Stigma towards mental illness in Asian nations and low-and-middle-income countries, and comparison with high-income countries: A literature review and practice implications

Background

Stigma related to mental illness (and its treatment) is prevalent worldwide. This stigma could be at the structural or organizational level, societal level (interpersonal stigma), and the individual level (internalized stigma). Vulnerable populations, for example, gender minorities, children, adolescents, and geriatric populations, are more prone to stigma. The magnitude of stigma and its negative influence is determined by socio-cultural factors and macro (mental health policies, programs) or micro-level factors (societal views, health sectors, or individuals' attitudes towards mentally ill persons). Mental health stigma is associated with more serious psychological problems among the victims, reduced access to mental health care, poor adherence to treatment, and unfavorable outcomes. Although various nationwide and well-established anti-stigma interventions/campaigns exist in high-income countries (HICs) with favorable outcomes, a comprehensive synthesis of literature from the Low- and Middle-Income Countries (LMICs), more so from the Asian continent is lacking. The lack of such literature impedes growth in stigma-related research, including developing anti-stigma interventions.

Aim

To synthesize the available mental health stigma literature from Asia and LMICs and compare them on the mental health stigma, anti-stigma interventions, and the effectiveness of such interventions from HICs.

Materials and Methods

PubMed and Google Scholar databases were screened using the following search terms: stigma, prejudice, discrimination, stereotype, perceived stigma, associate stigma (for Stigma), mental health, mental illness, mental disorder psychiatric* (for mental health), and low-and-middle-income countries, LMICs, High-income countries, and Asia, South Asian Association for Regional Cooperation/SAARC (for countries of interest). Bibliographic and grey literature were also performed to obtain the relevant records.

Results

The anti-stigma interventions in Asia nations and LMICs are generalized (vs. disorder specific), population-based (vs. specific groups, such as patients, caregivers, and health professionals), mostly educative (vs. contact-based or attitude and behavioral-based programs), and lacking in long-term effectiveness data. Government, international/national bodies, professional organizations, and mental health professionals can play a crucial in addressing mental health stigma.

Conclusion

There is a need for a multi-modal intervention and multi-sectoral coordination to mitigate the mental health stigma. Greater research (nationwide surveys, cultural determinants of stigma, culture-specific anti-stigma interventions) in this area is required.

VRE acquisition in hospital and its association with hospital antimicrobial usage -a non-linear analysis of an extended time series

BACKGROUND

Vancomycin resistant enterococci (VRE) have become endemic pathogens in many Australian hospitals causing significant morbidity. There are few observational studies that have evaluated the effect of antibiotic usage on VRE acquisition. This study examined VRE acquisition and its association with antimicrobial use. The setting was a NSW tertiary hospital with 800 beds over a 63 month period up to March 2020, straddling piperacillin-tazobactam (PT) shortages that occurred from in September 2017.

METHODS

The primary outcome was monthly inpatient hospital onset Vancomycin-resistant Enterococci (VRE) acquisitions. Multivariate adaptive regression splines (MARS) were used to estimate hypothetical thresholds, where antimicrobial use above threshold is associated with increased incidence of hospital onset VRE acquisition. Specific antimicrobials and categorised usage (broad, less broad and narrow spectrum) were modelled.

RESULTS

There were 846 hospital onset VRE detections over the study period. Hospital onset vanB and vanA VRE acquisitions fell significantly by 64% and 36% respectively after the PT shortage. MARS modelling indicated that PT usage was the only antibiotic found to exhibit a meaningful threshold. PT usage greater than 17.4 defined daily doses/1000 occupied bed-days (95%C I: 13.4, 20.5) was associated with higher onset of hospital VRE.

CONCLUSIONS

This paper highlights the large, sustained impact that reduced broad spectrum antimicrobial use had on VRE acquisition and showed that PT use in particular was a major driver with a relatively low threshold. It raises the question as to whether hospitals should be determining local antimicrobial usage targets based on direct evidence from local data analysed with non-linear methods.

The association between diabetes and mortality in young adults presenting with myocardial infarction

Background

The incidence of diabetes mellitus and coronary artery disease continue to rise and collectively comprise two of the most prevalent and costly diseases worldwide. The goal of this study is to report the prognosis of young patients with diabetes presented with acute myocardial infarction (AMI).

Methods

This is a retrospective observational cohort study that included consecutive patients aged 18–45 years who underwent cardiac catheterization for AMI between 2006 and 2016 in an integrated healthcare system in Southern California. The prognosis of patients with diabetes were compared to those without diabetes.

Results

A total of 1,560 patients (average age 40.2±5.3 years, 25.6% female) presenting with AMI were included. Of these 272 (17.4%) had diabetes. Diabetics were older (41.1±4.4 vs 40.0±5.4 years), more likely to be female (32.4% vs 24.1%, p=0.006), Hispanic (51.5% vs 40.5%, p<0.001), have a higher body mass index (BMI) (33.6±7.1 vs 31.2±6.8kg/m2, p<0.001), have hypertension (HTN) (67.6% vs 23.8%, p<0.001), hyperlipidemia (HLD) (78.3% vs 24.1%, p<0.001), peripheral vascular disease (9.9% vs 1.9%, p<0.001), chronic kidney disease (CKD) (23.2% vs 2.7%, p<0.001), hypothyroidism (7% vs 4%, p=0.034), and prior strokes (4.4% vs 2.2%, p=0.034).

