Antipsychotic Medication and Risk of Metabolic Disorders in People With Schizophrenia: A Longitudinal Study Using the UK Clinical Practice Research Datalink

BACKGROUND AND HYPOTHESIS

Antipsychotics are first-line drug treatments for schizophrenia. When antipsychotic monotherapy is ineffective, combining two antipsychotic drugs is common although treatment guidelines warn of possible increases in side effects. Risks of metabolic side effects with antipsychotic polypharmacy have not been fully investigated. This study examined associations between antipsychotic polypharmacy and risk of developing diabetes, hypertension, or hyperlipidemia in adults with schizophrenia, and impact of co-prescription of first- and second-generation antipsychotics.

STUDY DESIGN

A population-based prospective cohort study was conducted in the United Kingdom using linked primary care, secondary care, mental health, and social deprivation datasets. Cox proportional hazards models with stabilizing weights were used to estimate risk of metabolic disorders among adults with schizophrenia, comparing patients on antipsychotic monotherapy vs polypharmacy, adjusting for demographic and clinical characteristics, and antipsychotic dose.

STUDY RESULTS

Median follow-up time across the three cohorts was approximately 14 months. 6.6% developed hypertension in the cohort assembled for this outcome, with polypharmacy conferring an increased risk compared to monotherapy, (adjusted Hazard Ratio = 3.16; P = .021). Patients exposed to exclusive first-generation antipsychotic polypharmacy had greater risk of hypertension compared to those exposed to combined first- and second-generation polypharmacy (adjusted HR 0.29, P = .039). No associations between polypharmacy and risk of diabetes or hyperlipidemia were found.

CONCLUSIONS

Antipsychotic polypharmacy, particularly polypharmacy solely comprised of first-generation antipsychotics, increased the risk of hypertension. Future research employing larger samples, follow-up longer than the current median of 14 months, and more complex methodologies may further elucidate the association reported in this study.

Non-randomised feasibility study of training workshops for Talking Therapies service high-intensity therapists to optimise depression and anxiety outcomes for individuals with co-morbid personality difficulties: a study protocol

BACKGROUND

The NHS Talking Therapies for Anxiety and Depression programme ('TTad'; formerly Improving Access to Psychological Therapies 'IAPT') delivers high-intensity cognitive behavioural therapy (CBT) to over 200,000 individuals each year for common mental health problems like depression and anxiety. More than half of these individuals experience comorbid personality difficulties, who show poorer treatment outcomes. TTad therapists report feeling unskilled to work with clients with personality difficulties, and enhancing the training of TTad therapists may lead to improved treatment outcomes for individuals presenting with secondary personality difficulties alongside depression and anxiety.

METHODS

This is a pre-post non-randomised mixed-method feasibility study, exploring the feasibility and acceptability of a 1-day training workshop for high-intensity (HI) CBT therapists. The workshop is focused on understanding and assessing personality difficulties and adapting HICBT treatments for anxiety and depression to accommodate client needs. The feasibility and acceptability of the workshop and the evaluation procedures will be investigated. It will be examined to what extent the workshop provision leads to improvements in therapist skills and confidence and explored to what extent the training has the potential to enhance clinical outcomes for this client group.

DISCUSSION

This feasibility study will provide data on the acceptability and feasibility of delivering brief therapist training to adapt usual HICBT to optimise care for individuals with secondary personality difficulties seeking treatment in TTad services for a primary problem of depression and/or anxiety. The study will also evaluate proof of concept that such an approach has the potential to improve clinical outcomes for those with secondary personality difficulties and report any possible harms identified. The study will inform the design of a future randomised controlled trial designed to test the effectiveness and cost-effectiveness of the training.

TRIAL REGISTRATION

ISRCTN81104604 . Submitted on 6th June 2022. Registration date: 3rd January 2023.

Adversity, social support and risk of self-harm during the COVID-19 pandemic

Little is known about the degree to which social factors interact with COVID-19-related adversity to increase the risk of self-harm thoughts and behaviours. Using data derived from a UK cohort study, Paul & Fancourt found that loneliness was associated with an increase in the odds of self-harm thoughts and behaviours, whereas high-quality social support protected against self-harm thoughts and behaviours. The authors concluded that it is the quality of social support and interactions, rather than the act of engaging in social interaction per se, that protects against self-harm in the context of adversity. The COVID-19 pandemic may exert longer-lasting effects on population mental health, and continued surveillance of mental health, including self-harm status, will be essential. If accompanied by appropriate measures of the availability and quality of social support, such monitoring could also inform the development of more effective adaptive interventions for those at risk of engaging in self-harm.

Mental health before and during the COVID-19 pandemic in two longitudinal UK population cohorts

BACKGROUND

The COVID-19 pandemic and mitigation measures are likely to have a marked effect on mental health. It is important to use longitudinal data to improve inferences.

AIMS

To quantify the prevalence of depression, anxiety and mental well-being before and during the COVID-19 pandemic. Also, to identify groups at risk of depression and/or anxiety during the pandemic.

METHOD

Data were from the Avon Longitudinal Study of Parents and Children (ALSPAC) index generation (n = 2850, mean age 28 years) and parent generation (n = 3720, mean age 59 years), and Generation Scotland (n = 4233, mean age 59 years). Depression was measured with the Short Mood and Feelings Questionnaire in ALSPAC and the Patient Health Questionnaire-9 in Generation Scotland. Anxiety and mental well-being were measured with the Generalised Anxiety Disorder Assessment-7 and the Short Warwick Edinburgh Mental Wellbeing Scale.

RESULTS

Depression during the pandemic was similar to pre-pandemic levels in the ALSPAC index generation, but those experiencing anxiety had almost doubled, at 24% (95% CI 23-26%) compared with a pre-pandemic level of 13% (95% CI 12-14%). In both studies, anxiety and depression during the pandemic was greater in younger members, women, those with pre-existing mental/physical health conditions and individuals in socioeconomic adversity, even when controlling for pre-pandemic anxiety and depression.

CONCLUSIONS

These results provide evidence for increased anxiety in young people that is coincident with the pandemic. Specific groups are at elevated risk of depression and anxiety during the COVID-19 pandemic. This is important for planning current mental health provisions and for long-term impact beyond this pandemic.

