Psychosocial rehabilitation in schizophrenia: beginnings in acute hospitalization

Schizophrenic patients discharged from acute inpatient settings are often unprepared to function outside the hospital, leading to recidivism and frequent rehospitalization. Social skills training programs addressing this need have hitherto only been developed for use in outpatient or long-term inpatient settings. We describe the development of a social skills training program for application in a short-term acute inpatient unit. Nursing coordinates the program, which is designed for a 3 to 4 week hospitalization and is delivered in an open group setting. The training program emphasizes communication skills, problem solving, affect identification, needs recognition, and social relatedness. The program uses group discussions, writing tasks, physical activity, education, role-play, feed-back, and assignments. Goals include assessment of individual deficits, inculcation of awareness that life-objectives can be identified and achieved, assistance with transition to postdischarge living situation or outpatient treatment program, and development of awareness of one's roles and responsibilities. The evolution and present structure of the program are described and four representative lessons are detailed.

Variation in course of hepatitis E in experimentally infected cynomolgus monkeys

Five cynomolgus monkeys (Macaca fascicularis) developed hepatitis after inoculation with a prototype strain of hepatitis E virus (HEV) from Pakistan. Although all 5 monkeys displayed liver enzyme elevations, viremia, virus secretion in feces, and seroconversion, two different patterns of these parameters were observed. For 4 monkeys, increased alanine aminotransferase (ALT) activity was first observed on days 21-26, viremia occurred before and during enzyme elevation, and the animals seroconverted coincidentally with the end of viremia or shortly thereafter. One of these monkeys had a more severe hepatitis, with peak ALT values more than twice the peak levels of the other monkeys. The fifth monkey developed biphasic hepatitis with peaks of ALT activity on days 26 and 54. In this case, viremia and seroconversion were correlated only with the second peak of enzyme elevation and liver histopathology only with the first peak. Viral shedding in this fifth animal lasted two times longer than in other animals.

Accidental dural puncture in obstetric patients and long term symptoms

OBJECTIVE

To examine the association between accidental dural puncture and long term headache and related symptoms.

DESIGN

Postal questionnaire survey to elucidate new symptoms occurring after childbirth, and linking of these to data in obstetric and anaesthetic case notes. Women were surveyed between 13 months and nine years after delivery.

SETTING

Birmingham Maternity Hospital.

SUBJECTS

4700 women who had delivered their most recent baby under epidural anaesthesia, 74 of whom had suffered an accidental dural puncture.

MAIN OUTCOME MEASURES

Frequencies of new headache or migraine or neck ache starting within three months after childbirth and lasting over six weeks.

RESULTS

Among the 74 women who had had an accidental dural puncture there were 17 (23%) who reported one or more of the above symptoms. By comparison, among those who had had an epidural anaesthetic but no recorded puncture, only 329 (7.1%) reported these symptoms. The duration of the headache or migraine or neck ache in the dural tap group ranged from nine weeks to over eight years. Ten of these women reported still unresolved symptoms.

CONCLUSIONS

Conclusions on causality were tentative. Most women would remember a dural tap, and this might influence their reporting of subsequent symptoms attributable to the event. In addition, detailed characterisation of the symptoms was not available. Nevertheless, the findings provide a clear indication of the need for further study of the possible long term sequelae of accidental dural puncture.

Tubular carcinoma of the breast: mammographic appearance

OBJECTIVE

Tubular carcinoma of the breast is an uncommon malignant growth that can have subtle mammographic findings. Tubular carcinoma is usually found incidentally during screening mammography. It can be differentiated from conventional breast cancers by its smallness and the lack of palpable findings on physical examination of the breast. The mammographic findings in patients with pure tubular carcinoma (90% tubular formation or greater on histologic examination) have not been reported in the recent radiologic literature.

MATERIALS AND METHODS

We reviewed the mammographic and sonographic findings and clinical histories of 13 patients with biopsy-proved pure tubular carcinoma. Findings on physical examination of the breast were normal in nine patients.

