Separate domains of G3BP promote efficient clustering of alphavirus replication complexes and recruitment of the translation initiation machinery

G3BP-1 and -2 (hereafter referred to as G3BP) are multifunctional RNA-binding proteins involved in stress granule (SG) assembly. Viruses from diverse families target G3BP for recruitment to replication or transcription complexes in order to block SG assembly but also to acquire pro-viral effects via other unknown functions of G3BP. The Old World alphaviruses, including Semliki Forest virus (SFV) and chikungunya virus (CHIKV) recruit G3BP into viral replication complexes, via an interaction between FGDF motifs in the C-terminus of the viral non-structural protein 3 (nsP3) and the NTF2-like domain of G3BP. To study potential proviral roles of G3BP, we used human osteosarcoma (U2OS) cell lines lacking endogenous G3BP generated using CRISPR-Cas9 and reconstituted with a panel of G3BP1 mutants and truncation variants. While SFV replicated with varying efficiency in all cell lines, CHIKV could only replicate in cells expressing G3BP1 variants containing both the NTF2-like and the RGG domains. The ability of SFV to replicate in the absence of G3BP allowed us to study effects of different domains of the protein. We used immunoprecipitation to demonstrate that that both NTF2-like and RGG domains are necessary for the formation a complex between nsP3, G3BP1 and the 40S ribosomal subunit. Electron microscopy of SFV-infected cells revealed that formation of nsP3:G3BP1 complexes via the NTF2-like domain was necessary for clustering of cytopathic vacuoles (CPVs) and that the presence of the RGG domain was necessary for accumulation of electron dense material containing G3BP1 and nsP3 surrounding the CPV clusters. Clustered CPVs also exhibited localised high levels of translation of viral mRNAs as detected by ribopuromycylation staining. These data confirm that G3BP is a ribosomal binding protein and reveal that alphaviral nsP3 uses G3BP to concentrate viral replication complexes and to recruit the translation initiation machinery, promoting the efficient translation of viral mRNAs.

In order to repel viral infections, cells activate stress responses. One such response involves inhibition of translation and restricted availability of the translation machinery via the formation of stress granules. However, the host translation machinery is absolutely essential for synthesis of viral proteins and consequently viruses have developed a broad spectrum of strategies to circumvent this restriction. Old World alphaviruses, such as Semliki Forest virus (SFV) and chikungunya virus (CHIKV), interfere with stress granule formation by sequestration of G3BP, a stress granule nucleating protein, mediated by the viral non-structural protein 3 (nsP3). Here we show that nsP3:G3BP complexes engage factors of the host translation machinery, which during the course of infection accumulate in the vicinity of viral replication complexes. Accordingly, we demonstrate that the nsP3:G3BP interaction is required for high localized translational activity around viral replication complexes. We find the RGG domain of G3BP to be essential for the recruitment of the host translation machinery. In cells expressing mutant G3BP lacking the RGG domain, SFV replication was attenuated, but detectable, while CHIKV was essentially non-viable. Our data demonstrate a novel mechanism by which viruses can recruit factors of the translation machinery in a G3BP-dependent manner.

Versatile Trans-Replication Systems for Chikungunya Virus Allow Functional Analysis and Tagging of Every Replicase Protein

Chikungunya virus (CHIKV; genus Alphavirus, family Togaviridae) has recently caused several major outbreaks affecting millions of people. There are no licensed vaccines or antivirals, and the knowledge of the molecular biology of CHIKV, crucial for development of efficient antiviral strategies, remains fragmentary. CHIKV has a 12 kb positive-strand RNA genome, which is translated to yield a nonstructural (ns) or replicase polyprotein. CHIKV structural proteins are expressed from a subgenomic RNA synthesized in infected cells. Here we have developed CHIKV trans-replication systems, where replicase expression and RNA replication are uncoupled. Bacteriophage T7 RNA polymerase or cellular RNA polymerase II were used for production of mRNAs for CHIKV ns polyprotein and template RNAs, which are recognized by CHIKV replicase and encode for reporter proteins. CHIKV replicase efficiently amplified such RNA templates and synthesized large amounts of subgenomic RNA in several cell lines. This system was used to create tagged versions of ns proteins including nsP1 fused with enhanced green fluorescent protein and nsP4 with an immunological tag. Analysis of these constructs and a matching set of replicon vectors revealed that the replicases containing tagged ns proteins were functional and maintained their subcellular localizations. When cells were co-transfected with constructs expressing template RNA and wild type or tagged versions of CHIKV replicases, formation of characteristic replicase complexes (spherules) was observed. Analysis of mutations associated with noncytotoxic phenotype in CHIKV replicons showed that a low level of RNA replication is not a pre-requisite for reduced cytotoxicity. The CHIKV trans-replicase does not suffer from genetic instability and represents an efficient, sensitive and reliable tool for studies of different aspects of CHIKV RNA replication process.

