Antibody dependent cell cytotoxicity is maintained by the unmutated common ancestor of 6F5, a Gp41 conformational epitope targeting antibody that utilizes heavy chain VH1-2

In studies on monoclonal IgG antibodies (mAbs) from long-term non-progressors (LTNPs), our laboratory has previously described highly mutated Abs against a complex conformational epitope with contributions from both gp41 the N terminal and C terminal heptad repeat helices. Despite using the VH1-2 gene segment, known to contribute to some of the broadest neutralizing Abs against HIV, members of these Abs, termed group 76C Abs, did not exhibit broad neutralization. Because of the high number of mutations and use of VH1-2, our goal was to characterize the non-neutralizing functions of Abs of group 76C, to assess if targeting of the epitope correlates with LTNP, and to assess the maturation of these Abs by comparison to their predicted common ancestor. Serum competition assays showed group 76C Abs were enriched in LTNPs, in comparison to VRC-01. Specific group 76C clones 6F5 and 6F11, expressed as recombinant Abs, both have robust ADCC activity, despite their sequence disparity. Sequence analysis predicted the common ancestor of this clonal group would utilize the germline non-mutated variable gene. We produced a recombinant ancestor Ab (76Canc) with a heavy chain utilizing the germline variable gene sequence paired to the 6F5 light chain. Competition with group 76C recombinant Ab 6F5 confirms 76Canc binds HIV envelope constructs near the original group C epitope. 76Canc demonstrates comparable ADCC to 6F5 and 6F11 when using gp41 constructs of both clade B and clade C. The functional capability of Abs utilizing germline VH1-2 has implications for disease control and vaccine development.

Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation

BACKGROUND

We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics.

SETTING

Four HIV clinics in the northeastern United States.

METHODS

Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups.

RESULTS

Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork.

CONCLUSIONS

Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.

Working with HIV clinics to adopt addiction treatment using implementation facilitation (WHAT-IF?): Rationale and design for a hybrid type 3 effectiveness-implementation study

BACKGROUND

Tobacco, alcohol and opioid misuse are associated with substantial morbidity and mortality among people with HIV (PWH). Despite existence of evidence-based counseling and medications for addiction, these treatments are infrequently offered in HIV clinics. The Working with HIV clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study was conducted to address this implementation challenge. The study's goals were to conduct a formative evaluation of barriers to and facilitators of implementing addiction treatment for PWH followed by an evaluation of the impact of Implementation Facilitation (IF) on promoting adoption of addiction treatments and clinical outcomes.

METHODS

The study was conducted at four HIV clinics in the northeast United States, using a hybrid type 3 effectiveness-implementation stepped wedge design and guided by the Promoting Action on Research Implementation in Health Services Research (PARiHS) framework. A mixed-methods approach was used to identify evidence, context, and facilitation-related barriers to and facilitators of integration of addiction treatments into HIV clinics and to help tailor IF for each clinic. An evaluation was then conducted of the impact of IF on implementation outcomes, including provision of addiction treatment (primary outcome), organizational and clinician and staff readiness to adopt addiction treatment, and changes in organizational models of care used to deliver addiction treatment. The evaluation also included IF's impact on effectiveness outcomes, specifically HIV-related outcomes among patients eligible for addiction treatment.

CONCLUSIONS

Results will generate important information regarding the impact of IF as a reproducible strategy to promote addiction treatment in HIV clinics.

Socio-demographic and clinical characteristics of individuals with diagnoses of eating disorder in a university hospital in Istanbul

OBJECTIVE

This paper reports the first-ever description of a clinical eating disorder population from Turkey. The aim of this study was to examine the socio-demographic and clinical characteristics of individuals with diagnosis of eating disorders (IDED) referred to a university psychiatry clinic in Istanbul between 2003 and 2009.

METHOD

The diagnoses and subtype of 111 IDEDs, the referral type to the hospital, setting of treatment, and state of involuntary hospitalization were evaluated by interview and semi-structured questionnaire.

