High-content microscopy reveals a morphological signature of bortezomib resistance.

Drug resistance is a challenge in anticancer therapy, particularly with targeted therapeutics and cytotoxic compounds. In many cases, cancers can be resistant to the drug prior to exposure, i.e., possess intrinsic drug resistance. However, we lack target-independent methods to anticipate resistance in cancer cell lines or characterize intrinsic drug resistance without a priori knowledge of its cause. We hypothesized that cell morphology could provide an unbiased readout of drug sensitivity prior to treatment. We therefore isolated clonal cell lines that were either sensitive or resistant to bortezomib, a well-characterized proteasome inhibitor and anticancer drug to which many cancer cells possess intrinsic resistance. We then measured high-dimensional single-cell morphology profiles using Cell Painting, a high-content microscopy assay. Our imaging- and computation-based profiling pipeline identified morphological features typically different between resistant and sensitive clones. These features were compiled to generate a morphological signature of bortezomib resistance, which correctly predicted the bortezomib treatment response in seven of ten cell lines not included in the training dataset. This signature of resistance was specific to bortezomib over other drugs targeting the ubiquitin-proteasome system. Our results provide evidence that intrinsic morphological features of drug resistance exist and establish a framework for their identification.

Regulation of mRNA expression encoding chaperone and co-chaperone proteins of the glucocorticoid receptor in peripheral blood: association with depressive symptoms during pregnancy.

BACKGROUND: Major depressive disorder during pregnancy associates with potentially detrimental consequences for mother and child. The current study examined peripheral blood gene expression as a potential biomarker for prenatal depressive symptoms. METHOD: Maternal RNA from whole blood, plasma and the Beck Depression Inventory were collected longitudinally from preconception through the third trimester of pregnancy in 106 women with a lifetime history of mood or anxiety disorders. The expression of 16 genes in whole blood involved in glucorticoid receptor (GR) signaling was assessed using real-time polymerase chain reaction. In parallel, plasma concentrations of progesterone, estradiol and cortisol were measured. Finally, we assessed ex vivo GR sensitivity in peripheral blood cells from a subset of 29 women. RESULTS: mRNA expression of a number of GR-complex regulating genes was up-regulated over pregnancy. Women with depressive symptoms showed significantly smaller increases in mRNA expression of four of these genes - FKBP5, BAG1, NCOA1 and PPID. Ex vivo stimulation assays showed that GR sensitivity diminished with progression of pregnancy and increasing maternal depressive symptoms. Plasma concentrations of gonadal steroids and cortisol did not differ over pregnancy between women with and without clinically relevant depressive symptoms. CONCLUSIONS: The presence of prenatal depressive symptoms appears to be associated with altered regulation of GR sensitivity. Peripheral expression of GR co-chaperone genes may serve as a biomarker for risk of developing depressive symptoms during pregnancy. The presence of such biomarkers, if confirmed, could be utilized in treatment planning for women with a psychiatric history.

Natural history of claudication: long-term serial follow-up study of 1244 claudicants.

OBJECTIVE: The purpose of this study was to delineate the natural history of claudication and determine risk factors for ischemic rest pain (IRP) and ischemic ulceration (IU) among patients with claudication. METHODS: We prospectively collected data on 1244 men with claudication during a 15-year period, including demographics, clinical risk factors, and ankle-brachial index (ABI). We followed these patients serially with ABIs, self-reported walking distance (WalkDist), and monitoring for IRP and IU. We used Kaplan-Meier and proportional hazards modeling to find independent predictors of IRP and IU. RESULTS: Mean follow-up was 45 months; statistically valid follow-up could be carried out for as long as 12 years. ABI declined an average of 0.014 per year. WalkDist declined at an average rate of 9.2 yards per year. The cumulative 10-year risks of development of IU and IRP were 23% and 30%, respectively. In multivariate analysis using several clinical risk factors, we found that only DM (relative risk [RR], 1.8) and ABI (RR, 2.2 for 0.1 decrease in ABI) predicted the development of IRP. Similarly, only DM (RR, 3.0) and ABI (RR, 1.9 for 0.1 decrease in ABI) were significant predictors of IU. CONCLUSION: This large serial study of claudication is, to our knowledge, the longest of its kind. We documented an average rate of ABI decline of 0.014 per year and a decline in WalkDist of 9.2 yards per year. Two clinical factors, ABI and DM, were found to be associated with the development of IRP and IU. Our findings may be useful in predicting the clinical course of claudication.

Effects of two types of brief intervention and readiness to change on alcohol use in hazardous drinkers.