Correlative light and electron microscopy enables viral replication studies at the ultrastructural level

Electron microscopy (EM) is a powerful tool to study structural changes within cells caused e.g. by ectopic protein expression, gene silencing or virus infection. Correlative light and electron microscopy (CLEM) has proven to be useful in cases when it is problematic to identify a particular cell among a majority of unaffected cells at the EM level. In this technique the cells of interest are first identified by fluorescence microscopy and then further processed for EM. CLEM has become crucial when studying positive-strand RNA virus replication, as it takes place in nanoscale replication sites on specific cellular membranes. Here we have employed CLEM for Semliki Forest virus (SFV) replication studies both by transfecting viral replication components to cells or by infecting different cell types. For the transfection-based system, we developed an RNA template that can be detected in the cells even in the absence of replication and thus allows exploration of lethal mutations in viral proteins. In infected mammalian and mosquito cells, we were able to find replication-positive cells by using a fluorescently labeled viral protein even in the cases of low infection efficiency. The fluorescent region within these cells was shown to correspond to an area rich in modified membranes. These results show that CLEM is a valuable technique for studying virus replication and membrane modifications at the ultrastructural level.

The HER2 amplicon includes several genes required for the growth and survival of HER2 positive breast cancer cells

About 20% of breast cancers are characterized by amplification and overexpression of the HER2 oncogene. Although significant progress has been achieved for treating such patients with HER2 inhibitor trastuzumab, more than half of the patients respond poorly or become resistant to the treatment. Since the HER2 amplicon at 17q12 contains multiple genes, we have systematically explored the role of the HER2 co-amplified genes in breast cancer cell growth and their relation to trastuzumab resistance. We integrated aCGH data of the HER2 amplicon from 71 HER2 positive breast tumors and 10 cell lines with systematic functional RNA interference analysis of 23 core amplicon genes with several phenotypic endpoints in a panel of trastuzumab responding and non-responding HER2 positive breast cancer cells. Silencing of HER2 caused a greater growth arrest and apoptosis in the responding compared to the non-responding cell lines, indicating that the resistant cells are inherently less dependent on the HER2 pathway. Several other genes in the amplicon also showed a more pronounced effect when silenced; indicating that expression of HER2 co-amplified genes may be needed to sustain the growth of breast cancer cells. Importantly, co-silencing of STARD3, GRB7, PSMD3 and PERLD1 together with HER2 led to an additive inhibition of cell viability as well as induced apoptosis. These studies indicate that breast cancer cells may become addicted to the amplification of several genes that reside in the HER2 amplicon. The simultaneous targeting of these genes may increase the efficacy of the anti-HER2 therapies and possibly also counteract trastuzumab resistance. The observed additive effects seem to culminate to both apoptosis and cell proliferation pathways indicating that these pathways may be interesting targets for combinatorial treatment of HER2+ breast cancers.

Functional profiling of precursor MicroRNAs identifies MicroRNAs essential for glioma proliferation

Cancer initiation and progression involve microRNAs that can function like tumor suppressors and oncogenes. The functional significance of most miRNAs is currently unknown. To determine systematically which microRNAs are essential for glioma growth, we screened a precursor microRNA library in three human glioblastoma and one astroglial cell line model systems. The most prominent and consistent cell proliferation–reducing hits were validated in secondary screening with an additional apoptosis endpoint. The functional screening data were integrated in the miRNA expression data to find underexpressed true functional tumor suppressor miRNAs. In addition, we used miRNA-target gene predictions and combined siRNA functional screening data to find the most probable miRNA-target gene pairs with a similar functional effect on proliferation. Nine novel functional miRNAs (hsa-miR-129, -136, -145, -155, -181b, -342-5p, -342-3p, -376a/b) in GBM cell lines were validated for their importance in glioma cell growth, and similar effects for six target genes (ROCK1, RHOA, MET, CSF1R, EIF2AK1, FGF7) of these miRNAs were shown functionally. The clinical significance of the functional hits was validated in miRNA expression data from the TCGA glioblastoma multiforme (GBM) tumor cohort. Five tumor suppressor miRNAs (hsa-miR-136, -145, -342, -129, -376a) showed significant underexpression in clinical GBM tumor samples from the TCGA GBM cohort further supporting the role of these miRNAs in vivo. Most importantly, higher hsa-miR-145 expression in GBM tumors yielded significantly better survival (p<0.005) in a subset of patients thus validating it as a genuine tumor suppressor miRNA. This systematic functional profiling provides important new knowledge about functionally relevant miRNAs in GBM biology and may offer new targets for treating glioma.