On multivariate analysis accounting for other cardiovascular risk factors, the association remained significant (OR 1.82, 95% CI 1.04–3.19, p=0.036). At a median follow-up of 5.8 years (interquartile range 3.7–8.7 years), diabetes was independently associated with increased all-cause mortality (Hazard ratio [HR] 3.10, 95% CI 1.68–5.69, p<0.001) when adjusting for age, sex, race, BMI, HTN, HLD, CKD, hypothyroidism, prior stroke, and ACS etiology. In a propensity score matched cohort, diabetes remained significantly associated with all-cause mortality (HR 5.29, 95% CI 2.34–12.02, p<0.001).

Conclusion

Diabetes is an independent predictor of increased mortality in young adults <45 years old presenting with AMI.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): KAISER PERMANENTE LOS ANGELES MEDICAL CENTER

Choice of primary and secondary outcomes in randomised controlled trials evaluating treatment for uterine fibroids: a systematic review

BACKGROUND

Core outcome sets aim to reduce research heterogeneity and standardise reporting, allowing meaningful comparisons between studies.

OBJECTIVES

To report on outcomes used in randomised controlled trials (RCTs) investigating uterine fibroid treatments, towards the development of a core outcome set for fibroid research.

SELECTION STRATEGY

Database search of MEDLINE, PubMed, EMBASE and CINAHL (inception to July 2021) for all English-language RCTs involving surgical or radiological fibroid treatments.

DATA COLLECTION AND ANALYSIS

A total of 1885 texts were screened for eligibility by two reviewers independently according to PRISMA methodology. JADAD and Management of Otitis Media with Effusion in Cleft Palate (MOMENT) scores were used to assess methodological and outcome reporting quality of studies, respectively. Outcomes were mapped to nine domains. Non-parametric tests for correlation and to compare group medians were undertaken.

MAIN RESULTS

There were 23 primary outcomes (23 outcome measures) and 173 secondary outcomes (95 outcome measures) reported in 60 RCTs (5699 participants). The domains with highest frequency of primary outcomes reported were bleeding and quality of life (QoL). The most frequent primary outcomes were postoperative pain, QoL and menstrual bleeding. No primary outcomes were mapped to fertility domains. Median MOMENT outcome score was 5 (interquartile range 3). There was correlation between MOMENT outcome score and JADAD scores (r = 0.491, P = 0.0001), publishing journal impact factor (r = 0.419, P = 0.008) and publication year (r = 0.332, P = 0.01).

CONCLUSION

There is substantial variation in the outcomes reported in fibroid RCTs. There is a need for a core outcome set for fibroid research, to allow improved understanding regarding the effects of different treatments.

Investigate clinical characteristics and genetic mutations of CPVT patients in Taiwan and risk stratification

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology

Background

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare and lethal arrhythmia in children and young adults. RYR2 mutation accounts for 60% of CPVT patients. While many articles about CPVT are published in the Caucasian population, only a few studies are based on Asian ethnicity. A CPVT scorecard proposed using Caucasian patients is proven effective in reducing the burden of variants of uncertain significance (VUS) of RYR2 mutations is not yet tested in the Asian population.

Purpose

Identify mutations among Taiwanese CPVT patients and compare genetic and clinical results with other ethnicities. We also tested the efficacy of the CPVT scorecard in Taiwanese CPVT patients.

Methods

40 clinically diagnosed CPVT patients and their family members were consecutively enrolled from multi-centers. We compared clinical characteristics and genetic results with other ethnicities, and applied the Caucasian CPVT scorecard to test whether it is applicable in Taiwanese CPVT patients.

Results

This is the first nationwide CPVT cohort in Taiwan. Among the 29 patients with CPVT-related gene mutation, 12 RYR2 variants was identified in our cohort with 5 of them unreported in previous studies. The RYR2 yield rate was 55%, similar to other ethnicities. Exercise-induced symptoms including syncope and cardiac arrest were more severe in Taiwanese CPVT cohort, compared to Japanese and Caucasian cohorts. The CPVT scorecard also successfully reduced the VUS rate for the Taiwanese cohort.

Conclusions

Our study demonstrated genetic difference in CPVT patients across ethnicities, suggesting the importance of genetic testing in Taiwan. The CPVT scorecard is applicable to Taiwanese CPVT patients and is a helpful tool in interpreting genetic test results in clinical practice. Clinical characteristics of the cohort Gender (male, %) 15 (52%) Mean age of onset (years) 18 ± 15 Exercise-related syncope or cardiac arrest (n, %) 23 (79%) Exercise-related cardiac arrest (n, %) 14 (48%) Family history of unexplained sudden cardiac death (n, %) 5 (17%) Heart rate (bpm) 73 ± 16 Exercise stress test or Holter positive (n, %) 14 (48%) Ventricular arrhythmia (n, %) 23 (79%) Beta-blockers only (n, %) 10 (35%) Intracardiac defibrillator implantation (n, %) 15 (52%) CPVT score 6 ± 3

Triggers of stress cardiomyopathy and their association with clinical outcomes

Background

Stress cardiomyopathy can be a result of physical stress, emotional stress, or both. Whether the type of trigger affects clinical outcomes is not well studied.

Purpose

The objectives of this study were to identify the prevalence of emotional and physical stressors and to assess differences in patient characteristics and mortality based on the type of trigger.

Methods

We conducted a retrospective review of 523 consecutive patients who presented to our institution from 2006 to 2016. All patients presented with acute coronary syndrome. Triggers for stress cardiomyopathy were abstracted from reviewing patients' medical records. Patients were categorized into those with 1) physical trigger, 2) emotional trigger, 3) both physical and emotional trigger, or 4) no known trigger. Baseline characteristics and clinical outcomes were reported.

