Lived Experience-Led Research Agenda to Address Early Death in People With a Diagnosis of a Serious Mental Illness: A Consensus Statement

Importance

People with serious mental illness (SMI), defined as a diagnosis of schizophrenia spectrum disorder, bipolar disorder, or disabling major depressive disorder) die approximately 10 to 25 years earlier than the general population.

Objective

To develop the first-ever lived experience-led research agenda to address early mortality in people with SMI.

Evidence Review

A virtual 2-day roundtable comprising 40 individuals convened on May 24 and May 26, 2022, and used a virtual Delphi method to arrive at expert group consensus. Participants responded to 6 rounds of virtual Delphi discussion via email that prioritized research topics and agreement on recommendations. The roundtable was composed of individuals with lived experience of mental health and/or substance misuse, peer support specialists, recovery coaches, parents and caregivers of people with SMI, researchers and clinician-scientists with and without lived experience, policy makers, and patient-led organizations. Twenty-two of 28 (78.6%) of the authors who provided data represented people with lived experiences. Roundtable members were selected by reviewing the peer-reviewed and gray literature on early mortality and SMI, direct email, and snowball sampling.

Findings

The following recommendations are presented in order of priority as identified by the roundtable participants: (1) improve the empirical understanding of the direct and indirect social and biological contributions of trauma on morbidity and early mortality; (2) advance the role of family, extended families, and informal supporters; (3) recognize the importance of co-occurring disorders and early mortality; (4) redefine clinical education to reduce stigma and support clinicians through technological advancements to improve diagnostic accuracy; (5) examine outcomes meaningful to people with an SMI diagnosis, such as loneliness and sense of belonging, and stigma and their complex relationship with early mortality; (6) advance the science of pharmaceuticals, drug discovery, and choice in medication use; (7) use precision medicine to inform treatment; and (8) redefine the terms system literacy and health literacy.

Conclusions and Relevance

The recommendations of this roundtable are a starting point for changing practice and highlighting lived experience-led research priorities as an option to move the field forward.

Contribución de la prueba rápida NS1 e IgM al diagnóstico de dengue en Colombia en el periodo pre-zika

Objetivo: Se considera que el diagnóstico del dengue es fundamentalmente clínico; sin embargo, las pruebas rápidas basadas en la detección de IgM o NS1/IgM están siendo utilizadas en los servicios de salud. Este estudio determinó la contribución de las pruebas rápidas al diagnóstico de dengue en un área endémica antes de la introducción del virus zika.Metodología: Diseño de corte transversal de pruebas diagnósticas realizado a partir del análisis secundario de un estudio previo en 14 instituciones de salud del Valle del Cauca. Se obtuvo información de 632 participantes con resultados de prueba rápida, diagnóstico clínico y pruebas de referencia ELISA NS1, ELISA IgM y RT-PCR. Se compararon la sensibilidad, especificidad, valores predictivos y razones de verosimilitud del uso solo, en serie, y paralelo de los componentes NS1, IgM, NS1/IgM de la prueba rápida y el diagnóstico clínico con las pruebas Q de Cochran y McNemar para datos pareados.Resultados: La sensibilidad del diagnóstico clínico (61,4% IC95% 56%-66,7%) fue superior a la de las pruebas rápidas (37% IC95% 29,6%-44,7%) (P<0,001). El uso en serie de la prueba NS1/IgM cuando el diagnóstico clínico fue negativo aumentó la sensibilidad a 79,5% y, el uso en serie cuando el diagnóstico clínico fue positivo aumentó la especificidad (de 66,3% a 98,7%). Sin embargo, este último disminuyó la sensibilidad a 32,2%. Todas las razones de verosimilitud negativas (LR-) fueron cercanas a 1; mientras que, el uso en serie cuando el diagnóstico clínico fue positivo tuvo LR+ mayores de 10.Conclusión: El diagnóstico clínico tiene una mayor sensibilidad que las pruebas rápidas, pero por si solo no es suficiente para confirmar o descartar dengue. Un resultado positivo en pruebas rápidas en pacientes con diagnóstico clínico de dengue es útil para confirmarlo, pero un resultado negativo no lo descarta.

'Why are we not doing more for them?': genocide prevention lessons from the Kindertransport

OBJECTIVES

Genocide remains one of the most widespread forms of preventable mortality and morbidity for children today. Despite the creation of multiple human rights treaties, genocide has not been eliminated and its effects disproportionally impact children. The Kindertransport was a series of rescue efforts that brought thousands of refugee children to the United Kingdom from Nazi Germany between 1938 and 1940. This qualitative study asks what public health professionals can learn from the prevention efforts of the Kindertransport by examining the experiences and reflections of individuals rescued as children. The specific aims of the study were (1) to analyze qualitatively the impact of the rescue on rescued children; (2) to evaluate the strengths and limitations of the Kindertransport as a prevention effort; and (3) to draw implications for contemporary public health responses to global genocide.

STUDY DESIGN

Qualitative research study.

METHODS

In-depth interviews, using a semi-structured interview guide, were conducted with 27 survivors of the rescue. The data were thematically coded, and excerpts exported and interpreted in reflection of patterns and themes using Dedoose.

RESULTS

Five inductive themes emerged from the data related to the broad spectrum of antisemitic persecution: the breakup of families; integration in the UK via the Kindertransport; the challenges of adapting to a new environment; and the implications for global rescue efforts.

CONCLUSIONS

The results suggest that the public health community should act to prevent genocide through rapid intervention and rescue; at the same time, the effects of persecution must be addressed and sustained social, emotional, and psychological support must be provided to those rescued.

