The relationship between insight and medication adherence in severely mentally ill clients treated in the community.

OBJECTIVE: To study the relationship between aspects of insight and medication adherence and elements of psychopathology. METHOD: Clients completed insight and adherence measures in interview; doctors and case managers independently completed ratings of adherence and psychopathology. Other client information was obtained from the clinical file. RESULTS: The subscale structure of the insight scale was well reproduced. Clients endorsed items relating to need for treatment more than items relating to relabelling of symptoms and awareness of illness. Self-reported insight was lower in those clients for whom either the treating doctor or the case manager or both thought the client was non-adherent. Insight was related positively to clinician ratings of depressed mood, and negatively to clinician ratings of personal functioning. CONCLUSION: Our data support the subscale structure of the insight questionnaire used, and previous suggestions that insight is positively related to depressive affect, and inversely related to impaired psychosocial functioning.

Video-assisted thoracic diskectomy and anterior release: a biomechanical analysis of an endoscopic technique.

This study evaluates the residual biomechanical stability of the spine following multilevel anterior diskectomies and anterior longitudinal ligament release using video-assisted thoracoscopic surgery (VATS). Eighteen domestic pigs were randomly divided into three groups of six pigs. Group 1 underwent thoracic anterior release from T4-T9 using a left-sided VATS approach, group 2 underwent thoracic anterior release from T4-T9 via a traditional left thoracotomy (open), and group 3 did not undergo surgery and served as a control. After surgery, the animals were euthanized, and the thoracic spinal columns were harvested for biomechanical testing. Nondestructive testing was performed on all specimens in pure compression, flexion, extension, right lateral bending, and torsion. Specimens from group 1 had significantly lower stiffness values (P<.05) than the control group for all five test modes. These data demonstrate that adequate anterior release of the thoracic spine can be obtained with the VATS technique. Further prospective clinical studies on VATS are required before the widespread application of this technique.

Murine cytomegalovirus infection-induced polyclonal B cell activation is independent of CD4+ T cells and CD40.

The results of this study demonstrate that murine cytomegalovirus (MCMV) induces polyclonal B cell activation in mice during the acute phase of primary infection. First flow cytometric analysis revealed that surface expression of CD45R, IgM, and IgK by splenocytes from MCMV-infected mice was significantly reduced with a concomitant increase in the frequency of surface IgG-expressing cells. Second, ELIspot assays demonstrated that the changes revealed by flow cytometry were paralleled by increases in the numbers of IgG-producing cells, especially those secreting IgG2a. Third, the IgG antibodies from MCMV-infected animals reacted against a variety of self and foreign antigens. MCMV-induced B cell activation was independent of CD4+ T-cell-mediated help and CD40, since activation was observed in two models of mice deficient for this T cell subset and in mice deficient for CD40. Reverse transcription-polymerase chain reaction analysis showed that mRNA transcripts for the cytokines IL-6, IL-10, and IFN-gamma were rapidly induced following infection with MCMV, but only IL-6 and IFN-gamma proteins were detectable by ELISA. In addition, the numbers of cells producing IL-6 and IFN-gamma were significantly increased in the spleen. The magnitude of the polyclonal B cell activation response was diminished by 50% in IL-6-deficient mice but not in mice lacking IFN-gamma. In the absence of IFN-gamma, surface expression and serum levels of IgG2a were reduced while IgG1 expression was increased.

Invasive pneumococcal infections. A comparison between adults and children.

A similar number of adults and children had invasive pneumococcal infection. There was male predominance, and different ethnic distribution between children and adults. The majority of adults (78%), had underlying diseases, but this was less frequent in children (24%). The presenting illness differed between adults and children. Complications of invasive pneumococcal infection occurred more frequently in adults than in children. The mortality rate in adults was 21.5%; in children, only 3.8%. The rate of penicillin-resistant pneumococci at our hospital was 23%, while cefotaxime resistance was 4.2%. Penicillin-resistant pneumococci were not isolated more frequently from children than from adults. Patients with penicillin-resistant pneumococci had longer duration of hospitalization and more nosocomially acquired infections. No difference in the mortality rate was found between patients with resistant or sensitive pneumococci. Ninety-five percent of strains were included in the current vaccine, but less than 2% of patients had been vaccinated. Isolates prevalent in Europe and the United States (19, 5, 1, 14, 6, 18, 12, 4, 9, 23, 7) were also most prevalent in Jerusalem. The distribution of serotypes differed between children and adults, and between patients from whom resistant organisms were isolated as opposed to sensitive organisms.

Long-term effect of primary immunization on subsequent immune responsiveness.

