Postnatal demoralisation among women admitted to a hospital mother-baby unit: validation of a psychometric measure.

Demoralisation is a psychological state characterised by experiences of distress and sadness, helplessness, subjective incompetence and hopelessness, in the context of a stressful situation. Experiences of demoralisation may be particularly relevant to women who have recently given birth, who can feel incompetent, isolated and helpless. The psychometric properties of the Demoralisation Scale among women in the postnatal period participating in a clinical program were examined. Women admitted with their infants to a hospital mother-baby unit in Australia for five nights were recruited consecutively (N = 209) and assessed at admission and discharge. The Demoralisation Scale was perceived as relevant and exhibited high reliability, acceptable construct validity and good sensitivity to change. The mean demoralisation score was high (M = 30.9, SD = 15.5) and associated with negative experiences of motherhood and functional impairment, independent of depression and anxiety symptoms. Mean demoralisation decreased significantly after program completion (M = 18.4, SD = 12.4). More participants showed a significant improvement in demoralisation (57.5 %) than in depression (34.8 %) and anxiety (9.8 %) symptoms. Demoralisation can provide a useful framework for understanding and measuring the experiences of women participating in postnatal clinical programs and in directing treatment towards helping women to acquire the necessary caregiving skills and increasing parental efficacy. The Demoralisation Scale is a useful clinical tool for assessing intervention effects.

Targeted induction of apoptosis via TRAIL and cryoablation: a novel strategy for the treatment of prostate cancer.

Adjuvant therapies contribute to the successful treatment of cancer. Our previous reports have shown that combining cryoablation with cytotoxic agents enhances cell death. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a cytotoxic agent that preferentially induces apoptosis in a variety of human cancer cells. Human prostate cancer cells (PC-3) are resistant to many cytodestructive agents, including cryoablation and TRAIL. Here, we evaluated the effects of TRAIL combined with cryoablation on PC-3 and normal prostate (RWPE-1) cell death. Exposure of PC-3 cells to freezing (-10 degrees C) or TRAIL (500 ng/ml) results in minimal cell death, whereas a complete loss of viability is observed with the simultaneous combination. The synergistic effect was found to be due to a marked increase in apoptosis. Western blot analysis revealed a significant level of caspase-8 and -3 cleavage between 12 and 24 h post-exposure. Caspase activation assays provided similar results and also indicated a role for caspase-9. Inhibitors to caspase-8 and -9 along with a pan-caspase inhibitor were incorporated to determine which pathway was necessary for the combined efficacy. Inhibition of caspase-8 significantly blocked the combination-induced cell death compared to cells that did not receive the inhibitor (63% compared to 10% viable). The addition of the caspase-9 inhibitor resulted in only a minimal protection. Importantly, the combination was not effective when applied to normal prostate cells. The results describe a novel therapeutic model for the treatment of prostate cancer and provide support for future in vivo studies.

Blockage of drug resistance in vitro by disulfiram, a drug used to treat alcoholism.

BACKGROUND: P-glycoprotein (P-gp) pumps a wide range of cytotoxic drugs out of cells. Inhibiting maturation of P-gp would be a novel method for circumventing P-gp-mediated multidrug resistance, which complicates cancer chemotherapy and treatment of patients infected with human immunodeficiency virus. We examined the effect of disulfiram (Antabuse(TM)) on the maturation and activity of P-gp. METHODS: Embryonic kidney cells were transfected with a complementary DNA for the P-pg gene, and the effects of disulfiram on the sensitivity of the transfected cells to cytotoxic agents were determined. Enzyme assays were used to determine the effects of disulfiram on the verapamil-stimulated adenosine triphosphatase (ATPase) activity of P-gp. Disulfiram modifies cysteine residues, and mutant forms of P-gp that lack individual cysteines were used to determine whether particular cysteine residues mediate disulfiram's effects on P-gp activity. Maturation of recombinant P-gp was followed on immunoblots. RESULTS: Disulfiram increased the sensitivity of P-gp-transfected cells to vinblastine and colchicine and inhibited P-gp's verapamil-stimulated ATPase activity. Half-maximal inhibition of ATPase activity occurred at 13.5 microM disulfiram. Disulfiram (at 100 microM) inhibited a P-gp mutant by 43% (95% confidence interval [CI] = 37%-48%) when cysteine was present at position 431 only and by 72% (95% CI = 66%-77%) when cysteine was present at position 1074 only. Treatment of P-gp-transfected cells with 50 nM disulfiram blocked maturation of recombinant P-gp. CONCLUSIONS: Disulfiram can potentially reduce P-gp-mediated drug resistance by inhibiting P-gp activity (possibly via cysteine modification) and/or by blocking its maturation. These results suggest that disulfiram has the potential to increase the efficacy of drug therapies for cancer and acquired immunodeficiency syndrome.

