Effects of medical illness and somatic symptoms on treatment of depression in a family medicine residency practice.

The specific aims of this pilot study were to describe the treatment received by depressed patients in a family practice residency setting and to compare treatment modalities and intensity of treatment between patients with and without medical illnesses. A 12-month chart audit of a cohort of 340 patients randomly sampled from a family practice waiting room for a previous study revealed a 1-year period prevalence for diagnosed depression of 10.3% (35 patients). No patient met DSM-III-R criteria for major depressive disorder and yet 57% received tricyclic antidepressant therapy and 60% were eventually referred for specialist mental health care. Tricyclic therapy and follow-up visits for depression were less likely to take place for patients with more severe medical illnesses or high levels of somatic symptoms. These findings suggest that patients in primary care settings may have depressive symptoms severe enough to provoke tricyclic therapy or referral but do not meet current diagnostic criteria. Furthermore, medical illness and somatic symptoms may deleteriously affect treatment in primary care patients. Additional prospective research is needed to determine appropriate criteria for treatment of depressive symptoms in primary care patients and to evaluate the effects of medical illness and somatic symptoms on treatment by primary care physicians.

Selection of patients for cardiac transplantation.

Selection of potential cardiac recipients is not a simple process. Identification of patients who are declining from end-stage cardiac disease and may be expected to die within 12 months or less and deciding which of a number of cardiac invalids are reasonable candidates for cardiac transplantation involves prognostication as well as a working knowledge of the expected benefits and survival rates in cardiac transplantation. Screening by means of the currently accepted contraindications for cardiac transplantation is somewhat more difficult in 1986 than it was 10 years ago when these contraindications were changing less rapidly. However, for optimal use of the limited supply of donor organs and maintenance of reasonable survival rates such screening is absolutely necessary. A second area of restriction that is less approachable by the physician is that of financial limitations. It would appear that the working poor and lower middle class may be deprived of the opportunity for cardiac transplantation much as they are deprived of the opportunity for optimal medical care in our society today.

Cyclosporine: an immunosuppressive panacea?

Between March 29, 1979, and March 1, 1985, 62 heart transplants were done in 61 patients at the University Medical Center, University of Arizona. There were two treatment groups with nearly equal numbers in each; conventional immunosuppression (1979 to 1982) and cyclosporine (1982 to the present). Comparison of actuarial survival, number of rejection episodes, number of fatal rejection episodes, number of infections, and number of "other complications" failed to reveal any significant difference between the two groups. The cyclosporine-treated patients had a documented increase in blood urea nitrogen and serum creatinine accompanied by an increase in diastolic blood pressure. The length of hospital stay of the cyclosporine group was approximately one half of that of the conventionally treated patients, and they required fewer rehospitalizations. The cost for initial hospitalization was not significantly different between the two groups. Therefore, in 1979 dollars, the cost for cyclosporine-treated patients has decreased. This difference in cost was only minimally diminished by the difference in expenditure for outpatient pharmaceuticals, which was four times higher in the cyclosporine group. We believe that cyclosporine is a potent immunosuppressive agent but that it has toxic, possibly irreversible effects on the kidney. In view of the minimal differences that we were able to demonstrate in survival rejection and infection, it seems prudent to reduce or modify present doses of cyclosporine in an attempt to avoid irreversible renal damage.

Detection of HBsAg in a clone derived from the PLC/PRF/5 human hepatoma cell line.

A total of 28 clones were established from the PLC/PRF/5 hepatoma cell line by a plating procedure. All clones were found to secrete HBsAg into the supernatant culture fluids. Of these, one clone (No. 23) free of detectable mycoplasma contamination and showing smooth epithelial morphology was selected for further study. Maximum accumulation of HBsAg occurred 9 days after sub-culture and intracellular antigen was detected by indirect immunofluorescence both in the cytoplasm and at the plasma membrane. Granules and perinuclear staining reactions were also observed in clone 23 cells and these findings are compared to the previously published properties of the parental PLC/PRF/5 cell line.

Nondetection of infectious hepatitis B virus in a human hepatoma cell line producing hepatitis B surface antigen.

The PLC/PRF/5 human hepatoma cell line producing hepatitis B surface antigen (HBsAg) was studied to determine whether infectious hepatitis B virus (HBV) was also being produced. 2 chimpanzees with no previous exposure to HBV and no serologic markers of past or active HBV infection were inoculated intravenously with 50 ml of either tissue culture supernatant fluid (357 ng/ml HBsAg) or a suspension of cells disrupted by repeated freeze-thaw cycles (57 ng/ml HBsAg). No evidence of HBV infection was detected in either chimpanzee during 6 months of evaluation. This study suggests that the expression of a portion of the HBV genome, when a portion or all of that genome has been incorporated into a host cell, can result in the production of HBsAg without infectious HBV. If it becomes possible to produce a similar expression of this portion of the genome by itself in nonmalignant cells, HBsAg without HBV may be produced in vitro for use in hepatitis B vaccines.

Hepatitis B surface antigen production as a growth cycle-related terminal event in PLC/PRF/5 hepatoma cells.

The dynamics of hepatitis B surface antigen production of PLC/PRF/5 hepatoma cells were studied using a quantitative radioimmunoassay method. Maximum rates of antigen production were found in nutrient-depleted, non-dividing cultures and were temporally related to cytological changes preceding cell death. These results indicate that antigen production may be cell-cycle related and represent a terminal event.