Cost-effectiveness of expanded latent TB infection testing and treatment: Lynn City, Massachusetts, USA

BACKGROUND: Between October 2016 and March 2019, Lynn Community Health Center in Massachusetts implemented a targeted latent TB infection testing and treatment (TTT) program, increasing testing from a baseline of 1,200 patients tested to an average of 3,531 patients tested, or 9% of the population per year.METHODS: We compared pre-implementation TTT, represented by the first two quarters of implementation data, to TTT, represented by 12 quarters of data. Time, diagnostic, and laboratory resources were estimated using micro-costing. Other cost and testing data were obtained from the electronic health record, pharmaceutical claims, and published reimbursement rates. A Markov cohort model estimated future health outcomes and cost-effectiveness from a societal perspective in 2020 US dollars. Monte Carlo simulation generated 95% uncertainty intervals.RESULTS: The TTT program exhibited extended dominance over baseline pre-intervention testing and had an incremental cost-effectiveness ratio (ICER) of US$52,603 (US$22,008â-"US$95,360). When compared to baseline pre-TTT testing, the TTT program averted an estimated additional 7.12 TB cases, 3.49 hospitalizations, and 0.16 deaths per lifetime cohort each year.CONCLUSIONS: TTT was more cost-effective than baseline pre-implementation testing. Lynn Community Health Centerâ-™s experience can help inform other clinics considering expanding latent TB infection testing.

Large-scale manufacturing of base-edited chimeric antigen receptor T cells

Base editing is a revolutionary gene-editing technique enabling the introduction of point mutations into the genome without generating detrimental DNA double-stranded breaks. Base-editing enzymes are commonly delivered in the form of modified linear messenger RNA (mRNA) that is costly to produce. Here, we address this problem by developing a simple protocol for manufacturing base-edited cells using circular RNA (circRNA), which is less expensive to synthesize. Compared with linear mRNA, higher editing efficiencies were achieved with circRNA, enabling an 8-fold reduction in the amount of RNA required. We used this protocol to manufacture a clinical dose (1 × 108 cells) of base-edited chimeric antigen receptor (CAR) T cells lacking expression of the inhibitory receptor, PD-1. Editing efficiencies of up to 86% were obtained using 0.25 μg circRNA/1 × 106 cells. Increased editing efficiencies with circRNA were attributed to more efficient translation. These results suggest that circRNA, which is less expensive to produce than linear mRNA, is a viable option for reducing the cost of manufacturing base-edited cells at scale.

A network-informed approach to investigating a tuberculosis outbreak: implications for enhancing contact investigations

BACKGROUND

To elucidate networks of Mycobacterium tuberculosis transmission, it may be appropriate to characterize the types of relationships among tuberculosis (TB) cases and their contacts (with and without latent TB infection) in addition to relying on traditional efforts to distinguish 'close' from 'casual' contacts.

SETTING

A TB outbreak in a US low incidence state.

OBJECTIVE

To evaluate whether social network analysis can provide insights into transmission settings that might otherwise go unrecognized by routine practices.

DESIGN

All adult outbreak-associated cases (n = 19) and a convenience sample of their contacts with and without latent TB infection (LTBI) (n = 26) were re-interviewed in 2001 using a structured questionnaire. Network analysis software was used to create diagrams illustrating important persons within the outbreak network, as well as types of activities TB cases engaged in with their contacts.

RESULTS

Drug use and drug sharing were more commonly reported among cases and their infected contacts than among contacts without LTBI. TB cases central to the outbreak network used crack cocaine, uncovering the need to focus control efforts on specific sites and persons involved in illicit drug use.

CONCLUSION

Outbreaks occur even in areas with low TB incidence, frequently among groups whose drug use or other illegal activities complicate control efforts. TB programs should consider the use of network analysis as a supplement to routine contact investigations to identify unrecognized patterns of M. tuberculosis transmission.