Bow-tie diagrams for risk management in anaesthesia.

Bow-tie analysis is a risk analysis and management tool that has been readily adopted into routine practice in many high reliability industries such as engineering, aviation and emergency services. However, it has received little exposure so far in healthcare. Nevertheless, its simplicity, versatility, and pictorial display may have benefits for the analysis of a range of healthcare risks, including complex and multiple risks and their interactions. Bow-tie diagrams are a combination of a fault tree and an event tree, which when combined take the shape of a bow tie. Central to bow-tie methodology is the concept of an undesired or 'Top Event', which occurs if a hazard progresses past all prevention controls. Top Events may also occasionally occur idiosyncratically. Irrespective of the cause of a Top Event, mitigation and recovery controls may influence the outcome. Hence the relationship of hazard to outcome can be viewed in one diagram along with possible causal sequences or accident trajectories. Potential uses for bow-tie diagrams in anaesthesia risk management include improved understanding of anaesthesia hazards and risks, pre-emptive identification of absent or inadequate hazard controls, investigation of clinical incidents, teaching anaesthesia risk management, and demonstrating risk management strategies to third parties when required.

Major depression and depressive symptoms in Australian Gulf War veterans 20 years after the Gulf War.

BACKGROUND: Risk of major depression (depression) was elevated in Australia's Gulf War veterans in a 2000-2002 (baseline) study. A follow up study has measured the Gulf War-related risk factors for depression, also the current prevalence and severity of depression, use of anti-depressant medication, and persistence, remittance or incidence of depression since baseline in Gulf War veterans and a military comparison group. METHODS: Participants completed the Composite International Diagnostic Interview v.2.1, the 9-item Patient Health Questionnaire and the Military Service Experience Questionnaire, and consented to Repatriation Pharmaceutical Benefits Scheme (RPBS) and PBS linkage. RESULTS: Prevalence of depression (9.7% Gulf War veterans and 7.7% comparison group; adj RR=1.2, 95% CI 0.8-1.7), and pattern of persistence, remittance and incidence of depression since baseline, were similar in the two groups, however veterans reported slightly more severe symptoms (adj median difference 1, 95% CI 0.26-1.74) and were more likely to have been dispensed anti-depressant medication (adj RR=1.56, 95% CI 1.05-2.32). Depression amongst veterans was associated with self-reported Gulf War-related stressors in a dose-response relationship (adj RR 1.06, 95% CI 1.02-1.09). LIMITATIONS: Lower participation rates at follow up resulted in reduced statistical power compared with baseline, Gulf War related stressor data collected at baseline was at risk of recall bias, and RPBS and PBS databases do not capture all dispensed Nervous System medications. CONCLUSIONS: More than 20 years after the Gulf War, veterans are experiencing slightly more severe depressive symptoms than a military comparison group, and depression continues to be associated with Gulf War-related stressors.

Determining the structure and mechanism of the human multidrug resistance P-glycoprotein using cysteine-scanning mutagenesis and thiol-modification techniques.

The multidrug resistance P-glycoprotein is an ATP-dependent drug pump that extrudes a broad range of hydrophobic compounds out of cells. Its physiological role is likely to protect us from exogenous and endogenous toxins. The protein is important because it contributes to the phenomenon of multidrug resistance during AIDS and cancer chemotherapy. We have used cysteine-scanning mutagenesis and thiol-modification techniques to map the topology of the protein, show that both nucleotide-binding domains are essential for activity, examine packing of the transmembrane segments, map the drug-binding site, and show that there is cross-talk between the ATP-binding sites and the transmembrane segments.

Influence of phosphorylation by protein kinase A on CFTR at the cell surface and endoplasmic reticulum.