RESULTS

On mammograms, 11 of the 13 tubular carcinomas appeared as small (1.7-cm diameter or less) spiculated masses. The average tumor diameter measured on mammograms was 0.8 cm in patients with normal results of physical examination of the breasts and 1.2 cm in patients with a palpable mass. In two patients, mammography showed suspicious microcalcifications or normal findings. Sonography was performed in three patients and results were normal.

CONCLUSION

Tubular carcinoma of the breast manifests mammographically as a small spiculated mass. Because of their smallness, tubular carcinomas can be differentiated from other forms of infiltrating ductal carcinoma on mammograms. Tubular carcinomas are most frequently found incidentally at screening mammography. With the growing emphasis on screening mammography, an increase in the detection of this form of breast cancer can be expected.

A symmetric inhibitor binds HIV-1 protease asymmetrically

Potential advantages of C2-symmetric inhibitors designed for the symmetric HIV-1 protease include high selectivity, potency, stability, and bioavailability. Pseudo-C2-symmetric monools and C2-symmetric diols, containing central hydroxymethylene and (R,R)-dihydroxyethylene moieties flanked by a variety of hydrophobic P1/P1' side chains, were studied as HIV-1 protease inhibitors. The monools and diols were synthesized in 8-10 steps from D-(+)-arabitol and D-(+)-mannitol, respectively. Monools with ethyl or isobutyl P1/P1' side chains were weak inhibitors of recombinant HIV-1 protease (Ki > 10 microM), while benzyl P1/P1' side chains afforded a moderately potent inhibitor (apparent Ki = 230 nM). Diols were 100-10,000x more potent than analogous monools, and a wider range of P1/P1' side chains led to potent inhibition. Both classes of compounds exhibited lower apparent Ki values under high-salt conditions. Surprisingly, monool and diol HIV-1 protease inhibitors were potent inhibitors of porcine pepsin, a prototypical asymmetric monomeric aspartic protease. These results were evaluated in the context of the pseudosymmetric structure of monomeric aspartic proteases and their evolutionary kinship with the retroviral proteases. The X-ray crystal structure of HIV-1 protease complexed with a symmetric diol was determined at 2.6 A. Contrary to expectations, the diol binds the protease asymmetrically and exhibits 2-fold disorder in the electron density map. Molecular dynamics simulations were conducted beginning with asymmetric and symmetric HIV-1 protease/inhibitor model complexes. A more stable trajectory resulted from the asymmetric complex, in agreement with the observed asymmetric binding mode. A simple four-point model was used to argue more generally that van der Waals and electrostatic force fields can commonly lead to an asymmetric association between symmetric molecules.

Evaluation of obstetric analgesia and anaesthesia: long-term maternal recollections

Opinions about pain relief were sought from a sample of 11,701 women 13 months to 9 years after giving birth. Their opinions related both to levels of satisfaction with the particular forms of pain relief used and to the presence of any feelings of deprivation of the birth process. Of all forms of pain relief examined epidural anaesthesia was associated with the highest levels of satisfaction. In vaginal deliveries, 69.4% of those who had an epidural were fully satisfied, compared with 29.5% for inhalation analgesia, 20.7% for pethidine and 29.4% for relaxation techniques. Women who had spontaneous deliveries and shorter labours were least satisfied with their epidurals, while the reverse was generally true for the other forms of pain relief. After an epidural for vaginal delivery 7.1% of women reported feelings of deprivation of the full pleasure of childbirth. This was higher than the 1.4% previously reported by women in the same maternity unit when questioned immediately after the delivery,(1) but still only represents a minority of women. After an emergency caesarean section administered under epidural feelings of deprivation were expressed by 5.1%, but by only 1.7% after an elective section under epidural. Among women using pethidine 3.5% felt that this had deprived them of the pleasure of giving birth.

Erythropoietin levels in amniotic fluid and extraembryonic coelomic fluid in the first trimester of pregnancy

OBJECTIVE

The aim was to measure erythropoietin levels in amniotic fluid and extraembryonic coelomic fluid from 7-12 weeks' gestation.

