The effect of psychiatric decision unit services on inpatient admissions and mental health presentations in emergency departments: an interrupted time series analysis from two cities and one rural area in England

AIMS

High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach.

METHODS

We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation.

RESULTS

The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: -0.45%/week, 95% confidence interval [CI] = -0.78%, -0.12%; Urban: -0.49%/week, 95% CI = -0.73%, -0.25%); PDU implementation in each was associated with an estimated 35-38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (-20.4%, CI = -29.7%, -10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (-16.6%, 95% CI = -23.9%, -8.5%) but no significant (long-term) trend change (-0.20%/week, 95% CI = -0.74%, 0.34%) and no short- (-2.8%, 95% CI = -19.3%, 17.0%) or long-term (0.08%/week, 95% CI = -0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period.

CONCLUSIONS

The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

The use of social media platforms by migrant populations during the COVID-19 pandemic

Background

The rapid expansion of internet and social media use has meant that both useful and potentially harmful health information can spread rapidly. Groups experiencing barriers to health systems may be more reliant on social media as a source of health information. We did a systematic review to determine the extent and nature of social media use in migrant and ethnic minority communities for COVID-19 information, and implications for preventative health measures including vaccination intent and uptake.

Methods

We reviewed published and grey literature following PRISMA guidelines (PROSPERO registered CRD42021259190). Global research was included that reported on the use of social media by migrants and/or ethnic minority groups in relation to COVID-19.

Results

1849 unique records were screened, and 21 data sources included in our analysis involving studies from the UK, US, China, Jordan, Qatar, and Turkey. We found evidence of consistent use of a range of social media platforms for COVID-19 information in some migrant and ethnic minority populations (including WeChat, Facebook, WhatsApp, Instagram, Twitter, YouTube), which may stem from difficulty in accessing COVID-19 information in their native languages or from trusted sources. There were positive and negative associations with social media use reported, with some evidence suggesting circulating misinformation and social media use may be associated with lower participation in preventative health measures, including vaccine intent and uptake, findings of which are likely relevant to multiple population groups.

Conclusions

Urgent actions and further research are now needed to better understand the use of social media platforms for accessing health information by groups who may be marginalised from health systems, effective approaches to tackling circulating misinformation, and to seize on opportunities to make better use of social media platforms to support public health communication.

Key messages

Strategies to increase catch-up vaccination among migrants: a qualitative study and rapid review

Background

WHO’s Immunization Agenda 2030 has placed renewed focus on catch-up vaccination across the life course to meet global targets for reduction in vaccine-preventable diseases through increased vaccine coverage, including among migrant groups who may require catch-up vaccination to align them with host country vaccination schedules.

Methods

We did a global rapid review (01/2010 to 04/2022) to explore drivers of vaccine hesitancy among migrants followed by an in-depth qualitative study (semi-structured, telephone interviews) among recently arrived adult migrants (foreign-born, >18 years old, residing in the UK < 10 years). Interviews explored views on routine vaccination including accessibility, confidence and awareness. Data were analysed iteratively using thematic analysis.

Results

63 papers were included in the rapid review, including data from 22 countries/regions. Multiple factors driving under-immunisation and hesitancy in migrants were reported, including language barriers, low health literacy, social exclusion, low cultural competency and accessibility in healthcare systems. Our qualitative study recruited 40 migrants (mean age: 36.7 years; 62.5% female) resident in the UK (6 refugees, 19 asylum-seekers, 8 undocumented, 7 labour migrants). Major barriers to catch-up vaccination included a lack of provider recommendation and low awareness, with vaccination viewed as only relevant to children. Hesitancy around specific vaccines, such as MMR, was often influenced by misinformation. Participants suggested that novel strategies such as walk-in or mobile access points, consistent provider recommendations, and translation of information into relevant languages, may enhance accessibility and uptake of routine vaccinations.

Conclusions

Targeted and tailored information campaigns, versatile and proactive access pathways and education for healthcare staff on cultural competency will be needed to ensure uptake of catch-up vaccination among marginalised migrant groups.

Key messages

• Newly arrived adult migrants face barriers to catch-up vaccination in host countries, which may hinder immunisation coverage and increase the risk of vaccine-preventable disease outbreaks.

• Health systems must develop novel mechanisms to proactively offer culturally competent and accessible catch-up vaccination services to adult migrants on and after arrival.