RESULTS

The clinical sample included 64 individuals with anorexia nervosa (AN), 38 with bulimia nervosa (BN), and 9 with eating disorder not otherwise specified (EDNOS), including only one male. Younger individuals and those with a lower BMI were significantly more likely to be family referred and hospitalized involuntarily.

DISCUSSION

The overall socio-demographic features of the sample are generally consistent with data collected in other communities. However, aspects of the clinical features, referral types of eating disorders and subtypes exhibit some characteristics peculiar to our sample.

Proposal of a 2-tier histologic grading system for canine cutaneous mast cell tumors to more accurately predict biological behavior

Currently, prognostic and therapeutic determinations for canine cutaneous mast cell tumors (MCTs) are primarily based on histologic grade. However, the use of different grading systems by veterinary pathologists and institutional modifications make the prognostic value of histologic grading highly questionable. To evaluate the consistency of microscopic grading among veterinary pathologists and the prognostic significance of the Patnaik grading system, 95 cutaneous MCTs from 95 dogs were graded in a blinded study by 28 veterinary pathologists from 16 institutions. Concordance among veterinary pathologists was 75% for the diagnosis of grade 3 MCTs and less than 64% for the diagnosis of grade 1 and 2 MCTs. To improve concordance among pathologists and to provide better prognostic significance, a 2-tier histologic grading system was devised. The diagnosis of high-grade MCTs is based on the presence of any one of the following criteria: at least 7 mitotic figures in 10 high-power fields (hpf); at least 3 multinucleated (3 or more nuclei) cells in 10 hpf; at least 3 bizarre nuclei in 10 hpf; karyomegaly (ie, nuclear diameters of at least 10% of neoplastic cells vary by at least two-fold). Fields with the highest mitotic activity or with the highest degree of anisokaryosis were selected to assess the different parameters. According to the novel grading system, high-grade MCTs were significantly associated with shorter time to metastasis or new tumor development, and with shorter survival time. The median survival time was less than 4 months for high-grade MCTs but more than 2 years for low-grade MCTs.

Are pANCA, ASCA, or cytokine gene polymorphisms associated with pouchitis? Long-term follow-up in 102 ulcerative colitis patients

OBJECTIVE

Pouchitis is the most frequent complication after ileal pouch-anal anastomosis for ulcerative colitis. This study aims to analyze the frequency and characteristics of pouchitis in long-term follow-up in a large population, and to determine whether a significant association exists between five immunogenetic markers and pouchitis.

METHODS

From a population of over 500 ulcerative colitis patients who had undergone ileal pouch-anal anastamosis 5-12 yr earlier, 102 subjects participated in the study. Using clinical data obtained from interviews and chart reviews, patients were classified into three groups: no pouchitis; 1-2 episodes per year; and >2 episodes per year. Coded sera from the patients were analyzed for ulcerative colitis-associated perinuclear antineutrophil cytoplasmic antibodies and Crohn's disease-associated anti-saccharomyces cerevesiae antibodies. Interleukin-1 receptor antagonist, tumor necrosis factor (TNF), and lymphotoxin beta (lymphotoxin) polymorphisms were also analyzed.

RESULTS

Pouchitis affected 49% of the study population. Antineutrophil cytoplasmic antibodies, anti-saccharomyces cerevesiae antibodies, and lymphotoxin-beta polymorphisms were not associated with pouchitis. Carriage of interleukin-1 receptor antagonist allele 2 was significantly greater among those without pouchitis than those with pouchitis. Patients without pouchitis had a significantly greater carriage rate of TNF allele 2.

CONCLUSIONS

Perinuclear antineutrophil cytoplasmic antibodies and anti-saccharomyces cerevesiae antibodies are not correlated with pouchitis, but interleukin-1 receptor antagonist and TNF may play a role in its development. Further evaluation of these markers in pouchitis will require larger populations, long-term prospective observation, and studies that correlate polymorphisms with specific immunologic functions.