Results

Among 523 patients with stress cardiomyopathy, 151 (28.9%) had a physical trigger, 189 (36.1%) had an emotional trigger, 30 (5.7%) had both physical and emotional triggers, and 153 (29.3%) had no known triggers identified. Men comprised the higher proportion of patients with physical triggers. Comorbidities including diabetes, pulmonary disease, chronic kidney disease and hypothyroidism were more prevalent among patients with physical triggers. Compared to patients with no obvious triggers, patients with a physical trigger had a much higher mortality rate (hazard ratio 2.0, 95% CI 1.2–3.3, p=0.007), whereas patients with an emotional trigger had significantly lower mortality (hazard ratio 0.40, 95% CI 0.21–0.89, p=0.007).

Conclusion

Different triggers for stress cardiomyopathy is associated with different baseline characteristics and clinical outcomes. Overall survival is worst in the group with an identified physical trigger.

Figure 1

Funding Acknowledgement

Type of funding source: None

Screening for high hip fracture risk does not impact on falls risk: a post hoc analysis from the SCOOP study

A reduction in hip fracture incidence following population screening might reflect the effectiveness of anti-osteoporosis therapy, behaviour change to reduce falls, or both. This post hoc analysis demonstrates that identifying high hip fracture risk by FRAX was not associated with any alteration in falls risk.

INTRODUCTION

To investigate whether effectiveness of an osteoporosis screening programme to reduce hip fractures was mediated by modification of falls risk in the screening arm.

METHODS

The SCOOP study recruited 12,483 women aged 70-85 years, individually randomised to a control (n = 6250) or screening (n = 6233) arm; in the latter, osteoporosis treatment was recommended to women at high risk of hip fracture, while the control arm received usual care. Falls were captured by self-reported questionnaire. We determined the influence of baseline risk factors on future falls, and then examined for differences in falls risk between the randomisation groups, particularly in those at high fracture risk.

RESULTS

Women sustaining one or more falls were slightly older at baseline than those remaining falls free during follow-up (mean difference 0.70 years, 95%CI 0.55-0.85, p < 0.001). A higher FRAX 10-year probability of hip fracture was associated with increased likelihood of falling, with fall risk increasing by 1-2% for every 1% increase in hip fracture probability. However, falls risk factors were well balanced between the study arms and, importantly, there was no evidence of a difference in falls occurrence. In particular, there was no evidence of interaction (p = 0.18) between baseline FRAX hip fracture probabilities and falls risk in the two arms, consistent with no impact of screening on falls in women informed to be at high risk of hip fracture.

CONCLUSION

Effectiveness of screening for high FRAX hip fracture probability to reduce hip fracture risk was not mediated by a reduction in falls.

The pharmacokinetics of pimobendan enantiomers after oral and intravenous administration of racemate pimobendan formulations in healthy dogs

Pimobendan is a benzimidazole-pyridazinone derivative, marketed as a racemic mixture for the management of canine heart failure. Pharmacokinetics of the enantiomers of pimobendan and its oral bioavailability have not been described in dogs. The aim of this study was to describe pharmacokinetics of three formulations of pimobendan in healthy dogs: the licensed capsule product, and novel liquid and intravenous formulations. A three-period, nested randomized two-treatment crossover design was used. Pimobendan was administered p.o. at 0.25 and i.v. at 0.125 mg/kg. Blood and plasma samples were analysed by liquid chromatography-mass spectrometry. Noncompartmental modelling was used to describe the pharmacokinetics. Parameters were compared between formulations using a general linear model. Bioequivalence of the oral formulations was tested using CI90 for AUC(0-∞) and Cmax . Bioavailability of pimobendan after oral dosing was 70%. Liquid and capsule formulations were bioequivalent only for AUC. The positive enantiomer of pimobendan (PE) had a larger volume of distribution than the negative enantiomer (NE) (281 ± 48 vs. 215 ± 68 mL/kg; P = 0.003) and a shorter half-life (21.7 vs. 29.9 min; P = 0.004). The NE was distributed more quickly than the PE into blood cells. Enantiomers of pimobendan have differing absorption, distribution and elimination. The pharmacokinetics of pimobendan in healthy dogs was described.

Pictogram-based method of visualizing dietary intake

BACKGROUND

Pictograms have been shown by many studies to be an effective way of conveying information. An easy-to-understand pictorial description is essential for communication of dietary intake in the computer era.

OBJECTIVES

We proposed a novel approach that represents textual descriptions of dietary intake into a pictorial representation with the concept of pictograms. The computational implementation in terms of a web-based tool was investigated on how well the pictograms carry their intended message.

METHODS

1) We investigated how well the pictograms are comprehended in terms of subjects' accuracy rate and response time. In the study (n = 90), pictorial variants with three types of food images (black-and-white sketch, colored sketch, and colored photograph) were tested. 2) We also investigated how well subjects were able to select the standard food size among various food portions with the use of the tool. A comparison was made against the current standard of an educational session taught by a registered dietitian. We recruited 86 university students who were asked to select a standard size out of five different size categories. Three types of shapes were used. The bowl is the container that is widely used in the participants' country. The pork strip was to represent foods with elliptical cross-section. The apple was used to represent a baseball-like size and shape.

RESULTS

Two pictograms with black-and-white food image were low of less than 50% in accuracy rate. The rest of the twenty-seven pictograms derived from portions of the nine foods were well understood with high accuracy rates (above 85%). Participants in using the tool without the dietitian's session was better than participants in the dietitian education session in selecting a standard portion size of an apple (p < 0.0001; p = 0.0009 after adjustment for gender and age). The rate of correct bowl and pork strip size estimates were similar between the two conditions (p > 0.05).

CONCLUSION

The development of pictograms could be used as a computational visual aid for comprehending and identifying dietary intake. Broader investigation is required for considering the effectiveness of the pictograms on recall, measurement, or estimation as well as for further evaluation in the clinical practice.