Self-harm in primary school-aged children: Prospective cohort study

Introduction

No prospective studies have examined the prevalence, antecedents or concurrent characteristics associated with self-harm in non-treatment-seeking primary school-aged children.

Methods

In this cohort study from Melbourne, Australia we assessed 1239 children annually from age 8–9 years (wave 1) to 11–12 years (wave 4) on a range of health, social, educational and family measures. Past-year self-harm was assessed at wave 4. We estimated the prevalence of self-harm and used multivariable logistic regression to examine associations with concurrent and antecedent factors.

Results

28 participants (3% of the 1059 with self-harm data; 18 girls [3%], 10 boys [2%]) reported self-harm at age 11–12 years. Antecedent (waves 1–3) predictors of self-harm were: persistent symptoms of depression (sex-age-socioeconomic status adjusted odds ratio [aOR]: 7.8; 95% confidence intervals [CI] 2.6 to 24) or anxiety (aOR: 5.1; 95%CI 2.1 to 12), frequent bullying victimisation (aOR: 24.6; 95%CI 3.8 to 158), and recent alcohol consumption (aOR: 2.9; 95%CI 1.2 to 7.1). Concurrent (wave 4) associations with self-harm were: having few friends (aOR: 8.7; 95%CI 3.2 to 24), poor emotional control (aOR: 4.2; 95%CI 1.9 to 9.6), antisocial behaviour (theft—aOR: 3.1; 95%CI 1.2 to 7.9; carrying a weapon—aOR: 6.9; 95%CI 3.1 to 15), and being in mid-puberty (aOR: 6.5; 95%CI 1.5 to 28) or late/post-puberty (aOR: 14.4; 95%CI 2.9 to 70).

Conclusions

The focus of intervention efforts aimed at preventing and reducing adolescent self-harm should extend to primary school-aged children, with a focus on mental health and peer relationships during the pubertal transition.

A rare exception to Haldane's rule: Are X chromosomes key to hybrid incompatibilities?

The prevalence of Haldane's rule suggests that sex chromosomes commonly have a key role in reproductive barriers and speciation. However, the majority of research on Haldane's rule has been conducted in species with conventional sex determination systems (XY and ZW) and exceptions to the rule have been understudied. Here we test the role of X-linked incompatibilities in a rare exception to Haldane's rule for female sterility in field cricket sister species (Teleogryllus oceanicus and T. commodus). Both have an XO sex determination system. Using three generations of crosses, we introgressed X chromosomes from each species onto different, mixed genomic backgrounds to test predictions about the fertility and viability of each cross type. We predicted that females with two different species X chromosomes would suffer reduced fertility and viability compared with females with two parental X chromosomes. However, we found no strong support for such X-linked incompatibilities. Our results preclude X-X incompatibilities and instead support an interchromosomal epistatic basis to hybrid female sterility. We discuss the broader implications of these findings, principally whether deviations from Haldane's rule might be more prevalent in species without dimorphic sex chromosomes.

An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP)

INTRODUCTION

The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report.

METHODS

This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP)

INTRODUCTION

The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report.

METHODS

This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

Teaching patients clean intermittent self-catheterisation prior to anti-incontinence or prolapse surgery: is it necessary in women with obstructive voiding dysfunction?

PURPOSE

To determine the value of pre-operative teaching of clean intermittent self-catheterisation (CISC) in women who undergo anti-incontinence and/or prolapse surgery and who are at 'high risk' to have post-operative incomplete bladder emptying.

METHODS

Out of the 402 patients who underwent anti-incontinence and/or prolapse surgery at our institute (March 2008-March 2009), 48 patients had at least one obstructive lower urinary tract symptom and one obstructive urodynamic parameter before surgery and were considered at 'high risk' to have post-operative incomplete bladder emptying. They were taught CISC pre-operatively.

RESULTS

Out of the 48 patients, 7 (14.6%) had incomplete bladder emptying. The incidence of post-operative incomplete bladder emptying was higher in the older women (P < 0.01) but was not affected by the type of surgery or by any particular pre-operative urodynamic parameter. None of the patients in this 'high risk' group were required to perform CISC post-operatively.

CONCLUSIONS

Routine teaching of the technique of CISC to 'high risk' patients prior to anti-incontinence and/or prolapse surgery appears to be an unnecessary use of valuable nursing time as well as being an invasive intervention which is unlikely to be required post-operatively.

How useful are the BSUG database outcome criteria: validation using the MESA questionnaire

Urinary stress incontinence is common, but there is a wide range of prevalence which might account for variations in definition of incontinence and variations in study methodology. Our study assessed the validity and reliability of the British Society of Urogynaecology's (BSUG) database subjective outcome scores after the tension-free vaginal tape (TVT), by correlating these with the changes in the Medical Epidemiologic and Social Aspects of Ageing (MESA) questionnaire score. A total of 100 women with urodynamic stress incontinence underwent TVT, completed a MESA questionnaire preoperatively and at 6 months postoperatively. We also collected information about three outcome measures of the BSUG database, patients' global impression of outcome and stress and urge symptom analyses. Our study showed that the postoperative patients' global impression of outcome improved significantly in 85% of cases and had 73.89% reduction in mean MESA scores (p < 0.001). The outcome measures of the BSUG database relates well to symptom improvement, based on MESA scores and these subjective assessments currently used by the BSUG's database are a valid assessment of TVT outcome.

Urinary leakage during coitus in women

During a 4-year period from 1993 to 1997, a total of 2153 women were referred to our urogynaecology clinic complaining of urinary incontinence. Of these women, 228 (10.6%) admitted to coital incontinence. Only 22 of these 228 women complained of this symptom without direct questioning. Urine loss occurred during penetration in 158 women, during orgasm in 45 women and during both in 25 women. Comparison of these groups showed few other differences in their presenting symptoms, examination findings, urodynamic data or diagnosis. Genuine stress incontinence was present in 79.8% of women with urinary leakage during penetration, in 93.2% with leak on orgasm and in 92.0% who leaked on both. Detrusor instability was uncommon. In most women who complain of urinary leakage during sexual intercourse, the underlying pathophysiological mechanism is urethral sphincter incompetence. Compared with women presenting with urinary incontinence in the absence of coital incontinence, women with coital leakage had a higher incidence of stress and urge incontinence, and a significantly greater incidence of anterior vaginal wall prolapse and demonstrable stress incontinence on examination.