Echovirus 1 infection depends on biogenesis of novel multivesicular bodies

Non-enveloped picornavirus echovirus 1 (EV1) clusters its receptor α2β1 integrin and causes their internalization and accumulation in α2β1 integrin enriched multivesicular bodies (α2-MVBs). Our results here show that these α2-MVBs are distinct from acidic late endosomes/lysosomes by several criteria: (i) live intra-endosomal pH measurements show that α2-MVBs are not acidic, (ii) they are not positive for the late endosomal marker LBPA or Dil-LDL internalized to lysosomes, and (iii) simultaneous stimulation of epidermal growth factor receptor (EGFR) and α2β1 integrin clustering leads to their accumulation in separate endosomes. EGFR showed downregulation between 15 min and 2 h, whereas accumulation of α2β1 integrin/EV1 led to an increase of integrin fluorescence in cytoplasmic vesicles further suggesting that EV1 pathway is separate from the lysosomal downregulation pathway. In addition, the results demonstrate the involvement of ESCRTs in the biogenesis of α2-MVBs. Overexpression of dominant-negative form of VPS4 inhibited biogenesis of α2-MVBs and efficiently prevented EV1 infection. Furthermore, α2-MVBs were positive for some members of ESCRTs such as Hrs, VPS37A and VPS24 and the siRNA treatment of TSG101, VPS37A and VPS24 inhibited EV1 infection. Our results show that the non-enveloped EV1 depends on biogenesis of novel multivesicular structures for successful infection.

Protein lysate microarray analysis to identify microRNAs regulating estrogen receptor signaling in breast cancer cell lines

Predicting the impact of microRNAs (miRNAs) on target proteins is challenging because of their different regulatory effects at the transcriptional and translational levels. In this study, we applied a novel protein lysate microarray (LMA) technology to systematically monitor for target protein levels after high-throughput transfections of 319 pre-miRs into breast cancer cells. We identified 21 miRNAs that downregulated the estrogen receptor-alpha (ERalpha), as validated by western blotting and quantitative real time-PCR, and by demonstrating the inhibition of estrogen-stimulated cell growth. Five potent ERalpha-regulating miRNAs, miR-18a, miR-18b, miR-193b, miR-206 and miR-302c, were confirmed to directly target ERalpha in 3'-untranslated region reporter assays. The gene expression signature that they repressed highly overlapped with that of a small interfering RNA against ERalpha, and across all the signatures tested, was most closely associated with the repression of known estrogen-induced genes. Furthermore, miR-18a and miR-18b showed higher levels of expression in ERalpha-negative as compared with ERalpha-positive clinical tumors. In summary, we present systematic and direct functional evidence of miRNAs inhibiting ERalpha signaling in breast cancer, and demonstrate the high-throughput LMA technology as a novel, powerful technique in determining the relative impact of various miRNAs on key target proteins and associated cellular processes and pathways.

Knowledge of diabetes mellitus, diets and nutrition in diabetic patients

A multiple choice questionnaire was used to test the level of knowledge abut diabetes mellitus and diet-nutrition in diabetic patients (n = 317), non-diabetic patients (n = 70), nursing personnel (n = 53) and third-year medical students (n = 43). The results concerning diabetes were better than those for diet-nutrition. A score of greater than or equal to 80% in diet-nutrition was considered necessary for proper management of the diet at home. This level was reached by 84% of the students, 26% of the nursing personnel, 29% of the insulin-treated diabetics (n = 178, 9% of the tablet-treated diabetics (n = 124) and 4% of the non-diabetic patients. It was concluded that the piecemeal instruction system used to teach the diabetic patients is inefficient and should be replaced by a formal educational program integrated into the patient care system. The level of knowledge among nursing personnel needs to be improved.

On the influence of vitamin K-rich vegetables and wine on the effectiveness of warfarin treatment

Thrombotest (TT) values were studied in patients fed an ordinary diet and on continuous and well controlled warfarin therapy because of deep venous thrombosis or pulmonary embolism. The aim was to characterize the effect of single and multiple administrations (daily during one week) of vitamin K1 (Konakion), vitamin K-rich vegetables such as spinach and broccoli, and table wine. Single administration of 250 micrograms vitamin K1, 250 g spinach, 250 g broccoli and 37.5 cl wine did not result in TT-values outside the therapeutic range. However, when Konakion, broccoli and spinach were given daily during one week the TT-values tended to rise above the therapeutic limit, requiring dose adjustment. On the basis of this study it appears that excessive intake of vitamin K-rich food and a moderate intake of alcohol on one occasion may be permitted during anticoagulant therapy.