157 PREGNANCIES AND CALVES AFTER TRANSFER OF IN VITRO-PRODUCED RIVER BUFFALO EMBRYOS AFTER CRYOPRESERVATION

In the buffalo, the use of embryo-based biotechnologies for breeding and genetic improvement is still very limited because multiple-ovulation embryo transfer delivers poor results compared with cattle and in vitro embryo production has been used mainly for research purposes. At present, very few reports are available on the transfer of in vitro-produced (IVP) and cryopreserved buffalo embryos. Therefore, the scope of this work was to perform a pilot study to evaluate the viability of frozen-thawed IVP embryos by nonsurgical embryo transfer to recipients in an IVF-embryo transfer program on a farm located on the north coast of Colombia, South America. Buffalo oocytes were recovered at the slaughterhouse from selected donors, matured in vitro for 18 to 20 h in TCM-199 + 10% FCS and 0.5 IU of FSH and 0.5 IU of LH in 5% CO2 at 38.5°C. Four different bulls were used for IVF. After thawing, the semen was separated on a Percoll® gradient and then diluted into SOF-IVF media supplemented with 1 μg mL–1 of heparin and phenylalanine. Presumptive zygotes were cultured in modified SOF supplemented with MEM amino acids for 6 days. Half of the medium was replaced on Day 4 and 6. Developing embryos were selected for freezing on Day 6 and 7. Grade 1 embryos were frozen at the blastocyst stage by slow cooling in 10% glycerol or 1.5 M ethylene glycol. Recipients (heifers n = 79 and uniparous cows n = 17) were synchronized using the CIDR-Synch protocol: on Day 0, gonadotropin-releasing hormone was injected and a CIDR was inserted; on Day 7, prostaglandin F2α was administered; on Day 9, the CIDR was removed; on Day 11, a second injection of gonadotropin-releasing hormone was given; and on Day 17, the embryo was transferred. Each female received, nonsurgically, 1 or 2 embryos in the ipsilateral horn to the functional corpus luteum evaluated by ultrasonography. Pregnancies were evaluated by ultrasonography 30 days after transfer and confirmed by rectal palpation 30 days later. This work was performed in 2 successive experiments during the breeding seasons (January and December, respectively). Overall, 96 recipients were transferred, with 136 embryos obtaining 23 pregnancies (24.2%). There were no statistical differences in pregnancy rate between heifers and cows (25.3 vs 17.7%) and between single (n = 56) and double (n = 39) embryo transfers (21.4 vs 27.5%) by chi square test (P > 0.05). To date, 4 females and 5 males have been born by spontaneous calving (1 stillborn male due to dystocia), 3 pregnancies have been aborted (13%) and 11 pregnancies are ongoing (>7 months). The pregnancy rate obtained in this study in farm conditions (24.2%) is lower than generally obtained with frozen IVP cattle embryos, but it is still a good result in buffalo, where even conventional AI provides a lower success rate as compared with cattle. Finally, this work demonstrates that in vitro embryo production can be successfully implemented in buffalo breeding programs for the exploitation of superior genetics. This work was supported by Regione Lombardia, Por Fers 2007–2013, n°13827741, InnovaB.

A national programme for patient and staff dose monitoring in interventional cardiology

A national programme on patient and staff dose evaluation in interventional cardiology made in cooperation with the haemodynamic section of the Spanish Society of Cardiology has recently been launched. Its aim is to propose a set of national diagnostic reference levels (DRLs) for patients as recommended by the International Commission on Radiological Protection and to initiate several optimisation actions to improve radiological protection of both patients and staff. Six hospitals have joined the programme and accepted to submit their data to a central database. First to be acquired were the quality control data of the X-ray systems and radiation doses of patients and professionals. The results from 9 X-ray systems, 1467 procedures and staff doses from 43 professionals were gathered. Provisional DRLs resulted in 44 Gy cm(2) for coronary angiography and 78 Gy cm(2) for interventions. The X-ray systems varied up to a factor of 5 for dose rates in reference conditions. Staff doses showed that 50 % of interventional cardiologists do not use their personal dosemeters correctly.

Interactions between protease inhibitors and acid-reducing agents: a systematic review

OBJECTIVE

The purpose of this article is to provide a systematic review of the available pharmacokinetic and clinical data on drug interactions between protease inhibitors (PIs) and acid-reducing agents, and their clinical relevance.

METHODS

A literature search was performed using Medline and EMBASE, abstracts of the previous 2 years of major conferences were searched and the drug information service of the manufacturer of every currently available PI was contacted. All data were summarized, and verified by at least two authors.

RESULTS

A total of 1231 references were identified, 22 of which were studies of pharmacokinetic interactions between PIs and acid-suppressive agents and a further 12 of which provided pharmacokinetic and/or clinical data.

CONCLUSIONS

Many pharmacokinetic studies show a lack of a drug interaction between at least one acid-reducing agent and most PIs. Little clinical information is available, except on interactions between atazanavir and acid-reducing agents. This is probably a consequence of the complexity of the interaction.

Lipoplatin plus gemcitabine versus cisplatin plus gemcitabine in NSCLC: Preliminary results of a phase III trial

