Outcome in general medical patients presenting with common symptoms: a prospective study with a 2-week and a 3-month follow-up

Human T-cell-mediated autoimmune diseases are often genetically linked to particular alleles of HLA class II genes. Vogt-Koyanagi-Harada's (VKH) disease, which is regarded as an autoimmune disorder in multiple organs containing melanocytes, has been found to be associated with HLA-DR4 (DRB1(*)0405) and HLA-DR53 (DRB4(*)0101). Tyrosinase is a melanoma antigen (Ag) expressed by normal melanocytes as well as melanoma cells against which responses by autologous T cells have been detected. We established a T-cell line from the peripheral blood of a patient with VKH disease which responded to synthetic peptides corresponding to tyrosinase. The T-cell line was generated which recognized the tyrosinase p188 - 208 peptide when presented by the HLA-DR4 (DRB1(*)0405) molecule on the surface of HLA class II-expressing L-cell transfectants. The minimal antigenic peptide which induced T-cell responses was an 11-amino-acid sequence and located at tyrosinase p193 - 203 (E-I-W-R-D-I-D-F-A-H-E). This peptide contained the DRB1(*)0405-binding peptide motif (hydrophobic residues (Y, F, W) at position 1 as an anchor residue, and negatively charged residues (D, E) at position 9), which corresponded to the W at p195 and the D at p203. These observations demonstrate that tyrosinase peptides are immunogenic, and may be a candidate for an autoantigen in VKH disease, suggesting that probing the T-cell responses against synthetic peptides is a productive approach for identifying the autoantigenic peptides associated with autoimmune diseases including VKH disease.     

Psychiatric comorbidity, health status, and functional impairment associated with alcohol abuse and dependence in primary care patients: Findings of the PRIME MD-1000 study.

The psychiatric comorbidity, health, and functioning of primary care patients with alcohol abuse and dependence (AAD) was investigated in a sample of 1,000 patients. Psychiatric symptomatology was assessed with the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic system. Health and functional status was assessed with the Medical Outcomes Study Short Form General Health Survey (SF-20). Results indicated that use of the PRIME-MD system brought about a 71% increase in physician recognition of AAD. AAD patients were diagnosed with substantial psychiatric comorbidity, and they reported poorer health and functioning than did patients without any psychiatric disorders. However, they reported less impairment and psychiatric comorbidity than did patients with other psychiatric disorders. Results also indicated that AAD patients' health and functioning were associated with the presence or absence of psychiatric comorbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The value of screening for psychiatric disorders in rheumatology referrals

BACKGROUND: Musculoskeletal complaints are common and often unexplained and often lead to rheumatology referrals. The prevalence of psychiatric disease in patients with musculoskeletal complaints is unknown. OBJECTIVES: To determine the prevalence of common psychiatric disorders among patients referred to a rheumatology clinic and the likelihood of establishing a rheumatic diagnosis if a psychiatric disorder is present. DESIGN: Prospective diagnostic survey. SETTING: Two hospital-based rheumatology clinics and a general medicine clinic. PARTICIPANTS: A consecutive sample of newly referred patients (n = 185) and their rheumatologists (n = 9). INTERVENTION: Before their visit, all patients filled out a self-administered version of PRIME-MD (Primary Care Evaluation of Mental Disorders), a questionnaire that makes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version, diagnoses of depressive, anxiety, and somatoform disorders. After the visit, the study rheumatologists, who were unaware of the PRIME-MD results, completed a questionnaire regarding their diagnostic assessment. These patients were compared with 210 patients with musculoskeletal complaints who were cared for in a general medicine clinic. MAIN OUTCOME MEASURES: Psychiatric and rheumatic disorders. RESULTS: Compared with patients with musculoskeletal complaints in a general medicine clinic, patients referred to a rheumatology clinic had a higher prevalence of psychiatric disease (40% vs 29%; P = .008), had an almost 2-fold higher prevalence of anxiety disorders, and were more likely to have multiple psychiatric disorders (odds ratio = 2.70, 95% confidence interval = 1.50-5.00). The likelihood of a psychiatric disorder differed among patients with connective tissue disease, nonsystemic articular or periarticular disorders, and nonarticular disorders (27%, 38%, 55%, respectively; P = .006). In a best-fitting logistic regression model, psychiatric disorders markedly decreased the likelihood of a connective tissue disease (odds ratio = 0.24, 95% confidence interval = 0.09-0.62). CONCLUSIONS: Forty percent of patients referred to a rheumatology clinic in this study had a psychiatric disorder, and its presence predicted a lower likelihood of a connective tissue disease. Prospective studies are needed to determine if screening for psychiatric disease before referring patients with unexplained musculoskeletal complaints would reduce costs or improve recognition of potentially treatable psychiatric disorders.     