Prevalence of hypercalcaemia in a health screening in Stockholm

A free health check, offered to 21417 20-63-year-old employees of the Stockholm City and County Council in 1971-73, was accepted by 15903 persons. The examination included a multichannel chemical analysis of a single blood sample. Serum calcium levels greater than or equal to 11.0 mg/100 ml (2.75 mmol/l) and greater than or equal to 11.1 mg/100 ml (2.78 mmol/l) were encountered in 3.9% and 1.1% of the population, respectively. Among subjects below 50 years of age, the calcium concentration was significantly higher in males than in females. This difference disappeared in older subjects, essentially because the calcium level decreased with advancing age in the men. To a further investigation were invited 178 subjects with a single serum calcium registration greater than or equal to 11.1 mg/100 ml (2.78 mmol/l). Of this group, 95 persons (53.4%) exhibited hypercalcaemia (HC) on repeated testing. Twelve had been operated on prior to the actural follow-up and found to have parathyroid adenomata. Twenty subjects were on continuous treatment with diuretics of the thiazide type and seven had diseases that might induce HC (two had hyperthyroidism, two hypothyroidism, one sarcoidosis, one hypernephroma and one mammary carcinoma). In 56 patients the laboratory and physical examinations did not reveal any obvious cause for the HC except possible hyperparathyoidism (HPT). Eighty (84.2%) of the 95 HC subjects were women, mostly over 50 years. The 95 persons constituted 6% of the total number of health-screened persons. The highest prevalence, 13%, was recorded for women aged 60-63. The prevalence of HPT in the total material was 3.6%, which is higher than that found in several other studies. This is based on surgical findings to date.

C-reactive protein levels following standard neurosurgical procedures

BACKGROUND

The aim of the present study was to establish the magnitude and time-course of C-reactive protein increases following routine neurosurgical procedures in the absence of clinical and laboratory signs of infection.

METHOD

C-reactive protein levels were studied daily following ventriculo-peritoneal shunt implantation, anterior cervical fusion, vestibular schwannoma operation, supratentorial glioma surgery, endovascular intracranial aneurysm treatment and open cerebral aneurysm surgery.

FINDINGS

The magnitude of the C-reactive protein increase depended on the extent of surgical trauma and peak-levels were recorded between postoperative day one and four after which the levels tapered off.

INTERPRETATION

Increases occurring after the fourth postoperative day are likely to be caused by complications of surgery, e.g. infection.

One-Session treatment of specific phobias in youths: a randomized clinical trial

Sixty children, ages 7-17 years, who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis for various specific phobias were randomized to (a) 1-session exposure treatment alone, (b) 1-session treatment with a parent present, or (c) wait-list control group for 4 weeks. After the waiting period, the wait-list patients were rerandomized to the active treatments. The patients' phobias were assessed with behavioral approach tests (approach behavior, experienced anxiety, and physiological reactions), whereas general anxiety, depression, phobic tendencies, and anxiety sensitivity were assessed with self-report inventories. Assessments were done pre-, post-, and 1-year following treatment. Results showed that both treatment conditions did significantly better than the control condition, whereas the treatment groups did equally well on most measures, and the effects were maintained at follow-up. The implications of these results are discussed.

Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground

OBJECTIVE

To compare the effect of walking training on a treadmill with body weight support (BWS) and walking training on the ground at an early stage of rehabilitation in patients with hemiparesis after stroke.

DESIGN

Randomized controlled experimental study.

SETTING

Multicentre design; three departments of rehabilitation medicine.

SUBJECTS

Seventy-three consecutive first stroke patients admitted to a rehabilitation clinic were randomized into a treatment group and a control group.

INTERVENTIONS

The treatment group received walking training on a treadmill with BWS for 30 minutes, 5 days a week. The control group received walking training according to the Motor Relearning Programme (MRP) on the ground for 30 minutes 5 days a week, not including treadmill training. During the time in the rehabilitation department (about two months), all patients in the study also received professional stroke rehabilitation besides the walking training in the two groups.

MAIN OUTCOME MEASURES

Functional Independence Measure (FIM), walking velocity for 10 m, Functional Ambulation Classification (FAC), Fugl-Meyer Stroke Assessment and Berg's Balance Scale. The assessments were performed at admission, at discharge and at 10-month follow-up.

RESULTS

There were no statistically significant differences between the groups at discharge or at the 10-month follow-up with regard to FIM, walking velocity, FAC, Fugl-Meyer Stroke Assessment, and Berg's Balance Scale. Patients in both groups improved in these variables from admission to the 10-month follow-up.

CONCLUSIONS

Treadmill training with BWS at an early stage of rehabilitation after stroke is a comparable choice to walking training on the ground.

Randomised controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia

BACKGROUND

No controlled trial of treatment of generalised social phobia has been conducted in general practice.

AIMS

To examine the efficacy of sertraline or exposure therapy, administered alone or in combination in this setting.