Analysing drivers of routine and COVID-19 vaccination in migrants to develop tailored interventions

Background

Migrants in Europe are at risk of under-immunisation and may also have lower COVID-19 vaccination intent and uptake. There is an urgent need to better understand the drivers of uptake in these groups to inform the development of migrant-sensitive interventions for COVID-19 vaccination and routine vaccination beyond the pandemic.

Methods

We did a systematic review (PROSPERO: CRD42020219214) following PRISMA guidelines to explore factors influencing vaccine uptake in migrants in the EU/EEA and identify determinants of under-immunisation. We also held 3 participatory workshops with multinational migrant community leaders (n = 23) in London, to explore solutions and approaches to strengthen COVID-19 vaccine roll-out.

Results

We included 66 papers reporting data on 262,761 migrants in the review. Numerous access-related factors (e.g. government policy, communication barriers) influenced uptake. Vaccine hesitancy was attributed to lack of information, concerns about side-effects, and cultural beliefs/stigma around specific vaccinations. Migrants who had recently arrived, were older, female or of African and Eastern Mediterranean origin were at risk for under-immunisation for key vaccine-preventable diseases. Migrant community leaders reported considerable hesitancy towards COVID-19 vaccination in their communities and misinformation circulating via social media. Leaders requested support in producing simple COVID-19 guidance that could be translated and adapted locally, alongside more meaningful engagement and partnership-working.

Conclusions

Access barriers and vaccine hesitancy may affect vaccine uptake in some migrant populations in Europe, which needs to be urgently addressed for COVID-19 vaccine roll-out but also beyond the pandemic to strengthen uptake of routine vaccinations. Actively involving migrant communities in the planning, co-production and implementation of tailored and targeted approaches will be essential.

On behalf of ESGITM.

Key messages

Access barriers and vaccine hesitancy (from information gaps, cultural factors) contribute to low vaccine uptake in some migrant populations in the EU/EEA, with implications for COVID-19 vaccination. Meaningful engagement and co-production of tailored approaches with under-immunised migrants are urgently needed to ensure their inclusion in COVID-19 and routine vaccination programmes.

Digital screening tool (Health Catch-UP!) to promote multi-disease screening in migrants

Background

The ECDC has called for innovative strategies to deliver multi-disease screening (TB, LTBI, HIV, hepatitis B/C, Chagas, Strongyloidiasis and schistosomiasis) and catch-up vaccination (MMR, DTP) to adult migrants within the primary care context. We did a UK i qualitative study to explore current practice and seek views on a novel integrated digital tool to support delivery of screening recommendations for migrants https://emishealth.vids.io/videos/a49ad1bb1a18e4c72c/health-catch-up-with-requested-edits-mp4).

Methods

Phase 1 was conducted via telephone with clinical primary care practitioners (PCPs) (phase 1) and informed data collection and analysis for phase 2 with administrative staff. Data were analysed iteratively, informed by thematic analysis (Ethics no.20/HRA/1674).

Results

64 participants were recruited in Phase 1 (25 general practitioners [GPs], 15 nurses, 7 healthcare assistants, 1 pharmacist); Phase 2 comprised administrative staff (11 Practice-Managers, 5 receptionists). There was lack of consistency in delivery of screening and vaccination. Most GP practices adopted a practice-specific approach, or had no system in place; screening only for HIV and hepatitis B/C. Barriers to screening were perceived lack of knowledge/training and limited financial resources. Facilitators included having an infectious disease/migrant-health champion, incentivisation, and clear protocols. Participants responded positively to the integrated Health Catch-UP! tool, confirming that it would increase screening and vaccination, reduce missed opportunities for preventative healthcare, and raise awareness of migrant health.

Conclusions

Infectious disease screening and catch-up vaccination is not currently delivered well in primary care in high-migrant receiving European countries. Innovative digital tools like Health Catch-UP! could aid clinical decision-making and facilitating improved health outcomes for migrants. Further work is needed to evaluate this intervention.

Key messages

Infectious disease screening and catch-up vaccination is not currently delivered well in primary care in high-migrant receiving European countries. Innovative digital tools could aid clinical decision-making and facilitating improved health outcomes for migrants.

Developing and testing a principle-based fidelity index for peer support in mental health services

PURPOSE

Evidence suggests that the distinctive relational qualities of peer support-compared to clinical-patient relationships-can be eroded in regulated healthcare environments. Measurement of fidelity in trials of peer support is lacking. This paper reports the development and testing of a fidelity index for one-to-one peer support in mental health services, designed to assess fidelity to principles that characterise the distinctiveness of peer support.