Parental perceptions surrounding risks and benefits of immunization

In recent years, parental concerns about vaccine safety have increased as the threat of disease has decreased. A national survey showed that, in general, parents agree that vaccines benefit their children and that their children may be at risk for contracting a disease if unvaccinated. When asked about understanding the benefits and risks of vaccines, most parents (57%) found numbers and statistics most helpful. A substantial minority (17%) of parents were somewhat or not confident in vaccine safety. Parents less confident in vaccine safety agreed less with the statement that they usually followed the advice of their child's doctor. Incomes and education levels affected responses. This positive relationship between confidence in vaccine safety and reliance on doctors for advice may indicate the need for healthcare providers to identify opportunities to (1) solicit questions about vaccine safety, (2) address vaccine safety-related questions in a way meaningful to parents, and (3) strengthen doctor-patient relationships. A parent communication tool is proposed.

Mammalian plasma membrane ecto-nucleoside triphosphate diphosphohydrolase 1, CD39, is not active intracellularly. The N-glycosylation state of CD39 correlates with surface activity and localization

CD39 is a member of the membrane-bound ecto-nucleoside triphosphate diphosphohydrolase family. The active site for native CD39 is located on the outer surface of the cellular plasma membrane; however, it is not yet known at what stage this enzyme becomes active along the secretory pathway to the plasma membrane. In this study, sucrose density fractionations performed on CD39-transfected COS-7 cell membranes suggest that CD39 activity resides primarily in the plasma membrane. Furthermore, we have created recombinant, soluble versions of CD39, one that is secreted and others that are retained in the endoplasmic reticulum, to demonstrate that CD39 is not active until it reaches the plasma membrane both in yeast and COS-7 cells. Moreover, the secreted active soluble CD39 in COS-7 cells is found to receive a higher degree of N-glycan addition than the inactive form retained intracellularly. When COS-7 cells were treated with tunicamycin to prevent N-glycosylation, soluble CD39 was not detected in the extracellular medium and remained inactive intracellularly. Surface biotinylation analysis also revealed that surface-expressed wild type CD39 receives a higher degree of N-glycosylation than intracellular forms and that inhibition of N-glycosylation prevents its plasma membrane localization. In addition, both intact and digitonin-permeablized COS-7 cells transfected with CD39 possess similar ecto-ATPase activities, further supporting the conclusion that only surface-expressed CD39 is enzymatically active. All of these data suggest that intracellular CD39 is inactive and that only a fully glycosylated CD39 has apyrase activity and is localized at the cell surface.

The effect of body weight and age on frequency of repairs in lower-limb prostheses

INTRODUCTION

Overweight patients sometimes present a practical problem for provision of lower-limb prostheses. Most information about the effect of body weight on the endurance of prostheses is based on laboratory tests. This is a retrospective study based on an audit to study the effect of body weight and age on the frequency of repairs.

SUBJECTS

One hundred and sixteen patients were involved (98 male), age 16-96 years, mean=58.7 years; weight 47-140 kg, mean=88 kg; 68 were transtibial amputees and 48 were transfemoral amputees. Causes of amputation were trauma (49), peripheral vascular disease (29), and others (38). Amputation was done 1-66 years prior to assessment, mean=13.66 years. Period of use of current prostheses was 0.5-28 years, mean=3.5 years.

RESULTS

One hundred and one repairs were done in a period of 6 months. The number of repairs was found to correlate significantly with weight (P value<0.001) and inversely with age (P value=0.003). No significant correlation was found between repairs and gender, cause of amputation, or level of amputation.

CONCLUSION

Body weight and age of amputee are determining factors in the frequency of repairs of lower-limb prostheses. However, a larger study for a longer period will be needed to confirm our finding.

