The impact of reclassification of C3 predominant glomerulopathies on diagnostic accuracy, outcome and prognosis in patients with C3 glomerulonephritis.

BACKGROUND: C3 glomerulonephritis is a recently described entity with heterogeneous histopathological features. This study was conducted to assess the effect of reclassification of C3 glomerulopathies on renal outcomes, mortality, and response to therapy. METHODS: We undertook a retrospective analysis of 857 renal biopsies collected at The Canberra Hospital. Samples with predominant C3 staining were reviewed by a renal histopathologist. Of 31 biopsies with predominant C3 staining, 10 fulfilled histological criteria for C3 glomerulonephritis, while the remaining 21 cases were used as C3 Controls. RESULTS: Aside from a higher incidence of C3 glomerulonephritis in Torres Strait islanders (40% vs 5% C3 Controls, p = 0.04), presentation demographics were similar between the two groups. Median creatinine at diagnosis was higher in patients with C3 glomerulonephritis (253 umol/L IQR 103-333 vs 127 umol/L C3 Controls, IQR 105-182, p = 0.01). Prior to reclassification, a majority of C3 glomerulonephritis cases were diagnosed as membranoproliferative glomerulonephritis (60% vs 5% (C3 Controls) p < 0.01). Electron microscopy demonstrated all C3 glomerulonephritis patients had C3 deposition (100% vs 38% p = 0.02), these deposits were amorphous in nature (50% vs 5% respectively p = 0.007). C3 glomerulonephritis patients had shorter median follow-up (405 days IQR 203-1197 vs 1822 days respectively, IQR 1243-3948, p = 0.02). Mortality was higher in C3 glomerulonephritis patients (30% vs 14% in C3 Controls (log rank p = 0.02)). CONCLUSION: We have devised a diagnostic and treatment algorithm based on the results of literature review and our current study. Further prospective assessment is required to review diagnostic and treatment outcomes for this disease in Australian centres.

Recurrent glomerulonephritis following renal transplantation and impact on graft survival.

BACKGROUND: Recurrence of primary glomerulonephritis in the post-transplant period has been described in the literature but the risk remains poorly quantified and its impact on allograft outcomes and implications for subsequent transplants remain under-examined. Here we describe the rates and timing of post-transplant glomerulonephritis recurrence for IgA nephropathy, focal segmental glomerulosclerosis, mesangiocapillary GN and membranous GN based on 28 years of ANZDATA registry transplant data. METHODS: We investigated the rates of GN recurrence and subsequent graft outcomes in 7236 patient from 28 years of ANZDATA transplant registry data. Data were analysed in R, using Kaplan Meier Survival analysis and adjusted analyses performed using Cox Proportional Hazards methods. A competing risk model was also analysed. RESULTS: GN recurrence occurred in 10.5% of transplants and was most common in mesangiocapillary GN. Median time to recurrence was shorter for FSGS compared to IGAN. GN recurrence was less common in patients over 50 years of age and after unrelated kidney donation. We identified a significantly higher risk of recurrence in secondary grafts following recurrence in a primary allograft for FSGS (RR 5.70, 95 CI: 2.41-13.5, p < 0.001) but not IGAN, MCGN or MN. At 10 years, recurrence occurs in 8.7, 10.8, 13.1, and 13.4% of allografts for FSGS, IGAN, MCGN and MN respectively. In all GN, recurrence significantly reduced death censored graft survival at 5 and 10 years. CONCLUSIONS: GN recurrence occurs in a minority of patients at a significantly different rate for each GN. After a recurrence, there is no evidence for an increased risk of further recurrence in a subsequent graft except in FSGS.

Increased glomerulonephritis recurrence after living related donation.