METHODS

A draft index was developed using expert panels of service user researchers and people doing peer support, informed by an evidence-based, peer support principles framework. Two rounds of testing took place in 24 mental health services providing peer support in a range of settings. Fidelity was assessed through interviews with peer workers, their supervisors and people receiving peer support. Responses were tested for spread and internal consistency, independently double rated for inter-rater reliability, with feedback from interviewees and service user researchers used to refine the index.

RESULTS

A fidelity index for one-to-one peer support in mental health services was produced with good psychometric properties. Fidelity is assessed in four principle-based domains; building trusting relationships based on shared lived experience; reciprocity and mutuality; leadership, choice and control; building strengths and making connections to community.

CONCLUSIONS

The index offers potential to improve the evidence base for peer support in mental health services, enabling future trials to assess fidelity of interventions to peer support principles, and service providers a means of ensuring that peer support retains its distinctive qualities as it is introduced into mental health services.

A temperature model for laser lithotripsy

Objective

To derive and validate a mathematical model to predict laser-induced temperature changes in a kidney during kidney stone treatment.

Methods

A simplified mathematical model to predict temperature change in the kidney for any given renal volume, irrigation flow rate, irrigation fluid temperature, and laser power was derived. We validated our model with matched in vitro experiments.

Results

Excellent agreement between the mathematical model predictions and laboratory data was obtained.

Conclusion

The model obviates the need for repeated experimental validation. The model predicts scenarios where risk of renal tissue damage is high. With real-time knowledge of flow rate, irrigating fluid temperature and laser usage, safety warning levels could be predicted. Meanwhile, clinicians should be aware of the potential risk from thermal injury and take measures to reduce the risk, such as using room temperature irrigation fluid and judicious laser use.

What is the impact of psychiatric decision units on mental health crisis care pathways? Protocol for an interrupted time series analysis with a synthetic control study

BACKGROUND

The UK mental health system is stretched to breaking point. Individuals presenting with mental health problems wait longer at the ED than those presenting with physical concerns and finding a bed when needed is difficult - 91% of psychiatric wards are operating at above the recommended occupancy rate. To address the pressure, a new type of facility - psychiatric decision units (also known as mental health decision units) - have been introduced in some areas. These are short-stay facilities, available upon referral, targeted to help individuals who may be able to avoid an inpatient admission or lengthy ED visit. To advance knowledge about the effectiveness of this service for this purpose, we will examine the effect of the service on the mental health crisis care pathway over a 4-year time period; the 2 years proceeding and following the introduction of the service. We use aggregate service level data of key indicators of the performance of this pathway.

METHODS

Data from four mental health Trusts in England will be analysed using an interrupted time series (ITS) design with the primary outcomes of the rate of (i) ED psychiatric presentations and (ii) voluntary admissions to mental health wards. This will be supplemented with a synthetic control study with the same primary outcomes, in which a comparable control group is generated for each outcome using a donor pool of suitable National Health Service Trusts in England. The methods are well suited to an evaluation of an intervention at a service delivery level targeting population-level health outcome and the randomisation or 'trialability' of the intervention is limited. The synthetic control study controls for national trends over time, increasing our confidence in the results. The study has been designed and will be carried out with the involvement of service users and carers.

DISCUSSION

This will be the first formal evaluation of psychiatric decision units in England. The analysis will provide estimates of the effect of the decision units on a number of important service use indicators, providing much-needed information for those designing service pathways.

TRIAL REGISTRATION

primary registry: isrctn.com Identifying number: ISRCTN77588384 Link: Date of registration in primary registry: 27/02/2020.

PRIMARY SPONSOR

St George's, University of London, Cramner Road, Tooting, SW17 ORE. Primary contact: Joe Montebello.

[The Confusion Assessment Method: Transcultural adaptation of a French version]

INTRODUCTION

The Confusion Assessment Method (CAM) is a validated key tool in clinical practice and research programs to diagnose delirium and assess its severity. There is no validated French version of the CAM training manual and coding guide (Inouye SK). The aim of this study was to establish a consensual French version of the CAM and its manual.

METHODS

Cross-cultural adaptation to achieve equivalence between the original version and a French adapted version of the CAM manual.