Control of Drosophila perineurial glial growth by interacting neurotransmitter-mediated signaling pathways

Drosophila peripheral nerves, similar structurally to the peripheral nerves of mammals, comprise a layer of axons and inner glia, surrounded by an outer perineurial glial layer. Although it is well established that intercellular communication occurs among cells within peripheral nerves, the signaling pathways used and the effects of this signaling on nerve structure and function remain incompletely understood. Here we demonstrate with genetic methods that the Drosophila peripheral nerve is a favorable system for the study of intercellular signaling. We show that growth of the perineurial glia is controlled by interactions among five genes: ine, which encodes a putative neurotransmitter transporter; eag, which encodes a potassium channel; push, which encodes a large, Zn(2+)-finger-containing protein; amn, which encodes a putative neuropeptide related to the pituitary adenylate cyclase activator peptide; and NF1, the Drosophila ortholog of the human gene responsible for type 1 neurofibromatosis. In other Drosophila systems, push and NF1 are required for signaling pathways mediated by Amn or the pituitary adenylate cyclase activator peptide. Our results support a model in which the Amn neuropeptide, acting through Push and NF1, inhibits perineurial glial growth, whereas the substrate neurotransmitter of Ine promotes perineurial glial growth. Defective intercellular signaling within peripheral nerves might underlie the formation of neurofibromas, the hallmark of neurofibromatosis.

Cerebral sinovenous thrombosis in children

BACKGROUND

Cerebral sinovenous thrombosis in children is a serious disorder, and information is needed about its prevention and treatment.

METHODS

The Canadian Pediatric Ischemic Stroke Registry was initiated in 1992 at the 16 pediatric tertiary care centers in Canada. Children (newborn to 18 years of age) with symptoms and radiographic confirmation of sinovenous thrombosis were included.

RESULTS

During the first six years of the registry, 160 consecutive children with sinovenous thrombosis were enrolled, and the incidence of the disorder was 0.67 cases per 100,000 children per year. Neonates were most commonly affected. Fifty-eight percent of the children had seizures, 76 percent had diffuse neurologic signs, and 42 percent had focal neurologic signs. Risk factors included head and neck disorders (in 29 percent), acute systemic illnesses (in 54 percent), chronic systemic diseases (in 36 percent), and prothrombotic states (in 41 percent). Venous infarcts occurred in 41 percent of the children. Fifty-three percent of the children received antithrombotic agents. Neurologic deficits were present in 38 percent of the children, and 8 percent died; half the deaths were due to sinovenous thrombosis. Predictors of adverse neurologic outcomes were seizures at presentation and venous infarcts.

CONCLUSIONS

Sinovenous thrombosis in children affects primarily neonates and results in neurologic impairment or death in approximately half the cases. The occurrence of venous infarcts or seizures portends a poor outcome.

Implementing the revised American Psychiatric Association practice guideline for the treatment of patients with eating disorder

Practice guidelines aspire to be authoritative statements regarding the state of the art in quality care for various clinical problems. The American Medical Association Partnership has set forth stringent parameters for guideline development by professional organizations, and these have been followed by the American Psychiatric Association in creating its practice guidelines for the treatment of patients with eating disorders. The revised edition, published in January 2000, benefitted from extensive input from a wide array of psychiatrists, psychologists, pediatricians, and other recognized experts who blended together available evidence-based practice with a considerable amount of clinical experience and consensus. These guidelines are useful for practitioners, students, and health-resource managers. Future research will continue to lead to constant upgrades.

E-mail as a therapeutic adjunct in the outpatient treatment of anorexia nervosa: Illustrative case material and discussion of the issues

OBJECTIVE

To explore using adjunctive e-mail in treating anorexia nervosa.

METHOD

Four treatment plans were supplemented by obligatory e-mail emphasizing patients' reports of specific eating-related behaviors. Office visits occurred weekly to once every few months. E-mail contact occurred once to several times per week. Patients also saw other providers.

RESULTS

All patients have shown good clinical improvement. Patients provided their assessments of contributions made by the use of e-mail and generally found it to be helpful.

DISCUSSION

E-mail has had excellent patient acceptability and adherence. Benefits have been attributed to increased therapeutic contact, "talking" on demand, and having to frequently confront one's integrity, honesty, and eating behaviors. Little clinician time is needed for reading and responding to e-mails. Informed consent and confidentiality issues must be carefully addressed. Controlled trials are warranted to further evaluate the roles that adjunctive e-mail may play in clinical research and practice.