National audit of incontinence surgery in the United Kingdom

The aim of the study was to describe the experience, current trends and management of incontinence surgery for urodynamic stress incontinence (USI) in the United Kingdom. The study was a postal questionnaire survey that was sent to a cohort of surgeons known to be performing continence surgery. The subjects addressed included the considered role of the surgeon, the total number and type of operations performed in the last year, urodynamics and physiotherapy prior to incontinence surgery, operative complications, postoperative advice and follow-up (lengths and methods). The response rate was 54%. Large variations were found in all areas. The survey provides evidence of the number of incontinence operations performed, potentially important trends and differences in the practice and management of incontinence in the United Kingdom. This survey may be helpful in making guidelines and standards for audit at regional, local and individual levels as well as recommendations for strategies to enhance professional expertise in urogynaecology in the United Kingdom.

Management of diabetic pregnancies in the United Kingdom

The aim of this postal questionnaire survey was to identify facilities currently available for the care of pregnant diabetic women in the United Kingdom and determine how closely these reflect the standards recommended by The St Vincent Declaration Action Programme. A questionnaire was sent to a physician and an obstetrician in each of the 255 obstetric hospitals in the UK. Two hundred and forty-five (96.1%) hospitals replied, with most of these managing 20 or less insulin dependent diabetics per year. Of the hospitals, 58.4%, had a special combined diabetic antenatal clinic; 86.6% of the units had a single physician responsible for diabetic care, whilst more than one obstetrician was involved in 50.6% of the units. Prepregnancy counselling was provided in 87.4% of the hospitals. Home blood glucose monitoring was used in 97.9% of the units. Ideal mean pre- and postprandial blood glucose concentrations were 6.0 mmol/1 (SD 0.82) and 7.9 mmol/l (SD 0.91), respectively. Ultrasound was routinely used to assess fetal growth in 98.7% of the units. The mean gestational age for elective caesarean section was 38.2 weeks (SD 0.55), compared with 39.0 weeks (SD 0.35) for planned vaginal delivery. During labour, 98% of the units used a dextrose and insulin infusion, but only 53.7% of the units maintained an intrapartum maternal blood glucose of between 4 and 6 mmol/l. We conclude that there is widespread variation in the management of the pregnant diabetic patient, and much practice is suboptimal. Many of the recommendations of the St Vincent Declaration are not being met by current UK practice.

Tension-free vaginal tape (TVT) in the United Kingdom

Four hundred and twenty-six surgeons identified as performing TVT in the United Kingdom in the year ended 1 January 2002 were sent a postal questionnaire to identify the technique employed and the complications encountered. An 81% response rate was achieved. Over 7000 TVT operations were reported. Large numbers of surgeons perform a small number of operations each year. A variety of different surgical techniques and anaesthetics are used. Bladder perforations have been reported by 44% and de novo bladder overactivity by 37% of surgeons. Tape erosion is seen in 0.33%. Twenty-eight per cent of surgeons have seen voiding abnormalities that persist for more than 6 weeks. Fifty-seven per cent of surgeons perform short-term follow-up only. The operation is performed in a variety of different ways, by surgeons with variable experience and volumes of work. The different surgical techniques have not been evaluated prospectively and complications are seen more commonly than originally reported.

Screening for gestational diabetes in the United Kingdom: a national survey

To determine the attitudes of British obstetricians to screening for gestational diabetes a postal questionnaire survey was undertaken. A questionnaire was sent to a single obstetrician in each of 255 obstetric hospitals identified in the United Kingdom. Of the 189 (75%) units that replied, only 42.3% had a protocol for screening for gestational diabetes. Routine antenatal screening was performed by urinalysis and blood glucose tests in 89.4% and 32.8% of units respectively. Clinical risk factors were used as an indication for routine blood glucose testing in 91.5% units. Following a positive screening test 54.5% of units performed a 75 g oral glucose tolerance test (GTT) and of these 64% relied on the World Health Organisation diagnostic criteria to interpret the result. There currently appears to be widespread variation in the practice of screening for gestational diabetes in the United Kingdom.

National survey on the management of prolapse in the UK

AIMS

To assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners, and compare practice between urogynaecologists (tertiary centres), gynaecologists with a special interest in urogynaecology and general gynaecologists.

METHODS

A postal questionnaire survey was sent to practising consultant gynaecologists in UK Hospitals. They included urogynaecologists in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP.

RESULTS

Four hundred fifty-eight responses were received and 398 were completed. For anterior vaginal wall prolapse, anterior colporrhaphy was the procedure of choice in 77% of respondents. With concomitant urodynamic stress incontinence, a Burch was the procedure of choice in 11%, but 79% of respondents would perform a midurethral tape combined with repair. In women with utero-vaginal prolapse the procedure of choice was a vaginal hysterectomy and repair (82%). Twenty-four percent of respondents would operate in women whose family was incomplete. In women with posterior vaginal wall prolapse (PWP), the procedure of choice was posterior colporrhaphy with midline fascial plication (75%). For vault prolapse, 66% of respondents would operate. Thirty-six percent would perform urodynamics prior to surgery. The procedure of choice was an abdominal sacrocolpopexy (38%).

CONCLUSION

There are wide variations in the surgical management of prolapse. Management of POP by urogynaecologists varied in some respects from the general gynaecologists, but were similar to the practices of gynaecologists with a designated interest in urogynaecology.

A prospective evaluation of the pathogenesis of detrusor instability in women, using electron microscopy and immunohistochemistry

OBJECTIVE

To characterize the types of detrusor smooth muscle junctions in the bladders of women with detrusor instability and in a control group without, and to assess whether there are differences in the cell junctions between these groups.

PATIENTS AND METHODS

The study included 13 women with detrusor instability (median age 57 years, range 32-86) and 11 control women (median age 50 years, range 33-62). Bladder biopsies were taken from each participant, processed for electron microscopy and immunohistochemistry (using a labelled antibody to vinculin) and analysed by investigators who were unaware of the patients' diagnoses.

RESULTS

Adherens (intermediate) junctions in classic and rudimentary forms were present in all biopsies from patients and controls. Adherens junctions and dense plaques occupied almost the complete cell border in most samples. Complete immunohistochemistry was possible in seven patients and five controls. In almost every detrusor smooth muscle cell studied, there was staining of the entire cell border with labelled antibody to vinculin in all biopsies.