RESULTS

A rigorous process was conducted including control of cultural adequacy of the tool's components, double forward and back translations, reconciliation, expert committee review (including bilingual translators with different nationalities, a linguist, highly qualified clinicians, methodologists) and pretesting. A consensual French version of the CAM was achieved.

CONCLUSION

Implementation of the CAM French version in daily clinical practice will enable optimal diagnosis of delirium diagnosis and enhance communication between health professionals in French speaking countries. Validity and psychometric properties are being tested in a French multicenter cohort, opening up new perspectives for improved quality of care and research programs in French speaking countries.

Direct to consumer genetic testing: a systematic review of position statements, policies and recommendations

In healthcare settings, genetic tests to determine whether an individual had inherited a genetic mutation are ordered by a health professional, and the results are interpreted and conveyed to the patient by that person. However, direct to consumer genetic testing (DTCGT) has enabled individuals to purchase genetic tests and receive results without the intervention of a health professional. To inform a set of guidelines for consumers and health professionals, we undertook a systematic review of position statements, policies and recommendations on the use of DTCGT. We performed a search of seven databases and the Internet for relevant documents. The search terms were 'direct to consumer' and 'genetic test', and documents in English published from 2002 to 2011 were included. The search retrieved 314 items, of which 14 were eligible for review. Five themes were derived from thematic analysis: motivation for use, potential benefits, potential harms, recommendations to guide consumers and need for research. The authors of these documents described more potential harms than benefits, but, although some stated that direct to consumer testing should be actively discouraged, others supported consumer rights to make autonomous choices. Further research into the impact of direct to consumer testing on health services and consumers is required to inform policies.

The teacher as observer and experimenter in the modification of disputing and talking-out behaviors

Disputing and talking-out behaviors of individual pupils and entire classroom groups in special education classes and regular classes from white middle-class areas and from all black poverty areas ranging from the first grade to junior high school were studied. The classroom teacher in each case acted as the experimenter and as an observer. Various means of recording behaviors were used and reliability of observation was checked by an outside observer, another teacher, a teacher-aide, a student, or by using a tape recorder. Observation sessions varied from 15 min to an entire school day. After baseline rates were obtained, extinction of inappropriate disputing or talking-out behaviors and reinforcement of appropriate behavior with teacher attention, praise and in some cases a desired classroom activity or a surprise at the end of the week brought a decrease in undesired verbalizations. A reversal of contingencies brought a return to high levels of inappropriate talking with a return to low levels when reinforcement for appropriate talking was reinstated. The experiments demonstrated that teachers in a variety of classroom settings could obtain reliable observational records and carry out experimental manipulations successfully using resources available in most schools.

An association of lower serum citrulline levels within 30 days of acute rejection in patients following small intestine transplantation

INTRODUCTION

In a prospective protocol we studied whether serum citrulline level within 30 days of an acute rejection was predictive of the episode.

METHODS

An acute rejection episode was defined as the date of occurrence of any biopsy-proven rejection in which treatment was initiated until two successive biopsies showed no further rejection. We compared the mean citrulline level based on values determined within 30 days of the start of an acute rejection episode with the mean citrulline level measured on the same patient during a rejection-free period. Serum citrulline measurements were available immediately prior to the occurrence of rejection for 22 patients who experienced 37 episodes.

RESULTS

For the 12 episodes of mild rejection, the mean serum citrulline level +/- SE (standard error) was 15.0 + 2.3 micromol/L prior to rejection and 18.8 +/- 2.4 micromol/L during the rejection-free periods. A paired t test of the mean differences was not significant (P = 17). For the 25 episodes of moderate or severe rejection, the mean serum citrulline level was 12.4 +/- 1.1 micromol/L before rejection and 18.8 +/- 2.0 micromol/L during the rejection-free periods. A paired t test of the mean difference was statistically significant (P = .002).

CONCLUSIONS

Although further study of citrulline as a marker for the early detection of acute rejection episodes is needed, our hope is that its use will help to prevent some of these early episodes from evolving into full-blown moderate or severe grades of rejection.

Serum sialic acid, a reputed cardiovascular risk factor, is related to serum leptin concentrations in Fijians

BACKGROUND

Serum sialic acid (TSA) has been shown to be a cardiovascular risk factor and an acute phase reactant, with elevated concentrations associated with increased cardiovascular mortality and to precede the onset of type 2 diabetes.

AIM

The purpose of this present study was to test the hypothesis that serum TSA may be related to serum leptin concentrations in healthy individuals.