OBJECTIVE: Brief interventions for hazardous and low-dependent drinkers in the primary care setting have considerable empirical support. The purpose of this study was to (1) evaluate the effects of brief advice (BA) and motivational enhancement (ME) interventions on alcohol consumption. In addition, a hindsight matching design was used to (2) study the moderator effects of patient readiness to change (alcohol use) on alcohol consumption. METHOD: The subjects (N = 301, 70% men) were patients 21 years of age or older who presented for treatment at one of 12 primary care clinics. After screening for eligibility and providing consent to participate in the study, the patients completed a baseline assessment and were randomly assigned to the BA, ME or standard care (SC) interventions condition. Follow-up assessments were completed at 1-, 3-, 6-, 9- and 12-months postbaseline assessment. RESULTS: Evaluation of the first hypothesis (n = 232 for these analyses) showed that all participants tended to reduce their alcohol use considerably between the baseline and 12-month assessments. In addition, evaluation of the second hypothesis showed a moderator effect of readiness to change in predicting the number of drinks at 12 months, such that the BA intervention seemed more effective for patients relatively low in readiness to change compared to those higher in readiness. Readiness to change did not seem to be related to changes in drinking of participants in the SC or ME conditions. CONCLUSIONS: The results confirm that, among primary care patients, substantial changes in alcohol consumption are possible. They further suggest that matching studies of patient readiness to change their alcohol use, as well as other variables, are warranted.

The relationship between eligibility criteria for participation in alcohol brief intervention trials and other alcohol and health-related variables.

In clinical trials of brief interventions for alcohol use, individuals typically are defined as eligible for the research through meeting quantity-frequency (QF) of alcohol consumption criteria, alcohol-related problems criteria, or both. The purpose of this study was to evaluate preintervention and posttreatment differences among three groups of research participants eligible for participation in a brief intervention clinical trial by meeting the AUDIT total score criterion only, the QF criterion only, or both. The participants were 301 men and women 21 years of age or older who presented for medical treatment at one of twelve primary care clinics and were screened for participation in the clinical trial. Participants completed an assessment protocol at preintervention and 1, 3, 6, 9, and 12 months postintervention. The analyses showed statistical differences among the three subgroups on three outcome dimensions of alcohol consumption, related consequences and behaviors, and medical complications; for both consumption and complications, the AUDIT + QF participants showed greater severity than participants in either of the other two groups. For consequences, AUDIT + QF participants scored higher than the QF participants on one variable constituting this dimension. The overall subgroup differences were maintained at six months in the consumption and consequences data. The implications of these findings for sensitivity of brief intervention trial design, the discovery of patient moderators of intervention effectiveness, and clinical practice are discussed.

Three questions can detect hazardous drinkers.

OBJECTIVE: The researchers evaluated the Alcohol Use Disorders Identification Test (AUDIT), the first 3 questions of the AUDIT (AUDIT-C), the third AUDIT question (AUDIT-3), and quantity-frequency questions for identifying hazardous drinkers in a large primary care sample. STUDY DESIGN: Cross-sectional survey. POPULATION: Patients waiting for care at 12 primary care sites in western Pennsylvania from October 1995 to December 1997. OUTCOMES MEASURED: Sensitivity, specificity, likelihood ratios, and predictive values for the AUDIT, AUDIT-C, and AUDIT-3. RESULTS: A total of 13,438 patients were surveyed. Compared with a quantity-frequency definition of hazardous drinking (> or =16 drinks/week for men and > or =12 drinks/week for women), the AUDIT, AUDIT-C, and AUDIT-3 had areas under the receiver-operating characteristic curves (AUROC) of 0.940, 0.949, and 0.871, respectively. The AUROCs of the AUDIT and AUDIT-C were significantly different (P=.004). The AUROCs of the AUDIT-C (P<.001) and AUDIT (P <.001) were significantly larger than the AUDIT-3. When compared with a positive AUDIT score of 8 or higher, the AUDIT-C (score > or =3) and the AUDIT-3 (score > or =1) were 94.9% and 99.6% sensitive and 68.8% and 51.1% specific in detecting individuals as hazardous drinkers. CONCLUSIONS: In a large primary care sample, a 3-question version of the AUDIT identified hazardous drinkers as well as the full AUDIT when such drinkers were defined by quantity-frequency criterion. This version of the AUDIT may be useful as an initial screen for assessing hazardous drinking behavior.

Physician perceptions of a national formulary.

