Obsessive-Compulsive Disorder: A Medical School Curriculum and Textbook Review.

OBJECTIVES: We conducted a curriculum review of Canadian undergraduate medical programs to identify why aggressive obsessions (among those with obsessive-compulsive disorder [OCD]) are so often misidentified by primary care physicians and professional students. METHODS: This study involved standardized interviews with representatives from Canadian medical schools regarding the content, time, and teaching styles used to deliver curricula related to OCD. Further, we utilized a set of standardized criteria to assess the OCD content of recommended textbooks from these schools. RESULTS: Canadian medical curricula failed to provide a comprehensive picture of OCD. One-third of medical programs did not provide an example of aggressive obsessions to students, with textbook case examples centered heavily (70%) on contamination or symmetry. Only 25% of programs (and 60% of textbooks) discussed the composition of the Unacceptable Thought Domain to include aggressive, sexual, and religious obsessions. Finally, over half of medical programs failed to indicate that aggressive obsessions are ego-dystonic and do not lead people to harm themselves or others. CONCLUSION: A series of recommendations are provided for medical schools intended to improve the comprehensiveness of OCD-related training.

Patient-perceived usefulness of an emergency medical card and a continuity-of-care report in enhancing the quality of care.

OBJECTIVE: To evaluate the patients' opinion on the usefulness of the electronic medical card (EMC) and continuity-of-care report in enhancing quality of care, and to assess the effects of the patient-entered data on the quality of data in the electronic medical record (EMR). DESIGN: A structured survey assessed patients' opinion on the usefulness of the EMC and continuity-of-care report. The accuracy of EMR data involved comparing the patient-entered data in the continuity-of-care report with the healthcare-provider-entered data in the EMR. The analysis assessed whether the EMR information was consistent with the patient-entered data. A data completeness evaluation compared data entries in the EMR collected before and after the use of continuity-of-care record application. RESULTS: One hundred and thirty-three patients used the application, of which 76% who had actually used the EMC and continuity-of-care report to seek medical care and/or update EMR information were surveyed. Age was associated with the reported usefulness of the documents. Few users (16%) printed the continuity-of-care reports to take to their healthcare providers for data updates and fewer (9%) to correct errors in the EMR. Overall, 68% of patients found the documents to be useful. CONCLUSIONS: Patients reported that the EMC and continuity-of-care report were useful in enhancing quality of care. They were able to identify missing or erroneous data in the EMR data, making them an important source of quality control for their information in the healthcare-provider-maintained EMR.

Postnatal Expansion, Maturation, and Functionality of MR1T Cells in Humans.

MR1-restricted T (MR1T) cells are defined by their recognition of metabolite antigens presented by the monomorphic MHC class 1-related molecule, MR1, the most highly conserved MHC class I related molecule in mammalian species. Mucosal-associated invariant T (MAIT) cells are the predominant subset of MR1T cells expressing an invariant TCR α-chain, TRAV1-2. These cells comprise a T cell subset that recognizes and mediates host immune responses to a broad array of microbial pathogens, including Mycobacterium tuberculosis. Here, we sought to characterize development of circulating human MR1T cells as defined by MR1-5-OP-RU tetramer labeling and of the TRAV1-2+ MAIT cells defined by expression of TRAV1-2 and high expression of CD26 and CD161 (TRAV1-2+CD161++CD26++ cells). We analyzed postnatal expansion, maturation, and functionality of peripheral blood MR1-5-OP-RU tetramer+ MR1T cells in cohorts from three different geographic settings with different tuberculosis (TB) vaccination practices, levels of exposure to and infection with M. tuberculosis. Early after birth, frequencies of MR1-5-OP-RU tetramer+ MR1T cells increased rapidly by several fold. This coincided with the transition from a predominantly CD4+ and TRAV1-2- population in neonates, to a predominantly TRAV1-2+CD161++CD26++ CD8+ population. We also observed that tetramer+ MR1T cells that expressed TNF upon mycobacterial stimulation were very low in neonates, but increased ~10-fold in the first year of life. These functional MR1T cells in all age groups were MR1-5-OP-RU tetramer+TRAV1-2+ and highly expressed CD161 and CD26, markers that appeared to signal phenotypic and functional maturation of this cell subset. This age-associated maturation was also marked by the loss of naïve T cell markers on tetramer+ TRAV1-2+ MR1T cells more rapidly than tetramer+TRAV1-2- MR1T cells and non-MR1T cells. These data suggest that neonates have infrequent populations of MR1T cells with diverse phenotypic attributes; and that exposure to the environment rapidly and preferentially expands the MR1-5-OP-RU tetramer+TRAV1-2+ population of MR1T cells, which becomes the predominant population of functional MR1T cells early during childhood.