METHODS

Thirty Fijian individuals were studied (8 males and 22 females). They were urban Melanesians living in Raiwaga, a suburb of Suva in Fiji.

RESULTS

Serum TSA significantly correlated with subject body mass index (BMI, rho 0.39, P<0.05) and serum leptin concentration (rho 0.44, P<0.05). In stepwise multiple regression analysis serum TSA independently correlated with subject waist/hip ratio (r(2)=0.167, P<0.02) and diastolic blood pressure (r(2)=0.300, P<0.01) but not with age, BMI, serum insulin-like growth factor binding protein (IGFBP-1), fasting plasma glucose or systolic or diastolic blood pressure.

CONCLUSIONS

Serum TSA is related to markers of obesity and adipose tissue metabolism which may help to explain why it is a reputed cardiovascular risk factor and why elevated serum TSA concentrations precede the development of type 2 diabetes mellitus.

Serum sialic acid, a possible cardiovascular risk factor is not increased in Fijian Melanesians with impaired glucose tolerance or impaired fasting glucose

BACKGROUND

Serum total sialic acid (TSA) has been shown to be a strong cardiovascular risk factor with increased concentrations being associated with increased mortality. Serum TSA is also elevated in patients with type 2 diabetes including those with micro- and macrovascular complications. We wished, therefore, to test the hypothesis that serum TSA may be abnormal in individuals with impaired glucose tolerance (IGT) and impaired fasting glucose (IFG), in Fijian Melanesians.

METHOD

Twenty-one subjects with IGT (17 women and four men) were recruited along with 20 subjects with IFG (14 women and six men) and 22 normal subjects (12 women and 10 men). Serum TSA was 2.18 +/- 0.027 mmol//L, 2.19 +/- 0.033 mmol/L and 2.24 +/- 0-042 mmol/L in the three groups, respectively, which was not statistically different. Both systolic and diastolic blood pressure were, however, higher in the IGT group compared with the IFG and normal groups (P<0.04).

CONCLUSION

Serum TSA is not elevated in Fijian Melanesians with IGT and IFG although it is reported to be elevated in type 2 diabetes mellitus in other populations. Further research is needed to establish why serum TSA is a potent independent cardiovascular risk factor and is elevated in type 2 diabetes mellitus in some populations.

Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial

OBJECTIVE

Disagreement exists concerning the appropriate delivery room management of the airway of vigorous meconium-stained infants. Some suggest a universal approach to intubation and suctioning of the airway in all such neonates, whereas others advocate a selective approach. We performed this investigation: 1) to assess whether intubation and suctioning of apparently vigorous, meconium-stained neonates would reduce the incidence of meconium aspiration syndrome (MAS); and 2) to determine the frequency of complications from delivery room intubation and suctioning of such infants.

METHODS

Inclusion criteria included: 1) gestational age >/=37 weeks; 2) birth through meconium-stained amniotic fluid of any consistency; and 3) apparent vigor immediately after birth. Subjects were randomized to be intubated and suctioned (INT) or to expectant management (EXP). Primary outcome measures included: 1) the incidence of respiratory distress, including MAS, and 2) the incidence of complications from intubation.

RESULTS

A total of 2094 neonates were enrolled from 12 participating centers (1051 INT and 1043 EXP). Meconium-stained amniotic fluid consistency was similar in both groups. Of the 149 (7.1%) infants that subsequently demonstrated respiratory distress, 62 (3.0%) had MAS and 87 (4.2%) had findings attributed to other disorders. There were no significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%) or in the development of other respiratory disorders (INT = 3.8%; EXP = 4.5%). Of 1098 successfully intubated infants, 42 (3.8%) had a total of 51 complications of the procedure. In all cases, the complications were mild and transient in nature.

CONCLUSIONS

Compared with expectant management, intubation and suctioning of the apparently vigorous meconium-stained infant does not result in a decreased incidence of MAS or other respiratory disorders. Complications of intubation are infrequent and short-lived.