METHOD

Study was of a randomised, double-blind design. Patients (n = 387) received sertraline 50-150 mg or placebo for 24 weeks. Patients were additionally randomised to exposure therapy or general medical care.

RESULTS

Sertraline-treated patients were significantly more improved than non-sertraline-treated patients (chi(2)=12.53, P<0.001; odds ratio=0.534; 95% Cl 0.347-0.835). No significant difference was observed between exposure- and non-exposure-treated patients (chi(2)=2.18, P=0.140; odds ratio=0.732; 95% Cl 0.475-1.134). In the pairwise comparisons, combined sertraline and exposure (chi(2)=12.32; P<0.001) and sertraline (chi(2)=10.13; P=0.002) were significantly superior to placebo.

CONCLUSIONS

Sertraline is an effective treatment for generalised social phobia. Combined treatment with sertraline and exposure therapy, conducted by the general practitioner, may enhance the treatment efficacy in primary care.

Balance function and fall-related efficacy in patients with newly operated hip fracture

OBJECTIVE

To investigate the relation between fall-related efficacy in daily-life activities and functional as well as instrumental tests of balance in patients with hip fracture.

DESIGN

Analysis of different aspects of balance using the Falls Efficacy Scale, Swedish version FES(S), questions on fear of falling, Functional Reach (FR) and tests on a balance platform (Chattanooga).

SUBJECTS

Fifty-five elderly inpatients (mean age 82.3) with newly operated hip fracture who were assessed during the last week in hospital before discharge.

RESULTS

The results showed a significant relationship between the subjective ability measured with the FES(S) and the objectively measured balance in the Functional Reach test and also between fall-related efficacy measured with FES(S) and fear of falling. Very few significant correlations were found between the results from balance tests on the force platform and those obtained with FES(S) and FR.

CONCLUSIONS

Both the Falls Efficacy Scale, Swedish version, and the Functional Reach have been shown to be useful in analysing balance function in elderly patients newly operated on for hip fracture. The Falls Efficacy Scale also indicates which of the daily activities the patient perceives as troublesome and thus require further training.

Fear of falling in patients with stroke: a reliability study

OBJECTIVE

To examine the scaling properties and test-retest reliability of an expanded version of the Falls Efficacy Scale (FES) and to compare group differences in the scores. The expanded version focuses on more basic, primary activities of daily living (ADL), which makes the scale more suitable for subjects with moderate to low functional ability, e.g. patients with stroke.

DESIGN

A test-retest reliability study with one group convenience sample.

SETTING

Two day-care units: a rehabilitation unit and a geriatric rehabilitation unit.

SUBJECTS

A volunteer sample of 30 patients (mean age 65 years, SD 11 years) who had sustained stroke between 5 and 84 months prior to the investigation.

MAIN OUTCOME MEASURE

A 13-activity questionnaire (the Swedish modification of the Falls Efficacy Scale (FES(S)) comprising the 10 activities of the original FES and three additional activities was used. Falls efficacy was rated on a 10-point visual analogue scale for each activity on two occasions, 5-22 (mean 10, Md 7) days apart.

RESULTS

The overall test-retest reliability of the FES(S) was high (intraclass correlation coefficient (ICC) = 0.97). The ICC for the personal ADL (items 1-6) scores was 0.93 and for the instrumental ADL (items 8-13) 0.97. ICC for the individual items ranged from 0.76 to 0.97.

CONCLUSIONS

On the basis of these preliminary findings, the FES(S) appears to have acceptable test-retest reliability. The test may be a reasonable addition for assessing stroke patients with balance disturbances and risk for falls.

Evaluation of refractory epilepsy treated with vagus nerve stimulation for up to 5 years

We assessed the long-term efficacy of vagus nerve stimulation (VNS) in 64 refractory epilepsy patients. After implantation, intermittent stimulation was delivered and seizure frequency and severity were counted. Average treatment time was 20 months. Nineteen of 47 patients with partial seizures, five of nine patients with idiopathic generalized seizures, and five of eight patients with Lennox-Gastaut syndrome had >50% seizure reduction. Side effects were mild. VNS is a safe and effective treatment for refractory epilepsy.