8-Bromo-cyclic AMP induces phosphorylation of two sites in SRC-1 that facilitate ligand-independent activation of the chicken progesterone receptor and are critical for functional cooperation between SRC-1 and CREB binding protein.

Elevation of intracellular 8-bromo-cyclic AMP (cAMP) can activate certain steroid receptors and enhance the ligand-dependent activation of most receptors. During ligand-independent activation of the chicken progesterone receptor (cPR(A)) with the protein kinase A (PKA) activator, 8-bromo-cAMP, we found no alteration in cPR(A) phosphorylation (W. Bai, B. G. Rowan, V. E. Allgood, B. W. O'Malley, and N. L. Weigel, J. Biol. Chem. 272:10457-10463, 1997). To determine if other receptor-associated cofactors were targets of cAMP-dependent signaling pathways, we examined the phosphorylation of steroid receptor coactivator 1 (SRC-1). We detected a 1.8-fold increase in SRC-1 phosphorylation in transfected COS-1 cells incubated with 8-bromo-cAMP. Phosphorylation was increased on two mitogen-activated protein kinase (MAPK) sites, threonine 1179 and serine 1185. PKA did not phosphorylate these sites in vitro. However, blockage of PKA activity in COS-1 cells with the PKA inhibitor (PKI) prevented the 8-bromo-cAMP-mediated phosphorylation of these sites. Incubation of COS-1 cells with 8-bromo-cAMP resulted in activation of the MAPK pathway, as determined by Western blotting with antibodies to the phosphorylated (active) form of Erk-1/2, suggesting an indirect pathway to SRC-1 phosphorylation. Mutation of threonine 1179 and serine 1185 to alanine in COS-1 cells coexpressing cPR(A) and the GRE(2)E1bCAT reporter resulted in up to a 50% decrease in coactivation during both ligand-independent activation and ligand-dependent activation. This was due, in part, to loss of functional cooperation between SRC-1 and CREB binding protein for coactivation of cPR(A). This is the first demonstration of cross talk between a signaling pathway and specific phosphorylation sites in a nuclear receptor coactivator that can regulate steroid receptor activation.

Charge heterogeneity in wildtype and variant glucocorticoid receptors.

Two-dimensional electrophoresis was used to examine charge heterogeneity in glucocorticoid receptors (GCRs) from sublines of the thymic-derived, mouse P1798 lymphosarcoma which were sensitive (S) or resistant (R) to glucocorticoid-mediated apoptosis. Previous work had identified the 97 kDa wildtype GCR (WT-GCR) in S cells and two variant GCRs in R cells: a 45 kDa, steroid-binding truncated GCR (TR-GCR), and a 97 kDa non steroid-binding GCR (NSB-GCR). Using denaturing isoelectric focusing, we now show that S cells as well as adult mouse thymus gland also express the NSB-GCR at pI 5.6 in addition to the WT-GCR which resolves between pH 5.9-7.1. Thus, the NSB-GCR is detected in steroid-sensitive cells and is not unique to R cells. Separation of receptors by native isoelectric focusing suggested that the TR-GCR in R cells resolved at a single, high pI (8.1) relative to the WT-GCR which resolved in a broad range (pI 5.8-8.0). The high pI of the TR-GCR may alter its functional activity thereby contributing to the resistance phenotype.