Development and validation of the Parental Intrusiveness Rating Scale among bulimic and comparison women

OBJECTIVE

Based on hypotheses generated during clinical interviews with 80 women with a lifetime history of bulimia nervosa (BN), we designed an instrument for assessing the extent to which women with BN report parental intrusiveness and breakdown of appropriate role boundaries during their adolescent development.

METHOD

Through an iterative process of item generation and scale administration, the Parental Intrusiveness Rating Scale (PIRS), consisting of 20 maternal items and 20 paternal items, was developed. Maternal subscales include Invasion of Privacy, Jealousy and Competition, and Overconcern with the Daughter's Eating, Weight, and Shape. Paternal subscales include Invasion of Privacy, Seductiveness, and Overconcern with the Daughter's Eating, Weight, and Shape. We validated the instrument using a subset of the above BN and comparison women (ns = 55 and 33, respectively), as well as an independent sample of women with BN and college comparison subjects (ns = 31 and 540, respectively).

RESULTS

Parental intrusiveness scores were significantly positively correlated with disturbed relationships in the family of origin of our initial cohort. Reliability analyses, both test-retest and item-scale correlations, revealed adequate to strong statistical associations in the combined sample.

CONCLUSION

The PIRS promises to enrich our understanding of problematic parental behaviors among women who develop BN and allows us to broaden the conceptualization of familial risk factors for this disorder.

Parental intrusiveness in adolescence recalled by women with a history of bulimia nervosa and comparison women

OBJECTIVE

To learn if women with a lifetime history of bulimia nervosa (BN) report more intrusive parental behavior during adolescence than their nonclinical peers, and to provide further validation of the Parental Intrusiveness Rating Scale (PIRS).

METHOD

We administered the PIRS to 86 women with a lifetime history of BN and 573 comparison subjects and examined between-group differences.

RESULTS

Relative to the comparison group, lifetime BN subjects reported higher levels of parental intrusiveness, specifically maternal invasion of privacy, maternal jealousy and competition, paternal seductiveness, and maternal and paternal overconcern with the daughter's eating, weight, and shape. There were no between-group differences in paternal invasion of privacy. In exploratory analyses with the comparison sample, Caucasian women reported greater maternal jealousy and competition than Asian American/Pacific Islander women, but there were no other differences.

CONCLUSION

These results support clinical observations of high levels of parental intrusiveness in the adolescent experiences of women who develop BN. Nonclinical women of diverse ethnic backgrounds report largely equivalent experiences.

Social support, social adjustment, and recovery status in bulimia nervosa

OBJECTIVE

To examine recovery status in bulimia nervosa (BN) and its relation to social support and social adjustment.

METHOD

Using a cross-sectional design, we administered the modified Social Support Questionnaire and the Social Adjustment Scale-Self-Report (SAS-SR) to 40 women, each of whom was actively bulimic (ABN), was in remission from BN (RBN), or had no history of eating disturbance (comparison).

RESULTS

In terms of social support, relative to RBN and comparison subjects, the ABN group had significantly fewer persons in their friendship and kinship networks available to provide emotional support, although the groups were equivalent in number of persons available to provide things and advice. Relative to the comparison group, both bulimic groups were significantly dissatisfied with the quality of emotional support provided by relatives. On the SAS-SR, women in the ABN group displayed the poorest overall social functioning. The RBN group was functioning significantly better than the ABN group, but significantly more poorly than the comparison group.

DISCUSSION

Our results suggest that the social functioning of RBN women lies between ABN women and non-eating-disordered women, indicating both gains relative to the active phase and residual deficits.

