Sudden death in psychiatric patients

Background The present study investigated histories of prior psychiatric treatment in cases of sudden death reported to the coroner Methods A matching survey linked the register of deaths reported to the coroner with a comprehensive statewide psychiatric case register covering both inpatient and community-based services. Results Sudden death was five times higher in people with histories of psychiatric contact. Suicide accounted for part of this excess mortality but deaths from natural causes and accidents were also elevated. Schizophrenic and affective disorders had similar suicide rates. Comorbid substance misuse doubled the risk of sudden death in affective and schizophrenic disorders. Conclusions The rates of sudden death are sufficiently elevated to raise questions about current priorities in mental health care. There is a need both for greater attention to suicide risk, most notably among young people with schizophrenia, to the early detection of cardiovascular disorders and to the vigorous management of comorbid substance misuse.

p75 neurotrophin receptor-mediated neuronal death is promoted by Bcl-2 and prevented by Bcl-x(L)

The p75 neurotrophin receptor (p75NTR) has been shown to mediate neuronal death through an unknown pathway. We microinjected p75NTR expression plasmids into sensory neurons in the presence of growth factors and assessed the effect of the expressed proteins on cell survival. We show that, unlike other members of the TNFR family, p75NTR signals death through a unique caspase-dependent death pathway that does not involve the death domain and is differentially regulated by Bcl-2 family members: the anti-apoptotic molecule Bcl-2 both promoted, and was required for, p75NTR killing, whereas killing was inhibited by its homologue BcI-x(L). These results demonstrate that Bcl-2, through distinct molecular mechanisms, either promotes or inhibits neuronal death depending on the nature of the death stimulus.

Continuity of care and readmission in two service systems: a comparative Victorian and Groningen case-register study

Objective: We compared service consumption, continuity of care and risk of readmission in a record linkage follow-up study of cohorts of patients with schizophrenia and related disorders in Victoria (Australia) and in Groningen (The Netherlands). These areas are interesting to compare because mental health care is in a different stage of deiustitutionalization. More beds are available in Groningen and more community resources are available in Victoria. Method: The cohorts were followed for 4 years, since discharge from inpatient services using record linkage data available in the psychiatric case-registers in both areas. Survival analysis was used to study continuity of care and risk of readmission. Results: Available indicators showed a higher level of continuity of care in Victoria. While the relative risk of readmission was the same in both areas and not affected by aftercare contact after discharge, the number of days spent in hospital was much higher in the Groningen register area. Conclusion: These findings provide further support for earlier reports that the risk of readmission is predominantly affected by attributes of mental illness. However, the duration of admissions, is strongly affected by service system variables, including the provision of continuity of care.

HIV infection among women admitted to the gynaecology service of a district hospital in South Africa

Our objective was to determine the prevalence of HIV infection and disease-specific HIV prevalence among women admitted to the gynaecology service of a district hospital in South Africa over a 3-month period in 1997. This was done with the goal of developing HIV education and counselling services in this setting. HIV status was determined among 196 (96%) of 205 consecutive admissions; 82 (42%) tested HIV positive. The HIV-infected women were younger than the HIV uninfected women (mean age 27 vs 33 years, P=0.001). The disease-specific HIV prevalence was greater than or equal to 40% among women who had had abortions, pelvic inflammatory disease, or ectopic pregnancy. The length of hospital stay (mean 5.4 days) and mortality (1%) were similar in the 2 groups. Inpatient gynaecology services may be act important setting in Africa, within which to provide HIV education, counselling and care.

Parental reactions to infant death: The effects of resources and coping strategies

The aim of this research was to examine, from a stress and coping perspective, the effects of resources (both personal and environmental) and coping strategies on parental reactions to infant death. One hundred and twenty-seven parents (60 fathers, 67 mothers) participated in the study. The predictors of parental distress (background factors, resources, coping methods) were initially assessed at 4-6 weeks post-loss. Parental distress (assessed using a composite measure of psychiatric disturbance, physical symptoms, and perinatal grief) was further assessed at 6 months post-loss and at 15 months postloss. After control for the stability in adjustment across time, there was consistent evidence that higher levels of education were associated with lower levels of parental distress over time. Among mothers, the number of friends in whom mothers had the confidence to confide emerged as a positive predictor of adjustment to infant death. A reliance on problem-focused coping was associated with greater maternal distress at 6 months post-loss, whereas coping by seeking support was associated with less distress at 15 months post-loss. There is no evidence that background factors and resources influenced parental distress through coping.