BACKGROUND: Kidney transplantation confers superior outcomes for patients with end stage kidney disease, and live donor kidneys associate with superior outcomes compared to deceased donor kidneys. Modern immunosuppression has improved rejection rates and transplant survival and, as a result, recurrence of glomerulonephritis has emerged as a major cause of allograft loss. However, many glomerulonephritides have significant genetic risk which may manifest through kidney intrinsic or systemic mechanisms. We hypothesise that heritable kidney intrinsic predisposition to glomerulonephritis will result in increased risk of glomerulonephritis recurrence in kidneys transplanted from genetically related donors. METHODS: We investigated the effect of living related donation on rates of recurrence and subsequent graft outcomes in 7236 patient from 28 years of ANZDATA transplant registry data. Data were analysed in R, using Kaplan Meier Survival analysis and adjusted analyses performed using Cox Proportional Hazards methods. A competing risk model was also analysed. RESULTS: Glomerulonephritis recurrence rates were significantly higher in living related donor grafts compared to either living unrelated or deceased donor grafts (p < 0 · 001). In IgA nephropathy, transplantation from living related donor kidneys demonstrated a 10 year recurrence rate of 16 · 7% compared to 7 · 1% in living unrelated donors and 9 · 2% in deceased donors (HR:1 · 7, 95% CI:1 · 26-2 · 26, p = 0 · 0005 for living related vs deceased donors). In focal segmental glomerulosclerosis, risk of recurrence at 10 years was 14 · 6% in living related donors compared to 10 · 8% in living unrelated donors and 6 · 6% in deceased donors (HR:2 · 2, 95% CI 1 · 34-3 · 64, p = 0 · 002) for living related vs deceased donors. Primary glomerulonephritis death censored graft survival was superior for living donor grafts, related or unrelated, compared to deceased donor grafts. CONCLUSIONS: We identified a significant increase in the risk of glomerulonephritis recurrence in IgA Nephropathy and Focal Segmental Glomerulosclerosis in living related donors compared to a deceased donors.

Systemic capillary leak syndrome: recognition prevents morbidity and mortality.

Idiopathic systemic capillary leak syndrome (SCLS) is extremely rare but carries a high morbidity and mortality. The diagnosis is made clinically by a classic triad of hypotension, hypoalbuminaemia and haemoconcentration. There have been recent advances in understanding the pathophysiological basis for SCLS and in effective prophylaxis. We report a case of SCLS to increase awareness of the condition and to highlight the benefits of prophylactic intravenous immunoglobulin in this condition.

Behavior genetic research on gambling and problem gambling: a preliminary meta-analysis of available data.

A meta-analysis of family and twin studies on gambling and problem gambling was initiated in an effort to determine the probable role of genetic factors in high risk wagering. Two twin studies and 17 investigations employing the family history or family study method were included in this meta-analysis. A summation of the 19 studies produced a small but significant overall effect size (weighted phi = .10, unweighted phi = .13), with both family (weighted phi = .12, unweighted phi = .14) and twin (weighted phi = .06, unweighted phi = .05) studies achieving significant individual mean effects. Given the paucity of twin data, further analysis was confined to family studies and revealed a stronger familial effect for the sons of problem gambling fathers than for the daughters of problem gambling mothers and for more severe forms of problem gambling than for less severe forms of problem wagering, and was strongest for high severity problem gambling in males. The implications of these results are discussed.

Spontaneous remission from alcohol, tobacco, and other drug abuse: seeking quantitative answers to qualitative questions.

A quantitative review of the substance abuse literature revealed a mean general prevalence of spontaneous remission from alcohol, tobacco, and other drugs abuse of 26.2% when a broad definition of remission was employed and 18.2% when a narrow definition was implemented. From the results of this review, it was concluded that few meaningful differences exist between spontaneous remitters and persons who either continue misusing substances or remit through treatment on pre-remission measures of prior drug involvement. Of the factors cited by self-remitters as important in facilitating their desistance from substances, the present review found that health concerns, pressure from friends and family, and extraordinary events were instrumental in initiating spontaneous remission, while social support, non-drug-using friendships, willpower, and identity transformation were pivotal in maintaining change. Evidence is presented to indicate that spontaneous remission from alcohol and illicit drugs and spontaneous remission from tobacco smoking may differ in several key respects.

Planning for change: an alternative to treatment planning with sexual offenders.

This article describes how a change plan can be helpful in defining intervention goals and objectives. The change-plan concept derives from lifestyle theory and deviates from the traditional treatment plan in its delineation of roles, point of focus, and attention to process. A case example is used to illustrate how the change plan can be implemented with sexually offending clients. Several potential limitations of the change-plan concept are also discussed.

Problem gambling in a federal prison population: results from the South Oaks Gambling Screen.