The quality of psychiatric residency : the assessment of programs and options for distributing psychiatric residents in the service of health care reform

Recent health care reform initiatives proposed training fewer medical specialists, including psychiatrists, and determining the size and location of training programs via centralized regulatory mechanisms. Facing such potential future developments, the American Association of Directors of Psychiatric Residency Training appointed a Task Force on the Quality of Residency Programs to develop informed recommendations for the field. This paper describes the Task Force's considerations and recommendations concerning how the least damaging and most effective decisions could be made regarding the distribution of residency positions, program size, and the future funding of training stipends. The recommendations emphasize voluntary decisions, feedback from local and regional stakeholders regarding perceived needs and demands for psychiatrists, and Federal or regional funding of postgraduate training stipends that are not primarily tied to providing clinical services.

Downsizing psychiatric residency programs : a pilot study

Under the varied pressures of decreasing recruitment of American medical school graduates into psychiatry, the thrust of health care policymakers to decrease the production of specialist physicians, and financial cutbacks for training by hospitals, universities, and governments at all levels, many psychiatric training programs are considering downsizing or have already implemented plans to do so. The authors describe the motivations, early experiences, anticipated concerns, and thoughts regarding downsizing obtained from interviews or questionnaires provided by 17 programs in 1993. On the basis of the authors' experiences, some recommendations are offered for the many programs likely to deal with this issue in the future.

Practice guidelines and psychiatric education : potential implications

The American Psychiatric Association's practice guidelines provide authoritative guidance for assessing and treating major clinical problems that psychiatrists face. This article reviews the social context in which practice guidelines have emerged, opportunities they afford educators, and limitations in their educational and practice applications. Practice guidelines should be used in residents' and medical students' seminars and in continuing medical education activities. The incentive to study guidelines may increase as their likely use as information sources for questions on in-service and specialty board certification examinations as well as in clinical quality-assurance activities becomes more widely recognized.

Intercomparison of analytical methods for arsenic speciation in human urine

An intercomparison exercise was conducted for the quantification of arsenic species in spiked human urine. The primary objective of the exercise was to determine the variance among laboratories in the analysis of arsenic species such as inorganic As (As+3 and As+5), monomethylarsonic acid (MMA), and dimethylarsinic acid (DMA). Laboratories that participated had previous experience with arsenic speciation analysis. The results of this interlaboratory comparison are encouraging. There is relatively good agreement on the concentrations of these arsenic species in urine at concentrations that are relevant to research on the metabolism of arsenic in humans and other mammals. Both the accuracy and precision are relatively poor for arsenic concentrations of less than about 5 micrograms/l.

Preparing psychiatric residents for managed care. Values, proficiencies, curriculum, and implications for psychotherapy training

As managed care psychiatric service systems become increasingly prominent in academic centers and the larger world of psychiatric practice, residency programs find themselves having to adapt to the value systems and training paradigms necessary for preparing house staff to deal with these systems. Many of the values and some of the necessary proficiencies differ considerably from those of traditional fee-for-service psychiatric practice. This article delineates the value systems under which managed care systems operate, the clinical proficiencies that will be needed by psychiatrists practicing in such settings, the experiential and didactic curriculum necessary to prepare today's psychiatric residents for adapting to managed care-oriented practices, and the implications of these changes for psychotherapy education and training.

Histories of childhood trauma and complex post-traumatic sequelae in women with eating disorders

The profound self-destructiveness and tenacity of eating disorders found among women abused and neglected in childhood become comprehensible when understood within a complex posttraumatic conceptualization as desperate attempts to regulate overwhelming affective states and construct a coherent sense of self and system of meaning. Trauma leads to the predictable consequences of dysregulation of the arousal system, avoidance, and constriction of affect; coherence of self and world are shattered. Abused patients' childhood experiences teach them that to need is to expose oneself to the pain of abandonment and betrayal at the hands of individuals responsible for their care. Consequently, needs-psychological, physical, and spiritual-come to be perceived as dangerous, and human relationships are simultaneously yearned for and feared. Robbed of the opportunity to develop a cohesive self and a coherent system of meaning and faith to sustain from within, the traumatized eating-disorder patient turns to the culture to tell her who to be and how to live; she learns that to conquer rather than satisfy needs and to be "in control" (an internal state of equanimity manifested externally in a thin body) will bring meaning and purpose. Binge eating, purging, and starving become apt metaphors for the boundless hunger, the wish to fulfill needs together with the wish to rid oneself forever of need, the desire to "purify" the damaged psychic and physical self, and the hope of restoring meaning. The treatment of the traumatized eating disorder patient is complex. Individual therapy provides the opportunity for intensive relational work that begins to restore faith in human connection and that provides a "safe base" from which to examine the trauma and separate past from present. Therapy groups for eating-disordered women and trauma survivors provide relief from isolation, valuable perspectives from others who have "been there," and the opportunity to contribute to others' healing as one heals. Ultimately, these patients must be willing to leave the world of obsession with food and weight, which guarantees safety from interpersonal hurt while it simultaneously guarantees that hope will not be restored. Though reconnecting with humanity carries the risk of further pain, it opens up the opportunity for connection, healing, and growth.

