interaction with antigen. The informed selection of residues in such positions may prove essential for the success of loop transplants in antibodies. Variation of these sites may also have a role in shaping the diversity of structures found in the primary repertoire, and in affinity maturation.

Initial reliability and validity of the childhood trauma interview: a new multidimensional measure of childhood interpersonal trauma

OBJECTIVE

The Childhood Trauma Interview, a new instrument for brief and comprehensive retrospective assessment of childhood interpersonal trauma, is presented with initial evidence of its reliability and validity.

METHOD

Drug- or alcohol-dependent patients (N = 220) were given the Childhood Trauma Interview and a questionnaire measure of child abuse, the Childhood Trauma Questionnaire. Convergent and discriminant validity for the Childhood Trauma Interview were tested by comparing correlations between analogous and nonanalogous trauma scales to those of the Childhood Trauma Questionnaire.

RESULTS

Interrater reliability for the majority of trauma dimensions measured by the Childhood Trauma Interview was very high (63% had intraclass correlations above 0.90). Principal-components analysis yielded six rotated factors that accounted for 74% of the variance among scores: separations and losses, physical neglect, emotional abuse or assault, physical abuse or assault, witnessing violence, and sexual abuse or assault. Since these six factors exactly represented the areas that the interview was designed to assess, the construct validity of the Childhood Trauma Interview was supported. Without exception, convergent correlations were significantly higher than discriminant correlations, and convergence was improved when multidimensional variables from the Childhood Trauma Interview and their interactions were regressed onto Childhood Trauma Questionnaire scores.

CONCLUSIONS

These initial findings suggest that the Childhood Trauma Interview is a reliable and valid method for brief assessment of multiple dimensions of six types of childhood interpersonal trauma.

Kinetic maturation of an immune response

Is the affinity maturation of antibodies under thermodynamic or kinetic control, or both? We compared the physical constants of hapten binding by antibodies from 2-phenyl-5-oxazolone-specific hybridomas from primary, secondary and tertiary responses. In addition to an increase in equilibrium constant, there was a shift in the antibody repertoire after the primary response towards an immunoglobulin family with an extremely high on-rate constant. This shift occurred in spite of the average or below-average affinity of this group of antibodies. This is consistent with B-lymphocyte proliferation being subject to a kinetic selection, with a premium on binding target antigens rapidly, in parallel with a thermodynamic selection based on binding tightly.

Conformational isomerism and the diversity of antibodies

The fact that one cell encodes a single antibody sequence does not necessarily mean that the resulting antibody folds into a single structure, although this is a common assumption. Here we challenge this view and suggest that many antibodies do not have a single conformation at the combining site. The basis for this proposal comes from the kinetic analysis of a set of murine hybridomas derived from defined stages of the immune response to 2-phenyl-5-oxazolone (Ox). Among them we have identified three antibodies that exhibit complex hapten-binding kinetics. We observed biphasic or triphasic reactions in stopped-flow fluorescence experiments, indicating that ligand binding involved isomerization, as well as associative steps. The existence of an equilibrium between at least two antibody conformations, with ligands binding preferentially to one form, was deduced from the variation with hapten concentration of the apparent rate of each phase.

Expression of an antibody Fv fragment in myeloma cells

The antigen binding site on antibodies is fashioned by loops at the tips of the beta-sheet framework of both heavy and light chain variable domains. A heterodimer of both variable domains (Fv fragment), incorporating loops from an anti-lysozyme antibody, was expressed and secreted from myeloma cells in good yield (8 mg/l in supernatant from roller bottles), and shown to bind lysozyme. The two subunits were found to be in dynamic equilibrium but are overwhelmingly associated at neutral pH. The small size of Fv fragments (25 x 10(3) Mr) make them attractive for structural studies, in vivo imaging, and therapy.

Polysubstance use among alcoholics

Contemporary alcoholics often use multiple substances, but there is little systematic research on this. This study examines the drug use comorbidity of alcoholics (DSM diagnosis, frequency and quantity of drug use); the relationship between drinking and drug use; the relative severity of alcohol- and drug-related problems; and the validity of reports of illicit drug use. Data on substance use were collected from 248 treatment-seeking alcoholics using an expanded Time-line Follow-Back (TLFB) interview. Self-reports of substance use were validated with data from biological specimens (urine and hair). Lifetime diagnosis of joint alcohol and drug dependence/abuse was 64%. Two-thirds (68%) reported using drugs in the past 90 days: 33% powder cocaine; 29% crack cocaine; 15% heroin, and 24% cannabis. The mean proportions of exposed days on which users reported consuming a substance were 57% (alcohol), 26% (powder cocaine), 46% (crack cocaine), 47% (heroin), and 29% (cannabis). Subjects reported consuming an average of 14 standard drinks on a drinking day and $67 worth of drugs on a using day. Drug users reported drinking less than nonusers on a drinking day. Frequency of drinking and drug use were positively correlated; almost all drug users reported simultaneous drinking and drug use; and they rated drugs as the bigger problem. Considerable under-reporting of drug use occurred for the previous 3-4 days, but was more accurate for the previous month.