Flotillin 2 is distinct from epidermal surface antigen (ESA) and is associated with filopodia formation

ECS-1, a monoclonal antibody (MoAb) raised to cultured human keratinocytes, stains the intercellular glycocalyx with a pemphigus-like pattern and recognizes a 35-kDa epidermal surface antigen (ESA) on Western blotting of keratinocyte extracts. When ECS-1 MoAb was used to screen a keratinocyte expression library, a unique cDNA was identified that predicted a 42-kDa globular protein of unknown function. This putative ESA was conserved between mice and humans and was encoded by a gene on chromosome 17q11-12 in linkage with neurofibromin. Homology between the cDNA sequence has been reported with flotillin 1, a caveolae associated protein, as well as Reggie 1 and 2, neuronal proteins expressed during axonal regeneration present in activated GPI-anchored cell adhesion molecules in non-caveolar-associated micropatches. In order to determine whether the cDNA predicted protein and ECS-1 antigen were identical, we compared ECS-1 with the immunoreactivity of a new antibody raised to the cDNA fusion protein in epidermis and cultured cells. The cDNA fusion protein was expressed in bacteria and in cos cells with his, FLAG, and EGFP reporter tags and by stable transfection as an EGFP fusion protein. The fusion protein and native protein of 42 kDa were detected by the new antibody, but not by the original ECS-1. Thus, the ECS-1 antigen, ESA (35 kDa), is clearly distinct from the protein predicted by the cDNA (renamed flotillin 2). Stable transfection of ESA/flotillin 2 fusion protein in cos cells induced filopodia formation and changed epithelial cells to a neuronal appearance. Thus, the function of flotillin 2 may resemble that of the goldfish optic nerve neuronal regeneration proteins, Reggie 1 and 2.

Evaluation of RU58841 as an anti-androgen in prostate PC3 cells and a topical anti-alopecia agent in the bald scalp of stumptailed macaques

The effect of androgen receptor transcriptional activation by RU58841, a nonsteroidal anti-androgen, was studied in the human prostate cancer PC3 cell line by cotransfection with wild-type androgen receptor (wt AR) and an androgen-responsive reporter (MMTV-ARE-CAT) construct. Anti-and rogens, hydroxyflutamide, and Casodex, and the antiestrogen, genistein, were studied in parallel for comparison with RU58841. The wt AR was activated only by the androgen dihydrotestosterone (DHT). Neither the anti-androgens nor antiestrogen can enhance AR transcriptional activity at 10(-11)-10(-7)M in PC3 cells. Hydroxyflutamide, RU58841, and Casodex, but not genistein, displayed competitively suppressive effects on DHT activation of wt AR. The potency of RU58841 was comparable to that of hydroxyflutamide. From this result, topical application of RU58841, which is considered to be a potential therapy for skin diseases, may induce systemic side effects. However, RU58841, on topical application, revealed a potent increase in density, thickening, and length of hair in the macaque model of androgenetic alopecia, whereas no systemic effects were detected. Together our results suggest that RU58841 may have potent antagonism to the wt AR and could be considered as a topically applied active anti-androgen for the treatment of androgen-dependent skin disorders, such as acne, androgenetic alopecia, and hirsutism.

Localized Darier disease. Implications for genetic studies

BACKGROUND

Darier disease is an uncommon genodermatosis characterized by the symmetrical eruption of keratotic reddish-brown papules occurring in the seborrheic areas of the body. A unilateral, or localized, variant has been identified. We report 4 new cases of localized Darier disease and review the English-language literature. The implications of these cases on future genetic studies are also discussed.

OBSERVATIONS

Localized Darier disease occurred with equal frequency in males and females. The average age at onset was 27 years. The most frequent site of involvement was the trunk (40% [16/40]). This condition was aggravated by sunlight, heat, or sweating in 42% (19/40) of reported cases, and 38% (15/40) of the patients responded to treatment with topical tretinoin.

CONCLUSIONS

Many of the clinical features of localized Darier disease suggest that it is a genetic mosaic of generalized Darier disease. Further studies of localized Darier disease may therefore prove to be instrumental in the search for the Darier disease gene.

Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels

OBJECTIVE

Our purpose was to evaluate peripheral joint laxity during pregnancy and to determine whether serum relaxin levels are associated with increased joint laxity.

STUDY DESIGN

A prospective observational study was performed.

RESULTS

A significant increase in joint laxity was found in five of seven peripheral joints over the course of the pregnancy and post partum. There was no correlation with serum relaxin levels. There were no significant differences in joint laxity on the basis of parity, age, or prepregnancy exercise levels.

CONCLUSIONS

Peripheral joint laxity is noted to increase as pregnancy progresses. The cause of this change is undetermined.