Engineering of a sugar-derivatized porous network for hepatocyte culture

Many tissue engineering applications require a scaffold or template conducive to cell attachment and maintenance of functions. It may also be advantageous in some cases for these scaffolds to have a controlled porous architecture to facilitate cellular or tissue ingrowth. In this study, we have engineered a porous carbohydrate-derivatized substrate for hepatocyte culture. Polystyrene foams, with pore sizes up to 100 microns, fabricated by phase separation from a homogeneous naphthalene solution, were derivatized with lactose and heparin, both of which are known to promote rat hepatocyte attachment and maintenance of its differentiated functions. Rat hepatocytes cultured on these derivatized foams exhibited a rounded cellular morphology with many microvilli evident on the surface of the cells. The hepatocytes showed an increase in albumin secretion for the first 3 days of culture in a defined, serum-free medium, and dropped back to initial levels by the end of 7 days. The production of cytochrome P450-dependent hydroxytestosterone metabolites were also measured. Two testosterone metabolites were maintained and five others were present but decreased over a culture period of 1 week. These carbohydrate-derivatized porous substrates may be useful for large-scale culture of hepatocytes, toxicology screening and for use in a liver assist device.

Lasionectes exleyi, sp, nov., the first remipede crustacean recorded from Australia and the Indian Ocean, with a key to the world species

The first remipede crustacean from the Southern Hemisphere and the Indian Ocean is reported. Lasionectes exleyi, sp. nov., is described from an anchialine cave on the Cape Range peninsula of Western Australia. This is the eleventh species of modern remipede to be described and the second species to be described in the genus Lasionectes. A key to all known species is presented. The discovery of remipedes in Australia represents the first occurrence of a genus other than Speleonectes off the Bahamas Banks and only the second continental occurrence of extant remipedes. The species is known from below a density interface in a single nutrient-enriched cave.

Temporal evolution of neuropathologic changes in an immature rat model of cerebral hypoxia: a light microscopic study

The sequential evolution of neuropathologic changes was studied in an immature model of cerebral hypoxia-ischemia. According, 7-day postnatal rats were subjected to unilateral common carotid artery ligation combined with 2 h of hypoxia (breathing in 8% oxygen) and their brains were examined by light microscopy at recovery intervals ranging from 0 to 3 weeks. Immediately following hypoxia, a large area with a pale staining border was noted occupying most of the cerebral hemisphere ipsilateral (IL) to the occluded common carotid artery; in approximately half of the brains the dorsomedial cortex of the contralateral (CL) hemisphere was also involved. Most neurons in the pale area had nuclei containing a coarse granular condensation of chromatin. Within a few hours, the majority of neurons in the IL hemisphere had developed pyknotic nuclei and clear or eosinophilic perikarya. After 24 h these changes had evolved in the majority of brains into coagulation necrosis (infarction) in the IL hemisphere and foci of selective neuronal necrosis in the CL cortex. Within a few days infarcts became partially cavitated, and by 3 weeks a smooth-walled cystic infarct had developed. Activated microglia/macrophages and reactive astrocytes were first seen at 4 and 24 h, respectively. No parenchymal neutrophilic infiltrate was seen at any time point.