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Background: Lipoplatin is a liposomal formulation of cisplatin, designed to reduce its adverse reactions without reducing efficacy. Its nanoparticles evade immune surveillance and extravasate preferentially into tumors inducing tumor cell apoptosis; lipoplatin may also act as antiangiogenesis factor. This is the initial report of a randomized, multicenter, phase III trial comparing the two drugs. Methods: Eligibility criteria included confirmed diagnosis of inoperable/metastatic NSCLC, no previous chemotherapy, WHO PS 0–1, adequate end-organ function. Patients received Lipoplatin 120 mg/m2 D1,8,15 or cisplatin 100 mg/m2 D1, combined with gemcitabine 1,000 mg/m2 D1,8, in 3-week cycles, with disease evaluation after 3 and 6 cycles. Primary endpoints are overall survival and toxicity, with Response Rates, PFS and QOL also being evaluated. Results: 59 patients have been treated, 33 with lipoplatin and 26 with cisplatin; 17 have completed treatment. 2 lipoplatin patients had a hypersensitivity reaction during the first infusion. There were no grade 4 toxicities. Grade 3 toxicities were observed in <5% of the patients and were comparable for the two groups, except neutropenia (3% for lipoplatin, 15% for cisplatin). Main grade 1–2 toxicities were anemia (93% vs 88%), leucopenia (51% vs 38%), neutropenia (45% vs 30%), thrombocytopenia (58% vs 31%), hepatotoxicity (38% vs 46%), nausea/vomiting (13% vs 35%), asthenia (31% vs 30%) and anorexia (32% vs 34%). Concerning nephrotoxicity, grade 2 was reported in only 6% of lipoplatin patients vs 19% in cisplatin, although lipoplatin was administered without pre-hydration as a 6-hour infusion. Neurotoxicity was also markedly less in lipoplatin. So far, 32 patients have been assessed for response, 16 in each group; 4 partial responses have been reported in each group. However, difference has been observed in stable disease (23% in lipoplatin vs 12% in cisplatin) as well as progressive disease (16% vs 35%). Conclusions: Preliminary results show that lipoplatin may have a better safety and therapeutic profile than cisplatin, when combined with gemcitabine, in advanced NSCLC. Particularly important might be its significantly lower neuro- and nephro-toxicity and its administration on an outpatients basis.

No significant financial relationships to disclose.

Varicella pneumonia in pregnancy

Pregnant patients with varicella infections have an increased risk of life threatening pulmonary complications. Prompt diagnosis and aggressive early therapy with acyclovir are important aspects of treating varicella pneumonia. The stress of severe hypoxia usually necessitates delivery by cesarean section. Preoperative evaluation of pulmonary function and choice of anesthetic are critical to intraoperative management. This paper presents the successful treatment of varicella pneumonia in the third trimester of pregnancy with survival of both mother and infant.

Intravascular ultrasound of the elastic pulmonary arteries: a new approach for the evaluation of primary pulmonary hypertension

OBJECTIVE

To assess the structural and functional characteristics of pulmonary arteries by intravascular ultrasound (IVUS) in the setting of primary pulmonary hypertension, and to correlate the ultrasound findings with haemodynamic variables and mortality at follow up.

DESIGN

Prospective observational study.

SETTING

University hospital (tertiary referral centre).

PATIENTS

20 consecutive patients with primary pulmonary hypertension (16 female; mean (SD) age, 39 (14) years).

METHODS

Cardiac catheterisation and simultaneous IVUS of pulmonary artery branches at baseline and after infusion of epoprostenol.

RESULTS

33 pulmonary arteries with a mean diameter of 3.91 (0.80) mm were imaged, and wall thickening was observed in all cases, 64% being eccentric. Mean wall thickness was 0.37 (0.13) mm, percentage wall area 31.0 (9.3)%, pulsatility 14.6 (4.8)%, and pulmonary/elastic strain index 449 (174) mm Hg. No correlation was observed between IVUS findings and haemodynamic variables. Epoprostenol infusion increased pulsatility by 53% and decreased the pulmonary/elastic strain index by 41% (p = 0.0001), irrespective of haemodynamic changes. At 18 (12) months follow up, nine patients had died. A reduced pulsatility and an increased pulmonary/elastic strain index were associated with increased mortality at follow up (12.0 (4.4)% v 16.4 (4.4)%, p = 0.03; 369 (67) v 546 (216) mm Hg, p = 0.02).

CONCLUSIONS

IVUS demonstrated pulmonary artery wall abnormalities in all patients with primary pulmonary hypertension, mostly eccentric. The severity of the changes did not correlate with haemodynamic variables, and epoprostenol improved pulmonary vessel stiffness. There was an association between impaired pulmonary artery functional state as determined by IVUS and mortality at follow up.

Spectral characteristics of B-waves and other low-frequency activity

Low frequency oscillations of intracranial pressure (ICP) between 0.5 to 2.0 cycles/min have been termed B-waves. While such low frequency activity may be generated by cerebral vasomotor activity, activity in the B-wave band may also be related to other causes. The objective of this study is to: 1) describe the low frequency characteristics of ICP and arterial blood pressure (ABP) recordings with a mathematical model based on ventilator-induced intrathoracic pressure (ITP) modulation of arterial blood pressure; and 2) use the model to eliminate low frequency activity within the B-wave range unrelated to vasomotor activity. The model describes the frequency locations of spectra associated with ventilation about both the principal and first harmonic cardiac frequency to within 1% error. Spectra within the B-wave range harmonically related to the ventilator frequency were classified as caused by patient-ventilator interaction. Of 11 patients with severe head-injury, 64% (7/11) demonstrated B-wave activity, and 4 patients demonstrated the activity solely in the ICP recording. Variation of heart rate did not correspond to the occurrence of B-waves. The proposed model describes the low frequency spectra found within ABP and ICP recordings and can be used to eliminate spectra with the B-wave range related to ventilation.

Frequency and clinical significance of myocardial ischemia detected early after coronary stent implantation

A high number (30%-50%) of reversible defects have been detected early after coronary balloon angioplasty. Inadequate luminal enlargement despite a good angiographic appearance has been suggested as a possible mechanism of these perfusion abnormalities, and some reports have shown better coronary flow reserve after coronary stent implantation than after balloon dilatation. The primary objective of this study was to evaluate the frequency of early ischemic defects detected by maximal exercise (plus dipyridamole) with (99m)Tc-tetrofosmin SPECT after successful coronary angioplasty with stent implantation. A secondary objective was to determine the prognostic value of these early ischemic defects.