Low-melting sulphate glasses and glass-ceramics,and their utility as fire and smoke retarder additives for poly(vinyl chloride)

Low-melting sulphate glasses and glass-ceramics, which are effective fire and smoke retarder additives for poly(vinyl chloride) (PVC), have been developed. They are based on low-melting, glass-forming compositions in the K₂SO₄-Na₂SO₄-ZnSO₄ ternary system. The preferred ternary sulphate glass melts at 420° C and has the composition K₂SO₄ · Na₂SO₄ · 2ZnSO₄, which also corresponds to the composition of a congruently melting ternary compound. In a simple, tin-stabilized PVC compound, 10 phr (parts per hundred of resin) resulted in a 54% reduction in smoke in the flaming mode of the NBS Smoke Chamber. 40 phr gave a smoke reduction of 83%. The preferred ternary sulphate glass also works in concert with low levels of other known smoke retarders. For example, 10 phr of the ternary glass and 5 phr of MoO₃ gave a smoke reduction of 78%, while 40 phr of the glass and 5 phr of MoO₃ gave a smoke reduction of 93%. The addition of transition metal sulphates to low-melting compositions in the K₂SO₄- Na₂SO₄-ZnSO₄ system led to the development of low-melting glasses and glass-ceramics containing Ni²⁺, Cu²⁺ and VO²⁺. These transition metal modified sulphates were also very effective smoke retarders in the simple PVC compound. All of the low-melting sulphate glasses and glass-ceramics promoted intumescence and char formation during combustion of the simple PVC compound. In this way they effectively formed thermal barriers to retard further combustion.     

Clinician-educators in academic medical centers: a two-part challenge

Between 1967 and 1996, > 18,700 strains of Yersinia species, excluding Yersinia pestis, were recovered in Belgium from a variety of gastrointestinal and extraintestinal sites in patients. Full identification and serotyping were performed by the two Belgian reference laboratories. Yersinia enterocolitica serogroup O:3 predominated (79.4% of strains), followed by serogroup O:9 (11.1%). The remaining 9.5% of isolates belonged to serogroups and related species generally considered nonpathogenic. Acute enterocolitis was the most common clinical form of Y. enterocolitica infection, affecting primarily children younger than 5 years of age. Since 1967, there was a steady increase in isolations every year, with 305 cases in 1975 and up to 1,469 in 1986. From 1987 on, there was a clear decrease in the number of reported cases, although the number of participating laboratories and culture techniques remained constant. This significant decrease in the occurrence of Y. enterocolitica infections may be explained by changes in the slaughtering procedures and eating habits of the population.     

The value of screening for psychiatric disorders prior to upper endoscopy

The small subunit of bacteriophages SPP1 and SF6 terminase, G1P, share 71% identity clustered in three conserved segments (I, II, and III). Within segment I the helix-turn-helix DNA-binding domain was mapped, whereas segment III was found to be nonessential. For terminase activity, chimeric G1Ps, obtained by domain swapping between gene 1 of SPP1 and the SF6 origin (Chi1 to Chi4), were purified. The chimeric proteins behave in all respects similarly to the G1P of SPP1 or SF6. The major determinant for G1P:G1P interactions was found to lie within segment II. We showed that a G1P derivative (G1P*) lacking the 62 N-terminal residues (segment I), and Chi1 lacking the 45 C-terminal residues (segment III) interact with G1P. The N-terminal domain of G1P is necessary for terminase subunit assembly, because the large subunit of the terminase (G2P) interacts only with G1P and Chi1, but fails to do so with G1P*. These results suggest that segment III and the extended C-terminal part of SPP1 G1P do not play a major role in DNA recognition and that G1P recognizes an extended nucleotide sequence and DNA structure.     

