Computerised diagnosis in acute psychiatry: validity of CIDI-Auto against routine clinical diagnosis.

The validity of the self-administered CIDI-Auto for detecting ICD-10 diagnoses was assessed in a study of 126 patients admitted to an acute psychiatry unit. A comparison was made between the level of agreement of the CIDI-Auto with a psychiatrist and that between two psychiatrists. The CIDI-Auto generated an average of 2.3 diagnoses per subject, and the psychiatrists 1.3. Agreement measured by overall agreement and by Kappas between the CIDI-Auto and the psychiatrist's principal diagnosis was poor, whereas agreement between psychiatrists was good. At the level of general diagnostic class (e.g. substance use disorder, schizophrenic disorder, mood disorder), agreement between CIDI-Auto and psychiatrist on principal diagnosis was poor, Kappa = 0.23, while agreement between psychiatrists was good, Kappa = 0.69. The findings indicate that the self-administered CIDI-Auto has poor validity measured against clinical diagnosis for hospitalised patients of acute psychiatric services. Poor validity of computer-based diagnosis limits the diagnostic utility of these methods in clinical situations. It also creates uncertainty of diagnostic findings in survey use.

Clinical utility and patient acceptance of the computerized Composite International Diagnostic Interview.

OBJECTIVE: The study evaluated the utility to clinicians and the acceptability to patients of the self-administered computerized version of the Composite International Diagnostic Interview (CIDI-Auto) in an acute psychiatric setting. METHODS: Patients admitted to an acute psychiatric unit completed the CIDI-Auto. Reports of CIDI-Auto diagnoses and symptoms were given to treating psychiatrists, who completed a questionnaire evaluating the accuracy and usefulness of the reports. Patients answered a questionnaire about their attitudes toward computers before completing the CIDI-Auto, and after completing it, they answered a questionnaire about their reactions to the interview. RESULTS: Psychiatrists agreed with only 50 percent of CIDI-Auto current diagnoses and indicated that only 22 percent of CIDI-Auto reports provided useful new diagnoses, although 63 percent helped to clarify diagnoses and 58 percent could save clinicians some time. They endorsed the CIDI-Auto as a possible aid to indirect or remote diagnosis where histories would be taken by nonexpert staff. Ninety-four percent of patients liked the computerized interview, and 83 percent understood the questions without difficulty. Sixty percent felt more comfortable with the computerized interview than with a doctor. Education and previous computer experience promoted positive attitudes and satisfaction with the computerized interview. CONCLUSIONS: Psychiatrists considered the current CIDI-Auto completed by patients to be of limited value in diagnosis and history taking. Despite patients' acceptance and positive reactions to the computer interview, satisfactory computerized diagnosis is yet to be attained.

Cytokine-induced expression of vascular cell adhesion molecule-1 (VCAM-1) by astrocytes and astrocytoma cell lines.

Astrocytes in the central nervous system (CNS) associate intimately with vascular endothelial cells and are integral to the blood-brain barrier (BBB). Leukocyte transmigration across the BBB is a cardinal feature of CNS inflammation, as observed in experimental autoimmune encephalomyelitis, and very late antigen-4 (VLA-4)/vascular cell adhesion molecule-1 (VCAM-1) interactions have recently been proposed as essential for this process. VCAM-1 expression by astrocytes was recently reported. We addressed the regulation of VCAM-1 expression by inflammatory cytokines in primary human astrocytes and two human astrocytoma cell lines. Astrocytoma cells up-regulated surface VCAM-1 expression in response to cytokines in the following order: IFN-gamma plus TNF-alpha > IFN-gamma plus IL-1 beta > TNF-alpha > IFN-gamma. Cytokine-activated astrocytoma cells expressed 7-domain VCAM-1, as indicated by accumulation of 3.2-kb VCAM-1 mRNA and immunoprecipitation of a 100-kDa protein with anti-VCAM-1 mAb. Lymphoblast adhesion to cytokine-activated astrocytoma cell monolayers was significantly blocked by mAb specific for VCAM-1 and VLA-4, indicating that astrocytoma cell VCAM-1 was functional. Astrocytoma cell expression of VCAM-1 could be a constituent of the astrocyte phenotype. To support this possibility, we demonstrated that cytokine-treated adult human and rat primary astrocytes expressed VCAM-1, and the rank order of cytokine potency for VCAM-1 induction in primary and neoplastic astrocytes was strikingly similar. This is the first documentation of VCAM-1 expression by adult human astrocytes. Expression of VCAM-1 by astrocytes at the BBB could play a role in mononuclear leukocyte entry into the CNS.

Inequalities in the regional distribution of private psychiatric services provided under Medicare.