Signaling of neuronal cell death by the p75NTR neurotrophin receptor

The neurotrophin receptor (p75NTR) is best known for mediating tropic support by participating in the formation of high-affinity nerve growth factor (NGF) receptor complexes with trkA, however, p75NTR more recently has been shown to act as a bona fide death-signaling receptor, which can signal independently of trkA. This article discusses the evidence for an active role of p75NTR in neuronal cell death and the mechanisms controlling this process, including roles for Bcl-2 family members, the c-jun stress kinase JNK, the transcription factor nuclear factor kappa B (NF kappa B), and caspases.

Providing evidence-based answers to clinical questions - A pilot information service for general practitioners

Objective: To pilot a clinical information service for general practitioners. Methods: A representative sample of 31 GPs was invited to submit clinical questions to a local academic department of general practice. Their views on the service and the usefulness of the information were obtained by telephone interview. Results: Over one month, nine GPs (29% of the sample, 45% of those stating an interest), submitted 20 enquiries comprising 45 discrete clinical questions. The median time to search for evidence, appraise it and write answers to each enquiry was 2.5 hours (range, 1.0-7.4 hours). The median interval between receipt of questions and dispatch of answers was 3 clays (range, 1-12 days). Conclusions: The GPs found the answers useful in clinical decision making; in four out of 20 cases patient management was altered.

Altered adhesion, proliferation and death in neural cultures from adults with schizophrenia

The causes of schizophrenia are unknown, but there is evidence linking subtle deviations in neural development with schizophrenia. Embryonic brain development cannot be studied in an adult with schizophrenia, but neurogenesis and early events in neuronal differentiation can be investigated throughout adult life in the human olfactory epithelium. Our past research has demonstrated that neuronal cultures can be derived from biopsy of the human adult olfactory epithelium. In the present study, we examined mechanisms related to neurogenesis and neuronal differentiation in adults with schizophrenia versus well controls. Forty biopsies were collected under local anaesthesia from ten individuals with DSM III-R schizophrenia and ten age- and sex-matched well controls. All patients, except one, were receiving antipsychotic medication at the time of the biopsy, Immunostaining for neuronal markers indicated that neurogenesis occurred in the biopsies from both patients and controls since all contained cells expressing tubulin and/or olfactory marker protein. The major findings of this study are: 1. biopsies from patients with schizophrenia showed a significantly reduced ability to attach to the culture slide: 29.9% of patient biopsies attached compared to 73.5% of control biopsies; 2. biopsies from patients with schizophrenia had a significantly greater proportion of cells undergoing mitosis: 0.69% in the patients compared to 0.29% in the controls; and 3. dopamine (10 mu M) significantly increased the proportion of apoptotic cells in the control cultures but significantly decreased the proportion in patients' cultures. (C) 1999 Elsevier Science B.V. All rights reserved.

Predictors of death and vascular events in the elderly - The Perth Community Stroke Study

Background and Purpose-The goal of the present study was to identify risk factors for vascular disease in the elderly. Methods-We conducted a prospective study of control subjects from a population-based study of stroke in Perth, Western Australia, that was completed in 1989 to 1990 and used record linkage and a survey of survivors to identify deaths and nonfatal vascular events. Data validated through reference to medical records were analyzed with the use of Cox proportional hazards models. Results-Follow-up for the 931 subjects was 88% complete. By June 24, 1994, 198 (24%) of the subjects had died (96 from vascular disease), and there had been 45 nonfatal strokes or myocardial infarctions. The hazard ratio for diabetes exceeded 2.0 for all end points, whereas the consumption of meat >4 times weekly was associated with a reduction in risk of less than or equal to 30%. In most models, female sex and consumption of alcohol were associated with reduced risks, whereas previous myocardial infarction was linked to an increase in risk. Conclusions-There are only limited associations between lifestyle and major vascular illness in old age. Effective health promotion activities in early and middle life may be the key to a longer and healthier old age.

Differential localization and regulation of death and decoy receptors for TNF-related apoptosis-inducing ligand (TRAIL) in human melanoma cells

Induction of apoptosis in cells by TNF-related apoptosis-inducing ligand (TRAIL), a member of the TNF family, is believed to be regulated by expression of two death-inducing and two inhibitory (decoy) receptors on the cell surface. In previous studies we found no correlation between expression of decoy receptors and susceptibility of human melanoma cells to TRAIL-induced apoptosis, In view of this, we studied the localization of the receptors in melanoma cells by confocal microscopy to better understand their function. We show that the death receptors TRAIL-R1 and R2 are located in the trans-Golgi network, whereas the inhibitory receptors TRAIL-R3 and -R4 are located in the nucleus. After exposure to TRAIL, TRAIL-R1 and -R2 are internalized into endosomes, whereas TRAIL-R3 and -R4 undergo relocation from the nucleus to the cytoplasm and cell membranes. This movement of decoy receptors was dependent on signals from TRAIL-R1 and -R2, as shown by blocking experiments with Abs to TRAIL-R1 and -R2, The location of TRAIL-R1, -R3, and -R4 in melanoma cells transfected with cDNA for these receptors was similar to that in nontransfected cells, Transfection of TRAIL-R3 and -R4 increased resistance of the melanoma lines to TRAIL-induced apoptosis even in melanoma lines that naturally expressed these receptors. These results indicate that abnormalities in decoy receptor location or function may contribute to sensitivity of melanoma to TRAIL-induced apoptosis and suggest that further studies are needed on the functional significance of their nuclear location and TRAIL-induced movement within cell.