METHODS

Thirty patients without previous myocardial infarction who successfully underwent 1-vessel coronary angioplasty with stent implantation were studied. Maximal-exercise (99m)Tc-tetrofosmin myocardial SPECT, with simultaneous dipyridamole if exercise was suboptimal, was performed at 6 +/- 1 d (mean +/- SD) after percutaneous transluminal coronary angioplasty. At 8 +/- 3 mo, all patients were followed up clinically, and 77% of them underwent follow-up angiography.

RESULTS

The percentage of stenosis decreased from 68.5% +/- 12.6% of luminal diameter to 9.3% +/- 8.8% after stent implantation, and minimal luminal diameter increased from 0.89 +/- 0.36 mm to 2.85 +/- 0.45 mm. Mild-to-moderate reversible myocardial defects in the territory of the dilated artery were detected in 5 patients (17%), with no angiographic or procedural differences occurring between them and patients without ischemic defects. At follow-up, the target lesion revascularization rates depending on the presence or absence of early ischemic defects were 40% and 8%, respectively (P = 0.18). Angiographic restenosis occurred in 3 of 4 patients who had early ischemic defects and underwent follow-up angiography and in 3 of 19 patients who had no early ischemic defects and underwent follow-up angiography (restenosis rate, 75% and 16%, respectively; P < 0.05).

CONCLUSION

Coronary angioplasty with stent implantation is associated with a 17% rate of ischemic defects early after the procedure. Patients with early myocardial perfusion defects after coronary stent implantation had a high rate of restenosis.

Strategy for optimal aortic regurgitation quantification by Doppler echocardiography: agreement among different methods

BACKGROUND

Although different Doppler methods have been validated for aortic regurgitation quantification, the benefit of combining information from different methods has not been defined.

METHODS

Our study included 2 phases. In the initial phase (60 patients), Doppler parameters (jet width, short-axis jet area, apical jet area, regurgitant fraction from pulmonary and mitral flow, and deceleration slope) were correlated with angiography; range values for each severity grade were defined and intraobserver and interobserver and intermachine variability were studied. In the validation phase (158 patients), defined value ranges were prospectively tested and a strategy based on considering as the definitive severity grade that in which the two best methods agreed was tested.

RESULTS

Jet width had the best correlation with angiography (r = 0.91), and its ratio with the left ventricular outflow diameter did not improve the correlation (r = 0.85) and decreased reproducibility. Apical jet area and regurgitant fraction from pulmonary flow permitted acceptable quantification (r = 0.87 and 0.86, respectively) but with worse reproducibility. The other methods were not assessable in 20% to 30% of studies. Concordance with angiography decreased in jet width when the jet was eccentric (90% vs 77%, P <.01), in apical jet area when mitral valve disease was present (84% vs 65%, P <.02), and in short-axis jet area and regurgitant fraction from pulmonary flow with concomitant aortic stenosis (77% vs 44%, P <.002 and 77% vs 53%, P <.02, respectively). Agreement with angiography was very high (94 [95%] of 99) when severity grade coincided in both jet width and apical jet area. In 59 cases without concordance, regurgitant fraction from pulmonary flow was used as a third method. Overall, this strategy permitted concordance with angiography in 146 patients (92%).

CONCLUSIONS

Jet width is the best predictor in aortic regurgitation quantification by Doppler echocardiography. However, better results were obtained when a strategy based on concordance between jet width and another Doppler method was established, particularly when the jet was eccentric.

Synthesis of 1-amino-6,7,8,8a-tetrahydroacenaphthene and its effect on the inhibition of the MAO-enzyme at the brain cortex and liver level

(+/-)-1-Amino-6,7,8,8a-tetrahydroacenaphthene was synthesized and evaluated as a novel drug acting on the dopaminergic system. It was shown that the new compound displays activity as MAO inhibitor.

Long-term follow-up of idiopathic chronic pericardial effusion

BACKGROUND

A large idiopathic chronic pericardial effusion can be defined as a collection of pericardial fluid that persists for more than three months and has no apparent cause. We conducted a prospective study of the natural history and treatment of this disorder.

METHODS

Between 1977 and 1992, we prospectively evaluated and enrolled patients with large idiopathic chronic pericardial effusion. We performed pericardiocentesis in most of the patients. We performed pericardiectomy when large pericardial effusion reappeared after pericardiocentesis. Follow-up ranged from 18 months to 20 years (median, 7 years).

RESULTS

During the study period, we evaluated a total of 1108 patients with pericarditis, 461 of whom had large pericardial effusion. Twenty-eight of these patients (age range, 7 to 85 years; median, 61) had large idiopathic chronic effusion and were included in the study. The duration of effusion ranged from 6 months to 15 years (median, 3 years). At the initial evaluation, 13 patients were asymptomatic. Overt tamponade was found in eight patients (29 percent). Therapeutic pericardiocentesis, performed in 24 patients, was followed by the disappearance of or marked reduction in the effusion in 8. Five of the 24 patients underwent early pericardiectomy, and in 11 large pericardial effusion reappeared. Cardiac catheterization, performed in 16 patients, showed elevated intrapericardial pressure (4.75+/-3.79 mm Hg) and reduced transmural pressure (1.0+/-2.50 mm Hg) before pericardiocentesis. Both of these abnormalities in pressure improved significantly after pericardiocentesis. Pericardiectomy, performed in 20 patients, yielded excellent long-term results. At the end of the follow-up period, 10 patients had died, but none had died from pericardial disease.

CONCLUSIONS

Large idiopathic chronic pericardial effusion is well tolerated for long periods in most patients, but severe tamponade can develop unexpectedly at any time. Pericardiocentesis alone frequently results in the resolution of large effusions, but recurrence is common and pericardiectomy should be considered whenever a large effusion recurs after pericardiocentesis.