Enhanced generation of interleukins 1 beta and 6 may contribute to the cachexia of chronic disease

The cachexia of disease may be promoted by proinflammatory cytokines, eg, interleukin (IL) 1 beta, tumor necrosis factor alpha (TNF-alpha), and IL-6. These, as well as some antiinflammatory cytokines, eg, IL-1 receptor antagonist (IL-1ra), IL-10, and transforming growth factor beta 1 (TGF-beta 1), were analyzed in serum (IL-6, IL-1ra, IL-10, TGF-beta 1) and stimulated blood monocytes (IL-1 beta, TNF alpha, IL-6) obtained from elderly patients with protein-energy malnutrition (PEM). Twenty-one uninfected malnourished patients aged 75 +/- 1 y (mean +/- SD), with a body mass index (BMI; in kg/m2) of 17.2 +/- 0.5 and various noncancer disorders, and 22 healthy matched control subjects aged 72 +/- 1 y, with a BMI of 25.4 +/- 0.7 (significantly different from patients, P < 0.001), were included. Fifteen patients and their corresponding control subjects were reexamined 3 mo later. Isolated monocytes were stimulated with lipopolysaccharide (LPS) and concentrations of IL-1 beta, TNF-alpha, and IL-6 were determined. Serum concentrations of IL-6, IL-1ra, IL-10, TGF-beta 1, and acute-phase reactants were analyzed. Serum concentrations of orosomucoid and IL-6 were higher in the malnourished subjects than in the control subjects (1.14 +/- 0.1 compared with 0.8 +/- 0.3 g/L, P < 0.001; and 5 ng/L compared with undetectable concentrations, P < 0.01, respectively). Higher generation of IL-1 beta (2.7-fold; P < 0.05) and IL-6 (3.7-fold; P < 0.05) was found in monocytes from patients with PEM relative to the control subjects when monocytes were stimulated with 0.1 microgram LPS/L. Monocyte TNF generation and serum concentrations of IL-10, IL-1ra, and TGF-beta 1 did not differ. Similar results were obtained at follow-up. IL-1ra was negatively correlated with delayed cutaneous hypersensitivity (r = -0.34, P < 0.05). We conclude that enhanced generation of proinflammatory cytokines such as IL-6 and IL-1 beta in malnourished patients may contribute to the PEM often encountered in chronic nonmalignant disorders.

Prediction of outcome in the treatment of specific phobia. A cross validation study

The purpose of this study was to investigate possible predictors of treatment outcome in specific phobia at 1 week after treatment, and at I year follow-up. The subjects (n = 138) came from four studies (two on spider phobia, one on blood phobia and one on injection phobia), and all had been diagnosed with simple phobia according to DSM-III-R. The dependent variable was clinically significant improvement in three different factors; avoidance behavior in a behavior test, self-rated anxiety during the test, assessor rating of phobic severity or fainting behavior. Fourteen variables covering self-report, demographic and physiological variables, and data from the behavior test were used as prognostic variables. Multiple regression analyses were used in a cross validation procedure. The results showed that diastolic blood pressure at pretest was a predictor at post-treatment for one sample and credibility was found as a predictor for the other sample both at post-treatment and at 1 year follow-up. Analyses were made for the diagnoses and the treatments but the results were inconclusive. Despite the large sample size and the cross validation procedure no stable predictors were found for short- and long-term outcome. The few significant predictors should be considered as chance findings.

One versus five sessions of applied tension in the treatment of blood phobia

Thirty patients with blood phobia, fulfilling the DSM-III-R criteria for simple phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to 3 different conditions: (1) 5 sessions of applied tension; (2) 1 session of applied tension (maximum 2 h); and (3) I session of tension-only (maximum 2 h). The results showed that the patients in the 3 treatments were all significantly improved at post-treatment and the effects were maintained at the 1 yr follow-up. At post-treatment and follow-up the proportions of clinically improved patients were: AT5 50 and 60%, AT1 0 and 70%, and T1 30 and 60%, respectively. The conclusion that can be drawn is that I-session therapist-directed applied tension or tension-only is the treatment of choice for blood phobia, but completed with a maintenance program of self-exposure.

One-session therapist directed exposure vs two forms of manual directed self-exposure in the treatment of spider phobia

Fifty-two patients with spider phobia, fulfilling the DSM-III-R criteria for simple phobia, were assessed with behavioral, physiological and self-report measures. They were randomly assigned to five different treatment conditions: (1) one session therapist-directed exposure (maximum 3 hours), (2) specific manual-based treatment in the home, (3) specific manual-based treatment at the clinic, (4) general manual-based treatment in the home and (5) general manual-based treatment at the clinic. The results show that therapist-directed one-session treatment was significantly more effective than three of the manual-based treatments, both at the post-treatment and follow-up stages. Specific manual-based treatment at the clinic was significantly more successful than the other manual-based treatments, but only at follow-up. The proportion of clinically significant improved patients at follow-up was 80% in the therapist-directed group compared to 63% for the specific manual-based treatment at the clinic, 10% for specific manual-based treatment in the home, 9% for general manual-based treatment in the home, and 10% for general manual-based treatment at the clinic. The conclusion that can be drawn is that one-session therapist-directed treatment is the treatment of choice for spider phobia but manual-based treatment is a good alternative in some cases.