Hedgehog-dependent oligodendrocyte lineage specification in the telencephalon

In the caudal neural tube, oligodendrocyte progenitors (OLPs) originate in the ventral neuroepithelium under the influence of Sonic hedgehog (SHH), then migrate throughout the spinal cord and brainstem before differentiating into myelin-forming cells. We present evidence that oligodendrogenesis in the anterior neural tube follows a similar pattern. We show that OLPs in the embryonic mouse forebrain express platelet-derived growth factor alpha-receptors (PDGFRA), as they do in more caudal regions. They first appear within a region of anterior hypothalamic neuroepithelium that co-expresses mRNA encoding SHH, its receptor PTC1 (PTCH) and the transcription factors OLIG1, OLIG2 and SOX10. Pdgfra-positive progenitors later spread through the forebrain into areas where Shh is not expressed, including the cerebral cortex. Cyclopamine inhibited OLP development in cultures of mouse basal forebrain, suggesting that hedgehog (HH) signalling is obligatory for oligodendrogenesis in the ventral telencephalon. Moreover, Pdgfra-positive progenitors did not appear on schedule in the ventral forebrains of Nkx2.1 null mice, which lack the telencephalic domain of Shh expression. However, OLPs did develop in cultures of Nkx2.1−/− basal forebrain and this was blocked by cyclopamine. OLPs also developed in neocortical cultures, even though Shh transcripts could not be detected in the embryonic cortex. Here, too, the appearance of OLPs was suppressed by cyclopamine. In keeping with these findings, we detected mRNA encoding SHH and Indian hedgehog (IHH) in both Nkx2.1−/− basal forebrain cultures and neocortical cultures. Overall, the data are consistent with the idea that OLPs in the telencephalon, possibly even some of those in the cortex, develop under the influence of SHH in the ventral forebrain.

25-Hydroxyvitamin D3, the prohormone of 1,25-dihydroxyvitamin D3, inhibits the proliferation of primary prostatic epithelial cells

The hormonal metabolite of vitamin D, 1alpha,25-dihydroxyvitamin D3 [1,25(OH)2D3] is known to inhibit the proliferation of prostatic epithelial cells. This has stimulated interest in vitamin D compounds as therapeutic agents for prostate cancer. However, the therapeutic use of 1,25(OH)2D3 is limited because elevations in serum 1,25(OH)2D3 can cause dangerous elevations in serum calcium levels. We wondered whether the prohormone of 1,25(OH)2D3, 25-hydroxyvitamin D3 (25-OH-D3), which is much less calcemic, could also achieve antiproliferative effects in prostatic cells. 25-OH-D3 is converted to 1,25(OH)2D3 by the mitochondrial enzyme 1-alpha-hydroxylase. We have recently shown that human prostatic cells also possess significant 1-alpha-hydroxylase activity (Schwartz et al., Cancer Epidemiol. Biomark. Prev., 7: 391-395, 1998). We studied 1-alpha-hydroxylase gene expression in four strains of primary human prostatic epithelial cells by reverse transcription PCR amplification (RT-PCR) of 1-alpha-hydroxylase. Human prostatic stromal cells were negative for 1-alpha-hydroxylase by RT-PCR. This led us to hypothesize that 25-OH-D3 would inhibit the proliferation of prostatic epithelial cells because 25-OH-D3 would be converted to 1,25(OH)2D3 intracellularly. We studied the effects of 25-OH-D3 and 1,25(OH)2D3 on the proliferation of prostatic epithelial cells using high density growth and clonal growth assays on two different primary cell strains derived from normal human prostatic peripheral zone. 25-OH-D3 and 1,25(OH)2D3 each inhibited growth in a dose- and time-dependent manner. Growth inhibition was evident at 1 nM, and maximal inhibition was observed at 100 nM within 10-12 days of exposure. The potencies of 25-OH-D3 and 1,25(OH)2D3 were not significantly different. These data demonstrate that 25-OH-D3, which previously was thought to have little biological activity, can become a potent antiproliferative hormone for prostatic cells that express 1-alpha-hydroxylase. Because 25-OH-D3 exhibits similar potency to 1,25(OH)2D3 but is less calcemic, 25-OH-D3 may offer a safer option than 1,25(OH)2D3 for prostate cancer therapy. Moreover, because 25-OH-D3 is produced endogenously from vitamin D, these findings support a potential role for vitamin D in the chemoprevention of prostate cancer.