Effect of fructose on markers of non-alcoholic fatty liver disease (NAFLD): a systematic review and meta-analysis of controlled feeding trials

BACKGROUND/OBJECTIVES

In the absence of consistent clinical evidence, there are concerns that fructose contributes to non-alcoholic fatty liver disease (NAFLD). To determine the effect of fructose on markers of NAFLD, we conducted a systematic review and meta-analysis of controlled feeding trials.

SUBJECTS/METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Library (through 3 September 2013). We included relevant trials that involved a follow-up of ≥ 7 days. Two reviewers independently extracted relevant data. Data were pooled by the generic inverse variance method using random effects models and expressed as standardized mean difference (SMD) for intrahepatocellular lipids (IHCL) and mean difference (MD) for alanine aminotransferase (ALT). Inter-study heterogeneity was assessed (Cochran Q statistic) and quantified (I(2) statistic).

RESULTS

Eligibility criteria were met by eight reports containing 13 trials in 260 healthy participants: seven isocaloric trials, in which fructose was exchanged isocalorically for other carbohydrates, and six hypercaloric trials, in which the diet was supplemented with excess energy (+21-35% energy) from high-dose fructose (+104-220 g/day). Although there was no effect of fructose in isocaloric trials, fructose in hypercaloric trials increased both IHCL (SMD=0.45 (95% confidence interval (CI): 0.18, 0.72)) and ALT (MD=4.94 U/l (95% CI: 0.03, 9.85)).

LIMITATIONS

Few trials were available for inclusion, most of which were small, short (≤ 4 weeks), and of poor quality.

CONCLUSIONS

Isocaloric exchange of fructose for other carbohydrates does not induce NAFLD changes in healthy participants. Fructose providing excess energy at extreme doses, however, does raise IHCL and ALT, an effect that may be more attributable to excess energy than fructose. Larger, longer and higher-quality trials of the effect of fructose on histopathological NAFLD changes are required.

Long-term efficacy of electroacupuncture for chronic neck pain: a randomised controlled trial

Electroacupuncture is a safe treatment for chronic neck pain. Nonetheless, one month after treatment, improvement of neck pain is similar to that in placebo-treated controls. This suggests that the efficacy may not be due to specific effect of the treatment procedure.

Number of suture throws and its impact on the biomechanical properties of the four-strand cruciate locked flexor tendon repair with FiberWire

FiberWire is a popular suture in flexor tendon repair that allows for early mobilization, but its poor knot-holding properties have raised concerns over the potential effects on tendon healing and strength. We examined how the number of knot throws affects the 2 mm gap force, ultimate tensile strength, and mode of failure in a four-strand cruciate locked tendon repair in porcine flexor tendons in order to elucidate the optimal number of suture throws. There was no effect on the 2 mm gap force with increasing knot throws, but there was a significant increase in ultimate tensile strength. A minimum of six-knot throws prevents unravelling, whereas five out of 10 of repairs unravelled with less than six throws.

The health of homeless immigrants

BACKGROUND

This study examined the association between immigrant status and current health in a representative sample of 1189 homeless people in Toronto, Canada.

METHODS

Multivariate regression analyses were performed to examine the relationship between immigrant status and current health status (assessed using the SF-12) among homeless recent immigrants (< or = 10 years since immigration), non-recent immigrants (>10 years since immigration) and Canadian-born individuals recruited at shelters and meal programmes (response rate 73%).

RESULTS

After adjusting for demographic characteristics and lifetime duration of homelessness, recent immigrants were significantly less likely to have chronic conditions (RR 0.7, 95% CI 0.5 to 0.9), mental health problems (OR 0.4, 95% CI 0.2 to 0.7), alcohol problems (OR 0.2, 95% CI 0.1 to 0.5) and drug problems (OR 0.2, 95% CI 0.1 to 0.4) than non-recent immigrants and Canadian-born individuals. Recent immigrants were also more likely to have better mental health status (+3.4 points, SE +/-1.6) and physical health status (+2.2 points, SE +/-1.3) on scales with a mean of 50 and a SD of 10 in the general population.

CONCLUSION

Homeless recent immigrants are a distinct group who are generally healthier and may have very different service needs from other homeless people.

A novel cationic cardiolipin analogue for gene delivery

The optically active R and S isomers of cationic cardiolipin analogues (CCA) were synthesized and evaluated as a liposome based transfection reagent. Both isomers form stable liposomes with mean diameters of about 120 nm without any additional lipid ingredients. No significant change in particle size distribution profile was observed over one-month storage at room temperature (20-25 degrees C). The gel to liquid crystalline phase transition temperature (Tm) of cationic liposomes comprised of both R and S isomers was approximately 2 degrees C, as measured by differential scanning calorimetry (DSC). Both isomers also formed stable liposomes when combined with DOPE. In vitro transfection efficiency of the CCA/DOPE liposomes complexed to plasmid DNA was evaluated using a luciferase reporter gene. Both liposomes composed of R and S isomers of the cationic cardiolipin displayed higher transfection efficiency than commercially available Lipofectin. Further in vivo studies are warranted.

Cantonese tone perception ability of cochlear implant children in comparison with normal-hearing children

BACKGROUND AND OBJECTIVE

Cantonese is a tone language. A change in the fundamental frequency pattern within the same phonemic segment causes a change in the lexical meaning. The present study examined the Cantonese tone perception ability of cochlear implant children in comparison with normal-hearing children. It was hypothesized that cochlear implant children follow a similar pattern of tone perception development, as do normal children.

METHOD

225 normal-hearing and 15 hearing-impaired children with cochlear implants were recruited. The high level (tone 1), high rising (tone 2) and low falling (tone 4) were the target tones examined. The three tones were arranged into tone pairs for identification. Each pair shared exactly the same segmental information but differed only in tones (e.g. /sy/ in tones 1 and 2 meaning 'book' and 'mouse', respectively). Subjects were required to point to the corresponding pictures after the live voice presentations.