Effects of a program of intervention on parental distress following infant death

A longitudinal study of 144 patents (65 fathers, 79 mothers) was conducted to evaluate the effectiveness of a program of intervention in relieving the psychological distress of parents affected by infant death. Participants were assessed in terms of their psychiatric disturbance, depression, anxiety, physical symptoms, dyadic adjustment, and coping strategies. The experimental group (n = 84) was offered an intervention program comprising the use of specially designed resources and contact with a trained grief worker. A control group (n = 60) was given routine community care. Parental reactions were assessed at four to six weeks postloss (prior to the implementation of the intervention program), at six months postloss, and at 15 months postloss. A series of multivariate analyses of valiance revealed that the intervention was effective in reducing the distress of parents, particularly those assessed prior to the intervention as being at high-risk of developing mourning difficulties. Effects of the intervention were noted in terms of parents' overall psychiatric disturbance, marital quality, and paternal coping strategies.

Role of neurotrophin receptor p75NTR in mediating neuronal cell death following injury

1. The neurotrophin receptor p75NTR has been shown to mediate neuronal cell death after nerve injury. 2. Down-regulation of p75NTR by antisense oligonucleotides is able to inhibit both sensory and motor neuron death and this treatment is more effective than treatment with growth factors. 3. p75NTR induces cell death by a unique death signalling pathway involving transcription factors (nuclear factor kappa B and c-jun), Bcl-2 family members and caspases.

Cell death and immunohistochemistry of p53, c-Fos and c-Jun after spermine infection into the rat striatum

Administration of polyamines into the central nervous system results in tissue damage, possibly through the excitotoxic actions of the NMDA receptor. Direct injection of 100 nmol of spermine into the rat striatum produced a lesion equivalent to approximately 50% of the striatum. Analysis of the DNA in this region revealed the distinct ladder-like pattern of degradation often associated with apoptosis. This DNA fragmentation was confirmed in vivo using terminal deoxynucleotidyl-transferase-mediated biotinylated deoxyuridine triphosphate nick end labelling (TUNEL). The morphology of the TUNEL-positive cells showed marked differences at the needle tract when compared with cells in damaged areas away from the needle tract, suggesting a differential mechanism of cell death in these two regions. The patterns of p53, c-Fos and c-Jun protein expression were determined using immunohistochemistry. The number of p53-immunoreactive cells increased up to 14 h and returned to basal levels by 24 h. c-Fos protein expression transiently increased, peaking at 8 h after injection, c-Jun exhibited a protracted pattern of expression, remaining elevated up to 24 h. p53 protein expression was colocalised with TUNEL staining in areas away from the needle tract, but not in cells at the needle tract, suggesting once again a differential mechanism of cell death. At 14 h, c-Fos and c-Jun were not colocalised with TUNEL staining, suggesting that they are either not involved with the cell death process or that the time course of protein expression and the onset of DNA fragmentation do not overlap. This work represents the first characterisation of processes associated with cell death induced by spermine in vivo.

Preliminary experiences with a single-patient trials service in general practice

Objective: To pilot a single-patient trials (SPTs) service in general practice, designed to improve decision-making about long-term medications for chronic conditions. Design: 12-week within-patient, randomised, double-blind, placebo-controlled, crossover comparison of ibuprofen with paracetamol for osteoarthritis, involving three pairs of two-week treatment periods for each participating patient. Setting and patients: Patients attending an academic general practice with a clinical diagnosis of osteoarthritis, with pain of at least a month's duration severe enough to warrant consideration of long-term non-steroidal anti-inflammatory drug (NSAID) use. Main outcome measures: Pain and stiffness; measures of overall arthritis compared with previous fortnight; preference for NSAID at the end of each two-week treatment period; use of escape analgesia; side effects; and management changes as a result of the SPTs. Results: Eight of 14 patients completed SPTs. One was a clear responder to NSAIDs, five were non-responders, and two were indefinite. Of the five who were using NSAIDs before the SPT, two continued and three ceased using them. Clinically useful information assisted decision-making for all eight participants. Medication management changed for six. Conclusions: Single-patient trials can be successfully implemented in general practice and might be a valuable method for GPs to identify patients who respond to medication for chronic stable conditions such as osteoarthritis, in which individual response to medication is variable.