Oligodendrocyte lineage and the motor neuron connection

One of the more surprising recent discoveries in glial biology has been that oligodendrocytes (OLs) originate from very restricted regions of the embryonic neural tube. This was surprising because myelinating OLs are widespread in the mature central nervous system, so there was no reason to suspect that their precursors should be restricted. What we now know about early OL development suggests that they might have as much (or more) in common with ventral neurons-specifically motor neurons (MNs)-as with other types of glia. This has implications for the way we think about glial development, function, and evolution. In this article we review the evidence for a shared MN-OL lineage and debate whether this is the only lineage that generates OLs. We decide in favour of a single embryonic lineage with regional variations along the anterior-posterior neuraxis.

Usefulness and limitations of serum and urine lysozyme levels in the classification of acute myeloid leukemia: an analysis of 208 cases

The revised French-American-British (FAB) classification system for acute myeloid leukemia (AML) recommends the determination of serum lysozyme (SL) or urine lysozyme (UL) levels as an aid in distinguishing acute myeloblastic leukemia with maturation (FAB M2) from acute myelomonocytic leukemia (M4). We reviewed retrospectively 208 cases of adult leukemia in which SL and/or UL were obtained. Elevated lysozyme levels were not found in any of the M0, M3, or M7 cases, but were increased (false positive) in three (14%) M1 cases, 18 (19%) M2 cases and one (20%) M6 case. Although a UL value in excess of 3x normal was found in most cases of AML M4 and M5, only five (11%) M4 cases and three (20%) M5 cases had SL elevations of this magnitude. Lysozyme levels need to be interpreted in conjunction with other parameters for FAB classification.

Predictions of malaria vector distribution in Belize based on multispectral satellite data

Use of multispectral satellite data to predict arthropod-borne disease trouble spots is dependent on clear understandings of environmental factors that determine the presence of disease vectors. A blind test of remote sensing-based predictions for the spatial distribution of a malaria vector, Anopheles pseudopunctipennis, was conducted as a follow-up to two years of studies on vector-environmental relationships in Belize. Four of eight sites that were predicted to be high probability locations for presence of An. pseudopunctipennis were positive and all low probability sites (0 of 12) were negative. The absence of An. pseudopunctipennis at four high probability locations probably reflects the low densities that seem to characterize field populations of this species, i.e., the population densities were below the threshold of our sampling effort. Another important malaria vector, An. darlingi, was also present at all high probability sites and absent at all low probability sites. Anopheles darlingi, like An. pseudopunctipennis, is a riverine species. Prior to these collections at ecologically defined locations, this species was last detected in Belize in 1946.

Hemodynamic and echocardiographic assessment of the effects of diltiazem during transient occlusion of the left anterior descending coronary artery during percutaneous transluminal coronary angioplasty

The effects of diltiazem during transient myocardial ischemia were studied in 17 patients (age 58 +/- 11 years, 12 men, 5 women) undergoing 1-vessel left anterior descending percutaneous transluminal coronary angioplasty (PTCA). After hemodynamic, echocardiographic and electrocardiographic data were obtained during the control ischemic periods, diltiazem (10 mg intravenous bolus with 500 micrograms/min infusion) was given and 15 minutes later ischemia reinduced. Diltiazem reduced mean arterial pressure (113 +/- 16 to 95 +/- 15 mm Hg, p less than 0.05) and heart rate-pressure product (p less than 0.05) with no change in heart rate, pulmonary pressures or coronary (sinus, thermodilution technique) blood flow at rest. After diltiazem, times to ischemia-induced 1.0 mm ST-segment elevation (28 +/- 10 to 42 +/- 17 seconds, p less than 0.05) and new left ventricular wall motion abnormalities (by 2-dimensional echocardiography, 24 +/- 8 to 36 +/- 12 seconds, p less than 0.001) were prolonged without significant augmentation of great cardiac vein flow during coronary occlusion. Left ventricular (LV) ejection fraction decreased from 51 +/- 7 to 41 +/- 12% (p less than 0.05) during control ischemia, but declined less after diltiazem (54 +/- 12 to 47 +/- 14%, difference not significant; 47 +/- 14 vs 41 +/- 12%, p less than 0.01). Diltiazem can attenuate, but not abolish, some of the effects of myocardial ischemia on LV function during transient coronary artery occlusion. These data support the use of diltiazem as a beneficial adjunct that may be used acutely and safely during routine PTCA.