Cloning and characterization of a novel epidermal cell surface antigen (ESA)

We report here the isolation and characterization of a cDNA that encodes a novel extracellular epidermal molecule, epidermal surface antigen (ESA), which is thought to play a role in intercellular epidermal adhesion. Sequence analysis reveals that the 379 amino acid ESA has a molecular mass of about 41.7 kDa and an alpha-helix-rich secondary conformation. Much of this also has an heptad substructure, consistent with the formation of several bundles of alpha-helices in a compact globular structure. The ESA protein appears to consist of an NH2-terminal hydrophobic region with mixed alpha and beta structure followed by a more hydrophilic COOH-terminal region which is very rich in alpha-helix. The 2.5-kilobase ESA mRNA is expressed in cultured keratinocytes, melanocytes, fibroblasts, carcinoma, and melanoma cell lines. The ESA gene is conserved in all mammalian species examined and has been localized to human chromosome 17 (M17S1) in the same region as the gene for von Recklinghausen neurofibromatosis. The high level of expression of the ESA mRNA in human skin and in cultured cells derived from the epidermis, the appearance of ESA protein early in human development, and conservation of the ESA gene throughout mammalian evolution suggest that the novel ESA protein plays a vital role in epidermal structure and maintenance.

Endothelin- and oxytocin-induced calcium signaling in cultured human myometrial cells

The demonstration that endothelin (ET) induces rat uterine contraction, coupled with the observation that ET is present in human amniotic fluid, suggests that the myometrium may be an important target organ for this hormone. We show that in quiescent human myometrial cells ET produced a dose-dependent increase in cytosolic free Ca2+ (Cai2+), which was markedly attenuated when the cells were studied in Ca2(+)-free media. Preincubation with nicardipine, diltiazem, or verapamil reduced the ET-evoked Cai2+ transient by 30, 40, and 65%, respectively. The presence of voltage sensitive Ca2+ channels was demonstrated by Mn2+ quenching of fura-2. Activation of the Na+/H+ antiport could not be demonstrated with ET stimulation. In nonquiescent cells, the ET-evoked Cai2+ transient was significantly reduced, while the response to oxytocin was retained. This is at least partially explained by a reduction in Bmax (maximal binding capacity) for ET (mean +/- SEM) from 3,506 +/- 268 binding sites/cell in quiescent cells to 2,411 +/- 300 binding sites/cell, as well as 72% increase in Kd (equilibrium dissociation constant), in the nonquiescent cells. We conclude that, in human myometrial cells, ET and oxytocin modulate Cai2+ through independent receptors and propose that ET, like oxytocin, is an important endogenous modulator of uterine contractility.

Amitriptyline versus placebo in postherpetic neuralgia

To study the effects of amitriptyline in treating postherpetic neuralgia, 24 patients were randomly assigned to either drug or placebo in a double-blind crossover study. We found good to excellent pain relief in 16 of 24 patients (p less than or equal to 0.001). We did not find an antidepressant effect in most patients (p greater than 0.05). The median dose of amitriptyline was 75 mg. The median blood level was 65 ng per milliliter, and of nortriptyline 30 ng per milliliter. Good responses were maintained in 12 of 22 patients. Amitriptyline is useful in treating postherpetic neuralgia and may not act as an antidepressant.

A comparative study of borderline patients in a psychiatric outpatient clinic

The authors applied a list of operational criteria to all new patients in a large psychiatric outpatient department over a one-year period. A randomly selected group of patients clinically diagnosed as having borderline personality disorder was compared with groups with the diagnoses of schizophrenia, neurosis, and nonborderline personality disorder. The group with borderline personality disorder was significantly different from the other groups according to the criteria, especially on items reflecting impulsivity, affectivity, and overvaluation/derogation of others. Impaired reality testing proved a useful distinguishing criterion as well and should be retained as part of the borderline concept.

Induction of relaxin secretion in nonpregnant women by human chorionic gonadotropin

Five normal women using barrier forms of contraception has serum samples drawn every 2 days during control menstrual cycles. Relaxin was not detectable in their serum. All five subjects then received 2500 IU hCG im every 2 days beginning 8--10 days after presumed ovulation. All had immunoreactive relaxin detectable in serum 2--6 days after the first hCG injection. Relaxin rose to pregnancy levels (range, 0.26--0.62 ng/ml; mean, 0.38 +/- 0.17 ng/ml) by cycle day 31 and then declined before menstruation. Progesterone levels and cycle lengths of relaxin-secreting cycles were significantly higher (P less than 0.05) than control cycles. Three of the five subjects subsequently received 2500 IU hCG im every 2 days commencing 2--3 days after presumed ovulation until menstruation. Relaxin was not detectable in these cycles. hCG can induce relaxin secretion in nonpregnant women. A hCG stimulus which can induce relaxin secretion from an 8- to 10-day-old corpus luteum cannot induce relaxin secretion in a 2- to 3-day-old corpus luteum, suggesting that the age of the human corpus luteum of the menstrual cycle is an important determinant of responsiveness to hCG.