CFTR possesses a large cluster of strict dibasic consensus sites for phosphorylation by protein kinase A (PKA) in the R-domain and an obligatory dependence on phosphorylation is a hallmark of CFTR Cl(-) channel function. Removal of as many as 11 of these sites reduces the conformational change in the R-domain and the degree of channel activation in response to PKA. However, until recently a completely PKA-unresponsive CFTR variant has not been reported, leaving open the possibility that the residual response may be mediated by associating ancillary phosphoproteins. We traced the residual PKA-catalyzed (32)P-labelling of the variant with 11 sites mutagenized (11SA) to distinct CNBr phosphopeptides within the R-domain. Mutagenesis of 4 additional monobasic sites in these segments produced a 15SA variant in which Cl(-) channel response to PKA was abolished. Therefore, it can be concluded that ancillary phosphoproteins do not contribute to CFTR activation by PKA. Notably, however, the 15SA protein did exhibit a low level of constitutive channel activity not dependent on PKA, which might have reflected a down-regulating effect of phosphorylation of one or two of the 15 sites as suggested by others. However, this did not prove to be the case.Since immature CFTR has been claimed to be active in the endoplasmic reticulum (ER), we also examined whether it can be phosphorylated in cells and what influence if any this might have on its susceptibility to degradation. Teleologically, activation by phosphorylation of CFTR Cl(-) channels in the ER might be undesirable to the cell. Using various phosphorylation site mutants and kinase and phosphatase inhibitors in pulse-chase experiments, we have found that although nascent CFTR can be phosphorylated at the ER, this is without effect on its ability to mature and avoid proteolysis. Furthermore, we found that microsomes from cells expressing CFTR processing mutants such as DeltaF508 do not generate Cl(-) active channels when fused with planar bilayers unless maturation is promoted, e.g. by growth of cells at reduced temperature or other means. We conclude that the ER-retained mutant nascent chains which are incapable of maturation may be phosphorylated but do not form active channels. Stimulation by PKA of the insertion of CFTR containing vesicles into the plasma membrane as part of the mechanism of stimulation of chloride secretion has been reported, as has an influence of CFTR on the balance between endocytosis and exocytosis but these findings have not been universally confirmed.

Expression of rubella virus cDNA coding for the structural proteins.

A cDNA clone encoding the precursor polypeptide (Mr 115,000) to the nucleocapsid C (Mr 30,000) and two envelope glycoproteins E1 (Mr 58,000) and E2 (Mr 42,000-47,000) of rubella virus was inserted into a simian virus 40-derived eukaryotic expression vector. When the plasmid was introduced into COS cells, three proteins were synthesized. The expressed proteins were antigenically similar and identical in size to the authentic structural proteins of rubella virus. Expression in the presence of tunicamycin confirmed that E1 and E2 are glycoproteins. Unglycosylated E1 and E2 had Mrs of about 53,000 and 30,000, respectively. The mobility of the nucleocapsid protein was unaffected by tunicamycin. The locations of the translation start and stop codons for synthesis of the precursor to the structural proteins of rubella virus were determined by in vitro and in vivo expression studies. It was found that the first AUG codon at the 5' end of the rubella virus 24S cDNA acts as a start codon for translation. The stop codon was found to be 3183 bp from the start codon.

Expression of the cloned subunits of Escherichia coli transhydrogenase from separate replicons.

The pntA and pntB genes of Escherichia coli, encoding the alpha- and beta-subunits of the pyridine nucleotide transhydrogenase, were cloned individually in two different compatible plasmids into Escherichia coli mutants lacking transhydrogenase activity. Energy-linked and non-energy-linked transhydrogenase activities were produced only in cells carrying both plasmids thus showing that the products of both genes are required for the formation of an active enzyme. ATP-energized transhydrogenase activity was not increased in cells containing amplified levels of the transhydrogenase when the cell membrane ATPase was also amplified. It is suggested that the excess transhydrogenase is effectively uncoupled from the ATPase by compartmentalization in the cell.

Isolation of a fourth cysteinyl-containing peptide of the alpha-subunit of the F1 ATPase from Escherichia coli necessitates revision of the DNA sequence.