Concerns and expectations in patients presenting with physical complaints. Frequency, physician perceptions and actions, and 2-week outcome

BACKGROUND: Specific concerns and expectations may be a key reason that people with common physical complaints seek health care for their symptoms. OBJECTIVES: To determine the frequency of symptom-related patient concerns and expectations, physician perceptions and actions, and the relationship of these factors to patient satisfaction and symptom outcome. METHODS: This was a prospective cohort study of 328 adult outpatients presenting for evaluation of a physical complaint. The setting was a general medicine clinic in a teaching hospital. Measures included previsit patient questionnaire to identify symptom-related concerns and expectations; a postvisit physician questionnaire to determine physician perceptions and actions; and a 2-week follow-up patient questionnaire to assess symptom outcome and satisfaction with care. RESULTS: Pain of some type accounted for 55% of common symptoms, upper respiratory tract illnesses for 22%, and other physical complaints for 23%. Two thirds of patients were worried their symptom might represent a serious illness, 62% reported impairment in their usual activities, and 78%, 46%, and 41% hoped the physician would prescribe a medication, order a test, or provide a referral. Physicians often perceived symptoms as less serious or disabling and frequently did not order anticipated tests or referrals. While symptoms improved 78% of the time at 2-week follow-up, only 56% of patients were fully satisfied. Residual concerns and expectations were the strongest correlates of patient satisfaction. CONCLUSIONS: Improved recognition of symptom-related concerns and expectations might improve satisfaction with care in patients presenting with common physical complaints.     

The functional role of molybdenum trioxide as a smoke retarder additive in rigid poly(vinyl chloride)

The most effective smoke retarders for poly(vinyl chloride) are compounds of transition metals, such as molybdenum trioxide. MoO₃ when added to a rigid PVC compound shows three general effects. First, smoke formation is reduced dramatically as measured either by the NBS smoke chamber test or Goodrich smoke–char test. Second, volatile aromatic pyrolyzate formation is also reduced dramatically. The “pure” conjugated aromatic compounds (particularly benzene and naphthalene) are reduced more than the “mixed” aliphatic–aromatic compounds (such as toluene). Third, char formation is effectively promoted. Based on results from studying MoO₃ (and other metal-;based additives) in regular, perdeuterated, and syndiotactic PVC, we propose a “reductive coupling” scheme as the dominant mechanism to explain the smoke retarder action. In this mechanism the MoO₃ acts in the condensed phase to promote extensive crosslinking of the PVC polymer chains very early in the thermal degradation process. Specifically, the metal additive forms a redox catalyst system which promotes intermolecular crosslinking of polymer chains to form char, rather than the conventional degradation process which gives rise to aromatics and smoke.     

Identifying patients with depression in the primary care setting: a more efficient method

OBJECTIVE: To determine if there is a core subset of depressive symptoms that could be used to efficiently diagnose depression after administering the 2-item PRIME-MD a screening questionnaire for depression. METHODS: One thousand patients selected randomly and by convenience from 4 primary care clinics were assessed by PRIME-MD and completed a questionnaire measuring the following validation variables: functional status and well-being, disability days, somatic symptoms, depression severity, suicidal thoughts, health care utilization, and the physician-patient relationship. RESULTS: Four symptoms (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) accounted for virtually all the depression symptom-related variance in functional status and well-being, with 8.3% of patients having 2 of these symptoms and 8.2% having 3 or 4 of these symptoms. There was excellent agreement between diagnosis based on core symptoms and major depression (K= 0.77; overall accuracy rate, 94%). There were significant differences (P<.001) among patients with negative depression screen, 0 to 1, 2, and 3 to 4 core symptoms with scores on each of the validation variables getting progressively worse in these 4 groups. A cutoff point of 2 core symptoms identified all but 3 patients with major depression and an additional 5% of the entire sample without major depression who were significantly (P<.05) worse than patients without depression on each of the validation variables. CONCLUSION: A strategy that includes the use of a 2-item depression screener followed by the evaluation of 4 core depressive symptoms is an efficient and effective way of identifying and classifying primary care patients with depression in need of clinical attention.