Differential binding of mutant glucocorticoid receptors to the glucocorticoid response element of the tyrosine aminotransferase gene.

Glucocorticoid receptors (GCRs) in sublines of the mouse P1798 lymphosarcoma that are sensitive (S) or resistant (R) to glucocorticoid-induced cell lysis were examined for their ability to bind to a single glucocorticoid responsive element (GRE). Mobility shift assays detected two specific complexes that were identical in both S and R cellular extracts. Antibodies against the GCR N-terminus supershifted complexes, suggesting that the 97 kDa wild-type GCR (WT-GCR) in S cells, and the variant, 97 kDa non-steroid-binding GCR (NSB-GCR) in R cells were components of both complexes. Sephacryl S300 gel filtration column fractions containing the WT-GCR and NSB-GCR formed complexes with the GRE, while fractions containing a second GCR variant in R cells, the 45 kDa steroid-binding truncated GCR (TR-GCR), did not. Southwestern blotting detected a GRE-binding, 97 kDa protein band in both S and R extracts. A 45 kDa band was not detected. UV crosslinking of protein to DNA revealed protein in the range of 92-120 kDa crosslinked to the GRE in both S and R extracts. No crosslinking was detected at 45 kDa. Strong interaction of the NSB-GCR with GREs and lack of binding of the TR-GCR to single GREs illustrate a complex receptor system in the P1798 lymphosarcoma.

Identification and localization of steroid-binding and nonsteroid-binding forms of the glucocorticoid receptor in the mouse P1798 lymphosarcoma.

Glucocorticoid receptors (GCRs) were characterized in sublines of the mouse P1798 lymphosarcoma that are sensitive (S) or resistant (R) to glucocorticoid-mediated apoptosis. Previous work had identified two steroid-binding GCRs in S and R cells: a 97 kDa wild-type GCR in S cells (WT-GCR), and a 45 kDa truncated GCR in R cells (TR-GCR). A third GCR, a 97 kDa nonsteroid-binding GCR (NSB-GCR), was also identified in R cells. Using subcellular fractionation and Western blotting, we now show that in contrast to the WT-GCR which is localized in both the cytoplasm and nucleus of S cells, the NSB-GCR is localized predominantly in R cell nuclei. Moreover, gel filtration chromatography revealed that treatment with 400 mM NaCl and heat did not significantly alter the Stokes radius of the NSB-GCR suggesting that this receptor is not present in a heterooligomeric complex with other proteins. The TR-GCR was localized predominantly in the soluble cytoplasmic fraction but also in the crude membrane fractions of R cell nuclei, suggesting that this receptor is tightly associated with nuclear structures. It was not detected in the soluble nuclear fraction. Unexpectedly, a 45 kDa nonsteroid-binding immunoreactive protein was detected in crude membrane fractions of S cells. These studies describe a complex GCR system in the P1798 lymphosarcoma that necessitates a further consideration of glucocorticoid signaling in S and R cells.

Progesterone receptor coactivators.

Progesterone action is mediated by intracellular progesterone receptors that regulate target gene transcription. Recently, numerous proteins termed coactivators have been identified that are recruited by the liganded progesterone receptor and enhance receptor-dependent transactivation. Coactivators are a diverse group of molecules that bring multiple structural and enzymatic functions to the promoter. The existence of coactivators represents yet another level of regulation for progesterone receptor activation.

Eye injury and sport: sport-related eye injuries presenting to an eye casualty department throughout 1995.

A survey was undertaken of all patients attending the Eye Casualty Department at Waterford Regional Hospital with sports injuries in the twelve-month period 1st January 1995 to 31st December 1995. Ninety eight patients had problems associated with sport. Hurling was responsible for the largest group (30%) and football of different codes accounted for 29%. The next largest group was the racquet sports (13%). The most common injuries were to the anterior chamber (hyphaema and microhyphaema: 36%). There were three orbital fractures. 26 patients (27%) were admitted. 83 patients (85%) were male. The median age was 20 years. Sport is a significant cause of eye injury, which is often serious, and affects mostly young healthy males.