RESULTS

for each tone pair, each subject was awarded a score representing the proportion of stimuli pairs that were correctly discriminated by the subject. The average scores in the normal-hearing and hearing-impaired groups were 0.92 and 0.64, respectively. The normal group had the lowest average score in tone 2/tone 4 (0.87) while the hearing-impaired group performed the worst in tone 1/tone 2 (0.53) perception between the three tone contrasts.

CONCLUSIONS

the normal-hearing group performed significantly better than the hearing-impaired group in basic Cantonese tone perception. The pattern of tone perception development of cochlear implant children did not seem to follow that of normal children. Contributing factors on the tone perception performance of the cochlear implant children were subject's age, duration of special training, and durations of wearing the hearing aid and the cochlear implant.

Longitudinal outcome of verbal discourse in children with traumatic brain injury: three-year follow-up

PURPOSE

This study compared changes in discourse ability between two groups of children age 5 to 10 years after brain injury: those with severe traumatic brain injury (TBI) and those with mild/moderate injury over 3-year follow-up testing.

MATERIALS AND METHODS

Forty-three children with TBI were recruited from a larger research project examining cognitive and linguistic recovery after injury. Twenty-two of these patients had severe injuries and 21 sustained mild/moderate injuries. All children were presented an ordered sequence of pictures and asked to verbally produce a story/narrative discourse. Each child was then asked to produce a lesson relating to the story.

RESULTS

The severe group performed significantly worse than the mild/moderate group when performance across all four discourse domains was considered. Both groups improved across time on selected discourse measures. Qualitative analysis suggested that the severe group showed differential rates of improvement across the individual discourse variables over the 3-year interval.

CONCLUSIONS

Severe TBI can have a pernicious effect on discourse abilities in children years after injury compared with children with mild/moderate injuries. The major caveat is that the discourse measures must be sufficiently challenging when used to assess older children and children with milder forms of TBI.

Human and mouse ABCA1 comparative sequencing and transgenesis studies revealing novel regulatory sequences

The expression of ABCA1, a major participant in apolipoprotein-mediated cholesterol efflux, is regulated by a variety of factors, including intracellular cholesterol concentration. To identify sequences involved in its regulation, we sequenced and compared approximately 200 kb of mouse and human DNA containing the ABCA1 gene. Furthermore, expression of the human gene containing different 5' ends was examined in transgenic mice. Sequence comparison revealed multiple conserved noncoding sequences. The two most highly conserved noncoding elements (CNS1, 88% identity over 498 bp; CNS2, 81% identity over 214 bp) were also highly conserved in other organisms. Mice containing the human ABCA1 gene, 70 kb of upstream DNA, and 35 kb of downstream DNA expressed the transgene similarly to endogenous Abca1. A second transgene beginning 3' to exon 1 was expressed only in liver, providing strong evidence of an unsuspected liver-specific promoter. The identified conserved noncoding sequences invite further investigation to elucidate ABCA1 regulation.

Inverse agonist binding of peripheral benzodiazepine receptors in anxiety disorder

The binding characteristics of the pBR (peripheral benzodiazepine receptor) inverse agonist, [3H]-Ro 5-4864, were examined in patients diagnosed as generalized anxiety disorder. As compared to normal healthy controls, the anxious subjects demonstrated a statistically significant (p < 0.001) increase in the density of pBR in platelets. The enhanced pBR binding correlated significantly with the severity of global anxiety symptom of the Hamilton Anxiety Rating Scale (HAR-S, p < 0.001). The Psychic component, but not the Somatic component, of the HAR-S, correlated significantly (p < 0.001) with the enhanced pBR binding in platelets. The results provide evidence for the hypothesis of dysregulation of peripheral benzodiazepine receptors in generalized anxiety disorder.

Phthalocyanine 4 photodynamic therapy-induced apoptosis of mouse L5178Y-R cells results from a delayed but extensive release of cytochrome c from mitochondria

Photodynamic therapy (PDT) activates the mitochondrial pathway of apoptosis, for which the release of cytochrome c into the cytosol is considered critical. To further elucidate the role of cytochrome c release in PDT-induced apoptosis, we monitored cytochrome c localization immunocytochemically and related it to nuclear apoptosis of the same cells. When mouse L5178Y-R cells were treated with 300 nM phthalocyanine (Pc) 4 and 0-75 mJ/cm(2) red light, cytochrome c release had a dose response similar to that of clonogenic cell killing, with nearly identical threshold doses. Within individual cells, the release of cytochrome c appeared to be an all-or-none phenomenon. Moreover, it was tightly associated with activation of a caspase-3-like protease and changes in nuclear morphology. Thus, in response to Pc 4-PDT, the release of cytochrome c from mitochondria is a key determinant of apoptotic cell death.

Heart transplantation and the Batista operation for children with refractory heart failure

Medically refractory heart failure may be present in children with cardiomyopathy (CMP) or complex congenital heart disease (CHD). In adults, the surgical management of this condition is either heart transplantation or the Batista operation. From March 1995 to January 2000, a total of 6 children, aged from 1 to 16 years, with medically refractory heart failure associated with CMP or complex CHD underwent cardiac transplantation and one of them also had the Batista operation as a bridge to transplantation. One of the 6 patients died of intractable sepsis 17 days after the operation, but the other 5 were discharged with satisfactory hemodynamics. Immunosuppressive agents, including azathioprine, cyclosporin or FK-506, were given. One patient experienced moderate acute rejection, but it was controlled by FK-506, OKT-3 and solumedrol. However, another suffered from lymphoproliferative disease 8 months after transplant, but it was controlled by intravenous immunoglubulin, alpha-interferon and acyclovir. Cardiac function during serial follow-up (range, 1 month to 5 years) revealed normal systolic and diastolic function and none received any anticongestive medications. Almost all patients received an oversized donor heart. The left ventricle (LV) mass was remodeled, initially as an decrease and later as an increase. The patient who underwent the Batista operation was discharged 1 month after the operation with an increased LV ejection fraction (from 10% to 22%). She was successfully bridged to heart transplantation 7 months after the Batista operation. The results of cardiac transplantation in growing children are satisfactory and remain the mainstay of surgical treatment for medically refractory heart failure in these patients. However, with a shortage of donor hearts, the Batista operation may be adopted as a bridge to heart transplant with a fair response.