CONCLUSIONS

This study provides evidence against an ultrastructural basis for idiopathic detrusor instability based on possible differences in detrusor smooth muscle intercellular junctions. Virtually the entire cell membrane of detrusor smooth muscle fibres is occupied by adherens junctions in classic and rudimentary forms, and with dense plaques present in samples from women with an unstable bladder and from controls. There was no junction detected in those with instability that was not present in the control group. The adherens junctions in the bladder facilitate mechanical coupling between cells.

Tension-free vaginal tape for primary genuine stress incontinence: a two-centre follow-up study

OBJECTIVE

To assess the safety and efficacy of the tension-free vaginal tape procedure in the treatment of primary genuine stress incontinence.

PATIENTS AND METHODS

A two-centre follow-up study was conducted on 40 women with urodynamically confirmed primary genuine stress incontinence who had a tension-free vaginal tape inserted under local anaesthesia with sedation. Operative details were recorded and all patients followed up both subjectively, and objectively with repeat urodynamic studies and pad testing.

RESULTS

The mean (range) age of the women was 51.1 (33-86) years, the median parity 2 (0-4) and mean body mass index 25.1 (19-35). The mean anaesthesia and operative duration was 42 (25-65) min; 93% of the women resumed immediate spontaneous voiding with no need for catheterization. The mean inpatient stay was 2.2 (2-4) days (where 2 days is equivalent to one night in hospital). The follow-up was conducted at a mean interval of 12.3 (6-24) months. Subjectively, 80% of women were cured and 17.5% significantly improved; objectively, genuine stress incontinence was cured in 95%. Symptomatic postoperative detrusor instability was found in 15% of women and symptoms of voiding dysfunction identified in 5% of women. There were no defects in healing or tape rejection.

CONCLUSION

The tension-free vaginal tape procedure is a promising new technique that, in this short-term analysis, appears to be safe and effective. Intra-operative complications are uncommon and both hospital stay and recovery are short. Voiding complications are rare but symptomatic postoperative detrusor instability had an incidence of 15%.

Colposuspension or sling for low urethral pressure stress incontinence?

The aim of this study was to compare Burch colposuspension with the pubovaginal sling in the management of low urethral pressure urinary stress incontinence. Forty-five women with low urethral pressure stress incontinence were retrospectively reviewed: 21 underwent colposuspension and 24 a pubovaginal sling. The subjective success rate of the Burch colposuspension and the pubovaginal sling was 90% and 71% (P = 0.12), respectively; the objective success rate was 67% and 50% (P = 0.26), respectively. The incidence of postoperative complications, including de novo detrusor instability and symptomatic voiding dysfunction following the colposuspension, was 5% compared to 25% following the pubovaginal sling (P = 0.06). Colposuspension should be considered in the management of women undergoing surgical correction of low urethral pressure stress incontinence. In a clinically similar group of women, the Burch colposuspension had a superior subjective and objective success rate with a lower incidence of complications than did the pubovaginal sling. Although these differences failed to reach statistical significance, colposuspension can be safely considered in the management of women with low urethral pressure GSI.

Oral methotrexate in the management of refractory interstitial cystitis

To establish the safety and efficacy of low-dose oral methotrexate in treating refractory interstitial cystitis, 9 women who fulfilled internationally accepted criteria for the diagnosis of interstitial cystitis were enrolled in a prospective study. All had proven unresponsive to conventional treatment modalities. Assessment by pain score and frequency volume charts was performed pretreatment and up to 6 months during therapy. No significant adverse side effects were noted. At the end of follow-up, 4 women had noted a subjective improvement in bladder pain and wished to continue on methotrexate, 4 women noted little change and 1 woman reported a worsening of symptoms. Overall there was a significant reduction in pain score (p = 0.047) posttreatment. However, there was no significant difference in urinary frequency per 24 hours (p = 0.40), maximum voided volume (p = 0.089) or mean voided volume (p = 0.59). Methotrexate significantly improved bladder pain in women with interstitial cystitis, although no significant change was found in voiding pattern.

Urethral diverticula in pregnancy

In 4 cases, the clinical presentation of urethral diverticulum (UD) during pregnancy was a paraurethral mass (3), urinary incontinence (2), irritative symptoms (2), urinary tract infection (1), urethral pain and discharge (1) and voiding difficulty (1). The diagnosis of UD during pregnancy was made by transvaginal ultrasonography (2), cystoscopy (1), and after pregnancy by a voiding cystourethrogram (1). Management during pregnancy involved antibiotics (2), diverticulum aspiration (2) and incision and drainage (1). Delivery was by the vaginal route in 2 women with diverticular aspiration being performed during the second stage to aid delivery in 1 woman. Caesarean section was performed in the other 2 women for reasons unrelated to the presence of the UD. Three women had diverticulectomy performed following pregnancy for persisting symptoms. Although uncommon, it is important to diagnose urethral diverticula given the associated morbidity and the potential for causing complications during pregnancy.

Regulation of HIV production by blood mononuclear cells from HIV-infected donors: II. HIV-1 production depends on T cell-monocyte interaction

Cell-cell interactions induced between T cells and monocytes by certain soluble anti-CD3 monoclonal antibodies (MAbs) were previously shown to be required for high-level production of HIV-1 by peripheral blood mononuclear cells (PBMCs) from infected donors. Staphylococcal enterotoxin or superantigen (SAg) is another mitogen inducing monocytes-T cell interactions that exhibit potent induction of HIV-1 production. Antibodies to several adhesion molecules were used to test the requirements for T cell- and monocyte-associated adhesion molecules in HIV-1 production following activation with anti-CD3 or SAg. Blocking of either CD2-LFA-3, or CD18-ICAM-1, inhibited anti-CD3- or SAg-induced HIV-1 production by more than 90% without inhibiting CD4+ T cell proliferation. Inhibition of HIV production was observed when either the T cell or monocyte coreceptor was bound by MAbs to these adhesion molecules. Blocking of CD28-B7 interactions by soluble CTLA-4 fusion protein, a CD28 homolog, inhibited both HIV-1 production and CD4+ T cell proliferation. Fc binding was not required for HIV-1 inhibition by MAbs to CD2 and CD18, because Fab or F(ab')2 fragments of these MAbs inhibited HIV-1 production by more than 80%. A chimeric single-chain MAb to CD2 was produced, containing heavy and light chain variable regions from MAb 35.1 to CD2 linked to the constant regions of human IgG1 (CD2 SFv-Ig). This humanized CD2 SFv-Ig inhibited HIV-1 production by 30% to > 98%. These results thus indicate that simultaneous engagement of multiple adhesion pathways between T cells and monocytes are required for HIV production by patients PBMCs and may have implications for therapy of HIV infections.