Myometrial inhibiting activity of relaxin-containing extracts of human corpora lutea of pregnancy

Relaxin is a peptide hormone secreted by the human corpus luteum of pregnancy . Aqueous extracts of relaxin-rich pregnancy corpora lutea decreased the amplitude of spontaneous human myometrial strip contractions in vitro. Relaxin-poor extracts of menstrual cycle corpora lutea did not affect contractions. Antibody precipitation of relaxin from pregnancy luteal extracts eliminated the effect on myometrial strips. Relaxin removal was confirmed by bioassay. This demonstrates an inhibiting action of human relaxin on human myometrial tissue in vitro. This action suggests a mechanism for maintaining uterine quiesence in early pregnancy.

Distribution of relaxin in women during pregnancy

The purpose of this study was to determine by RIA the concentrations of relaxin in various compartments and tissues in pregnant women. Ten pairs of maternal venous and cord blood were studied. The mean relaxin concentrations, in immunoreactive equivalents of porcine relaxin, were 0.683 ng/ml in maternal serum and 0.009 ng/ml in cord serum. Relaxin was undetectable in 8 of 9 samples of amniotic fluid. Mean concentrations of relaxin in pg immunoreactive equivalents of porcine hormone per mg protein, from maternal tissues at term pregnancy were as follows: fat 96 (N = 5), myometrium 47 (N = 4), skin 62 (N = 5), placenta 51 (N = 9), and corpus luteum 13,000 (N = 8). These data suggest that little relaxin crosses the placenta and little is produced in the fetus. Contrary to prior suggestions that relaxin may also be a placental product, relaxin appears to be solely produced in the corpus luteum, making it the only peripherally measured hormone that can be used as an index of luteal activity in pregnancy.

Adsorption of insulin to infusion bottles and tubing

The adsorption of clinically used quantities of insulin to infusion systems was studied. Isotonic saline solutions containing tracer quantities of beef insulin-I-131, with or without varying amounts of nonradioiodinated (carrier) regular beef insulin, were added to bottles of 500 ml. infusion sets. The solutions were then allowed to flow out into collection beakers. Adsorption was assessed by measuring the decrease of radioactivity in the solutions and/or recovery from the bottles by 30 per cent potassium hydroxide (KOH). The influence of human serum albumin (HSA) on adsorption was evaluated by repeating the experiments after HSA was added to the infusion fluid.

Adsorption of insulin-I-131 to both bottles and tubing was considerable, especially at low concentrations of carrier insulin. HSA effectively reduced the adsorption to clinically insignificant amounts.

ON THE ANTIGENICITY OF INSULIN

On the basis of body weight, mice showed a higher percentage survival to large doses of insulin than did rabbits and these in turn were more resistant to insulin than guinea pigs. Antibodies to insulin were induced in five species of animals. Anti-insulins produced by the guinea pig, rabbit, sheep, and horse can each neutralize insulin extracted from the pancreas of the rabbit, sheep, horse, pig, ox, and monkey (Macacus rhesus), but none of the four can neutralize insulin extracted from guinea-pig pancreas. Guinea-pig anti-insulin can neutralize endogenous mouse insulin; horse anti-insulin cannot. The problem of the relative effectiveness of insulin as an antigen is discussed.

ON THE ANTIGENICITY OF INSULIN

On the basis of body weight, mice showed a higher percentage survival to large doses of insulin than did rabbits and these in turn were more resistant to insulin than guinea pigs. Antibodies to insulin were induced in five species of animals. Anti-insulins produced by the guinea pig, rabbit, sheep, and horse can each neutralize insulin extracted from the pancreas of the rabbit, sheep, horse, pig, ox, and monkey (Macacus rhesus), but none of the four can neutralize insulin extracted from guinea-pig pancreas. Guinea-pig anti-insulin can neutralize endogenous mouse insulin; horse anti-insulin cannot. The problem of the relative effectiveness of insulin as an antigen is discussed.