Septic arthritis of the hip caused by Salmonella typhi

We describe septic arthritis of the hip in a child with typhoid fever. The aetiological diagnosis was confirmed by a positive Widal test as well as by isolation of Salmonella typhi from joint aspirate. Treatment with ceftriaxone along with surgical drainage was successful.

The role of amino acid neurotransmitters in the regulation of pituitary gonadotropin release in fish

Both glutamate and gamma-aminobutyric acid (GABA) are involved in pituitary hormone release in fish. Glutamate serves 2 purposes, both as a neurotransmitter and as a precursor for GABA synthesis. Glutamate can be catabolized to GABA by the actions of 2 distinct but related enzymes, glutamate decarboxylase 65 (GAD65) and GAD67. They derive from 2 different genes that likely arose from an early gene duplication prior to the emergence of teleosts more than 400 million years ago. There is good evidence for the involvement of GABA in luteinizing hormone (LH) release in fish. The mechanism of GABA action to stimulate LH release appears to be a combination of effects on GnRH release, potentiation of gonadotropin hormone-releasing hormone (GnRH) action, and in some cases directly at the LH cell. These actions appear to be dependent on such factors as sex or sex steroid levels, and there may also be species differences. Nevertheless, the stimulatory effects of GABA on LH are present in at least 4 fish species. In contrast, convincing data for the inhibitory effects of GABA on LH release have only been observed in 1 fish species. The sites and mechanisms of action of amino acid neurotransmitters on LH release have yet to be fully characterized. Both 130N-methyl-D-aspartic acid (NMDA) and S-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) type glutamate receptors are likely to have important roles. We suggest that it is a receptor similar to the GABA(A) type which mediates the effects of GABA on LH release in fish, at least partially acting on the GnRH neuron, but likely directly acting at the gonadotroph as well. GABA may also be involved in regulating the release of other pituitary hormones in fish, namely follicle stimulating hormone (FSH = GTH-I), prolactin, and growth hormone. Based on the findings described in this review, a working model for the involvement of glutamate and GABA in the regulation of LH release in teleost fish is proposed.

Two double-blinded, randomized, comparative trials of 4 human immunodeficiency virus type 1 (HIV-1) envelope vaccines in HIV-1-infected individuals across a spectrum of disease severity: AIDS Clinical Trials Groups 209 and 214

The potential role of human immunodeficiency virus type 1 (HIV-1)-specific immune responses in controlling viral replication in vivo has stimulated interest in enhancing virus-specific immunity by vaccinating infected individuals with HIV-1 or its components. These studies were undertaken to define patient populations most likely to respond to vaccination, with the induction of novel HIV-1-specific cellular immune responses, and to compare the safety and immunogenicity of several candidate recombinant HIV-1 envelope vaccines and adjuvants. New lymphoproliferative responses (LPRs) developed in <30% of vaccine recipients. LPRs were elicited primarily in study participants with a CD4 cell count >350 cells/mm(3) and were usually strain restricted. Responders tended to be more likely than nonresponders to have an undetectable level of HIV-1 RNA at baseline (P=.067). Induction of new cellular immune responses by HIV-1 envelope vaccines is a function of the immunologic stage of disease and baseline plasma HIV-1 RNA level and exhibits considerable vaccine strain specificity.

Design of inhomogeneous materials with given structural properties

We describe a technique applicable to optimize certain quantities associated with the two-phase structure described by a model of penetrable grains. The solution is given in a form of an intensity surface that controls locations of the grains. Particular examples include maximization of the expected phase 2 volume and design of functionally graded materials with a given density profile.

Nonparametric and parametric estimation for a linear germination-growth model

Seeds are planted on the interval [0, L] at various locations. Each seed has a location x and a potential germination time t epsilon [0, infinity), and it is assumed that the collection of such (x, t) pairs forms a Poisson process in [0, L] x [0, infinity) with intensity measure dxd lambda(t). From each seed that germinates, an inhibiting region grows bidirectionally at rate 2v. These regions inhibit germination of any seed in the region with a later potential germination time. Thus, seeds only germinate in the uninhibited part of [0, L]. We want to estimate lambda on the basis of one or more realizations of the process, the data being the locations and germination times of the germinated seeds. We derive the maximum likelihood estimator of v and a nonparametric estimator of lambda and describe methods of obtaining parametric estimates from it, illustrating these with reference to gamma densities. Simulation results are described and the methods applied to some neurobiological data. An Appendix outlines the S-PLUS code used.