The epithelial cell response to rotavirus infection

Rotavirus is the most important worldwide cause of severe gastroenteritis in infants and young children. Intestinal epithelial cells are the principal targets of rotavirus infection, but the response of enterocytes to rotavirus infection is largely unknown. We determined that rotavirus infection of HT-29 intestinal epithelial cells results in prompt activation of NF-kappaB (<2 h), STAT1, and ISG F3 (3 h). Genetically inactivated rotavirus and virus-like particles assembled from baculovirus-expressed viral proteins also activated NF-kappaB. Rotavirus infection of HT-29 cells induced mRNA for several C-C and C-X-C chemokines as well as IFNs and GM-CSF. Mice infected with simian rotavirus or murine rotavirus responded similarly with the enhanced expression of a profile of C-C and C-X-C chemokines. The rotavirus-stimulated increase in chemokine mRNA was undiminished in mice lacking mast cells or lymphocytes. Rotavirus induced chemokines only in mice <15 days of age despite documented infection in older mice. Macrophage inflammatory protein-1beta and IFN-stimulated protein 10 mRNA responses occurred, but were reduced in p50-/- mice. Macrophage inflammatory protein-1beta expression during rotavirus infection localized to the intestinal epithelial cell in murine intestine. These results show that the intestinal epithelial cell is an active component of the host response to rotavirus infection.

Effectiveness of an educational strategy to improve family physicians' detection and management of depression: a randomized controlled trial

BACKGROUND

Depression, a common disorder often treated by family physicians, may be both underdiagnosed and undertreated. The objective of this study was to determine whether the diagnosis and treatment of depression by family physicians could be improved through an educational strategy.

METHODS

In this study, conducted between July and December 1997, 42 family physicians in Newfoundland were randomly assigned to an intervention group (3-hour case-based educational session on clinical practice guidelines [CPGs] for depression and access to a psychiatrist for consultation) or to a control group (receipt of CPGs without educational session or access to the psychiatrist). Physicians were asked to keep a log of patients with newly diagnosed depression and to record information on severity of depression, medications and referrals to mental health professionals. Patients were asked to complete the Centre for Epidemiologic Studies Depression (CES-D) scale before treatment and after 6 months of follow-up. The primary outcome measure was the "gain" score (difference between first and last CES-D scores).

RESULTS

During the study period physicians in the intervention group diagnosed 91 new cases of depression (mean 4.1 per physician) and those in the control group diagnosed 56 (mean 2.8 per physician); the difference was not significant. Most patients (91.2% in the intervention group and 89.3% in the control group received a prescription for an antidepressant on their first visit. Similar proportions (46.2% in the intervention group and 37.5% in the control group) took their medication for the full 6 months; however, significantly more patients in the intervention group were taking an antidepressant at the 6-month follow-up (56% v. 39.3%, p = 0.02). The mean number of visits per patient was similar in the 2 groups (7.7 in the intervention group and 7.6 in the control group). Physicians in the intervention group consulted the psychiatrist 9 times. The overall rate of referrals to psychiatrists and other mental health professionals was 10.9%; however, referrals were significantly higher in the intervention group (15.4% v. 3.5%, p = 0.05). After 6 months of follow-up, a significant difference in gain scores was detected between the intervention and control groups for both the patient's self-rated CES-D scores (mean gain score 19.3 v. 15.5 respectively, p = 0.04) and the physicians' ratings of depression severity before treatment and at 6 months (mean gain 1.1 v. 0.7 respectively, p = 0.02).

INTERPRETATION

The educational strategy had a modest beneficial effect on the outcomes of patients with depression, but there are still concerns regarding the low rates of drug treatment and referral to mental health professionals by family physicians.

Lack of a role for type I and type II interferons in the resolution of rotavirus-induced diarrhea and infection in mice

Rotavirus infects the intestinal epithelium of most mammalian species and causes diarrhea in infants. Previously, we have shown that both type I and II human interferons (IFNs) have potent and mechanistically discreet antiviral effects in vitro against rotavirus. We have also shown that adult IFN-gamma knockout (-/-) mice have no alteration in clearance of primary rotavirus infection. In the present studies, we wished to determine the importance of both IFN types in modulation of degree and duration of disease and infection in mice. Immunocompetent suckling mice were treated orally (5,000 IU) or parenterally (500 IU) with type I and II murine IFNs before and after challenge with virulent murine rotavirus. Treated animals developed diarrhea indistinguishable from that observed in untreated control mice. In other experiments, type I IFN receptor -/- suckling mice and IFN-gamma-/- suckling mice developed diarrhea of similar characteristics and duration and had comparable quantities of viral antigen in their intestines as did immunocompetent mice. Furthermore, type I IFN receptor -/- adult mice infected with rotavirus shed equivalent quantities of viral antigen and with similar kinetics as the control mice. Thus, IFNs do not seem to be major inhibitors of rotavirus diarrhea or replication in mice.

[Refractory angina caused by steal phenomenon in internal mammary artery resolved with embolization]

We report a patient with refractory angina in the postoperative period of a coronary artery bypass grafting. Ischemia was due to a large side branch of the left internal mammary artery causing steal phenomenon that was treated with transcatheter coil embolization.

[Diagnostic efficacy of myocardial tomographic imaging in the detection of restenosis after coronary angioplasty]

INTRODUCTION AND OBJECTIVES

To analyze the efficacy of single photon emission tomography (SPET) with 99mTc-compounds for the diagnosis of restenosis of previous percutaneous transluminal coronary angioplasty (PTCA).

PATIENTS AND METHODS

Seventy-one patients (16 women, median age: 60 years, 35 with multivessel disease, 78 arteries with PTCA) with previous PTCA and with coronary angiography performed after scintigraphy were studied. 99mTc-SPET exercise (53 with MIBI and 18 with tetrofosmin) was performed, for clinical reasons, to all patients between one month and 4 years after PTCA. Intravenous dipyridamole was administered simultaneously to 16 patients who had insufficient exercise.