SUBJECTS

Twenty healthy women with ultrasonographically normal first trimester pregnancies prior to surgical termination.

METHODS

Paired samples of amniotic fluid and extraembryonic coelomic fluid were collected by transvaginal ultrasound guided needling. Erythropoietin was measured in both pregnancy fluids using a radioimmunoassay.

RESULTS

There was a highly significant difference between erythropoietin levels in extraembryonic coelomic fluid (median level 15.45 mU/ml; range 6.8-32.1 mU/ml) and those in amniotic fluid (median 5.0 mU/ml; range < 5.0-5.8 mU/ml) (P < 0.0001; Mann-Whitney U-test). The levels of erythropoietin in maternal serum (median 15.4 mU/ml; range 5.6-29.4 mU/ml) were similar to those in the extra-embryonic coelom (P = 0.81; Mann-Whitney U-test). No relation was demonstrated between erythropoietin levels in amniotic fluid or coelomic fluid and stage of gestation.

CONCLUSION

High levels of erythropoietin in coelomic fluid suggests that the hormone is involved in the process of human extraembryonic erythropoiesis. The exact regulatory role remains unknown.

Vertebral osteomyelitis following manipulation of spondylitic necks--a possible risk

Neurological complications of neck manipulation are well recognised but are usually due to acute vascular incidents. However, we describe two patients with cervical spondylosis, who developed staphylococcal osteomyelitis of the cervical spine with progressive tetraplegia, apparently following manipulation of the neck by a chiropractor. Although it is possible that the manipulation resulted in cervical spine trauma sufficient to cause local haemorrhage, the area becoming a nidus for infection, it is also conceivable that the patients underwent neck manipulation in an attempt to relieve pain due to an already existing osteomyelitis of the cervical spine, and the manipulation may have hastened the onset of spinal cord paralysis. Clearly, this could have occurred, as the average time between the onset of symptoms and diagnosis of vertebral osteomyelitis in most published series is about 2 months. Approximately 80% of cases of osteomyelitis occur in the 50-70 age group, a group in which cervical spondylosis is extremely common. It would seem that neck manipulation is particularly contraindicated in older patients with cervical spondylosis.

A serologic relationship among the NFLD, BOW, and Wu red cell antigens

A survey of sera containing antibodies to multiple low-incidence antigens revealed a variety of patterns of reactions with NFLD+, BOW+, and Wu+ red cell samples. Although NFLD, BOW, and Wu are distinct antigenic determinants (International Society of Blood Transfusion numbers 700.37, 700.46, and 700.13, respectively), their ability to absorb and elute "crossreactive" antibodies indicates a serologic and possibly a genetic relationship among the three.

cDNA clone of hepatitis A virus encoding a virulent virus: induction of viral hepatitis by direct nucleic acid transfection of marmosets

Direct inoculation of marmoset livers with an in vitro transcription mixture containing cDNA and full-length genomic RNA transcripts of hepatitis A virus resulted in acute viral hepatitis. Elevations in serum levels of liver enzymes were correlated with appearance of antibody to hepatitis A virus. Genomes of infectious hepatitis A virus isolated from the feces of transfected marmosets contained the same mutation as the cDNA template used for transfection. Liver biopsies confirmed that the virus encoded by the cDNA clone induced histopathological changes equivalent to those caused by virulent wild-type virus.

Biochemical properties of the 75-kDa tumor necrosis factor receptor. Characterization of ligand binding, internalization, and receptor phosphorylation