Surgical validation and implications for transcatheter closure of quantitative echocardiographic evaluation of atrial septal defect

Accurate evaluation of secundum atrial septal defect (ASD) is important for the success of transcatheter closure. The purpose of this study was (1) to describe a quantitative evaluation by transthoracic (TTE) and transesophageal (TEE) echocardiography of the various morphologic features of ASD that might be important for patient selection for transcatheter closure, and (2) to assess the reliability of these 2 methods by surgical findings. Preoperative TTE and TEE were used to evaluate the ASD of 27 children undergoing surgical closure. Measurements included the diameters of ASD and the atrial septal lengths in the transverse and longitudinal axis, and the width of the superior, inferior, anteroinferior, and posterior septal margins. The shape and location of the ASD and the adequacy of the septal margins for anchoring occluding devices were determined. Echocardiographic data were compared with corresponding surgical measurements. No significant difference occurred in the means of all the parameters measured with the 3 methods, except for the transverse ASD diameter (p <0.05). Good agreement occurred between TTE and TEE and surgical data, except for the transverse ASD diameter, transverse atrial septal length, and the posterior septal margin on TTE. Intraclass correlations between TTE and TEE and surgical measurements of all parameters were good, except for the transverse ASD diameter. The accuracy in determining shape and location of the ASD by TTE and TEE were 100%, whereas that for determining the adequacy of septal margins was 98% and 97%, respectively. In conclusion, TTE and TEE are reliable methods for quantitative evaluation of ASD.

The role of amino acid neurotransmitters in the regulation of pituitary gonadotropin release in fish

Both glutamate and γ-aminobutyric acid (GABA) are involved in pituitary hormone release in fish. Glutamate serves 2 purposes, both as a neurotransmitter and as a precursor for GABA synthesis. Glutamate can be catabolized to GABA by the actions of 2 distinct but related enzymes, glutamate decarboxylase 65 (GAD65) and GAD67. They derive from 2 different genes that likely arose from an early gene duplication prior to the emergence of teleosts more than 400 million years ago. There is good evidence for the involvement of GABA in luteinizing hormone (LH) release in fish. The mechanism of GABA action to stimulate LH release appears to be a combination of effects on GnRH release, potentiation of gonadotropin hormone-releasing hormone (GnRH) action, and in some cases directly at the LH cell. These actions appear to be dependent on such factors as sex or sex steroid levels, and there may also be species differences. Nevertheless, the stimulatory effects of GABA on LH are present in at least 4 fish species. In contrast, convincing data for the inhibitory effects of GABA on LH release have only been observed in 1 fish species. The sites and mechanisms of action of amino acid neurotransmitters on LH release have yet to be fully characterized. Both N-methyl-D-aspartic acid (NMDA) and S-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) type glutamate receptors are likely to have important roles. We suggest that it is a receptor similar to the GABAA type which mediates the effects of GABA on LH release in fish, at least partially acting on the GnRH neuron, but likely directly acting at the gonadotroph as well. GABA may also be involved in regulating the release of other pituitary hormones in fish, namely follicle stimulating hormone (FSH = GTH-I), prolactin, and growth hormone. Based on the findings described in this review, a working model for the involvement of glutamate and GABA in the regulation of LH release in teleost fish is proposed.

Key words: glutamate, GABA, luteinizing hormone, muscimol, patch clamp electrophysiology, reproduction, fish.

Reduced mobilization of CD34+ stem cells in advanced human immunodeficiency virus type 1 disease

Granulocyte colony-stimulating factor (r-met Hu G-CSF; filgrastim; 10 microgram/kg/day for 7 days) was used to mobilize CD34+stem cells into the peripheral blood of human immunodeficiency virus type 1 (HIV-1)-infected individuals and a group of HIV-1-uninfected donors as a measure of immunologic reserve in HIV-1-infected people. G-CSF mobilized CD34+ cells of HIV-1-infected individuals with cell counts >500 CD4+ cells/mm3, as well as in HIV-1-uninfected donors. In contrast, CD34 cell mobilization was significantly blunted in HIV-1-infected individuals with cell counts <500 CD4+ cells/mm3 (<200 cell days vs. >650 cell days, P<.0005, compared with the >500 CD4+ cell cohort). At least 1.75x10(7) CD34 cells were harvested by leukapheresis from patients in each study cohort. CD34+ cell viability and the ability to differentiate precursor cells into myeloid and erythroid progenitor cells were not affected by HIV-1 infection.

Secretory event in intestinal grafts during preservation ischemia

BACKGROUND

Ischemia triggers secretion of proteins from the intestine, including type II secretory phospholipase A2 (sPLA2). This "secretory event" was studied in intestinal grafts during the first few hours of preservation by measuring total protein, sPLA2, and other enzymes in the UW preservation solution over time. The effect of PX-13, a PLA2 inhibitor, was also studied.

MATERIALS AND METHODS

Twenty-five centimeter intestinal grafts were harvested from Lewis rats, flushed, and preserved in UW solution +/- PX-13 at 4 degrees C. UW samples from 0 to 48 h (n = 5 each) were analyzed for total protein, sPLA2, lactate dehydrogenase (LDH), N-acetylglucosamine (NAGA), and lysozyme. Nonpreserved grafts were homogenized in PBS as tissue controls. Standard biochemical methods were used for all assays.

RESULTS

Total protein increased rapidly by 5 min, continued to rise more slowly until 30 min, and then stabilized. The most significant increase in sPLA2 activity occurred between 90 and 180 min. NAGA increased most markedly between 30 and 180 min, while LDH increased in the first 30 min, although the level of both enzymes was negligible compared to tissue enzyme. Lysozyme levels were minimal at all times. PX-13 decreased sPLA2 activity markedly at all time points.

CONCLUSION

Total protein levels increased before sPLA2, suggesting that sPLA2 may be secreted in response to other proteins or enzymes released even earlier during preservation (e.g., cytokines). These elevations do not appear to be caused by cell death. Phospholipase A2 secretion may be blocked, and this may greatly improve the outcome of intestinal preservation.