Rest and exercise evaluation of St. Jude Medical and Medtronic Hall prostheses. Influence of primary lesion, valvular type, valvular size, and left ventricular function

To compare St. Jude Medical and Medtronic Hall mechanical prosthetic heart valves, we prospectively randomized 90 consecutive patients requiring mechanical valve replacement and studied their rest and exercise hemodynamics by Doppler echocardiography. Fifty-six aortic and 42 mitral valves were implanted. All patients were examined preoperatively and postoperatively, and follow-up studies were obtained at rest and immediately after upright, treadmill exercise at 6 months (n = 68). Clinical parameters (mortality, morbidity, and congestive heart failure classification), as well as rest and exercise hemodynamics (valvular area, gradients, and left ventricular ejection fraction), were examined, and their relation to exercise duration was defined. Mortality (perioperative, 8.8% and late, 2.4%) was similar between patients in the two valve groups (five in each group). There was one late thromboembolic episode with each valve. Improvement in New York Heart Association congestive heart failure class was seen in 85% of patients at 6 months. There were no significant differences in calculated aortic valve areas (2.2 vs. 2.0 cm2), resting (24 vs. 21 mm Hg) and exercise (41 vs. 35 mm Hg) peak aortic gradients, and exercise duration between patients with the St. Jude Medical and Medtronic Hall aortic prostheses. In patients with aortic prostheses, valvular size was correlated with exercise duration (r = 0.41, p less than 0.05). In patients with mitral prostheses, we observed no significant differences between St. Jude Medical and Medtronic Hall prostheses in calculated mitral valve areas (3.4 cm2 vs. 3.4 cm2) and rest (2.5 vs. 3.0 mm Hg) and exercise (5.1 vs. 7.0 mm Hg) mean gradients.(ABSTRACT TRUNCATED AT 250 WORDS)

Small lymphocytic lymphoma: a clinicopathologic analysis of 268 cases

We analyzed specimens from 268 patients with small lymphocytic lymphoma (SL) to identify prognostic factors significant for survival. These patients were staged and treated according to the protocols of the Cancer and Leukemia Group B, Eastern Cooperative Oncology Group, Southeastern Cancer Study Group, and the Southwest Oncology Group. Univariate analysis showed that a large-cell grade greater than I, WBC greater than 10,000/microL, hemoglobin (Hgb) less than 11 g/dL, age greater than or equal to 55 years, and failure to respond to treatment were all poor prognostic factors. Multivariate analysis showed that large-cell grade, age, degree of capsular invasion, and symptom type were independently associated with survival. Separate analyses of cases with and without leukocytosis indicated differences in survival. In patients without leukocytosis, age, presence or absence of anemia, and treatment response were significant prognostic variables; in patients with leukocytosis, large-cell grade, presence or absence of anemia, symptom type, and treatment response were significantly related to survival. Multivariate analysis showed that age was the only significant independent prognostic variable in patients without leukocytosis; in patients with leukocytosis, symptom type, large-cell grade, and bone marrow involvement were independently associated with survival. We conclude that several parameters, both clinical and pathologic, should be assessed at the initial diagnosis of SL to predict prognosis better.