The rapid determination of cysteinyl residues by Creighton's method [(1980) Nature 284, 487-489] led to the discovery of a discrepancy between protein and DNA sequence data in the alpha-subunit of the F1 ATPase from Escherichia coli [(1984) Arch. Biochem. Biophys. 229, 320-328]. We have isolated a cysteinyl-containing decapeptide from the alpha-subunit with a protein sequence (AGCAMGEYFR) which is only partially recognizable from DNA data. Re-sequencing of DNA in the region coding for the peptide has resulted in two corrections: insertion of a cytosine before position 715 and deletion of a thymine at position 731 of the uncA gene.

Deletion of NH2- and COOH-terminal sequences destroys function of the Ca2+ ATPase of rabbit fast-twitch skeletal muscle sarcoplasmic reticulum.

Deletion mutants of the Ca2+ ATPase of rabbit fast-twitch skeletal muscle sarcoplasmic reticulum (SERCA1a) were constructed and expressed in COS-1 cells. The mutants were expressed at levels 7- to 15-fold lower than the wild-type and were inactive. In vitro transcription-translation-insertion experiments showed that deletion of transmembrane sequences M1 and M2, but not of M8, M9, M10 or the NH2-terminal 30 amino acids inhibited the stable insertion of the enzyme into the membrane. Thus there was no correlation between loss of function and membrane insertion. A signal sequence for membrane insertion may exist in M1 and M2.

A caution on the use of cut-points applied to screening instruments or diagnostic criteria.

Although cut-points or threshold scores are commonly used in screening instruments as well as in psychiatric diagnostic practice, much is still to be learned about their functional characteristics. This study demonstrates that, for a cut-off of y items on a screening instrument, there is great variability in the identification of caseness between different combinations of y items. The results suggest that the use of cut-points is perhaps not as reliable as is sometimes thought.

Comparing correlated kappas by resampling: is one level of agreement significantly different from another?

Researchers comparing diagnostic systems or screening tests frequently need to compare indices of agreement such as the kappa coefficient. While asymptotic methods exist for comparing kappas derived from independent samples, no satisfactory approach exists for comparing kappas derived from the same or related samples. Resampling methods for comparing kappa coefficients obtained from the same sample are presented. Easily undertaken using readily available software, these methods are illustrated by application to a small sample of psychiatric data, as well as to several thousand samples of simulated data. An acceptable type I error rate was exhibited. Resampling techniques-easily implemented and making few assumptions-deserve wider application in psychiatric research.

Detection of antibodies to individual proteins of rubella virus.

Individual rubella virus structural polypeptides were electroeluted from SDS-polyacrylamide gels. The eluted polypeptides were used, without further purification, as antigens in ELISA assays for the detection of rubella-specific antibodies in patients' sera. This provided a more sensitive detection method than that involving classical serological assays such as HI or VN or that using immunoprecipitation. Antisera against individual viral polypeptides were raised in mice. No haemagglutination inhibition activity was observed in any of these sera and weak virus neutralizing activity was only detected with antiserum to the E1 protein. Antisera to either the E1 or E2(a,b) complex proteins cross-reacted with both the E1 and E2(a,b) complex proteins.

Consultation-liaison psychiatry in Australia.

Consultation-liaison (C-L) psychiatry as a service entity has developed slowly and to a variable extent in Australia despite the presence of factors conducive to its development. These include a compulsory national health insurance system and a favorable disposition to the biopsychosocial model and to psychoanalytic ideas. C-L psychiatry, however, does enjoy a high profile in many undergraduate medical and postgraduate psychiatry teaching programs. Research on C-L psychiatry is emerging, complementing a strong history of research in psychosomatic medicine. An Australian and New Zealand C-L psychiatry interest group is being formed. Collaboration with the MICRO-CARES Consortium and the European Consultation-Liaison Workgroup is proving to be a great stimulus.

Establishing a consultation-liaison psychiatry clinical database in an Australian general hospital.

This paper describes the institution of a clinical database in the consultation-liaison psychiatry service of an Australian general hospital psychiatry unit. One of the problems faced was that many researchers and clinicians in Australia use the ICD-9 rather than the DSM-III-R classification system. Nevertheless, it was possible to use the DSM-III-R-based MICRO-CARES clinical database management system in this project. The data obtained during the first 12 months of its use are presented. Despite differences in the patient demographic characteristics, the data obtained are within the ranges described for North American and European sites. The local benefits of such a clinical database are described, and it is argued that such a database is also necessary for interhospital and international collaborative studies and comparisons.