Gradual withdrawal of long-term anticholinergic antiparkinson medication in Chinese patients with chronic schizophrenia

Previous antiparkinson drug withdrawal studies involving white subjects have yielded inconclusive findings, whereas there is a paucity of data concerning Asian patients. A double-blind, placebo-controlled, randomized trial using gradual withdrawal of antiparkinson medication was conducted to evaluate the need for maintenance antiparkinson therapy for clinically stable Chinese patients with chronic schizophrenia. Seventy-five schizophrenic subjects who had received a diagnosis according to DSM-IV who had been ill for at least 5 years and on antipsychotic and antiparkinson medication for a minimum of 2 years entered the study. After baseline assessment, 58 subjects were matched according to age, sex, age at onset, length of illness, dose and length of antipsychotic and antiparkinson medication, and the presence of various extrapyramidal side effects. Randomly assigned dose-reduction and control groups were formed consisting of 29 subjects each. Trihexyphenidyl (THP), the only oral antiparkinson drug used in the study, was reduced by 1 mg every 2 weeks, whereas other psychotropic medication remained unchanged. Monthly assessment was performed using the Brief Psychiatric Rating Scale, Hamilton Rating Scale for Depression, Abnormal Involuntary Movement Scale, Simpson-Angus Scale, Barnes Akathisia Rating Scale, and the Nursing Observation Scale for Inpatient Evaluation-30. Complete withdrawal of THP was possible in 25 (90%) of the 28 subjects who completed the study, whereas considerable dose reduction was achieved in the remaining 3 subjects. There were no significant differences between dose reduction and control groups on any of the rating scales at the completion of the study. Our results suggest that long-term prophylactic administration of antiparkinson medication is unnecessary in the treatment of the majority of Chinese patients with chronic schizophrenia because withdrawal was accomplished without adverse mental or motor effects.

Characterization of the analgesic and anti-inflammatory activities of ketorolac and its enantiomers in the rat

The marked analgesic efficacy of ketorolac in humans, relative to other nonsteroidal anti-inflammatory drugs (NSAIDs), has lead to speculation as to whether additional non-NSAID mechanism(s) contribute to its analgesic actions. To evaluate this possibility, we characterized (R,S)-ketorolac's pharmacological properties in vivo and in vitro using the nonselective cyclooxygenase (COX) inhibitors [indomethacin (INDO) and diclofenac sodium (DS)] as well as the selective COX-2 inhibitor, celecoxib, as references. The potency of racemic (R,S)-ketorolac was similar in tests of acetic acid-induced writhing, carrageenan-induced paw hyperalgesia, and carrageenan-induced edema formation in rats; ID50 values = 0.24, 0. 29, and 0.08 mg/kg, respectively. (R,S)-ketorolac's actions were stereospecific, with (S)-ketorolac possessing the biological activity of the racemate in the above tests. The analgesic potencies for (R,S)-, (S)-, and (R)-ketorolac, INDO, and DS were highly correlated with their anti-inflammatory potencies, suggesting a common mechanism. (R,S)-ketorolac was significantly more potent than INDO or DS in vivo. Neither difference in relative potency of COX inhibition for (R,S)-ketorolac over INDO and DS nor activity of (S)-ketorolac at a number of other enzymes, channels, or receptors could account for the differences in observed potency. The distribution coefficient for (R,S)-ketorolac was approximately 30-fold less than for DS or INDO, indicating that (R,S)-ketorolac is much less lipophilic than these NSAIDs. Therefore, the physicochemical and pharmacokinetics properties of (R,S)-ketorolac may optimize the concentrations of (S)-ketorolac at its biological target(s), resulting in greater efficacy and potency in vivo.

Radioprotection of cellular chromatin by the polyamines spermine and putrescine: preferential action against formation of DNA-protein crosslinks

Spermine is an efficient radioprotector of plasmid or viral DNA and of viral minichromosomes by a mechanism involving radical scavenging and the induction of compaction and aggregation of DNA. Based on radioprotection of SV40 minichromosomes at a lower spermine concentration than needed for SV40 DNA, Newton et al. (Radiat. Res. 145, 776-780, 1996) proposed that the differential concentration dependence could account for the greater radiosensitivity of open regions of cellular chromatin compared to bulk inactive chromatin at physiological levels of spermine. However, we recently reported that, whereas the effects of spermine on the formation of DNA double-strand breaks (DSBs) in dehistonized V79 cell DNA (nucleoids) were consistent with spermine-induced DNA compaction, spermine provided no radioprotection of native chromatin and only modest radioprotection of histone H1-depleted chromatin (Chiu and Oleinick, Radiat. Res. 148, 188-192, 1997). To further characterize the radioprotection of cellular chromatin by spermine, radiation-induced DNA-protein crosslinks (DPCs) were investigated, because of evidence that these lesions occur preferentially at or near the sites of anchorage of chromosomes to the nuclear matrix. In contrast to the relatively inefficient radioprotection of V79 cell chromatin against the formation of DSBs, low concentrations (<0.1 mM) of spermine or putrescine provided partial radioprotection against the formation of DPCs in both native and H1-depleted chromatin. Whereas all DPCs generated by the irradiation of chromatin, above the level generated in intact cells, could be blocked by 5 mM spermine, less than half could be blocked by 5 mM putrescine. The difference in efficiency of radioprotection of native chromatin by the two polyamines can be accounted for by assuming that the binding of spermine is 10 times as efficient as the binding of putrescine. The results suggest that (a) both spermine and putrescine bind preferentially and with high affinity at matrix-associated sites of formation of DPCs, disrupting the associations between DNA and protein that are essential for formation of DPCs and/or scavenging hydroxyl radicals at these sites; (b) a smaller fraction of the sites are susceptible to putrescine than to spermine; and (c) endogenous spermine is a major radioprotector of cells against the formation of DPCs, either because of specific features of the lesion or because of the site of lesion formation at the nuclear matrix.