Regulation of HIV production by blood mononuclear cells from HIV-infected donors: I. Lack of correlation between HIV-1 production and T cell activation

The relationship between production of HIV-1 by peripheral blood mononuclear cells (PBMCs) from HIV-1-infected donors and the level of T cell activation by various stimuli was examined. Stimulation of PBMCs with soluble anti-CD3 antibody or staphylococcal enterotoxin/superantigen (SAg) was found to be 100-1000 times more effective at inducing production of HIV-1 than was stimulation with immobilized anti-CD3 or various other T cell activating agents. However, proliferation of CD4+ T cells and lymphokine production following stimulation with soluble anti-CD3 were less than with immobilized anti-CD3. To determine whether immobilized anti-CD3 stimulated cells may produce a factor(s) that suppresses HIV production, dual-chamber coculture experiments were performed in which soluble and immobilized anti-CD3-stimulated CD8-depleted PBMCs were separated by porous membranes. Stimulation of cells by immobilized anti-CD3 suppressed HIV-1 production by soluble anti-CD3-stimulated cells in the inner chamber, suggesting that diffusible factor(s) are involved in suppressing HIV-1 production. Experiments in which exogenous cytokines were added to cells stimulated with soluble anti-CD3 did not reveal the suppressive factor(s) produced; however, IL-7 was found to markedly increase HIV-1 production. Both T cells and monocytes were found to be required for soluble anti-CD3 to induce high levels of HIV-1 production, suggesting a role for adhesion molecules. Our results thus show that (1) soluble anti-CD3 is a powerful stimulus for HIV production, (2) there is not an absolute correlation between the level of HIV-1 production and T cell activation following stimulation of PBMCs with T cell activating agents, (3) immobilized anti-CD3 stimulation produces a factor that decreases HIV replication, and (4) T cell monocyte interactions are important for production of HIV-1 following stimulation with soluble anti-CD3.

Inhibition of virus production in peripheral blood mononuclear cells from human immunodeficiency virus (HIV) type 1-seropositive donors by treatment with recombinant HIV-like particles

We have previously reported on the assembly of recombinant human immunodeficiency virus (HIV)-like particles that contain gag structural proteins and present env glycoproteins gp120 and gp41 on their surfaces (O. Haffar,. J. Garriques, B. Travis, P. Moran, J. Zarling, and S.-L. Hu, J. Virol. 64:2653-2659, 1990). On the basis of their structures, we hypothesized that the recombinant particles would interfere with virus infection and tested our hypothesis in vitro by using peripheral blood mononuclear cells (PBMC) from HIV type 1-seropositive donors. Addition of the recombinant particles to PBMC concomitant with stimulation by anti-CD3 inhibited virus production, as determined by reduced levels of p24 in the culture supernatants. This inhibition of p24 production correlated with lower levels of cell-associated viral DNA. Several lines of evidence suggested that the recombinant particles exerted their antiviral effects primarily by inhibiting virus production from latently infected cells and not by inhibiting subsequent virus spread. Importantly, CD4+ T-cell stimulation by specific antigen or by anti-CD3 was not inhibited by treatment with the recombinant particles. This apparent selective inhibition of virus replication in infected PBMC represents a novel property of the recombinant HIV-like particles.

HIV-specific humoral and cellular immunity in rabbits vaccinated with recombinant human immunodeficiency virus-like gag-env particles

Recombinant human immunodeficiency virus type-1 (HIV-1)-like gag-env particles produced in mammalian cells were inoculated into two New Zealand white rabbits. In parallel, two control rabbits were inoculated with the homologous HIV-1 virions inactivated by ultra violet light (uv) and psoralen treatments. The humoral and cellular immune responses to HIV-1 were evaluated for both groups of animals. Recombinant particles elicited humoral immunity that was specific for all the viral structural proteins. The antibodies recognized both denatured and nondenatured proteins. Moreover, the sera neutralized the in vitro infectivity of the homologous virus in CEM cells. Importantly, the recombinant particles also generated a T helper response by priming with the HIV proteins. Similar results were observed with inactivated virus immunization. Therefore, our results suggest that the recombinant HIV-like particles elicit functional humoral immunity as well as cellular immunity and represent a novel vaccine candidate for AIDS.

Inhibition of HIV-1 replication in seropositive patients' CD4+ T-cells by pokeweed antiviral protein-monoclonal antibody conjugates

Pokeweed antiviral protein (PAP) inhibits HIV-1 replication in HIV-1 infected CD4+ cells and PAP targeted to CD4+T-cells by conjugation with monoclonal antibodies (mAb) against CD4 is approximately 1000 times more potent than non-conjugated PAP. Furthermore, PAP-antiCD4 inhibits HIV-1 production in seropositive patients' CD4+ T-cells activated with mAb to CD3 which was found to be the most potent means to activate HIV-1 production. These findings, together with previous observations that PAP-mAb conjugates have an in vivo plasma half-life of about 30 times that of non-conjugated PAP, suggest that PAP-antiCD4 may be a useful therapy in HIV-infected humans. Additionally, because PAP is known to have antiviral activity against several other human viruses, PAP-mAb conjugates may also have clinical potential for treating other viral diseases.