An analysis was carried out on Medicare data to find out if there are inequalities in the geographical distribution of private psychiatric services in Australia. The number of psychiatric services and persons becoming patients per 100,000 population was calculated for each federal electorate for the year 1985/86 and related to social indicators derived from the 1986 census. As a comparison, services provided by consultant physicians were analyzed as well. The data were based on the electorate of the patient rather than the electorate of the practitioner. Consultant psychiatrist services were found to be received more often in high socio-economic status electorates and those with older populations, and less often in rural areas. A similar pattern was found for consultant physician services, although the relationship with socio-economic status was not as strong. Frequent psychiatric consultations of longer duration, which are an indicator of insight psychotherapy, were more common in higher socioeconomic status electorates. A limitation of the Medicare data is that they cover only private services. To overcome this limitation, a supplementary analysis was carried out on the distribution of consultations for mental disorders using data from the National Health Survey. These data confirmed that individuals of high socio-economic status with a mental disorder are more likely to receive specialist treatment.

Syn-capping of human T lymphocyte adhesion/activation molecules and their redistribution during interaction with endothelial cells.

Lymphocyte-endothelial cell interactions are mediated in part by multiple lymphocyte surface adhesion/activation molecules and their cognate ligands. We investigated the surface localization of several of these molecules implicated in T cell adhesion and transendothelial migration mechanisms to determine if spatial regulation of their distribution contributes to these processes. T lymphocyte suspensions were stained to define distribution, ability to be aggregated into energy-dependent caps, and potential cocapping of several adhesion structures. CD2, CD44, L-selectin (LAM-1, LECCAM-1), and CD11a/CD18 (LFA-1) exhibited uniform distribution on the T cell surface by direct immunofluorescence but formed caps in an energy-dependent, and therefore cytoskeletally driven, manner when examined by indirect immunofluorescence. CD2 was shown to syn-cap (unidirectionally cocap) with CD44 and CD11a/CD18 (LFA-1), an observation potentially related to functional cooperation among these molecules in T cell activation. T cells were also added to endothelial cell monolayers to assess, in a physiologically relevant context, potential surface molecule reorganization. Lymphocytes co-cultured with human umbilical vein endothelial cells (HUVEC) underwent a profound shape change, from essentially round cells to polarized cells bearing pseudopodia. Immunofluorescent localization of T cell adhesion/activation molecules using confocal microscopy revealed the redistribution of CD2, CD44, and L-selectin to the pseudopod. In contrast, CD11a/CD18 remained globally distributed on the cell surface, even in severely deformed cells. Both lymphocyte shape change and membrane molecule redistribution appear to be cell-cell contact-dependent phenomena requiring intact, viable endothelial cells. Mechanisms that control these events may be critical to lymphocyte recirculation and inflammation.

General practitioner services under Medicare.

This paper examines how general practitioner numbers, bulk-billing rates and sociodemographic variables determined usage of general practitioners and services delivered over the period from 1984 to 1990. A 10 per cent sample of patient services, maintained by the Commonwealth Department of Health, Housing and Community Services, provided the data. Data were aggregated into 148 electorates. Separate regression analyses examined the determinants of the proportion of the population attending a general practitioner and of the number of general practitioner services delivered per patient. Determinants of the growth of these levels over the seven-year period were also examined. Region (metropolitan versus rural), age structure and general practitioner supply were significant factors in these analyses. Bulk-billing rates explained nine per cent of variance in patient numbers and 22 per cent of variance in service numbers after sociodemographic variables and general practitioner supply had been taken into account. The analyses suggest that bulk-billing and general practitioner supply influence the behaviour of patients and doctors and that the effect of bulk-billing is independent of indices of medical need. This implies that bulk-billing may increase service rates and this increase is not clearly directed to improving access to medically necessary services. Because no measures of treatment outcome are available. it is not possible to decide whether the effects observed represent an improvement in health care or are better seen as overuse by patients and demand inducement by practitioners.

Trends in general practitioner distribution from 1984 to 1989.

An analysis of the distribution of general practitioners by electorates during the six years 1984 to 1989 showed that the maldistribution of practitioners in Australia has worsened despite significant increases (26%) in total general practitioner numbers. One in five rural electorates had worse population-to-general-practitioner ratios in 1989 than in 1984. The changes in distribution of general practitioners ran counter to the changes in distribution of the population over the period studied. In 1984, the 38.7% of the population living in rural Australia was served by 33% of the nation's general practitioners. By 1989, more of the population (39.8%) lived in rural areas but they were served by a smaller proportion (32%) of the general practitioner workforce. It is clear that many urban electorates have fewer people per general practitioner than the most generous ideal ratios, while most rural electorates have more people per general practitioner than the least generous.

Cell surface glycoconjugates in intercellular and cell-substratum interactions.

Progress in understanding the role of the carbohydrate moieties of cell surface adhesion molecules is evaluated. Functional roles of the oligosaccharides of extracellular matrix glycoproteins are also considered. Selected examples of glycoconjugate participation in cell-cell and cell-substratum interactions are presented with emphasis on systems in which structures of functionally important glycosyl moieties of glycoproteins and glycolipids have been determined. Where available, cases of altered cell adhesive behavior attributable to transformation-associated alterations in glycosylation of adhesion molecules are cited.

Naming of patients by therapists.