An expression plasmid encoding the human 75-kDa tumor necrosis factor (TNF) type 2 receptor (TNF-R2) was constructed and used to generate a stable human cell line (293/TNF-R2) overexpressing TNF-R2. Ligand binding analysis revealed high affinity binding (Kd = 0.2 nM) with approximately 94,000 +/- 7,500 sites/cell for 125I-TNF-alpha and approximately 5-fold lower affinity for TNF-beta (Kd = 1.1 nM) with 264,000 +/- 2,000 sites/cell. Cross-linking of 125I-TNF-alpha and 125I-TNF-beta to 293/TNF-R2 cells yielded predominant complexes with apparent molecular weights of 211,000 for TNF-alpha and 205,000 and 244,000 for TNF-beta, suggesting these complexes contain two or three TNF-R2 molecules. Immunoprecipitation of TNF-R2 from 32P-labeled 293/TNF-R2 cells demonstrated that the receptor is phosphorylated. The majority (97%) of 32Pi incorporation was found in serine residues with a very low level of incorporation (3%) in threonine residues. TNF-alpha treatment of 293/TNF-R2 cells did not significantly affect the degree or pattern of phosphorylation. Cell surface-bound 125I-TNF-alpha was slowly internalized by the 293/TNF-R2 cell line with a t1/2 = 25 min. Shedding of the extracellular domain of TNF-R2 was induced by 4 beta-phorbol 12-myristate 13-acetate but not by TNF-alpha or TNF-beta.

Individual differences in response to stress

Observation of newborns and infants reveals individual differences in reactivity to stress. A measurement system based on threshold, dampening, and reactivation is described to assess these individual differences in the newborn period and thereafter. The three features are independent and, therefore, represent different aspects of reactivity. There is some evidence for stability of individual differences in reactivity between birth and 2 months of age. This stability is more apparent for infants who were highly reactive as newborns. The role of dispositional factors of reactivity, their stability, and the effects of the environment are discussed.

Serum procalcitonin as an index of inhalation injury in burns

The molecular heterogeneity of serum immunoreactive calcitonin (iCT) was analyzed from a prospective study of 41 burn patients. Using different region-specific anticalcitonin antisera, the ratio of mid-region-recognizing to carboxyl terminal-region-recognizing iCT was found to increase acutely in those who subsequently died. The highest ratios occurred in those who died early of respiratory complications. Sephadex chromatography and reversed-phase HPLC demonstrated that the serum iCT circulated predominantly in the large molecular mass prohormone form (16 kDa). In comparison, iCT of normal human lung and of normal thyroid was shown to consist primarily of smaller monomeric mass forms. Furthermore, in 12 normal volunteers who were evaluated with a calcium-pentagastrin infusion, the ratio of iCT levels did not differ from the baseline ratio despite a 50% increase in serum iCT. These results suggest that in burns, the inhalational injury-associated hypercalcitonemia is characterized by a preferential release of procalcitonin; a form of constitutive secretion. The measurement of serum procalcitonin levels would appear to be a useful prognostic indicator of the severity of inhalational injury occurring in burn patients.

Resistance to experimental autoimmune thyroiditis is correlated with the duration of raised thyroglobulin levels

We have used the mouse model of experimental autoimmune thyroiditis (EAT) to examine the hypothesis that the strengthening of self-tolerance to thyroglobulin by exogenous mouse thyroglobulin (MTg) or stimulation of endogenous MTg secretion by thyroid-stimulating hormone (TSH) is correlated with the length of time MTg rises above the normal range. Bacterial lipopolysaccharide (LPS) treatment increases the initial half-life of MTg from about 3 hr to about 5 hr, probably interfering with its clearance by the mononuclear phagocytic (reticuloendothelial) system. By pretreating mice with LPS, a subtolerogenic MTg dose is rendered tolerogenic. Similarly the effect of TSH infusion by osmotic minipumps, which stimulates MTg secretion and also strengthens tolerance to MTg, can be enhanced by injecting LPS shortly after pump implantation. The resulting increase in MTg level (due to delayed clearance of MTg) is greater than that from TSH alone and suppresses further the animals' susceptibility to disease induction by MTg and adjuvant. Moreover, resistance following pretreatment with LPS and subtolerogenic MTg is mediated by CD4+ suppressor T cells, as shown recently for the suppression in mice given high doses of tolerogenic MTg. These experiments are in full agreement with the hypothesis and confirm that small increases in circulating MTg concentrations, which could occur physiologically, can be effective in protecting against EAT induction.