Non-ACTH POMC fragments stimulate aldosterone production by human adrenal cells in vitro.

The possibility that non-ACTH proopiomelanocortin-derived fragments may stimulate aldosterone production has previously been studied using nonhuman cells with inconsistent results. We have examined the response of aldosterone to beta-endorphin (beta-End) and joining peptide (JP) and compared these with the response to ACTH using eight cell suspensions prepared from human adrenal glands. ACTH, 10(-6), 10(-8), and 10(-10) M, consistently stimulated aldosterone accumulation above that occurring in unstimulated cells (150 +/- 83, 120 +/- 62, and 77 +/- 32 fmol/10(4) cells above basal, respectively; mean +/- SE; p < 0.05). beta-End significantly stimulated aldosterone production at 10(-6) and 10(-8) M (114 +/- 84 and 50 +/- 24 fmol/10(4) cells above basal; p < 0.05); 10(-10) M beta-End did not provide significant stimulation. Furthermore, JP stimulated aldosterone biosynthesis (41 +/- 16 fmol/10(4) cells above basal; p < 0.05), only at the highest concentration used, 10(-6) M. The addition of 10(-8) M ACTH plus 10(-6) and 10(-10) M beta-End to human adrenal cells yielded values significantly greater than those achieved with either agent alone (267 +/- 152 and 183 +/- 89 fmol/10(4) cells above basal; p < 0.05). These data indicate for the first time that beta-End and JP have the capacity to stimulate aldosterone production in human adrenal cells in vitro. The physiological and potential clinical significance of these observations has yet to be elucidated.

The recognition of depression in patients referred to a consultation-liaison service.

The recognition of depression was examined in 987 medical and surgical patients referred to a consultation-liaison psychiatry service. Overall concordance of recognition of depression by the referring doctor and diagnosis of depression by the consultant psychiatrist was 74%; 41% false-positive rate, 15% false-negative rate. Concordance was higher in the Renal Unit and lower in the General Medical Unit. Patients for whom there was discordance were significantly older than those for whom there was concordance. Patients referred for depression but not diagnosed as such by psychiatrists received DSM-III-R diagnoses of Organic Mental Disorder, Somatoform and Related Disorders, Psychoactive Substance Use Disorders and Personality Disorders. On the other hand, patients diagnosed as having depression but not referred as such were referred instead for ill-defined reasons (suspected psychological component to illness, coping problems), suicide risk evaluation and routine pre-operative or pre-dialysis assessment. The results highlight the continuing misdiagnosis of psychiatric disorders, especially Organic Mental Disorders, as well as the mislabelling of the syndrome described by psychiatrists as depression. This is part of the wider problem of defining the boundaries of a clinical depressive syndrome in the physically ill.

Accurate confidence intervals for measures of test performance.

The use of confidence intervals to estimate population parameters is briefly reviewed. Exact binomial confidence intervals can be calculated through the use of tables or statistical software packages. As an alternative, a microcomputer program to calculate sensitivity and specificity, point estimates and binomial confidence intervals for false-negative and -positive rate, positive and negative predictive power, prevalence of cases and non-cases, correct classification rate, and misclassification rate has also been developed. Characteristics of the computer program, 'AccuCon', which is available from the authors, are described.

Demoralization syndrome--a relevant psychiatric diagnosis for palliative care.

Hopelessness, loss of meaning, and existential distress are proposed as the core features of the diagnostic category of demoralization syndrome. This syndrome can be differentiated from depression and is recognizable in palliative care settings. It is associated with chronic medical illness, disability, bodily disfigurement, fear of loss of dignity, social isolation, and--where there is a subjective sense of incompetence--feelings of greater dependency on others or the perception of being a burden. Because of the sense of impotence or helplessness, those with the syndrome predictably progress to a desire to die or to commit suicide. A treatment approach is described which has the potential to alleviate the distress caused by this syndrome. Overall, demoralization syndrome has satisfactory face, descriptive, predictive, construct, and divergent validity, suggesting its utility as a diagnostic category in palliative care.