Outcome of protein-energy malnutrition in elderly medical patients

PURPOSE

To assess the impact of protein-energy malnutrition (PEM) on mortality and the long-term variations in the nutritional status of subjects admitted as emergency cases in a 9-month prospective follow-up study.

PATIENTS AND METHODS

The study comprised 205 patients without cancer aged 75 years (+/- 1). Malnourished subjects were identified as having at least three nutritional variables (which included weight index, triceps skinfold thickness, arm muscle circumference, serum albumin, and delayed cutaneous hypersensitivity reaction) below the reference range.

RESULTS

The mortality was 44% in the 41 malnourished patients and 18% in the 164 nonmalnourished subjects (P < 0.001). Among malnourished patients with congestive heart failure the mortality was 80%. Multivariate analysis revealed congestive heart failure, multiple organ disease, and PEM to be predictors of death. When the interaction between these disorders and PEM was considered, the prognostic relevance of PEM remained among the patients with cardiac congestion. Of the surviving subjects, 125 were reexamined after 9 months. At admission, more than half of the patients had displayed elevated levels of serum acid glycoprotein as evidence of an ongoing inflammation and subnormal recordings for serum albumin and delayed cutaneous hypersensitivity. At the reexamination, these variables had normalized in the well-nourished patients and in the 9 patients who had recovered from PEM, but remained unchanged in the 10 patients with persistent PEM. The latter patients were severely malnourished, commonly infected, and often hospitalized.

CONCLUSIONS

Protein-energy malnutrition in noncancer medical patients is associated with an excess mortality in those with congestive heart failure. Improvement of PEM is accompanied by a decline in inflammatory activity.

Applied relaxation, exposure in vivo and cognitive methods in the treatment of panic disorder with agoraphobia

Forty-five psychiatric outpatients with DSM-III-R diagnosis of panic disorder with agoraphobia were assessed with a battery of self-report, behavioral and cognitive measures before and after therapy, and at a 1 yr follow-up. They were randomly assigned to either Applied Relaxation (AR; n = 15), Exposure in vivo (E; n = 15) or Cognitive Treatment (CT; n = 15) and received 12 individual therapy sessions, once weekly. All patients also had self-exposure instructions. The three treatments yielded significant improvements that were maintained at follow-up. One criterion of clinically significant improvement was fulfilled by 87% of the AR-, 80% of the E- and 60% of the CT-patients at the end of treatment, and 85, 79 and 67%, respectively, at follow-up. Between-group differences were observed on two measures only, both showing better results for AR than for CT. The conclusion that can be drawn is that the three treatments, focussed on different anxiety components, are about equally effective, and the results are maintained 1 yr after the end of treatment.

Nutritional status and performance capacity in internal medical patients

The nutritional status (3 anthropometric records, serum albumin and delayed cutaneous hypersensitivity (DCH)), recent weight loss, dynamometric capacity and mood were assessed in 205 recently admitted non-cancer internal medical patients. 20% of the subjects were classified as malnourished (3 of the 5 nutritional variables below the reference range). The occurrence of malnutrition was higher (1/3) in multiple organ dysfunction or chronic respiratory disease. In order to reduce the risk of overestimating malnutrition, the data for serum albumin and DCH were omitted when they appeared to be influenced by non-nutritional factors. Disease duration >2 years, old age and multiple organ dysfunction were independently related to malnutrition. Serum albumin correlated more strongly with the acute phase reactant, serum acid glycoprotein (r = 0.33, P < 0.001) than with the anthropometric variables (r < 0.24). Recalled recent weight loss >5% was found in 34% of the malnourished subjects. Malnourished, in comparison to well nourished patients, exhibited reduced (p < 0.05) recordings for hand grip strength, peak expiratory flow and time of ambulation. Depressive tendencies were seen in malnourished women (p < 0.05).

Nutritional status in recently hospitalized and free-living elderly subjects

Weight index (WI), triceps skinfold (TSF), serum albumin and delayed cutaneous hypersensitivity reaction (DCH) were measured in 96 hospitalized elderly patients and in 100 age- and sex-matched free-living controls. Using the 10th percentile of data obtained in the controls, WI was subnormal in 35% of the patients. Corresponding findings with regard to TSF, serum albumin and DCH were 32, 50 and 31%, respectively. The findings in the controls were mainly within the range observed in national reference groups. Patients were considered malnourished if they showed at least two variables (of which one was required to be anthropometric) below the cut-off limits used. When these limits were set at the 10th percentile of the recordings in the controls, the occurrence of undernutrition in the patients was 39%. By using the 5th percentile the corresponding figure was 16%. Malnourishment was most pronounced in patients with multiple organ disease and malignancy. It is concluded that low nutritional indices are a common occurrence in elderly subjects admitted to hospital and that undernutrition is related to the nature of the disease rather than age.