OBJECTIVE: To assess the perceptions of US Department of Veterans Affairs (VA) physicians regarding effects of a National Formulary (NF) on patient care, access to drugs, physician workload, and resident training approximately 1 year after it was implemented. STUDY DESIGN: Cross-sectional survey. METHODS: A questionnaire was sent to attending physicians working within the VA healthcare system. Participants included general internists (n = 2824), neurologists (n = 238), psychiatrists (n = 997), general surgeons (n = 429), and urologists (n = 152). The response rate was 45%. RESULTS: Most physicians (63%) thought that they could prescribe needed drugs; 65% agreed that patients could obtain needed nonformulary drugs. One third disagreed that access to prescription pharmaceuticals had increased; 29% stated the NF impinged on providing quality care to their own patients, and 21% thought it did so to patients from other VA facilities. Thirty eight percent of physicians perceived the NF to be more restrictive than private sector formularies; 16% thought that the NF diminished the ability to train residents for managed care. Forty percent thought that the NF added to workload. Generalists more often perceived that the NF improved their ability to provide care compared with neurologists (27% vs 18%, P = .046), psychiatrists (27% vs 22%, P = .027), and internal medicine subspecialists (27% vs 18%, P = .001). Physicians with more clinic time were more likely to perceive that the NF increased workload. CONCLUSION: Although differences of opinions among physicians were noted, most responding VA physicians did not perceive that the NF adversely affected patient care, access to pharmaceuticals, physician workload, or resident training.

Improving alcoholism treatment across the spectrum of services.

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The chair was Michael E. Hilton. The presentations were (1) The effects of brief advice and motivational enhancement on alcohol use and related variables in primary care, by Stephen A. Maisto, Joseph Conigliaro, Melissa McNiel, Kevin Kraemer, Mary E. Kelley, and Rosemarie Conigliaro; (2) Enhanced linkage of alcohol dependent persons to primary medical care: A randomized controlled trial of a multidisciplinary health evaluation in a detoxification unit, by Jeffrey H. Samet, Mary Jo Larson, Jacqueline Savetsky, Michael Winter, Lisa M. Sullivan, and Richard Saitz; (3) Cost-effectiveness of day hospital versus traditional alcohol and drug outpatient treatment in a health maintenance organization: Randomized and self-selected samples, by Constance Weisner, Jennifer Mertens, Sujaya Parthasarathy, Charles Moore, Enid Hunkeler, Teh-Wei Hu, and Joe Selby; and (4) Case monitoring for alcoholics: One year clinical and health cost effects, by Robert L. Stout, William Zywiak, Amy Rubin, William Zwick, Mary Jo Larson, and Don Shepard.

Outcome events in patients with claudication: a 15-year study in 2777 patients.

OBJECTIVE: The purpose of this study was to delineate the natural history of claudication and determine risk factors for death. METHODS: We reviewed the key outcomes (death, revascularization, amputation) in 2777 male patients with claudication identified over 15 years at a Veterans Administration hospital with both clinical and noninvasive criteria. Patients with rest pain or ulcers were excluded. Data were analyzed with life-table and Cox hazard models. RESULTS: The mean follow-up was 47 months. The cohort exhibited a mortality rate of 12% per year, which was significantly (P <.05) more than the age-adjusted US male population. Among the deaths in which the cause was known, 66% were due to heart disease. We examined several baseline risk factors in a multivariate Cox model. Four were significant (P <.01) independent predictors of death: older age (relative risk [RR] = 1.3 per decade), lower ankle-brachial index (RR = 1.2 for 0.2 change), diabetes requiring medication (RR = 1.4), and stroke (RR = 1.4). The model can be used to estimate the mortality rate for specific patients. Surprisingly, a history of angina and myocardial infarction was not a significant predictor. Major and minor amputations had a 10-year cumulative rate less than 10%. Revascularization procedures occurred with a 10-year cumulative rate of 18%. CONCLUSIONS: We found a high mortality rate in this large cohort and four independent risk factors that have a large impact on survival. Risk stratification with our model may be useful in determining an overall therapeutic plan for claudicants. A history of angina and myocardial infarction was not a useful predictor of death, suggesting that many patients in our cohort presented with claudication before having coronary artery symptoms. Our data also indicate that claudicants have a low risk of major amputation at 10-year follow-up.

Confirmation of a two-factor model of premorbid adjustment in males with schizophrenia.