Different mechanisms for Arabidopsis thaliana hybrid necrosis cases inferred from temperature responses.

Temperature is a major determinant of plant growth, development and success. Understanding how plants respond to temperature is particularly relevant in a warming climate. Plant immune responses are often suppressed above species-specific critical temperatures. This is also true for intraspecific hybrids of Arabidopsis thaliana that express hybrid necrosis due to inappropriate activation of the immune system caused by epistatic interactions between alleles from different genomes. The relationship between temperature and defence is unclear, largely due to a lack of studies that assess immune activation over a wide range of temperatures. To test whether the temperature-based suppression of ectopic immune activation in hybrids exhibits a linear or non-linear relationship, we characterised the molecular and morphological phenotypes of two different necrotic A. thaliana hybrids over a range of ecologically relevant temperatures. We found both linear and non-linear responses for expression of immunity markers and for morphological defects depending on the underlying genetic cause. This suggests that the influence of temperature on the trade-off between immunity and growth depends on the specific defence components involved.

Stable inhibition of specific estrogen receptor α (ERα) phosphorylation confers increased growth, migration/invasion, and disruption of estradiol signaling in MCF-7 breast cancer cells.

Elevated phosphorylation of estrogen receptor α (ERα) at serines 118 (S118) and 167 (S167) is associated with favorable outcome for tamoxifen adjuvant therapy and may serve as surrogate markers for a functional ERα signaling pathway in breast cancer. It is possible that loss of phosphorylation at S118 and/or S167 could disrupt ERα signaling, resulting in aggressive ERα-independent breast cancer cells. To this end, MCF-7 breast cancer cells were stably transfected with an ERα-specific short hairpin RNA that reduced endogenous ERα. The resulting cell line was stably transfected with wild-type ERα (ER-AB cells), or ERα containing serine to alanine mutation at S118 or S167 (S118A cells and S167A cells, respectively). These stable cell lines expressed approximately equivalent ERα compared with parental MCF-7 cells and were evaluated for growth, morphology, migration/invasion, and ERα-regulated gene expression. S118A cells and S167A cells exhibited increased growth and migration/invasion in vitro. Forward- and side-scatter flow cytometry revealed that S167A cells were smaller in size, and both S118A and S167A cells exhibited less cellular complexity. S118A and S167A cells expressed pancytokeratin and membrane localization of ß-catenin and did not express vimentin, indicating retention of epithelial lineage markers. Expression of ERα-target genes and other genes regulated by ERα signaling or involved in breast cancer were markedly altered in both S118A and S167A cells. In summary, attenuated phosphorylation of ERα at S118 and S167 significantly affected cellular physiology and behavior in MCF-7 breast cancer cells, resulting in increased growth, migration/invasion, compromised expression of ERα target genes, and markedly altered gene expression patterns.

Human steroidogenic factor-1 (hSF-1) regulates progesterone biosynthesis and growth of ovarian surface epithelial cancer cells.

The majority of cancers derived from ovarian surface epithelial (OSE) cells are lethal. Estrogens promote proliferation of OSE cells, whereas progesterone inhibits proliferation and promotes apoptosis of OSE cells. Human steroidogenic factor-1 (hSF-1) induction of the steroidogenic acute regulatory protein (StAR) gene, and the steroidogenic enzymes CYP11A1 and HSD3B2 is central to progesterone biosynthesis. Whereas hSF-1 and StAR are expressed in human ovarian surface epithelial (HOSE) cells, hSF-1 and StAR protein were not expressed in a panel of malignant ovarian cancer cell lines (SKOV-3, BG-1, and Caov-3), and in human OSE cells immortalized by SV40 large T antigen (IOSE-121). Transient expression of hSF-1 in SKOV-3 cells activated the expression of StAR, p450scc and 3betaHSD-II mRNAs, and induced progesterone biosynthesis. Additionally, hSF-1 suppressed proliferation and promoted apoptosis of SKOV-3 cells and suppressed SKOV-3 cell growth induced by ERalpha and estradiol. These findings suggest that hSF-1 is central to progesterone biosynthesis in OSE cells. Human SF-1 may decrease OSE cancer cell numbers directly by apoptosis, and indirectly by opposing estradiol-induced proliferation. These findings are consistent with the hypothesis, that down-regulation of hSF-1 contributes to progression of ovarian epithelial cancers.