Three hundred and sixty three medium security federal prison inmates were interviewed with the South Oaks Gambling Screen (SOGS) with 5.2% of the sample achieving SOGS scores greater than 4 and another 7.4% attaining scores of 3 or 4, traditional markers of pathological gambling and problem gambling, respectively. Attempts were made to evaluate the relative accuracy of the continuum and dichotomy models of problem gambling by contrasting three groups of subjects (SOGS<3, SOGS=3 or 4, SOGS>4) on a series of gambling-related measures and comparing the relative ability of the SOGS and a dichotomized version of the SOGS to account for residual variance in these same gambling-related measures. Results were consistent with the view that problem gambling embodies features of both a continuum and dichotomy. Nearly half the subjects had desisted from problem gambling on their own, although self-remitters displayed less severe and extensive patterns of problem gambling than non-remitting subjects.

Conducting psychoeducational interventions with drug abusing clients: the lifestyle model.

A psychoeducational model of intervention is proposed for use with drug abusing clients. This model may be particularly helpful during the early stages of intervention in reducing resistance to change because it addresses the eight thinking styles (mollification, cutoff, entitlement, power orientation, sentimentality, superoptimism, cognitive indolence, discontinuity) believed to shield the drug "lifestyle" from forces that would otherwise bring about change. Practical suggestions are offered as to how this information might be shared with clients.

Predictive validity of the Drug Lifestyle Screening Interview: a two-year follow-up.

One hundred and eighteen inmates enrolled in a comprehensive residential drug treatment program were administered the Drug Lifestyle Screening Interview (DLSI) and followed for 2 years. A marginally significant predictive effect was observed in which subjects achieving elevated DLSI scores (> or = 12) displayed more subsequent alcohol and drug misuse than lower scoring subjects, 21.7 versus 9.7%. The Lifestyle Criminality Screening Form (LCSF) enjoyed a somewhat stronger predictive relationship with future outcome in that 27.3% of the high scoring subjects (LCSF score > or = 10) subsequently misused alcohol or other drugs as opposed to only 4.4% of the low scoring subjects. Regression analysis also revealed the superiority of the LCSF in predicting future outcome. These findings suggest that criminal background should be taken into account when evaluating the relapse potential of drug-involved offenders once they leave treatment.

Discriminating between high and low volume substance abusers by means of the Drug Lifestyle Screening Interview.

One hundred and twenty inmates enrolled in a comprehensive residential drug treatment program were administered the Drug Lifestyle Screening Interview (DLSI), a structured interview designed to assess the four behavioral characteristics of lifestyle drug abuse: i.e., irresponsibility/pseudoresponsibility, stress-coping imbalance, interpersonal triviality, and social rule breaking/bending. Subjects reporting a high volume of prior substance misuse (moderate to severe abuse of at least three different substances or severe abuse of one substance other than marijuana) recorded significantly higher scores on each of the four behavioral dimensions of lifestyle drug abuse than subjects possessing a lower volume of prior substance misuse. Furthermore, a score of 10 or higher on the DLSI cumulative index classified 76.7% of the high volume users but only 37.2% of the low volume users as lifestyle drug abusers for an overall hit rate of 71.7%.

The gambling lifestyle: I. theory.

This paper describes the lifestyle model of gambling behavior in which compulsive gambling behavior is conceptualized as a lifestyle characterized by pseudoresponsibility, self-ascension, hypercompetitiveness, and social rule breaking/bending/ twisting. The underlying premise of this theory is that gambling behavior takes on the appearance of a lifestyle when it is viewed by the individual as a viable means of enhancing self-worth, minimizing personal insecurity, and controlling fear. Three primary areas of theoretical and research interest are covered in this paper: (1) the theoretical underpinnings of lifestyle theory; (2) the individual components (conditions, choice, cognition) of a gambling lifestyle; and (3) the developmental progression of a gambling lifestyle.

The gambling lifestyle: II. Treatment.

Two individuals with records of prior compulsive gambling involvement are profiled in order to illustrate the nature of a gambling lifestyle and describe the process of lifestyle change. The treatment model utilized by therapists proposing a lifestyle interpretation of compulsive gambling behavior is guided by three primary objectives or goals: (1) the cessation of lifestyle activities; (2) the development of skills useful in managing gambling-related conditions, choices, and cognitions; and (3) the implementation of an effective program of follow-up intervention and support. These goals give rise to the three stages of lifestyle intervention - (1) laying a foundation for change, (2) identifying vehicles for change, and (3) establishing a reinforcing nongambling life-style-from which specific change strategies are derived. The implications of this model and the possibility of limited generalizability are discussed.

The Lifestyle Criminality Screening Form and Antisocial Personality Disorder: predicting release outcome in a state prison sample.