Because schizophrenia is considered to be a neurodevelopmental disorder, premorbid adjustment is of particular interest. Premorbid adjustment is probably not a unitary construct but rather is expressed across a number of developmental domains. The current investigation examined the validity of a two-factor model that differentiated premorbid adjustment across social and academic domains and evaluated relationships between these premorbid adjustment domains and other variables of interest. Participants with schizophrenia (n = 141) underwent evaluation of premorbid adjustment (using the Premorbid Adjustment Scale), intellectual functioning, and psychiatric symptoms. Using confirmatory factor analysis, a two-factor model of premorbid adjustment was identified that included an academic domain and a social domain. The social domain was associated with symptom variables, while the academic domain was associated with measures of intelligence. Results provide evidence for at least two domains of premorbid adjustment in schizophrenia. Distinguishing between these two premorbid domains may be theoretically important because of potential differences in incidence rates and deterioration courses; some individuals with schizophrenia may exhibit adequate academic adjustment but poor social adjustment, while others may exhibit the opposite pattern.

A method for analyzing changes in response efficiency.

Although experimental effects typically are evaluated by summarizing levels of responding across time (e.g., calculating the mean levels of problem behavior during 10-min sessions), these data summaries may obscure important mechanisms that may be responsible for changes in responding. A case study is reported to illustrate alternative methods of data analysis when decreasing trends in responding may be due to increases in response efficiency.

An empirical investigation of the factor structure of the AUDIT.

This study investigated the Alcohol Use Disorders Identification Test's (AUDIT) factor structure and psychometric properties. The factor structure was derived from a sample of 7,035 men and women primary care patients. A principal components analysis identified 2 factors in the AUDIT data and was supported in a confirmatory factor analysis (CFA). The 2 factors were Dependence/Consequences and Alcohol Consumption. The CFA also provided support for a 3-factor model whose factors (Alcohol Consumption, Alcohol Dependence, and Related Consequences) matched those proposed by the AUDIT's developers. Psychometric indexes were determined by use of the baseline and 12-month follow-up data of 301 men and women who entered a clinical trial. The results showed that the 2 factors had good reliability. Validity tests supported the interpretation of what the 2 factors measure, its implications for relationships to other variables, and the comparability of the 2- and 3-factor models.

Further analysis of idiosyncratic antecedent influences during the assessment and treatment of problem behavior.

Recent research findings suggest that idiosyncratic variables can influence the outcomes of functional analyses (E. G. Carr, Yarbrough, & Langdon, 1997). In the present study, we examined idiosyncratic environment-behavior relations more precisely after identifying stimuli (i.e., a particular toy and social interaction) associated with increased levels of problem behavior. Two children, an 8-year-old boy with moderate mental retardation and a 5-year-old boy with no developmental delays, participated. Results of functional analyses for both children indicated that idiosyncratic antecedent stimuli set the occasion for occurrences of problem behavior (hand biting or hand flapping) and that problem behavior persisted in the absence of social contingencies. Further analyses were conducted to identify specific components of the stimuli that occasioned problem behavior. Treatments based on results of the analyses successfully reduced self-injury and hand flapping.

Does race make a difference among primary care patients with alcohol problems who agree to enroll in a study of brief interventions?

This study describes the severity, alcohol consumption, consequences, readiness to change, and coping behaviors of African-American and white primary care patients enrolled in a trial of brief interventions for problem drinking. In multivariate analysis, unemployment but not race was associated with clinical indicators of alcohol problems. African-Americans reported no difference in alcohol consumption and similar quality of life scores. African-American race and unemployment were both associated with increased identification and resolution of alcohol problems. There was no difference in readiness to change, but African-Americans reported more problems related to alcohol and greater use of coping behaviors to avoid drinking. African-Americans may be better equipped to manage drinking problems when they do occur due to increased familiarity with coping mechanisms.

Variable-time reinforcement schedules in the treatment of socially maintained problem behavior.

Noncontingent reinforcement (NCR) consists of delivering a reinforcer on a time-based schedule, independent of responding. Studies evaluating the effectiveness of NCR as treatment for problem behavior have used fixed-time (FT) schedules of reinforcement. In this study, the efficacy of NCR with variable-time (VT) schedules was evaluated by comparing the effects of VT and FT reinforcement schedules with 2 individuals who engaged in problem behavior maintained by positive reinforcement. Both FT and VT schedules were effective in reducing problem behavior. These findings suggest that VT schedules can be used to treat problem behavior maintained by social consequences.

Provider attitudes and self-reported behaviors related to hormone replacement therapy.