HIV-infected humans, but not chimpanzees, have circulating cytotoxic T lymphocytes that lyse uninfected CD4+ cells

It has been suggested that autoimmune phenomena contribute to the depletion of CD4+ T cells and the development of AIDS in HIV-1 infected humans based, in part, on observations that some HIV-1-infected humans have autoantibodies reactive with Ag expressed on uninfected CD4+ cells. In this study, 11 of 14 asymptomatic HIV-1-infected homosexuals and hemophiliacs, but none of 17 uninfected homosexuals or heterosexuals, were found to have cytotoxic lymphocytes in blood that can lyse uninfected CD4+ T cells from humans and chimpanzees but not human B lymphoblastoid cells or mouse T cells. The cytotoxic PBL were concluded to be CTL rather than NK cells, with the phenotype being CD3+, TCR-1 alpha beta+, CD8+, CD4-, CD16- based on findings that PBL-mediated lysis of uninfected CD4+ cells was 1) blocked by a mAb to CD3, which inhibits CTL but not NK activity; 2) diminished by treatment of PBL with a mAb to CD8 and C, but not by treatment with mAb to CD4 or CD16 and C; and 3) blocked by mAb WT31 directed against the TCR-1 alpha beta. In contrast, PBL from HIV-1-infected chimpanzees, which to date have not developed AIDS, lacked detectable CTL lytic for uninfected CD4+ cells.

HIV-infected humans, but not chimpanzees, have circulating cytotoxic T lymphocytes that lyse uninfected CD4+ cells

It has been suggested that autoimmune phenomena contribute to the depletion of CD4+ T cells and the development of AIDS in HIV-1 infected humans based, in part, on observations that some HIV-1-infected humans have autoantibodies reactive with Ag expressed on uninfected CD4+ cells. In this study, 11 of 14 asymptomatic HIV-1-infected homosexuals and hemophiliacs, but none of 17 uninfected homosexuals or heterosexuals, were found to have cytotoxic lymphocytes in blood that can lyse uninfected CD4+ T cells from humans and chimpanzees but not human B lymphoblastoid cells or mouse T cells. The cytotoxic PBL were concluded to be CTL rather than NK cells, with the phenotype being CD3+, TCR-1 alpha beta+, CD8+, CD4-, CD16- based on findings that PBL-mediated lysis of uninfected CD4+ cells was 1) blocked by a mAb to CD3, which inhibits CTL but not NK activity; 2) diminished by treatment of PBL with a mAb to CD8 and C, but not by treatment with mAb to CD4 or CD16 and C; and 3) blocked by mAb WT31 directed against the TCR-1 alpha beta. In contrast, PBL from HIV-1-infected chimpanzees, which to date have not developed AIDS, lacked detectable CTL lytic for uninfected CD4+ cells.

Protection of macaques against simian AIDS by immunization with a recombinant vaccinia virus expressing the envelope glycoproteins of simian type D retrovirus

Simian AIDS (SAIDS) is an endemic disease of macaques that shares many characteristics with AIDS in humans. SAIDS is etiologically linked to infection by a type D retrovirus, SAIDS retrovirus (SRV). Immunization with an inactivated whole-virus vaccine was shown to protect macaques against infection by SRV serotype 1. To identify the antigen(s) responsible for eliciting protective immunity, we have constructed a recombinant vaccinia virus (v-senv5) that expresses the envelope glycoproteins of SRV serotype 2 (SRV-2/W). Pig-tailed macaques (Macaca nemestrina) immunized with v-senv5 showed lymphoproliferative responses to purified SRV-2/W. They also generated antibodies that neutralized SRV-2/W infectivity in vitro and mediated antibody-dependent cellular cytotoxicity against SRV-2-infected cells. Four v-senv5-immunized animals, together with four control animals, were challenged intravenously with 5 x 10(3) tissue culture infectious doses of SRV-2/W. As early as 2 weeks after challenge, three of four control animals became viremic, and two of these three animals also seroconverted. The animal that was viremic but remained antibody negative died of symptoms of SRV infection 6 1/2 weeks after challenge. In contrast, all four v-senv5-immunized animals remained healthy, virus-free, and seropositive against only the immunizing envelope antigens. These results indicate that immunization with a recombinant vaccinia virus expressing the envelope antigens of SRV-2/W protects primates from infection by a retrovirus that causes immunodeficiency diseases.

Herpes simplex virus (HSV)-specific proliferative and cytotoxic T-cell responses in humans immunized with an HSV type 2 glycoprotein subunit vaccine

Studies were undertaken to determine whether immunization of humans with a herpes simplex virus type 2 (HSV-2) glycoprotein-subunit vaccine would result in the priming of both HSV-specific proliferating cells and cytotoxic T cells. Peripheral blood lymphocytes (PBL) from all eight vaccines studied responded by proliferating after stimulation with HSV-2, HSV-1, and glycoprotein gB-1. The PBL of five of these eight vaccines proliferated following stimulation with gD-2, whereas stimulation with gD-1 resulted in relatively low or no proliferative responses. T-cell clones were generated from HSV-2-stimulated PBL of three vaccinees who demonstrated strong proliferative responses to HSV-1 and HSV-2. Of 12 clones studied in lymphoproliferative assays, 9 were found to be cross-reactive for HSV-1 and HSV-2. Of the approximately 90 T-cell clones isolated, 14 demonstrated HSV-specific cytotoxic activity. Radioimmunoprecipitation-polyacrylamide gel electrophoresis analyses confirmed that the vaccinees had antibodies only to HSV glycoproteins, not to proteins which are absent in the subunit vaccine, indicating that these vaccinees had not become infected with HSV. Immunization of humans with an HSV-2 glycoprotein-subunit vaccine thus results in the priming of T cells that proliferate in response to stimulation with HSV and its glycoproteins and T cells that have cytotoxic activity against HSV-infected cells. Such HSV-specific memory T cells were detected as late as 2 years following the last boost with the subunit vaccine.

Lysis of cells infected with HIV-1 by human lymphocytes targeted with monoclonal antibody heteroconjugates

The present study was undertaken to determine whether human PBL can be specifically focused to lyse cells infected with HIV-1 by mAb heteroconjugates that can bridge target and effector cells. A mAb directed against the central portion of HIV-1 glycoprotein gp110 was chemically cross-linked to a mAb directed against the CD3/TCR complex or to a mAb directed against the CD16 Fc gamma-R expressed on large granular lymphocytes (LGL). HIV-1-infected cells, but not uninfected cells, were found to be lysed to a greater extent by PBL in the presence of the gp110 X CD3 or the gp110 X CD16 antibody heteroconjugate than in the presence of the single antibodies or a mixture of the mAb comprising the heteroconjugates. Pretreatment of PBL with anti-CD3 or IL-2 augments their ability to lyse HIV-1-infected cells in the presence of the heteroconjugates. Lysis by anti-CD3-activated PBL in the presence of the gp110 X CD3 heteroconjugate was found to be mediated by CD8+-enriched T cells, whereas lysis by IL-2-treated PBL in the presence of the gp110 X CD16 heteroconjugate is mediated by PBL enriched for CD16+ cells, which are primarily LGL. Furthermore, PBL from asymptomatic, HIV-1-infected seropositive donors were found to be functional in lysing HIV-1-infected cells in the presence of the antibody heteroconjugates. Such antibody heteroconjugates, which can target T cells or LGL to lyse HIV-1-infected cells, may be of prophylactic or therapeutic value in HIV-1-infected individuals.