Does chronic hypoxaemia induce transformations of fibre types?

The study comprised nine patients with chronic obstructive lung disease. Quadriceps muscle biopsies were studied with respect to fibre type composition before and after haemodilution that brought haemoglobin (Hb) to within normal limits. Ten days elapsed between the two biopsy occasions. The arterial oxygen tension (PaO2) and saturation (SaO2) were depressed to 8.4 +/- 2.0 kPa and 89 +/- 11% in the patients with chronic obstructive lung disease and increased to 9.2 +/- 2.1 and 91 +/- 8% with haemodilation. The type II fibre proportion was 71 +/- 12% before haemodilation and significantly higher than normal (reference group, see Aniansson et al. 1981). Following haemodilation the proportion of type II fibres decreased significantly to 60 +/- 14%. The proportion of type II fibres was directly related to the haemoglobin content before, but not after, haemodilation and was inversely related to PaO2 and SaO2 both before and after haemodilation. In conclusion, hypoxaemia may be a factor underlying the high proportion of type II fibres found in patients with chronic obstructive lung disease.

Decrease in myoglobin and enzyme contents with haemodilution in non-hypoxaemic polycythaemic patients

Quadriceps muscle biopsies from five patients with primary polycythaemia and four patients with non-primary polycythaemia, all with normal respiratory functions, were studied before and after normalization of haemoglobin and erythrocyte volume fraction by haemodilution or venaesectio. Since similar results were obtained from both groups of patients data were pooled. After normalization of the erythrocyte volume fraction myoglobin decreased by 19 +/- 16%, P less than 0.01, the activity of creatine kinase and citrate synthase by 12 +/- 8 and 14 +/- 18%, P less than 0.05, respectively. The decrease in myoglobin content was related to the decrease in haemoglobin concentration (r = 0.77, P less than 0.01). In conclusion, these data suggest that in non-hypoxaemic polycythaemia skeletal muscle shows adaptations indicative of an impaired oxygenation and a metabolic stress, adaptations that are reversed by haemodilution.

Cholesterol biosynthesis in nonketotic diabetics before and during insulin therapy

A previous study demonstrated that the net steroid balance, i.e., the total rate of cholesterogenesis, was within the normal range in insulin-treated patients with both insulin-dependent and noninsulin-dependent diabetes mellitus (NIDD). In contrast, the corresponding findings in diet-treated patients with NIDD were above normal regardless of whether sulfonylurea was also given. The aim of the current study was to reinvestigate nine patients with NIDD 3-38 months after the institution of insulin therapy. At the doses used there were no significant effects on blood glucose control but the bile acid formation and net steroid balance decreased in seven patients. It is suggested that insulin therapy depresses the rate of cholesterogenesis in NIDD. This effect may be achieved without normalizing blood glucose.

Effects of a high-protein and low-fat diet vs a low-protein and high-fat diet on blood glucose, serum lipoproteins, and cholesterol metabolism in noninsulin-dependent diabetics

Six middle-aged patients with noninsulin-dependent diabetes and six normoglycemic control subjects were fed protein-rich and fat-poor (diet A) or protein-poor and fat-rich food (diet B). The patients were hyperglycemic, VLDL triglycerides levels were higher, and HDL cholesterol levels lower than corresponding findings in control subjects. Bile acid formation and biliary lipid composition did not differ between the two groups, but net steroid balance in the patients was elevated by a factor of approximately 2. A switch from diet A to diet B in control subjects was associated with an increase in HDL cholesterol and decreases in bile acid synthesis and net steroid balance. Lipoprotein pattern in the patients remained unchanged, and effects on total bile acid production and steroid balance were less consistent. It is suggested that the response in the patients reflected diabetes-associated abnormalities in lipid metabolism.

Cholesterol and bile acid metabolism in middle-aged diabetics

Serum lipoproteins, bile and kinetics and net steroid balance were studied in 22 diet-treated and 5 insulin-treated patients with noninsulin-dependent diabetes mellitus, in 6 patients with insulin-dependent diabetes mellitus and in 15 normoglycemic controls. All subjects were middle-aged and the patients were hyperglycemic. Some of the diet-treated patients suffered from obesity and/or dyslipoproteinaemia mainly characterized by elevated levels of triglycerides and cholesterol in VLDL (very low-density lipoproteins). The diet-treated patients had enhanced fractional turnover of both cholic acid and chenodeoxycholic acid but bile acid formation was within the control range in all groups of patients. As the most significant finding net steroid balance (total cholesterogenesis) was raised in the diet-treated patients. Bile acid kinetics and net steroid balance were normal in insulin-treated patients irrespective of type of diabetes.