Cost-effectiveness of public health strategies for COVID-19 epidemic control in South Africa: a microsimulation modelling study

Background

Health-care resource constraints in low-income and middle-income countries necessitate the identification of cost-effective public health interventions to address COVID-19. We aimed to develop a dynamic COVID-19 microsimulation model to assess clinical and economic outcomes and cost-effectiveness of epidemic control strategies in KwaZulu-Natal province, South Africa.

Methods

We compared different combinations of five public health interventions: health-care testing alone, where diagnostic testing is done only for individuals presenting to health-care centres; contact tracing in households of cases; isolation centres, for cases not requiring hospital admission; mass symptom screening and molecular testing for symptomatic individuals by community health-care workers; and quarantine centres, for household contacts who test negative. We calibrated infection transmission rates to match effective reproduction number (R_e) estimates reported in South Africa. We assessed two main epidemic scenarios for a period of 360 days, with an R_e of 1·5 and 1·2. Strategies with incremental cost-effectiveness ratio (ICER) of less than US$3250 per year of life saved were considered cost-effective. We also did sensitivity analyses by varying key parameters (R_e values, molecular testing sensitivity, and efficacies and costs of interventions) to determine the effect on clinical and cost projections.

Findings

When R_e was 1·5, health-care testing alone resulted in the highest number of COVID-19 deaths during the 360-day period. Compared with health-care testing alone, a combination of health-care testing, contact tracing, use of isolation centres, mass symptom screening, and use of quarantine centres reduced mortality by 94%, increased health-care costs by 33%, and was cost-effective (ICER $340 per year of life saved). In settings where quarantine centres were not feasible, a combination of health-care testing, contact tracing, use of isolation centres, and mass symptom screening was cost-effective compared with health-care testing alone (ICER $590 per year of life saved). When R_e was 1·2, health-care testing, contact tracing, use of isolation centres, and use of quarantine centres was the least costly strategy, and no other strategies were cost-effective. In sensitivity analyses, a combination of health-care testing, contact tracing, use of isolation centres, mass symptom screening, and use of quarantine centres was generally cost-effective, with the exception of scenarios in which R_e was 2·6 and when efficacies of isolation centres and quarantine centres for transmission reduction were reduced.

Interpretation

In South Africa, strategies involving household contact tracing, isolation, mass symptom screening, and quarantining household contacts who test negative would substantially reduce COVID-19 mortality and would be cost-effective. The optimal combination of interventions depends on epidemic growth characteristics and practical implementation considerations.

Funding

US National Institutes of Health, Royal Society, Wellcome Trust.

A group motivational treatment for chemical dependency

Patient "motivation" has been implicated as a critical component in addiction treatment outcomes. To date, treatments utilizing motivational elements have been conducted as individual interventions. We describe the development of a Group Motivational Intervention (GMI), a four-session, manual-driven group approach that employs key hypothesized motivational elements. These include the six motivational elements derived by Miller and Sanchez (1994) from successful alcoholism treatments, described with the acronym, FRAMES (feedback, responsibility, advice, menu of options, empathy, and self-efficacy). GMI is additionally informed by concepts derived from "self-determination theory" (Deci & Ryan, 1985), concerned with understanding motivation as either internal/autonomous or external/controlled. Evidence indicates that people will value and persist longer in behaviors that they perceive as autonomously motivated. GMI techniques utilize the interpersonal factors found to be autonomy-supportive in self-determination theory. Preliminary results from a randomized clinical trial suggest that key motivational processes are affected by GMI: patients perceive the GMI environment and group leader as significantly more "autonomy supportive" than treatment "as usual."

Homotropic effects in aspartate transcarbamoylase. What happens when the enzyme binds a single molecule of the bisubstrate analog N-phosphonacetyl-L-aspartate?