OBJECTIVE: The purpose of this study was to survey providers within a large health maintenance organization regarding their attitudes and practice patterns related to counseling women about hormone replacement therapy (HRT). DESIGN: A total of 260 providers from gynecology (n = 81), family practice (n = 96), and internal medicine (n = 83) from owned and contracted clinics were surveyed. Each was asked about prescribing philosophies, behaviors, and barriers to providing counseling regarding HRT. RESULTS: Respondents reported HRT's greatest benefit to be in the prevention of osteoporosis (99%) and cardiovascular conditions (96%). Gynecologists were more likely to report the benefits of HRT for Alzheimer's than were clinicians in internal medicine or family practice (p < 0.05), and women providers were more likely than men to report this (p < 0.01). There was no statistical difference based on years in practice. Providers did not vary significantly by specialty or sex in their concerns of risk for breast cancer of endometrial cancer. However, those in family practice and internal medicine were significantly more likely to report concern about thromboembolism (p < 0.01). Only 42% of physicians claimed to initiate discussion with their patients more than 75% of the time. The two factors most often mentioned as barriers to counseling were time and lack of adequate knowledge. CONCLUSIONS: Providers want to be an integral part of their patient's education regarding HRT; however, time constrains and a need for adequate information make this difficult. Now health systems must examine models of education for both providers and patients to ensure that women have access to current information with which to make informed decisions.

Relations between cognitive and symptom profile heterogeneity in schizophrenia.

Although numerous studies have consistently revealed cognitive heterogeneity in schizophrenia, the relationships between such heterogeneity and clinical phenomenology are not clear. Clusters derived from cognitive heterogeneity studies may or may not be associated with symptom profile or severity of illness. The purpose of this study was to examine the relationship between cognitive heterogeneity and demographic and clinical phenomenological measures. We examined cognitive heterogeneity in schizophrenia by empirically deriving clusters of patients based upon WAIS-R subtest scores and then analyzed the way in which these clusters related to demographic and symptom variables and to DSM-III-R diagnostic subtypes. Four cognitive clusters were identified that were consistent with previous research. These clusters were differentiated on the basis of educational level and occupational status but not on the basis of symptom profile, severity, or DSM-III-R subtypes. Results suggest that cognitive measures are independent of severity of the disorder and phenomenological symptom presentation in these subgroups of schizophrenic patients.

Effects of reinforcement magnitude on spontaneous recovery.

Extinction of operant behavior has been associated with a number of undesirable effects. One such effect is the temporary reappearance of behavior after responding appears to be completely extinguished, known as spontaneous recovery. In this report, the occurrence of spontaneous recovery and its attenuation with large amounts of reinforcement were examined during the treatment of disruption.

Plasma catecholamine metabolites as markers for psychosis and antipsychotic response in schizophrenia.

The objective of this study was to determine the association between the patterns of change in the dopaminergic metabolite plasma homovanillic acid (HVA), the noradrenergic metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG), and psychosis following haloperidol withdrawal in schizophrenic patients. Weekly plasma measurements were obtained in 107 subjects with schizophrenia or schizoaffective disorder. Random regression was used to control for individual variance while modeling metabolite changes over time and relationships with psychosis. Changes in plasma MHPG were not significantly associated with relapse or psychosis, while increased plasma HVA was found to be associated with relapse. Psychosis was correlated negatively with plasma HVA levels. The current analysis, controlling for individual variance, indicates that there is evidence for pharmacological effects on plasma HVA, but not plasma MHPG. In addition, these metabolites do not appear to be direct markers of psychosis, but may be associated with a compensatory response by the system to return to the steady state.

Empirical validation of primary negative symptoms: independence from effects of medication and psychosis.

OBJECTIVE: Recent studies of negative symptoms in schizophrenia-specifically, those involving the deficit syndrome-have focused on uncovering the symptoms that are primary to the disease rather than secondary to the psychotic process. One of the foremost concerns in this effort is establishing whether the negative symptoms observed are the result of medication effects. METHOD: This study used negative symptom ratings obtained in a drug withdrawal paradigm to compare symptom profiles in the same schizophrenic patients when they were on and off antipsychotic drug treatment. The study group consisted of 93 physically healthy male patients with DSM-III-R-defined schizophrenia. Principal components analysis was performed on negative symptom data obtained separately during haloperidol treatment and again when the patients were drug free to determine whether there were meaningful factor scores that were consistent across medication conditions. Drug withdrawal effects on negative symptom factors were then tested for associations with secondary sources of variance including extrapyramidal side effects, anxiety/depression, and psychosis. RESULTS: Two factors, termed affective flattening and diminished motivation, exhibited similar loadings when the patients were both on and off medication. Changes in motivation were associated with changes in anxiety/depression and psychosis, while changes in affective flattening were associated with changes in extrapyramidal side effects. CONCLUSIONS: The documented secondary sources of negative symptoms are related to different and distinct aspects of negative symptoms; this finding will aid in the identification of primary negative symptoms.