The Lifestyle Criminality Screening Form (LCSF) was compared with a clinical diagnosis of Antisocial Personality Disorder for the purposes of determining the relative efficiency of each measure in predicting the release outcome of 100 medium security New Mexico state prisoners. An 18-month follow-up revealed that high LCSF scores (total score > or = 10) and clinical diagnoses of Antisocial Personality Disorder effectively identified inmates who were eventually reincarcerated for a parole violation or new offense. However, because substantial overlap occurred between these two predictors (kappa = .58) partial correlations were calculated and revealed that only the LCSF displayed a robust relationship with release outcome independent of the other predictor measure.

Differentiating between schizophrenic and manic inpatients by means of the MMPI.

Forty-five psychiatric inpatients with DSM-III diagnoses of schizophrenia and 31 inpatients with DSM-III diagnoses of bipolar disorder (and currently manic) were compared on the MMPI. Results indicated that although the schizophrenic patients achieved significantly higher scores on several of the MMPI scales (F, Pt, Sc, Si), these findings were of questionable clinical significance. On the other hand, the schizophrenic group did produce a significantly greater percentage of MMPI high-point pairs containing Scale 8(Sc): that is, 64.4% versus 35.5%.

Assessing dissimulation and denial on the MMPI in a sample of maximum security, male inmates.

Comparisons were made between three groups of maximum security inmates thought to possess varying degrees of motivation to either exaggerate or suppress psychiatric symptomatology in their Minnesota Multiphasic Personality Inventory (MMPI) self-report. A group of individuals requesting single-cell placement (the group hypothesized to be motivated to exaggerate symptomatology) were found to score significantly higher on Scale F, the F-K Index, and a number of special MMPI scales (i.e., D-O, Hy-O, Pd-O, Pa-O, Ma-O, Dissimulation Scale, total number of Obvious Items, O:S Ratio) and significantly lower on scales K, Hy-S, Ma-S, and the total number of Subtle items relative to inmates undergoing parole evaluations (denial condition) or entering group therapy (neutral condition). Differences between the parole and group therapy conditions were relatively small, with only D-O, Hy-O, and the Dissimulation Scale producing statistically significant results. These findings tend to support use of the MMPI in assessing a respondent's test-taking attitude, particularly in cases where the subject is attempting to exaggerate psychiatric symptomatology.

Screening for psychopathology in groups of black and white prison inmates by means of the MMPI.

Of 225 male offenders who were administered both the MMPI and a structured diagnostic interview, the Psychiatric Diagnostic Interview (PDI), 51 (25 blacks, 26 whites) earned highly elevated MMPI profiles (at least one clinical scale greater than or equal to T score of 90) and 46 (26 blacks, 20 whites) achieved profiles that were essentially within normal limits (all clinical scales less than T score of 70). It was noted that the concordance between the MMPI and the total number of PDI syndromes reported by inmates was significantly greater in the white group (classification accuracy = 96%) relative to the black group (classification accuracy = 71%). However, both the black and white hit rates were found to significantly improved upon chance.

Scale 4 (Pd) of the MMPI and the diagnosis antisocial personality.

The MMPI and a structured diagnostic interview were administered to 225 military offenders in an attempt to determine the relationship between Scale 4 (Pd) of the MMPI and a behavioral diagnosis of Antisocial Personality (AS). Individuals satisfying criteria for a diagnosis of AS were found to score significantly higher than inmates not satisfying these criteria on Scale 4, regardless of whether K- or non-K-corrected T scores were used. Several potential moderating variables were crossed with the AS measure but only confining offense (person crime vs nonperson crime) evidenced a statistically significant interaction with AS.

Discriminating between alcoholic and nonalcoholic blacks and whites on the MMPI.

The purpose of the present study was to investigate the influence of race (black, white) on the MMPI performance of alcoholic and nonalcoholic inpatients. Subjects were 73 (27 black, 46 white) male alcoholic inpatients and 73 (27 black, 46 white) male nonalcoholic psychiatric inpatients. While black and white alcoholics failed to differ on the MMPI, white alcoholics presented as less disturbed and black alcoholics as less defensive and distressed, compared to their respective nonalcoholic counterparts. Furthermore, only white alcoholics were accurately identified by the MMPI 2-4/4-2 high-point pair combination and only white alcoholics achieved more high-point pairs containing Scale 4 relative to nonalcoholic controls.