Kappa opioid binding sites in the dog cerebral cortex and spinal cord

In the dog cerebral cortex and spinal cord, [3H]bremazocine and [3H]U69593 both bound with high affinity to an apparent single population of binding sites under kappa-selective conditions. In the cortex similar Bmax values for both radioligands in the saturation studies and the high affinity of the kappa-selective agents PD117302 and U69593 for both [3H]bremazocine and [3H]U69593 labelled sites in the competition studies suggested a predominance of U69593-sensitive sites previously described as kappa 1 in the guinea-pig and rat brain. The lower slope values for the inhibition curves of PD117302 and U69593 against [3H]bremazocine but not against [3H]U69593 suggested that [3H]bremazocine could also be binding to a relatively minor proportion of additional, possibly kappa 2, sites while [3H]U69593 would appear to be selective for the kappa 1 site. In contrast, in the dog spinal cord, [3H]U69593 appeared to recognize only a proportion (approximately 35%) of the [3H]bremazocine labelled binding site. The significantly lower affinities and slope values of U69593 and PD117302 against [3H]bremazocine were consistent with the additional sites representing the k2 (benzomorphan) sites previously described in guinea-pig and rat spinal cord. Alternatively, the low (micromolar) affinity of the mu-selective ligand, [D-Ala2, MePhe4, Gly-ol5]enkephalin, implied that these additional sites might not be kappa 2 but possibly a low affinity mu site normally expressed under more physiological conditions.

Treatment of acute nonlymphocytic leukemia with neocarzinostatin

Neocarzinostatin (NCS) is a polypeptide antibiotic which has been shown to have antileukemic activity in Japanese trials. Twenty-two patients, who were in relapse with acute nonlymphocytic leukemia refractory to other agents, were studied with two dose schedules of NCS. Schedule 1, 2000-8000 units/m2/day by continuous infusion for 5-10 days, was given to 12 patients and schedule 2, 2000-6000 units/m2/day by iv bolus every 8 hours, was given to ten patients. Clearing of peripheral blast cell was seen in nine of 12 patients treated with schedule 1 and in four of ten patients treated with schedule 2. Bone marrow effect was variable and appeared to be dose-related. No unequivocal complete remissions were seen with either schedule. NCS perturbations of cycling bone marrow cells were studied in two patients receiving the drug by continuous infusion. Both of these patients showed G2 accumulation of marrow cells following treatment. Immunochemically detectable levels of drug were seen in three patients treated with continuous infusion. In summary, NCS has antileukemic effect in patients with acute nonlymphocytic leukemia refractory to other agents. However, its role in the therapy for acute leukemia required further evaluation.

Lymphoblastic transformation of Ph1-positive chronic myeloid leukaemia: therapeutic implications and relevance to haemopoietic stem cell theory

A proportion of patients with blast crisis of CML have blast cells identical to those found in common non-T, non-B all, and whilst this disease is often referred to as lymphoid blast crisis (LBC), evidence is presented that it may in fact arise from a prelymphoid, pre-myeloid (pluripotential) stem cell. Recently developed membrane and enzyme markers (anti-ALL antiserum, TdT assay) have provided convenient diagnostic tests for the detection of LBC. The clinical and haematological features of LBC are reviewed: patients with LBC show a higher response rate to therapy with vincristine and prednisolone, and their survival may be significantly prolonged. The frequent occurrence of meningeal leukaemia suggests the need for prophylactic CNS therapy in LBC patients achieving remission.

Lymphoid blast crisis in chronic myeloid leukaemia and Philadelphia positive acute lymphoid leukaemia

Membrane markers (anti-ALL and anti-Ia antisera) and an enzyme marker (terminal transferase) have been used to define an L-type or "lymphoid" type of acute transformation in chronic myeloid leukaemia and Ph1 positive acute leukaemia. Patients with L-type ("lymphoid") blasts responded to regimens including vincristine and prednisolone (VP). The markers showed better correlation with survival than did the morphology of blasts. The clinical course of patients was variable; elimination Ph1 positive clone (and hypoplasia), return to the chronic phase and relapses (including meningeal leukaemia) were observed. In contrast, patients with myeloid blasts ("M" type of blast crisis) failed to respond to vincristine and prednisolone.