RESULTS

SPET sensitivity, specificity, positive predictive values, negative predictive values and global values were all significantly higher than those obtained with exercise tests (80% vs 63%; p = 0.05; 83% vs 37%; p = 0.001; 91% vs 69%; p = 0.007; 64% vs 31%; p = 0.009, and 81% vs 55%; p = 0.0006, respectively). These results were significantly superior in patients with one vessel disease than in patients with multivessel disease.

CONCLUSIONS

SPET exercise with 99mTc-compounds is a test with a high efficacy for the diagnosis of post-PTCA restenosis, mainly in patients with one vessel disease.

[Quantification of left-to-right shunt in atrial septal defect using oximetry, isotopes, and Doppler echocardiography. Is there a method of reference?]

INTRODUCTION

Determination of pulmonary to systemic blood flow ratio (QP/QS) is considered to be important for the management of patients with atrial septal defect. The QP/QS provides information on shunt severity and is usually determined by three methods: oximetry, first-pass radionuclide angiocardiography and Doppler echocardiography. The aim of the present study was to assess the accuracy and concordance level of these three methods in QP/QS quantification in atrial septal defects.

PATIENTS AND METHODS

Sixty-four adult atrial septal defects patients in whom QP/QS was determined by these three methods with a 6 month interval were studied. Nuclear and echocardiographic post-surgical studies were repeated in 36 patients.

RESULTS

QP/QS values determined by the three techniques had a low correlation between them: oximetry (r = 0.52; SEE = 0.74); radionuclide angiocardiography (r = 0.40; SEE = 0.79) and Doppler echocardiography (r = 0.72; SEE = 0.57). Radionuclide angiocardiography underestimated QP/QS > 3 (-0.61 +/- 1.21; p < 0.01). Only in 33% of studies there concordance (differences < 0.5) among the three methods and in 58% between two methods. Right ventricular dilatation and tricuspid regurgitation influenced radionuclide accuracy. Nevertheless, the correlation between this technique and echocardiography was satisfactory when the 36 post-surgical were included (r = 0.75); both techniques agreed in the diagnosis of the two cases with residual post-surgical shunt.

CONCLUSIONS

Inter-method disparity in QP/QS quantification is high and no method can be used as a gold standard; clinical decisions therefore based on QP/QS quantification by one technique alone are ill-advised.

Identification of mutations in the rotavirus protein VP4 that alter sialic-acid-dependent infection

To explore further the role of VP4 as the rotavirus cell attachment protein, VP7 monoreassortants derived from the sialic-acid-dependent simian strain RRV and from the sialic-acid-independent human strains D, DS-1 and ST-3 were tested for susceptibility of infectivity of neuraminidase-treated MA-104 cells. Infectivity of RRV x D VP7 and RRV x ST-3 VP7 monoreassortants decreased when sialic acid was removed from the cell surface. However, of three separate RRV x DS-1 VP7 monoreassortants tested, only one was sialic-acid-dependent. Sequence analysis showed that both sialic-acid-independent strains contained a single amino acid change, Lys to Arg, at position 187. In addition, sialic-acid-independent infectivity was seen in one of 14 RRV VP4 neutralization escape mutants tested, and this strain was found to have a Gly to Glu change at amino acid position 150. These results indicate that positions 150 and 187 of VP4 play an important role in early rotavirus-cell interactions.

Studies of the role for NSP4 in the pathogenesis of homologous murine rotavirus diarrhea

A rotavirus (RV) nonstructural protein, NSP4, has recently been proposed to function as an enterotoxin in the pathogenesis of RV diarrhea. The role of NSP4 in the pathogenesis of RV diarrhea was examined by infecting cystic fibrosis transmembrane conductance regulator (CFTR) knockout mice with virulent murine RV and by comparing deduced amino acid sequences of RV gene 10 encoding NSP4 from three distinct sets of virulent and tissue culture-adapted avirulent variant RVs. Homozygous CFTR (CFTR-/-) mice, which do not respond to any known intestinal secretagogues, experienced diarrhea comparable to that in normal CFTR+/+ littermates after RV challenge. Comparison of amino acid sequences of NSP4 from virulent and attenuated pairs of RVs failed to show consistent or significant changes. Together, these data suggest that enterotoxigenic properties of RV NSP4 are not critical in the pathogenesis of murine RV diarrhea and that attenuation of murine RVs is not usually mediated by mutations in the gene encoding NSP4.

[De-novo reversible stenoses in tortuous arteries during coronary angioplasty due to the accordion effect. A clinical case and review of the literature]

During the performance of PTCA, the operator must be able to differentiate true complications from pseudocomplications. Mechanical coronary shortening and vessel wall invagination due to accordion effect, "pseudo-transection", dissection, coronary spasm, and localized thrombosis are sources of iatrogenic obstruction during angioplasty. We report a case in which straightening of a right tortuous coronary artery during angioplasty produced an iatrogenic lesion that has a typical invaginate appearance. Conservative management is indicated in the absence of definitive angiographic aspect of vessel trauma, because they disappear after withdrawal of angioplasty equipment or adequate management of the guidewire.

Treatment of Morton's neuroma by neurolysis

Thirty-five patients who had undergone neurolysis for Morton's neuroma were reviewed at a mean of 21.4 months. Those patients who had received diagnostic lidocaine (local anesthetic) injections as an evaluation tool before the operation did extremely well after this operation. Overall patient satisfaction was found to be extremely high, with 17 of 35 patients enjoying complete relief of their pain and 12 of 35 reporting minimal discomfort with activity. The likelihood of persistent symptoms seemed to be related to the presence of associated foot disorders.