Implementation of an emergency medical card and a continuity of care report using continuity of care standard.

OBJECTIVES: To describe the design and implementation procedures for an emergency medical card (EMC) and a continuity of care (CoC) report using the continuity of care record (CCR) standard. We also describe studies to evaluate the effectiveness of these documents in CoC. METHODS: We convened weekly planning, design, development, implementation, and evaluation meetings, involving 25 outpatient clinics at Intermountain Healthcare. The CCR standard schema and documentation from American Society for Testing and Materials were used to develop the data model. An outside consultant provided further advice on committee-approved designs. We then developed a functional design document for the CCR application implementation. Healthcare professionals (medical doctors and physician assistants) and fourth-year medical students will simulate the will simulate the EMC and CoC report use and assess their usefulness in CoC. The reviewers will review three randomly selected patient cases, using patient information in the electronic medical record, EMC and CoC report. A structured questionnaire with Likert scale will assess the reviewers' perceptions of the documents' usefulness in medical decision making. Other studies will compare patient- and HCP-entered data to evaluate the effect of patient-entered data on the quality of HCP-entered data and assess user-satisfaction with the documents' usefulness in CoC. RESULTS: An automated CCR application compliant with the CCR standard was developed and integrated in an already implemented patient portal at the Intermountain Healthcare clinics. Patients use the application to view, add, modify their information and use the data plus EMR data to create EMC and CoC report. CONCLUSIONS: The CCR standard can be used to implement an application to enable patients to not only view but add or modify personal health records, and create, print and share paper EMC and CoC report with HCPs. The documents can be created using HCP-maintained EMR data, in addition to patient-entered data as is currently the norm.

Hepatitis C virus in autoimmune liver disease in the UK: aetiological agent or artefact?

Hepatitis C virus antibody titres (anti-HCV) were measured in serum from 122 patients with autoimmune liver disease (96 with primary biliary cirrhosis and 26 with autoimmune chronic active hepatitis using three generations of enzyme immunoassay (EIA): first generation--Ortho, EIA1; second generation--Abbott, EIA2; and third generation--Murex, EIA3. Anti-HCV was below the positive cut-off level in all 26 autoimmune chronic active hepatitis patients for all tests, while seropositivity values in primary biliary cirrhosis were 31% (EIA1), 14% (EIA2), and 0% (EIA3). In primary biliary cirrhosis, anti-HCV values as measured by all three tests correlated positively with serum IgG concentrations, serum storage time, and a number of other indices of hepatic dysfunction. Multiple regression analysis showed that anti-HCV values were independently affected by both serum IgG and the length of storage time, although the magnitude of the effects varied between tests. When all three multiple regression models were applied to an extreme clinical example, however, EIA3 was least likely to give a false-positive result. The difference in test performance was emphasised further by examination of anti-HCV values in nine primary biliary cirrhosis patients (confirmed negative by recombinant immunoblot assay 2) in whom serial samples were tested (seven to 14 per patient, stored for one to 138 months). Apparent anti-HCV values (EIA1 and EIA2) increased with increasing serum storage time, but were unchanged when measured by EIA3. A similar pattern was evident in a limited study of five autoimmune chronic active hepatitis patients. As the second generation EIA is in widespread use and confirmatory testing is not always available, the effect of serum storage in addition to hyperglobulinaemia should be considered in the interpretation of positive results in auto immune and in other types of chronic liver disease.

Phosphorylation of steroid receptor coactivator-1. Identification of the phosphorylation sites and phosphorylation through the mitogen-activated protein kinase pathway.