A self-report questionnaire to elicit the patients' preferences for how they were to be addressed was given to 102 in-patients. Of 94 replies, 90 asked to be called by their first name.

Biochemical characterization of a unique canine myeloid antigen.

In marrow transplantation, radioisotope-labeled monoclonal antibodies may provide a way to selectively deliver high doses of radiation to target tissues (marrow in the case of myeloid malignancies) without significant toxicity to other normal organs. This paper describes the production and characterization of a novel monoclonal antibody, DM5, that we have developed for use in an animal model of radiotherapy targeted to the marrow. DM5 recognizes three glycosylation variants, gp19,21,23DM5, of a polypeptide core that is expressed on canine cells of the myeloid lineage, but not on lymphoid cells. The antigen recognized by DM5 is not present on most progenitor cells as determined by CFU-GM assays of DM5 positive and negative cell populations.

Murine embryonal carcinoma cell-surface sialyl LeX is present on a novel glycoprotein and on high-molecular-weight lactosaminoglycan.

Carbohydrate-specific monoclonal antibodies were used to demonstrate the expression of a new membrane glycoprotein on F9 murine embryonal carcinoma cells. Sialyl LeX was detected using monoclonal antibody FH6 in a sensitive, cell monolayer radioimmunoassay. The antigen codistributed in gel filtration of a crude homogenate and in a membrane-enriched fraction with two known lactosaminoglycan markers, i and SSEA-1 (LeX or X hapten). Sialyl LeX was further shown to be carried by a novel glycoprotein, termed small lactosaminoglycan-like glycoprotein (sLAG) which could be purified by immunoaffinity chromatography. In two-dimensional polyacrylamide gel electrophoresis this glycoprotein had an apparent molecular weight of 45 kDa and a pI of about 6.5. The more differentiated cell line PYS-2 also expressed sialyl LeX and i antigens but not LeX, and FH6-reactive sLAG could be extracted from PYS-2 membranes. Sialylation of fucosylated type 2 carbohydrate chains (X haptens) thus may be an early modification of embryonic carbohydrate antigens.

An approach to the unification of suppressor T cell circuits: a simplified assay for the induction of suppression by T cell-derived, antigen-binding molecules (T-ABM).

A system is presented in which the in vitro response to sheep red blood cells (SRBC) can be regulated using antigenic determinants coupled to SRBC and T cell-derived antigen-binding molecules (T-ABM) directed against the coupled determinants. T suppressor-inducer factors (TsiF's) are composed of two molecules, one of which is a T-ABM and one which bears I-J determinants (I-J+ molecule). Using two purified T-ABM which have not previously been shown to have in vitro activity, we produced antigen-specific TsiF's which were capable of inducing the suppression of the anti-SRBC response. Suppression was found to require both the T-ABM and the I-J+ molecule, SRBC conjugated with the antigen for which the T-ABM was specific, and a population of Ly-2+ T cells in the culture. Two monoclonal TsiF (or TsF1) were demonstrated to induce suppression of the anti-SRBC response in this system, provided the relevant antigen was coupled to the SRBC in culture. The results are discussed in terms of the general functions of T-ABM in the immune system. This model will be useful in direct, experimental comparisons of the function of T-ABM and suppressor T cell factors under study in different systems and laboratories.

The detection of alcohol use in psychiatric casualty patients.

This study assessed the extent of alcohol use among casualty attenders at a metropolitan psychiatric hospital. Seventeen of 97 patients showed measurable alcohol levels at the time of presentation. Patients with functional psychoses used alcohol excessively, but the heaviest and most frequent use was among women, especially those with personality disorders. It is suggested that routine alcohol testing is worthwhile and inexpensive, and it may lead to earlier detection and treatment of alcohol abuse.

Suicide in association with psychiatric hospitalisation.

A review of 46 subjects who suicided after having contact with a psychiatric hospital is presented. There were 33 men and 11 women, both with a mean age of 37 years. In comparison with a control group, those who suicided had a greater number of hospital admissions, a greater length of hospitalisation, were more often unemployed, had a history of more previous suicide attempts, more often received the diagnosis of schizophrenia or manic depressive illness (depressed phase), were more often overly depressed at their last contact, and were more often prescribed neuroleptic medications. Although these differences emerged, suicide is an infrequent event, and these factors lack specificity in prediction. The important association of psychiatric illness with subsequent suicide is noted.

Subsequent deaths after attempted suicide by drug overdose in the western region of Adelaide, 1976.

A five-year follow-up of 262 patients in the western region of Adelaide, who attempted suicide in 1976 by taking an overdose of a drug, showed that seven of these subsequently died by suicide and two from other causes. Six of the nine patients who died were migrants. Drug overdoses were most likely to be taken by young women from lower socioeconomic groups. A background of marital separation was common and, although migrants as a whole were underrepresented, German migrants were significantly more likely, while Italian and Greek migrants were significantly less likely, to take drug overdoses. The data suggest that psychiatric assessment is useful in reducing the likelihood of subsequent suicide; general physicians should select patients for further assessment.