Synthesis of (+/-)-1-amino-6,7,8,8a-tetrahydro acenaphthene with possible central dopaminergic activity

We describe the non stereoselective synthesis of (+/-)-1-amino-6,7,8,8a-tetrahydroacenaphthene (14), a novel compound that belongs to the acetanaphtene group, that is presented as a rigid non hydroxylated 2-aminoindan which has a structural disposition of a dopaminergic pharmacophore that possess a phenylethylamine fragment. Intracerebroventricular administration of this compound induces an increase in urinary volume and sodium excretion in conscious rats. The renal actions of 14 were blocked by haloperidol pretreatment, suggesting that 14 acts centrally through a dopaminergic mechanism.

Interleukin-1-induced prostaglandin E2 biosynthesis in human synovial cells involves the activation of cytosolic phospholipase A2 and cyclooxygenase-2

Treatment of human synovial cells with interleukin-1 (IL-1) results in a large increase in the production of prostaglandin E2 (PGE2), a function in which the activation of phospholipase A2 (PLA2) is a key step. In order to identify the enzymes that are linked to IL-1-mediated arachidonate availability and subsequent PGE2 production, we have investigated the changes in gene expression of the 85-kDa cytosolic PLA2 (cPLA2), the 14-kDa secretory PLA2 (sPLA2) and the two forms of cyclooxygenase in human synoviocytes after stimulation with recombinant IL-1 beta. Northern-blot analysis revealed that both cPLA2 and cyclooxygenase-2 mRNA were progressively upregulated upon exposure to IL-1 for 5 hours and the glucocorticoid, dexamethasone, blocked the increased expression of these two genes. In contrast, IL-1-induced sPLA2 gene expression determined in the same cell samples was weak and most often rapid, and dexamethasone further stimulated it. In addition, IL-1 did not modify the levels of the constitutive cyclooxygenase-1. The cPLA2 and cyclooxygenase-2 enzymic activities are dependent upon de novo synthesis of mRNA and protein, since they were inhibited by actinomycin D and cycloheximide. Our data suggest that the IL-1-induced production of PGE2 in human synoviocytes can be attributed to the stimulation of both cPLA2 and cyclooxygenase-2. These enzymes may represent appropriate targets for selective blockade of prostanoid production in the inflammed joints.

IL-1 beta amplifies bradykinin-induced prostaglandin E2 production via a phospholipase D-linked mechanism

The proinflammatory cytokine IL-1 was shown to increase the responsiveness of synovial cells to the potent inflammatory peptide bradykinin (BK). We have investigated the biochemical events linked to this amplifying action of IL-1. Stimulation of synoviocytes with only BK elicited a rapid increase in inositol phosphates and a concomitant accumulation of diacylglycerol (DAG), monoacylglycerol, and free arachidonic acid (AA). In contrast, IL-1 did not stimulate any of these events. Thus, BK can induce AA release via the hydrolysis of phosphatidylinositols by a phospholipase C (PLC). BK also activated a phospholipase D (PLD) to cleave phosphatidylcholine (PC), because it caused an increase in phosphatidic acid (PA) content and a sustained DAG formation, which both were inhibited by ethanol in [3H]myristic acid-labeled cells. Moreover, the addition of ethanol diverted PLD into the formation of phosphatidylethanol (PEt) thus inhibiting the amounts of PA and DAG formed. Priming of synovial cells with rIL-1 beta 24 h before exposure to BK in the presence of ethanol further enhanced the BK-induced formation of PEt. Conversely, preincubation with IL-1 did not influence the BK-induced PLC activation nor did it alter the liberation of AA. Finally, we demonstrated that the IL-1-mediated amplification of PGE2 release in response to BK was reduced by the presence of ethanol in the culture medium, suggesting that part of the synergistic action of IL-1 and BK on prostanoid production was dependent on the activation of the PC-specific PLD pathway.

IL-1 beta amplifies bradykinin-induced prostaglandin E2 production via a phospholipase D-linked mechanism

The proinflammatory cytokine IL-1 was shown to increase the responsiveness of synovial cells to the potent inflammatory peptide bradykinin (BK). We have investigated the biochemical events linked to this amplifying action of IL-1. Stimulation of synoviocytes with only BK elicited a rapid increase in inositol phosphates and a concomitant accumulation of diacylglycerol (DAG), monoacylglycerol, and free arachidonic acid (AA). In contrast, IL-1 did not stimulate any of these events. Thus, BK can induce AA release via the hydrolysis of phosphatidylinositols by a phospholipase C (PLC). BK also activated a phospholipase D (PLD) to cleave phosphatidylcholine (PC), because it caused an increase in phosphatidic acid (PA) content and a sustained DAG formation, which both were inhibited by ethanol in [3H]myristic acid-labeled cells. Moreover, the addition of ethanol diverted PLD into the formation of phosphatidylethanol (PEt) thus inhibiting the amounts of PA and DAG formed. Priming of synovial cells with rIL-1 beta 24 h before exposure to BK in the presence of ethanol further enhanced the BK-induced formation of PEt. Conversely, preincubation with IL-1 did not influence the BK-induced PLC activation nor did it alter the liberation of AA. Finally, we demonstrated that the IL-1-mediated amplification of PGE2 release in response to BK was reduced by the presence of ethanol in the culture medium, suggesting that part of the synergistic action of IL-1 and BK on prostanoid production was dependent on the activation of the PC-specific PLD pathway.

Evidence for a dopaminergic involvement in the renal action of centrally administered JA116a, a novel compound with possible dopaminergic activity, in rats

Intracerebroventricular (i.c.v.) administration of JA116a, induces an increase in urinary volume and sodium excretion in conscious male hydrated rats. The involvement of brain dopaminergic neurons in the JA116a renal action was investigated. Diuretic and natriuretic action of JA116a was blocked by haloperidol pretreatment. The renal effect was prevented by selective dopaminergic neuron, denervation by i.c.v. administration of 6-hydroxydopamine in combination with desmethylimipramine. Our results suggest that JA116a acts centrally, at least in part, via an interaction with endogenous dopamine neurons.