The management of adult acute lymphoblastic leukaemia

The important advances made in recent years in the therapy of adult ALL have been reviewed. The definition of bad-prognosis patients has been improved and includes those with T-ALL, ABLL, and Ph1+ALL, in addition to those presenting with evidence of extensive disease. In contrast to childhood ALL, induction chemotherapy should include another drug (or drugs) in addition to VCR and prednisolone, and one of the anthracycline drugs (ADR or DNR) has been employed most frequently in this context. Such therapy should result in a CR rate of 70 to 75%. Similar to the experience in childhood ALL, the improvement in haematological response rate has led to an apparent increase in CNS leukaemia, and the need for adequate CNS prophylaxis is stressed. Despite these improvements, the outlook for adults with ALL is not yet as good as it is for childhood ALL. Controlled studies involving large numbers of patients are urgently needed to provide answers to a number of questions. In induction therapy, the use of higher drug dosage, the use of more and other drugs, and the use of an individual patient's risk factors to determine drug dosage, must be assessed. The benefits of consolidation therapy and the optimal duration and intensity of maintenance therapy have yet to be established. Methods of CNS prophylaxis other than cranial irradiation and IT MTX must be carefully studied. These important questions require that adult patients with ALL should be concentrated in centres capable of providing optimal overall care and, at the same time, able to conduct the necessary clinical trials.

Briquet's syndrome, hysterical personality, and the MMPI

The authors compared the MMPI scores of 29 inpatients diagnosed by other authors as having hysterical personality and 21 outpatients diagnosed by the authors as having Briquet's syndrome. The two groups of patients differed significantly in age, on the MMPI lie scale, and on the MMPI hypochondriasis scale but not on any of the other MMPI scales. The authors discuss the implications of these findings for further defining the differences and similarities between hysterical personality and Briquet's syndrome.

Multiple myeloma with massive Bence Jones proteinuria and preservation of renal function

The case history of a patient having multiple myeloma with a remarkably high level of Bence Jones proteinuria (more than 20 g/day) is presented. The patient has responded well to therapy, and at no stage has he shown impairment of renal function as determined by creatinine clearance studies. A review of published reports has shown that such marked Bence Jones proteinuria at presentation is rare and is usually accompanied by renal impairment and a short survival. Additional presentation data from selected patients in the MRC First Myelomatosis Trial is presented. This suggests a higher incidence of marked Bence Jones proteinuria, and underlines the lack of correlation between the quantity excreted and the degree of renal impairment. The mechanisms by which Bence Jones protein may cause renal damage are discussed.

Mourning and depression: their similarities and differences

Previous studies have shown that bereaved people respond to their loss with a set of psychological symptoms which are in many instances indistinguishable from depressive illness, but accepted by them and their environment as normal (1,3,5). On the other hand, patients with primary affective disorder experience their condition as a “change”, “not usual self” (7), which leads them to seek help, and in this way they define themselves as patients. A comparison of frequencies of psychiatric symptoms between depressed 34, and bereaved 34, subjects matched for sex and age shows that hospitalized depressed subjects have more symptoms — 15 — than bereaved subjects (7). However, there is enough overlap that, on the basis of symptoms, the two groups cannot be differentiated satisfactorily for research purposes.

In psychiatry, most diagnostic criteria are arbitrary. If they are set narrow some patients with a mild form of illness are excluded, while if broad criteria are employed persons with other conditions or no illness at all are included. For research purposes if the symptoms of depression occur only after the death of a near relative the subjects should not be included in the group diagnosed as suffering from primary affective disorder.

The diagnostic use of the amylobarbitone interview among patients with psychotic illnesses

Since 1932 the amylobarbitone (amobarbital sodium, Amytal) interview has been used as a technique for diagnostic evaluation of patients with psychiatric illnesses (Lindemann, 1932). Amytal has also been used to make mute patients talk, as a sedative, a mood elevator, and as an agent in various other types of psychiatric treatment such as sleep therapy, abreaction, narcoanalysis (Horsley, 1936), narcosynthesis (Grinkeret al.,1945), narcosuggestion, and narcoplexis (Brickneret al.,1950).