Specific antigen/adjuvant combinations preferentially induce type 1 or type 2 cytokine responses. For example, BALB/c mice primed with TNP-ovalbumin in complete Freund's adjuvant (TNP-OVA/CFA) produce a type 2-dominated response characterized by the activation of IL-4-secreting cells and the production of IgG1 and IgE anti-TNP antibodies. In contrast, mice primed with TNP conjugated to Brucella abortus (TNP-BA) produce a type 1 response dominated by the secretion of IFN-gamma and IgG2a anti-TNP antibodies. We examined whether treating young mice with these antigen/adjuvant combinations altered the cytokine profile of their subsequent immune responses. Mice immunized with TNP-BA and boosted several months later with TNP-OVA/CFA developed a cytokine and antibody profile similar to the priming rather than boosting antigen. This was also observed in mice immunized with TNP-OVA/CFA and boosted with TNP-BA. Both the ratio of IL-4:IFN-gamma-secreting cells and the isotype of antibodies produced by these mice were altered by primary immunization. Analysis of Con A-responsive cells from these animals showed that long-lived changes in the frequency of T lymphocytes available to secrete type 1 versus type 2 cytokines were induced by strong primary immunogens.

Increasing fungal isolation from clinical specimens: experience in a university hospital over a decade.

The local patterns of fungal isolates were studied by a retrospective analysis of fungal species isolated from clinical specimens in a university hospital in Jerusalem. Between 1984 and 1993, 5630 fungi [4071 patient unique isolates (PUI)] were isolated and identified. During the study decade, the annual incidence of all isolates increased 2.7-fold, and PUI increased 1.6-fold. Candida albicans accounted for 61% of PUI; urine was the source of 53%. The intensive care units (ICUs) and the Bone Marrow Transplantation (BMT) Department had the highest incidence of fungal isolation. The following trends were observed: (1) a decrease in the relative frequency of C. albicans and increase in Candida tropicalis; (2) increased number of isolates from urine, surgical wounds and intra-abdominal sites; (3) increased number of isolates from ICUs and BMT. Fungi are emerging as important hospital-acquired pathogens in tertiary care and teaching hospitals, and are associated with high rates of morbidity and mortality. It is important to be familiar with the local patterns of fungal isolation in order to improve treatment.

What is the psychiatrist's role in drugs and alcohol?

OBJECTIVE: This article describes a consensus view of the role of psychiatrists in respect of alcohol and other drug (AOD) problems, in response to the view expressed by Wodak [1]. METHOD: The data were selected on the basis of the knowledge and experience of the authors. RESULTS: Psychiatrists have made major contributions in the primary, secondary and tertiary prevention of AOD problems over many years in Australia and New Zealand. In recent years there has been an explosion of new knowledge in the AOD area and a shift from mental health to primary and public health care for these patients. Substance use disorders (SUD) are highly prevalent in all areas of psychiatric practice, requiring treatment in their own right as well as complicating the treatment of coexisting psychiatric illness. CONCLUSION: It is argued that psychiatrists have important roles in harm reduction, prevention and policy development; brief and early intervention in SUD in liaison and child psychiatry; and systematic treatment for those with dependence and other psychiatric comorbidity. A research and collaborative approach to AOD services and patients should be encouraged, rather than engaging in divisive debate over "ownership' of this area of clinical practice.

Effect of HIV infection on the frequency of cytokine-secreting cells in human peripheral blood.

A selective decrease in type 1 cytokine secretion by in vitro stimulated peripheral blood cells is reportedly associated with disease progression in HIV-infected individuals. To examine whether a similar change in cytokine secretion occurs under physiologic conditions in vivo, sensitive and specific ELIspot assays were used to compare the phenotype and frequency of PBMC spontaneously producing interleukin (IL)-2, IL-4, IL-10, and interferon-gamma (IFN-gamma) in 83 HIV-infected subjects and 60 normal controls. Phenotypic analysis of freshly isolated cytokine-secreting cells showed that T cells were the primary source of IL-2, IL-4, and IFN-gamma while CD14+ macrophages/monocytes were the dominant source of IL-10 in vivo. The number of peripheral blood mononuclear cells (PBMC) spontaneously secreting both type 1 and type 2 cytokines was significantly reduced in HIV-infected patients versus controls. The magnitude of this decrease did not correlate with disease severity. Changes in IL-2-secreting cell number correlated with CD4 count, while changes in the frequency of IFN-gamma-secreting cells correlated with disease duration. These findings do not support the contention that a selective reduction in type 1 cytokine production correlates with disease progression.

Group A streptococcus bacteremia at the Hadassah Medical Center in Jerusalem.

Streptococcus pyogenes bacteremia occurred in 104 patients over a 6-year period, during which time the annual incidence remained constant. The clinical and epidemiologic characteristics are described for 90 of these patients. Of the 90 patients, 90% had community-acquired infection, and 77% had an underlying illness predisposing them to infection. Skin infection was the cause of bacteremia in 61% of the cases. Septic shock developed in 13 patients. The overall mortality rate was 15%. An increased likelihood of death was associated with septic shock and diabetes mellitus.