Steroid receptor coactivator-1 (SRC-1) is a member of a coactivator family that enhance the activation of the steroid/nuclear receptor superfamily of ligand-stimulated transcription factors. To study the regulation of SRC-1 by signaling pathways in the cell, the major phosphorylation sites of SRC-1 were identified in COS-1 cells using a combination of in vivo labeling with [(32)P]H(3)PO(4), modified manual Edman degradation, phosphoamino acid analysis, endoproteinase digestion, and mutagenesis of the SRC-1 phosphorylation sites. Seven phosphorylation sites were identified in SRC-1: serine 372, serine 395, serine 517, serine 569, serine 1033, threonine 1179, and serine 1185. All the sites contained consensus sequences for the serine/threonine-proline-directed family of protein kinases, and two sites (serine 395 and threonine 1179) contained a perfect consensus sequence for the mitogen-activated protein kinase family (Erk-1 and Erk-2). Furthermore, Erk-2 phosphorylated threonine 1179 and serine 1185 (and to a lesser extent, serine 395) in vitro, suggesting the importance of this pathway for SRC-1 regulation. Treatment of cells expressing SRC-1 with epidermal growth factor enhanced the ligand-dependent, progesterone receptor-mediated activation of a target reporter gene. These results identify phosphorylation as a regulatory modification of SRC-1 and provide a basis upon which to identify signaling pathways that regulate SRC-1 function and, consequently, modify steroid/nuclear receptor action.

Alternative splicing, muscle calcium sensitivity, and the modulation of dragonfly flight performance.

Calcium sensitivity of myosin cross-bridge activation in striated muscles commonly varies during ontogeny and in response to alterations in muscle usage, but the consequences for whole-organism physiology are not well known. Here we show that the relative abundances of alternatively spliced transcripts of the calcium regulatory protein troponin T (TnT) vary widely in flight muscle of Libellula pulchella dragonflies, and that the mixture of TnT splice variants explains significant portions of the variation in muscle calcium sensitivity, wing-beat frequency, and an index of aerodynamic power output during free flight. Two size-distinguishable morphs differ in their maturational pattern of TnT splicing, yet they show the same relationship between TnT transcript mixture and calcium sensitivity and between calcium sensitivity and aerodynamic power output. This consistency of effect in different developmental and physiological contexts strengthens the hypothesis that TnT isoform variation modulates muscle calcium sensitivity and whole-organism locomotor performance. Modulating muscle power output appears to provide the ecologically important ability to operate at different points along a tradeoff between performance and energetic cost.

Type III procollagen peptide: a marker of disease activity and prognosis in primary biliary cirrhosis.

The prognostic value of the aminoterminal propeptide of type III procollagen (P3NP) was investigated in 63 patients with primary biliary cirrhosis (PBC) followed for up to 87 months. No patient with an initially normal serum P3NP level died during the study; survival was significantly worse with increasing serum P3NP levels. Cox multivariate analysis confirmed that serum P3NP was an independent prognostic variable. Positive correlations were found between serum P3NP and histological stage, pericellular fibrosis, piecemeal necrosis, and serum concentrations of alanine aminotransferase and aspartate aminotransferase. Raised P3NP levels also correlated with the degree of cholestasis as evaluated by serum bilirubin, serum alkaline phosphatase, and copper binding protein deposition in the liver. Serum P3NP is of prognostic value because it reflects the major pathophysiological features of PBC.

Serum type III procollagen peptide, dynamic liver function tests and hepatic fibrosis in psoriatic patients receiving methotrexate.

The serum level of the aminoterminal peptide of type III procollagen (P3NP) was measured in 51 psoriatic patients on long-term, once weekly, low-dose methotrexate and in a control group of patients with extensive psoriasis who had never had systemic treatment. Serum P3NP levels were normal in all control patients, but were elevated in the majority of methotrexate-treated patients, even those with normal or non-specific liver histology. Although the highest P3NP values were found in the groups of patients with fibrosis and cirrhosis, isolated P3NP measurements did not discriminate between individuals with and without significant liver pathology. Neither standard nor dynamic liver function tests were able to identify patients with significant liver damage and in most cases results were in the normal range.