Lysis of cells infected with HIV-1 by human lymphocytes targeted with monoclonal antibody heteroconjugates

The present study was undertaken to determine whether human PBL can be specifically focused to lyse cells infected with HIV-1 by mAb heteroconjugates that can bridge target and effector cells. A mAb directed against the central portion of HIV-1 glycoprotein gp110 was chemically cross-linked to a mAb directed against the CD3/TCR complex or to a mAb directed against the CD16 Fc gamma-R expressed on large granular lymphocytes (LGL). HIV-1-infected cells, but not uninfected cells, were found to be lysed to a greater extent by PBL in the presence of the gp110 X CD3 or the gp110 X CD16 antibody heteroconjugate than in the presence of the single antibodies or a mixture of the mAb comprising the heteroconjugates. Pretreatment of PBL with anti-CD3 or IL-2 augments their ability to lyse HIV-1-infected cells in the presence of the heteroconjugates. Lysis by anti-CD3-activated PBL in the presence of the gp110 X CD3 heteroconjugate was found to be mediated by CD8+-enriched T cells, whereas lysis by IL-2-treated PBL in the presence of the gp110 X CD16 heteroconjugate is mediated by PBL enriched for CD16+ cells, which are primarily LGL. Furthermore, PBL from asymptomatic, HIV-1-infected seropositive donors were found to be functional in lysing HIV-1-infected cells in the presence of the antibody heteroconjugates. Such antibody heteroconjugates, which can target T cells or LGL to lyse HIV-1-infected cells, may be of prophylactic or therapeutic value in HIV-1-infected individuals.

T-cell responses to human immunodeficiency virus (HIV) and its recombinant antigens in HIV-infected chimpanzees

Peripheral blood lymphocytes from chimpanzees infected for 3 months to more than 3 years with human immunodeficiency virus (HIV) had normal T-cell proliferative responses after stimulation with a variety of recall antigens and mitogens, indicating that HIV infection does not cause detectable immunological impairment in chimpanzees. This finding contrasts with that obtained in HIV-infected humans, who often have impaired T-cell reactivity. Peripheral blood lymphocytes from most HIV-infected chimpanzees that were studied also had strong proliferative responses to purified HIV as well as to HIV envelope glycoproteins isolated from the virus, to recombinant HIV envelope glycoproteins gp120 and gp41, and to HIV gag protein p24. The HIV-specific T-cell responses in HIV-infected chimpanzees may contribute to prevention of the development of acquired immunodeficiency syndrome in this species.

Proliferative and cytotoxic T cells to AIDS virus glycoproteins in chimpanzees immunized with a recombinant vaccinia virus expressing AIDS virus envelope glycoproteins

PBL from chimpanzees immunized with a recombinant vaccinia virus that expresses HIV envelope glycoproteins ("env"), were found to proliferate after stimulation with HIV or with "env". Furthermore, CTL clones lytic for autologous target cells expressing HIV envelope glycoproteins were generated after stimulation of the chimpanzees' PBL with "env", indicating that immunization of these primates with a recombinant vaccinia virus primes HIV-specific CTL and also that HIV envelope glycoproteins serve as target antigens for CTL.

Proliferative and cytotoxic T cells to AIDS virus glycoproteins in chimpanzees immunized with a recombinant vaccinia virus expressing AIDS virus envelope glycoproteins

PBL from chimpanzees immunized with a recombinant vaccinia virus that expresses HIV envelope glycoproteins ("env"), were found to proliferate after stimulation with HIV or with "env". Furthermore, CTL clones lytic for autologous target cells expressing HIV envelope glycoproteins were generated after stimulation of the chimpanzees' PBL with "env", indicating that immunization of these primates with a recombinant vaccinia virus primes HIV-specific CTL and also that HIV envelope glycoproteins serve as target antigens for CTL.

T-cell responses to human AIDS virus in macaques immunized with recombinant vaccinia viruses

There is much interest in developing vaccines against acquired immune deficiency syndrome (AIDS), which is caused by a retrovirus termed human immunodeficiency virus (HIV). Isolates of this virus include human T-lymphotropic virus type III (HTLV-III), lymphadenopathy-associated virus (LAV), and AIDS-associated retrovirus (ARV). Several approaches towards the development of an AIDS vaccine result in the production of antibodies in subprimates. These methods involve the use of: antigens isolated from the AIDS virus; viral antigens expressed by transfected cells or by recombinant vaccinia viruses; and particular synthetic peptides of viral antigens. Because T-cell-mediated immunity (in addition to antibodies) is involved in resistance to diseases and death caused by various enveloped viruses, we sought to determine whether potential AIDS vaccines can induce T-cell responses against the AIDS virus. Here we report that immunization of non-human primates, Macaca fascicularis (macaques), with recombinant vaccinia viruses that express LAV envelope glycoproteins gp41 and gp110 results not only in the production of antibodies against the LAV envelope antigens but also in the generation of T-cells that proliferate and produce the lymphokine interleukin-2 (IL-2), in response to stimulation with purified LAV. We believe this is the first report demonstrating T-cell-mediated immunity to the virus that causes AIDS.

Herpes simplex virus (HSV)-specific human T-cell clones recognize HSV glycoprotein D expressed by a recombinant vaccinia virus

Human cytotoxic T-cell (CTL) clones that lyse autologous cells infected with herpes simplex virus (HSV) type 1 or 2 were generated by stimulating lymphocytes with a recombinant vaccinia virus (recombinant vaccinia-gD-1 virus) that expresses HSV type 1 glycoprotein D (gD-1). Furthermore, CTL clones generated with HSV type 1 or with cloned gD-1 lysed autologous cells infected with the recombinant vaccinia-gD-1 virus. Our findings thus showed that gD serves as a target antigen for human CTLs and that a recombinant vaccinia-gD virus activates HSV-specific human CTL.