Aspects of childhood physical punishment and family environment correlates in bulimia nervosa

Although histories of child sexual abuse among eating disorder patients have attracted considerable attention in the past decade, relatively little is known about parental physical abuse among these patients. We examined aspects of childhood parental physical punishment and its family environmental correlates among women with a lifetime history of bulimia nervosa (BN group; n = 80) and women with no history of eating disorder (Control group; n = 40), recruited primarily by newspaper advertisement. Women in the BN group reported significantly more physical punishment and perceived their discipline to have been more harsh and capricious than women in the Control group. Nonetheless, the groups did not differ significantly in the extent to which they believed they deserved their punishment or in their belief that they were "physically abused." Further, subjects often failed to assert that they had been physically abused despite meeting conservative criteria, while the reverse tendency was uncommon. Finally, increased levels of physical punishment were associated with greater global family pathology in the BN group, but not in the Control group. Our findings underscore the necessity of explicitly inquiring about physically punitive events in the histories of bulimic women, as well as beliefs regarding these events.

Providing residents with a comprehensive educational program in outpatient psychiatry : integrating an outpatient curriculum into outpatient management teams

As part of their efforts to prepare psychiatry residents for comprehensive, practical outpatient psychiatric practice, the authors have established an organized training program in ambulatory psychiatry. The program consists of outpatient management teams that run from mid-PGY-2 to PGY-4, a specified minimum number of mandatory outpatient hours for continuity patient care, and suggested guidelines for residents' outpatient experiences. An outpatient management team curriculum has been designed for team leaders and trainees that consists of specific topics in outpatient care, associated learning objectives, and readings for each topic. This curriculum, which supplements our previous program of conferences, individual supervision, and a yearlong psychotherapy seminar series, has been refined over the past 5 years. The authors describe the program and the topics included in the curriculum.

Coping styles differ between recovered and nonrecovered women with bulimia nervosa, but not between recovered women and non-eating-disordered control subjects

We examined potential differences in dispositional coping styles among women who had recovered from DSM-III-R bulimia nervosa (RBN; N = 40), women actively suffering from the disorder (N = 40), and women with no history of eating disturbance (control; N = 40). Using a 60-item self-report measure, we found that women with active bulimia nervosa were less likely than the other two groups to utilize active coping, planning, and seeking emotional support, and less likely than the recovering bulimia nervosa group to focus on and vent emotions. They were more likely than control subjects to use behavioral disengagement. On none of the scales did recovered women differ significantly from control subjects. Our findings suggest that the characteristic coping styles of women who have recovered from bulimia nervosa are as adaptive as those with no history of eating disorder, whereas women who are actively bulimic manifest fewer adaptive and more maladaptive coping behaviors.

A survival guide for aspiring academic psychiatrists : personality attributes and opportunities for academic success

Many residents in psychiatric residency training are interested in an "academic career" Recognizing that current academic departments require excellent teachers, clinicians, and administrators in addition to researchers, medical schools and their universities are wrestling with titles and tenure as they attempt to provide opportunities via a variety of academic career paths. What constitutes the most suitable career path for the academic aspirant depends on the person's goals, motivations, interests, values, personality style, talents, background, and training, as well as historically and geographically available training, mentoring, and employment opportunities. The authors examine alternative definitions of "academic success," relate these to the variety of personality types and opportunities found in academic settings, and provide some guidelines for advancement along the available career paths.

Childhood sexual, physical, and psychological abuse and their relationship to comorbid psychopathology in bulimia nervosa

We examined the relationship between childhood sexual, physical, psychological, and "multiple" abuse (i.e., abuse in more than one form) and comorbid Axis I and personality psychopathology among women with a lifetime history of bulimia nervosa (BN group; n =s 80) and a control group of noneating-disordered women (n = 40). Subjects were recruited primarily by newspaper advertisement. They participated in structured clinical interviews for diagnosis of Axis I and personality pathology, and they completed child abuse questionnaires in the interview setting. At odds with prediction, child abuse in various forms was not associated with the presence of lifetime comorbid Axis I disorders in general (i.e., 1 or more) or disorder classes in particular (mood, alcohol/substance use, anxiety) among BN subjects, although sexual, psychological, and multiple abuse were associated with the diagnosis of a higher total number of Axis I conditions. A history of psychological and multiple abuse (but not physical or sexual abuse alone) among BN subjects was strongly associated with the presence of personality disorder diagnoses, especially those in the "anxious-fearful" cluster (Cluster C). Finally, we found that when a personality disorder was present in addition to the Axis I conditions in question, significant relationships emerged between abuse and Axis I pathology, particularly for psychological and multiple abuse. In general, control group findings were in accord with BN group findings, indicating that our findings were not specific to eating-disordered women. Our results suggest that childhood abuse, particularly psychological abuse and abuse in multiple forms, increase the likelihood of lifetime comorbid Axis I disorders and personality pathology among bulimic patients. Eating-disordered women with a history of child abuse may thus represent a subgroup of patients requiring especially intensive intervention.