The active sites of aspartate transcarbamoylase from Escherichia coli were titrated by measuring the decrease in the enzyme-catalyzed arsenolysis of N-carbamoyl-L-aspartate caused by the addition of the tight-binding inhibitor, N-phosphonacetyl-L-aspartate. Because the enzyme is a poor catalyst for this non-physiological reaction, high concentrations are required for the assays (more than 1000-fold the dissociation constant of the reversibly bound inhibitor) and, therefore, virtually all of the bisubstrate analog is bound. From the endpoint of the titration, 5.7 active sites were calculated, in excellent agreement with the number, six, based on the structure of the enzyme. Simple inhibition was observed only when the molar ratio of inhibitor to enzyme exceeded five; under these conditions, as shown in earlier physical chemical studies, the R-conformational state of the enzyme is the sole or predominant species. At low ratios of inhibitor to enzyme, the addition of inhibitor caused an increase in activity which is attributable to the conversion of the enzyme from the low-activity T-state to the much more active R-state. Comparison of the linear increase in activity as a function of inhibitor concentration at the low molar ratio (0.01, i.e. 1 inhibitor/600 active sites) with the activity lost at the high ratio provided a direct value for the mean number of active sites converted from the T-state to the R-state as a result of the binding of one bisubstrate analog to an enzyme molecule. This number was four with Mg X ATP or carbamoyl phosphate present and 4.7 for the enzyme in the presence of Mg X PPi, values approaching or identical to the theoretical maximum, 4.7, for a concerted transition with all of the active sites of the molecule changing from the T- to R-state upon the formation of a binary complex of hexameric enzyme with a single inhibitor. With the enzyme in the absence of effectors or with Mg X CTP present, the titrations showed that an average of two and one sites, respectively, of 4.7 possible, changed conformation upon ligand binding. These results were interpreted as a manifestation of an equilibrium between a sub-population of T- and R-state enzyme complexes containing one bound inhibitor molecule. The R-state species would represent 40% of the population for aspartate transcarbamoylase in the absence of extraneous ligands.(ABSTRACT TRUNCATED AT 400 WORDS)

Hyperinsulinemia, coronary artery disease and syndrome X

OBJECTIVES

This study was conducted to compare the insulin responses to an oral glucose load in healthy volunteers and patients with syndrome X and patients with coronary artery disease.

BACKGROUND

An abnormal coronary flow reserve has been reported in syndrome X by several investigators. However, its cause is not known. Recently, it has been suggested that elevated insulin levels in syndrome X may contribute to microvascular dysfunction.

METHODS

Insulin responses to an oral glucose load (75 g) were compared in 17 patients with coronary artery disease, 17 patients with chest pain, positive exercise test findings, normal coronary arteries and impaired coronary flow reserve (syndrome X) and 17 healthy volunteers (control subjects). All were matched for age, gender and body weight. Patients with overt diabetes mellitus or hypertension were excluded. Venous blood samples were taken during fasting and at 30, 60, 90 and 120 min after the glucose load. Samples were analyzed for glucose, immunoreactive insulin and C peptides.

RESULTS

There was no significant difference in the glucose levels at all sampling points among the three groups. The C peptide and immunoreactive insulin levels were significantly higher than values in the control group at 60, 90 and 120 min in the groups with syndrome X and coronary artery disease. The peak responses and the areas under the curve were also significantly greater in the latter two groups. There was no significant difference at all sampling points between the group with syndrome X and the group with coronary artery disease.

CONCLUSION

Patients with syndrome X have stimulated hyperinsulinemia, which may contribute to the pathophysiology of syndrome X.

Comparison of the hemodynamic and metabolic effects of low-dose hydrochlorothiazide and lisinopril treatment in obese patients with high blood pressure

Patients with high blood pressure tend to be insulin resistant, glucose intolerant, hyperinsulinemic, and dyslipidemic. Since these metabolic defects are accentuated by obesity, we thought it important to compare the effects of 3 months' treatment with either lisinopril (20 mg/day) or low dose hydrochlorothiazide (12.5 mg/day) on blood pressure and glucose, insulin, and lipoprotein metabolism in obese patients with hypertension. There were 14 patients in each group, and they were similar (mean +/- SE) in age (54 +/- 3 v 50 +/- 4 years), gender (nine men/five women), and body mass index (33.4 +/- 0.8 v 33.9 +/- 0.9 kg/m2). Patients treated with lisinopril had a somewhat greater fall in both systolic (18 +/- 3 v 10 +/- 3 mm Hg) and diastolic (12 +/- 2 v 8 +/- 1 mm Hg) blood pressure, but only the change in systolic pressure was statistically significant (P < .05). Plasma glucose, insulin, and triglyceride concentrations were measured at hourly intervals from 8 AM to 4 PM (breakfast at 8 AM and lunch at 12 PM), and there was a modest increase in all three variables following hydrochlorothiazide treatment (P < .05 to P < .09). However, daylong plasma glucose, insulin, and triglyceride concentration did not change with lisinopril treatment. Finally, neither the ability of insulin to mediate glucose disposal nor fasting lipid and lipoprotein concentrations, changed with either treatment. In conclusion blood pressure decreased significantly following treatment with either lisinopril (20 mg/day) or hydrochlorothiazide (12.5 mg/day).(ABSTRACT TRUNCATED AT 250 WORDS)

Removal of UroLume endoprosthesis: experience of the North American Study Group for detrusor-sphincter dyssynergia application

PURPOSE

We present the experience of the North American UroLume Multicenter Study Group with removal of the UroLume endoprosthesis.