Human cytotoxic T cell clones directed against herpes simplex virus-infected cells. IV. Recognition and activation by cloned glycoproteins gB and gD

Results of studies in mice and clinical observations in man indicate that T cell-mediated immunity is important in resistance to herpes simplex virus (HSV) infections. This study was undertaken to elucidate the viral antigen specificity of human HSV-immune T cells. Purified HSV-1 glycoproteins gB-1 and gD-1, cloned and expressed in mammalian cells, were found to stimulate proliferation of, and interleukin 2 (IL 2) production by, peripheral blood lymphocytes (PBL) of HSV seropositive individuals, indicating the presence of memory T cells to gB-1 and gD-1 in individuals with serologic evidence of immunity to HSV. Second, T cell clones, generated by stimulation of PBL with HSV-1, were found to recognize gB-1 or gD-1, as evidenced by the ability of the clones to proliferate in response to stimulation with gB-1 or gD-1 in the absence of exogenous IL 2. Third, HSV-specific T cell clones, lytic for HSV-1 or both HSV-1- and HSV-2-infected autologous target cells, were generated after stimulation of PBL with purified cloned gB-1 or gD-1. Our findings, that human HSV-specific T cells can recognize and be activated by HSV subunit antigens gB-1 or gD-1, imply that these glycoproteins play a role in human T cell-mediated immunity to HSV and support the contention that a gB-1 or gD-1 subunit vaccine may be protective in man.

Human cytotoxic T cell clones directed against herpes simplex virus-infected cells. IV. Recognition and activation by cloned glycoproteins gB and gD

Results of studies in mice and clinical observations in man indicate that T cell-mediated immunity is important in resistance to herpes simplex virus (HSV) infections. This study was undertaken to elucidate the viral antigen specificity of human HSV-immune T cells. Purified HSV-1 glycoproteins gB-1 and gD-1, cloned and expressed in mammalian cells, were found to stimulate proliferation of, and interleukin 2 (IL 2) production by, peripheral blood lymphocytes (PBL) of HSV seropositive individuals, indicating the presence of memory T cells to gB-1 and gD-1 in individuals with serologic evidence of immunity to HSV. Second, T cell clones, generated by stimulation of PBL with HSV-1, were found to recognize gB-1 or gD-1, as evidenced by the ability of the clones to proliferate in response to stimulation with gB-1 or gD-1 in the absence of exogenous IL 2. Third, HSV-specific T cell clones, lytic for HSV-1 or both HSV-1- and HSV-2-infected autologous target cells, were generated after stimulation of PBL with purified cloned gB-1 or gD-1. Our findings, that human HSV-specific T cells can recognize and be activated by HSV subunit antigens gB-1 or gD-1, imply that these glycoproteins play a role in human T cell-mediated immunity to HSV and support the contention that a gB-1 or gD-1 subunit vaccine may be protective in man.

The utility of latent trait models in psychiatric epidemiology

Latent trait modelling is a recent psychometric technique with great potential for the construction and refinement of psychiatric instruments. It provides a greater insight into the nature of measurement in psychiatry and the statistical machinery for improving it. This expository paper starts with a non-technical outline of the latent trait model, gives a detailed analysis of the 12-item General Health Questionnaire (GHQ) and examines points raised by the empirical analysis through computer stimulation. It is shown that the latent trait model can give a good representation of empirical data and uncover new aspects of a familiar instrument. It provides a precise methodology for evaluating the functioning of a questionnaire and for developing better short instruments. It highlights the need, and provides the means, to tailor instruments for different tasks, such as (a) screening, and (b) measuring over the whole range of the population. We examine scoring in the light of the model, and show that simple scoring is often adequate. While points for further methodological development are noted, it is argued that the method is already sufficiently developed for general application.

Social relationships during the onset and remission of neurotic symptoms. A prospective community study

In a prospective study of a community sample, we examined changes in social relationships accompanying the onset and remission of neurotic symptoms. For those who developed symptoms in the course of 12 months, no decrease was found in the availability or reported adequacy of either close or diffuse ties, compared to those who remained symptom-free. For those having a remission, an increase in the adequacy of social relationships and a decrease in rows was observed only in those who improved later on, at the 12-month interview. But with either the onset or remission of symptoms, the availability of relationships remained unchanged. These observations cannot establish the direction of causality, but suggest that neurotic symptoms are more associated with the perception of social relationships than with the structure of personal networks.

THe changing seasonality of infant deaths in England and Wales 1912-78 and its relation to seasonal temperature

Seasonal variation in the rates of stillbirth, and of deaths under the age of one year, were studied for England and Wales in order to examine (a) changes in the seasonal variation over the years and (b) the correlation between seasonal rates and seasonal temperatures. The quarterly rates of stillbirths were studied for the period 1928-78; and of deaths under the age of one year, in six different age groups, for the period 1912-78. A disappearance of seasonal variation in rates ('deseasonality') occurrred from stillbirths in about 1950, and for neonatal deaths in about 1965. For deaths at 1-2 months a trend towards deseasonality has been apparent since 1955, but there has been no such trends for deaths at 3-11 months of age. In the period before deseasonality, and for the first quarter of the year, there was a high negative correlation between the neonatal death rate and the mean temperature in England and Wales but this correlation fell as the seasonal variation in rates fell. The findings suggest that seasonal variation in the neonatal death rate was closely related to winter temperatures during the period 1921-60. For deaths at 1-11 months old, there has been and still is a relation between temperature and seasonal variation in rates, but the relation was less close than for the neonatal death rate.

Raised parental age in psychiatric patients: evidence for the constitutional hypothesis

In two series of psychiatric patients (numbering about 6,000 and 2,000 respectively), the mean age of the mothers at the time of the patients' birth was found to be very significantly above expectation from the general population, and this was so for each of the major diagnostic groups. In the second series, the age of the fathers was also found to be very significantly above that expected from a sample survey of the general population, and this was so for each diagnostic group. Fathers' age was raised more than mothers', and was highest for schizophrenia. The raised parental age could not be explained in terms of the patient's year of birth or his father's social class. The raised mothers' age could largely be accounted for by regression on the raised fathers' age. The present findings, and those of previous studies, seem best explained on the hypothesis of a constitutional parental trait leading to delayed marriage.