Disseminated Nocardia transvalensis infection resembling pulmonary infarction in a liver transplant recipient.

Infections due to Nocardia transvalensis are extremely rare: only four disseminated infections with this pathogen have been reported, three of which ended fatally. This is the first report of a liver transplant recipient with Nocardia transvalensis infection. The patient had disseminated infection with pulmonary involvement, which presented as pulmonary infarction. Despite a ten-day delay in the administration of correct therapy, he responded rapidly to trimethoprim-sulfamethoxazole. The pitfalls of differentiating nocardial infection from pulmonary thromboembolism in solid organ transplant recipients and the diagnostic considerations unique to liver transplant recipients are discussed.

Infections with Chryseomonas luteola (CDC group Ve-1) and flavimonas oryzihabitans (CDC group Ve-2).

We have described 15 cases of infection due to Chryseomonas luteola and Flavimonas oryzihabitans isolated between May 1990 and May 1994. These infections were often associated with the presence of a foreign body, especially central venous access and joint prosthesis. The high frequency of isolating C. luteola and F. oryzihabitans probably expresses the awareness of the clinicians and the laboratory to the importance of these bacteria, especially in patients with the presence of a foreign material.

T-cell-depleted allogeneic bone marrow transplantation for acute leukaemia using Campath-1 antibodies and post-transplant administration of donor's peripheral blood lymphocytes for prevention of relapse.

One hundred and forty-six patients with acute leukaemia (81 with ANLL and 65 with ALL) received allogeneic bone marrow transplantation from their fully matched siblings. 121 patients underwent T-cell depletion (TCD) using Campath 1 monoclonal rat anti-human lymphocyte (CDw52) antibodies; 67 with Campath 1M and 54 with Campath 1G isotypes. Patients were conditioned for transplant using either total body irradiation combined with chemotherapy (125 patients) or busulfan and cyclophosphamide (21 patients). 112 recipients of T-cell depleted allografts received in addition total lymphoid irradiation (TLI) for prevention of rejection. Engraftment of neutrophils (> 0.5 x 10(9)/l) and platelets (> 25 x 10(9)/l) occurred on days 15 and 18, and on days 18 and 20 in recipients of Campath 1M and Campath 1G treated marrows respectively. Rejection was documented in 6.8% of T-cell depleted transplants. Leukaemia relapse-free survival at 2 years was 83% for patients transplanted in first CR, 76% in second CR (P2 = 0.34) and 42% in advanced leukaemia (P2 = 0.009). 81 marrow recipients, 38 with Campath 1M and 43 with Campath 1G treated marrow, received post-transplant graded increments of donor's peripheral blood lymphocytes (PBL) to induce graft-versus-leukaemia (GVL) effects. Administration of donor's PBL was associated with clinically significant GVHD and with decreased relapse rate especially in patients with ALL. Our data suggest that in patients receiving marrow allografts depleted of T cells by Campath 1 monoclonal antibodies, rejection can be reduced by adequate pregrafting immunosuppression. In patients with advanced disease, post-transplant cell-mediated immunotherapy (CMI) using donor's PBL may be beneficial; however, further studies are needed to define the optimal schedule of CMI for safe and effective prevention of relapse following TCD bone marrow transplantation in malignant haematological diseases.

Effective postcoital quinolone prophylaxis of recurrent urinary tract infections in women.

A total of 33 sexually active, premenopausal and postmenopausal women, suffering from recurrent urinary tract infections was randomized to receive postcoital prophylaxis with a dose of either 100 mg. ofloxacin (12), 200 mg. norfloxacin (11) or 125 mg. ciprofloxacin (10). While 130 urinary tract infections occurred in these patients during a mean of 8 months before postcoital quinolone prophylaxis, only 1 occurred during a mean of 15 months following prophylaxis. This difference was statistically highly significant. Each of these patients ingested a mean of 117 quinolone doses per year of postcoital prophylaxis. Before prophylaxis 74% of the introital cultures yielded gram-negative enterobacteria (mainly Escherichia coli), whereas only 11% yielded the same bacteria following prophylaxis. Postcoital oral prophylaxis with minimal quinolone doses is highly effective in the prevention of recurrent urinary tract infections in women, because it achieves high urinary bactericidal concentrations, and clears the majority of the introital and urethral Enterobacteriaceae without inducing resistance to the quinolones despite long-term treatment. This prophylaxis is highly recommended because of its ease of compliance, preservation of drug efficacy, lack of toxicity and cost-effectiveness. Postcoital quinolone prophylaxis is as good as or better than daily quinolone prophylaxis and uses only a third of the amount of drug consumed in daily prophylaxis.