MATERIALS AND METHODS

A total of 160 neurologically impaired patients were enrolled in the North American UroLume Multicenter Study Group for detrusor external sphincter dyssynergia application. Analysis was performed in 2 groups of patients in which the device was removed during insertion and after implantation, respectively.

RESULTS

Device retrieval was required during insertion in 21 patients (13%) mainly due to misplacement or migration in 17. Extraction was done with minimal complications and in all but 2 cases subsequent UroLume implantation was successful. Of 158 men with the device in place 31 (19.6%) required removal. In 34 procedures 44 devices were removed, mainly due to migration. Time from implantation to removal ranged from 4 days to 66 months (mean 22 months). The UroLume was removed en bloc in 20 cases and in parts or wire by wire in 19. The majority of patients had no or minimal complications after extraction. Only 2 patients had serious temporary complications, including bleeding and urethral injury, with no lasting consequences. No malignancy developed as a result of UroLume insertion.

CONCLUSIONS

While there is a potential for urethral injury and bleeding, UroLume endoprosthesis removal is largely a simple procedure with minimal complications and consequences.

Patients' perspective on the process of change in substance abuse treatment

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patient's view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.

Enhanced treatment outcomes for cocaine-using methadone patients

Cocaine dependent methadone patients were randomly assigned to 6 months of high intensity cognitive-behavioral therapy or low intensity therapy. A repeated measures ANOVA was conducted with patients stratified on severity of cocaine use at baseline. Both treatment groups showed significant and equivalent reductions in cocaine use during the post-treatment period. Completing either therapy and lower cocaine severity at baseline were associated with lower proportion of cocaine-positive urines across a 48-week post-treatment period. Examination of the treatment x cocaine severity interaction provided some evidence that high-severity patients improved more if exposed to high intensity treatment than to low intensity treatment. Positive outcomes for therapy completers relative to non-completers increased over time. The results are consistent with several clinical trials showing that: (1) participation in treatment is associated with reductions in cocaine use; and (2) the relationship between treatment intensity and outcome is not linear and may better be explained by an interaction between patient and treatment factors.

Gender differences in psychiatric comorbidity among cocaine-using opiate addicts

Psychiatric comorbidity was examined for a sample of 212 methadone patients dually addicted to opiates and cocaine, focusing on gender differences. Diagnoses were determined by the SCID for DSM-III-R. Men displayed more lifetime (but not current) substance use disorders, while women displayed more lifetime and current non-substance use disorders. There were several significant interactions among psychiatric disorders and gender. Women were more likely than men to present with concurrent mood and anxiety disorders. Women with ASPD were unlikely to have alcohol use disorder, but likely to have opioid use disorder. Men with anxiety were likely to be diagnosed with ASPD. Treatment implications of the findings are discussed.

Conformational correction mechanisms aiding antigen recognition by a humanized antibody

The crystal structure of the complex between hen egg lysozyme and the Fv fragment of a humanized antilysozyme antibody was determined to 2.7-A resolution. The structure of the antigen combining site in the complex is nearly identical to that of the complexed form of the parent mouse antibody, D1.3. In contrast, the combining sites of the unliganded mouse and humanized antilysozymes show moderate conformational differences. This disparity suggests that a conformational readjustment process linked to antigen binding reverses adverse conformations in the complementarity determining regions that had been introduced by engineering these segments next to human framework regions in the humanized antibody.

Early events in stricture formation in the guinea pig urethra

The early stages of urethal stricture formation have been examined by light and electron microscopy after injury of the anterior urethra in the guinea pig. It was found that initially an ulcerated surface formed which was subsequently covered by simple then stratified squamous epithelium. The tissue of the stricture contained elongated myofibroblasts and clumps of multinucleated giant cells. It is suggested that the myofibroblasts are responsible for the formation of the stricture and that the giant cells may be involved in continued collagen synthesis.

Neurobehavioral treatment for cocaine-using methadone patients: a preliminary report

Preliminary outcome evaluation results are reported for an innovative cocaine abuse treatment model adapted for cocaine-using methadone patients. Sixty-two patients were randomly assigned to six months of high intensity ("neurobehavioral") or lower intensity ("control") therapy for cocaine dependence. Therapy was completed by 49% of neurobehavioral and 53% of control patients. In paired comparisons between intake and six-month follow-up, neurobehavioral patients but not controls showed significant declines in cocaine and other drug use (measured by urinalysis and self-reports), as well as significant improvement in psychological status. The findings suggest that specialized cocaine abuse treatment can benefit methadone patients; intake to the study is continuing.