[Transesophageal echocardiography in the diagnosis of aortic dissection]

INTRODUCTION AND OBJECTIVE

Eighty-two patients with suspected aortic dissection were studied to assess the usefulness of transesophageal echocardiography in the diagnosis of this entity.

METHODS

All patients underwent transesophageal echocardiogram. The diagnosis of aortic dissection was established in 46 patients by other diagnostic procedures including angiography and computed tomography, surgery and necropsy.

RESULTS

The sensitivity and specificity of transesophageal echocardiography were 98% and 97%, respectively. By computed tomography, sensitivity was 92% and specificity 88%. By angiography, sensitivity and specificity were 97% and 93%, respectively. In the diagnosis of the dissection type, transesophageal echocardiography classified correctly in 98%, computed tomography in 89% and angiography 97% of cases. Transesophageal echocardiography visualized the tear in 82% of cases, and angiography in 53%.

CONCLUSIONS

Transesophageal echocardiography provides rapid, accurate diagnosis of aortic dissection and permits the initiation of appropriate treatment. Angiography is indicated in non-conclusive cases or those which supra-aortic involvement clinically suspected.

[The usefulness of Doppler echocardiography in the preoperative assessment of valvulopathies. A comparison with the hemodynamic and surgical findings]

The Doppler echocardiography and cardiac catheterization studies of all patients who underwent valvular surgery in a three-year period were reviewed to assess the correlation between the estimated severity of valvular disease by both methods. Two-hundred and thirty-five patients (group I: 140 male, age 58 +/- 12; 95 female, age 60 +/- 13) underwent both studies within 6 months. There was agreement on estimation of severity of valve lesions in 140 of 162 patients with aortic valve disease (93% of stenosis, 82% of regurgitations and 79% of mixed lesions), in 58 of 80 patients with mitral valve disease (83% of stenosis, 76% of regurgitations and 33% of mixed lesions) and in 10 of 16 patients with prosthetic valve disfunction. The correlation between both methods was significantly lower in mixed mitral lesions than in the remaining native valve lesions (p < 0.05). Significant disagreement occurred in 4 cases of aortic valve disease, four of mitral valve disease and five of prosthetic disfunction. When disagreement was present, Doppler often underestimated the severity of the disease. Disagreement was more frequent in patients with combined aortic and mitral disease. According to the surgical conclusions cardiac catheterization provided a diagnostic profit in the assessment of the disease severity in 8, 11 and 22% of cases of aortic and mitral valve disease and prosthetic valve disfunction, respectively. Coronary artery disease was present in 19% of patients who underwent coronary arteriography. One-hundred and two patients (group II: 44 m, 48 +/- 15; 58 f, 53 +/- 11) underwent surgery without previous cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

Interleukin-1-mediated phospholipid breakdown and arachidonic acid release in human synovial cells

OBJECTIVE

Interleukin-1 (IL-1), an important mediator contributing to joint destruction in rheumatoid arthritis, is known to stimulate the release of arachidonic acid (AA) and prostaglandin E2 (PGE2) from adherent synoviocytes. To study the intracellular pathways involved in these functions, we stimulated cultures of human synovial cells with recombinant IL-1 beta.

METHODS

AA liberation was measured after labeling synovial cells with 3H-AA, and PGE2 levels were determined by high performance liquid chromatography or radioimmunoassay. Identification of 3H-AA-labeled phospholipids was performed by thin layer chromatography. Cell-associated phospholipase A2 (PLA2) enzymatic activity was determined by an assay with cell-free systems and exogenous substrates.

RESULTS

Stimulation of synovial cells with recombinant IL-1 beta induced a decrease in phosphatidylcholine (PC), phosphatidylinositol (PI), and phosphatidylethanolamine (PE), and a marked increase in cell-associated PLA2 activity as compared with controls. In the presence of either quinacrine, an inhibitor of PLA2 pathway activation, or neomycin, which binds to PI mono- and biphosphate thus blocking their degradation by phospholipases, AA and PGE2 secretion were reduced in a dose-dependent manner. Kinetic studies revealed that quinacrine had little blocking activity on the IL-1-mediated AA release after 1 hour of stimulation but completely abolished it after 5 or 8 hours. In contrast, neomycin exerted a partial but significant inhibitory effect from the first hour of stimulation onward. Addition of quinacrine was also demonstrated to abolish the IL-1-induced hydrolysis of PC and PE but not PI, indicating that PC and PE are the preferred substrates for PLA2 enzymatic activity in human synovial cells.

CONCLUSION

Our findings strongly suggest that AA and PGE2 production by IL-1-triggered synoviocytes are largely dependent upon PLA2-mediated hydrolysis of PC and PE and to a lesser extent upon the earlier degradation of PI.

Infection of arterio-venous fistulas created for chronic haemodialysis

One of the complications of chronic haemodialysis is infection at the venous access site. A retrospective chart review (1985-1990) was done on patients requiring venoaccess for haemodialysis. 197 patients had 254 arterio-venous (A-V) fistulas created. 40 patients had 71 prosthetic implants and 157 patients had 183 autogenous fistulas created. 16 (22%) prosthetic grafts were infected versus 8 (4.3%) autogenous fistulas (p < 0.0001). Bacteraemia was present in 9/16 (56%) infected prosthetic grafts and 4/8 (50%) infected autogenous fistulas. Seven (43.8%) of the prosthetic grafts required removal; 6 (37.5%) were cured with drainage, irrigation and antibiotics, and 3 (18.8%) with antibiotics alone. One (12.5%) of the autogenous fistulas was removed, 4 (50%) required revision and 3 (37.5%) were treated with antibiotics alone. Whenever possible, A-V fistulas should be created in the arms with an autogenous graft as infections are less and easier to treat.