Litigation in residency training programs and suggested due process guidelines for "residents in trouble"

Litigation involving the dismissal of residents has increased in the past decades. A review of relevant court decisions and their implications for residency training programs is provided. To assure due process in such cases and to help programs deal fairly with situations involving problem residents that may never come to frank dismissal, a set of guidelines to assist training programs in dealing ivith residents "in trouble" is presented. The guidelines were developed collaboratively at University of California at Los Angeles (UCLA) and the University of Southern California (USC) and were reviewed and approved by the local hospital, university, and Veterans Affairs counsels to assure compliance with institutional policies and procedures regulating due process for employees and students. The guidelines were also reviewed and approved by an American Association of Directors of Psychiatric Residency Training (AADPRT) task force, but they were never published or widely distributed. Although modifications of these guidelines may be required to meet local educational or institutional variations, or to meet variations in state law or precedent, these suggestions provide a useful template with which to develop adequate and effective due process procedures.

Neurological proficiencies for psychiatrists : a pilot survey

Faculty at the University of California at Los Angeles were surveyed regarding appropriate proficiencies for general and subspecialty trained psychiatrists with respect to a number of neurological problems. Survey responses were obtained from 40 psychiatrists and 7 neurologists, representing 69% and 70%, respectively, of those surveyed in each group. Five levels of proficiency were defined, ranging from making a screening diagnosis to instituting definitive treatment and having laboratory expertise. Psychiatrists' expectations ranged from screening to monitoring proficiencies for a wide range of higher cortical func tion neurological disorders. Higher expected proficiencies were noted for schizophreniform symptoms of epilepsy, acute extrapyramidal reactions, tardive dyskinesias, dementias, and depressive syndromes associated with brain damage.

Childhood sexual, physical, and psychological abuse in bulimia nervosa

OBJECTIVE

This study sought to determine if rates of childhood sexual, physical, psychological, and multiple abuse (i.e., abuse in more than one form) differed between women with a lifetime history of bulimia nervosa and women with no history of eating disorders.

METHOD

Subjects were 80 women, aged 18-35, with a lifetime history of bulimia nervosa (40 women who had recovered for a year or more and 40 women currently suffering from bulimia nervosa) and 40 women who had never had an eating disorder or related difficulties. The cohort was obtained primarily by newspaper advertisement. Subjects participated in structured diagnostic interviews and completed paper-and-pencil questionnaires related to abusive experiences in childhood.

RESULTS

Women in the bulimia nervosa group reported higher levels of childhood physical, psychological, and multiple abuse. Contrary to expectation, rates of sexual abuse did not distinguish the groups, except in combination with other forms of abuse.

CONCLUSIONS

The higher rates of psychological, physical, and multiple abuse found among women with a lifetime history of bulimia nervosa than among comparison subjects underscore the importance of examining the full range of possible abusive experiences in women with eating disorders, rather than focusing simply on sexual abuse.

Psychosocial treatments for eating disorders

Biological and developmental vulnerabilities, maladaptive learning experiences, and pathological family patterns may all contribute to the appearance and persistence of eating disorder (Bruch 1973, Crisp 1980, Garfinkel and Garner 1982). Psychosocial treatment approaches are currently the most important and effective intervention methods for anorexia nervosa (American Psychiatric Association 1993, Garner 1985) and are at least equivalent to medication approaches for bulimia nervosa as well.