Rorschach scores in applied clinical practice: a survey of perceived validity by experienced clinicians.

We surveyed practicing clinicians who regularly used the Rorschach about the perceived clinical validity of specific Rorschach scores from many coding systems. The survey included quantitative feedback on the validity of specific variables as well as qualitative input in several areas, including the validity of specific variables, the potentially unique information that can be obtained from them, coding challenges associated with Comprehensive System (CS) codes, and recommendations for CS developments. Participants were recruited by applying a snowball sampling strategy. Based on responses from 246 experienced clinicians from 26 countries, composite judgments on rated variables were quite reliable (e.g., M α = .95 across 88 CS variables), despite limited agreement among any 2 judges. The aggregated judgments clearly differentiated among scores that were considered more and less clinically valid and the overall results aligned with recently obtained meta-analytic conclusions from the traditional validity literature (Mihura, Meyer, Dumitrascu, & Bombel, 2012). The judges also provided guidance concerning revisions and enhancements that would facilitate Rorschach-based assessment in the future. We discuss the implication of the quantitative and qualitative findings and provide suggestions for future directions based on the results.

Expression characteristics of dual-promoter lentiviral vectors targeting retinal photoreceptors and Müller cells.

PURPOSE: Growing evidence suggests that successful treatment of many inherited photoreceptor diseases will require multi-protein therapies that not only correct the genetic defects linked to these diseases but also slow or halt the related degenerative phenotypes. To be effective, it is likely that therapeutic protein expression will need to be targeted to specific cell types. The purpose of this study was to develop dual-promoter lentiviral vectors that target expression of two proteins to retinal cones and rods, rods only, or Müller cells. METHODS: Dual-promoter lentivectors were constructed using the following promoters: Xenopus opsin promoter (XOPS)1.3, murine opsin promoter (MOPS), interphotoreceptor retinoid binding protein promoter (IRBP156), rhodopsin kinase (RK), neural retina leucine zipper (NRLL), vimentin (VIM), cluster differentiation (CD44), and glial fibrillary acidic protein (GFAP). Vectors were packaged and injected into the neural tubes of chicken embryos. The activities of the promoters alone, in duplicate, or when paired with a different promoter were analyzed in transduced, fully-developed retinas, using direct fluorescent and immunofluorescent microscopy. RESULTS: IRBP156, NRLL, and RK were active in cones and rods while XOPS1.3 was active only in rods. Of the glial promoters, only GFAP activity was restricted to Müller cells; both VIM and CD44 were active in Müller and neural cells. Dual-promoter vectors carrying IRBP156 and RK or XOPS1.3 and MOPS, in the order listed, exhibited robust expression of both reporter transgenes in cones and rods or rods only, respectively. Expression of the upstream transgene was much lower than the downstream transgene in dual-promoter vectors constructed using two copies of either RK or IRBP156. Analyses of the expression of a dual-promoter vector carrying CD44 and VIM in the order listed showed that the activity of the VIM promoter was more restricted to glial cells when paired with the CD44 promoter, while the activity of the CD44 promoter was inhibited to the extent that no CD44-driven reporter protein was detected in transduced cells. CONCLUSIONS: We have identified two dual-promoter vectors, one that targets cones and rods and one that targets rods alone. Both vectors reliably express the two proteins encoded by the transgenes they carry. When two well matched promoters are not available, we found that it is possible to target expression of two proteins to single cells using dual-promoter vectors carrying two copies of the same promoter. These vectors should be useful in studies of retina when co-delivery of a reporter protein with an experimental protein is desired or when expression of two exogenous proteins in targeted cells is required.

Basis for immunization recommendations among countries of the worldHealth Organization European region.

Despite World Health Organization (WHO) goals to reduce the incidence of several vaccine preventable diseases across the European region, the adoption of new vaccines has been slower than expected. To identify factors that influence the decision to recommend new vaccines, especially hepatitis B and Haemophilus influenzae, type b (Hib) vaccines, we studied the factors used in immunization decision-making across this region. A structured questionnaire was sent to the Immunization Program Manager of each country with the option to return the completed survey by e-mail, fax or complete a web-based survey. Frequency distributions were explored for all survey items. Bivariate analysis was conducted to assess differences between countries by economic status. Of the 47 (89%) countries responding, the majority reported vaccine safety (91%), epidemiology of disease (85%), and the severity of disease prevented (74%) as very important factors when making immunization recommendations. Half of the countries reported the cost of disease burden and cost-effectiveness data were very important financial information when implementing vaccine recommendations. While no significant difference was seen by economic status in countries recommending hepatitis B vaccine (p = 0.1129), high economic status countries were significantly more likely to report Hib vaccine is part of the country's recommended schedule (p = 0.0011). Understanding the importance of the factors considered by countries when making national immunization recommendation decisions can aid public health experts in providing countries with information needed to support these decisions.

National immunization advisory committees of the World Health Organization's European Region.

This study sought to understand the prevalence, structure and decision-making process of national immunization advisory committees (IACs) among the 53 member countries of the World Health Organization (WHO)'s European region. Of the 47 countries responding to the electronically administered questionnaire, 37 (72%) have an IAC. The majority of committees have a legislative basis while just over half have formal terms of reference. Fewer than half have experts in health economics. The vast majority of countries do not allow the public to attend committee meetings nor distribute publicly the minutes of their meetings. Countries should partner with financial experts early in the process of immunization policy decision-making and should examine their policies regarding conflicts of interest and public access to meetings, as financial strategy and public trust are essential to the successful implementation of new vaccines.

Understanding the reasons why mothers do or do not have their adolescent daughters vaccinated against human papillomavirus.

PURPOSE: The objective of this study was to compare the reasons why mothers do or do not have their adolescent daughters vaccinated against HPV. METHODS: Mothers of vaccinated and unvaccinated 11- to 17-year-old girls seen during preventive care visits in outpatient family medicine or pediatric clinics underwent an audiotaped structured telephone interview that used open-ended questions to assess the reasons underlying maternal decisions about HPV vaccination. Qualitative methods categorized maternal responses into themes. RESULTS: Interviews of 52 mothers (19 declining vaccination, 33 accepting) identified several distinct factors underlying their decisions about HPV vaccination. Lack of knowledge about HPV, age-related concerns, and low perceived risk of infection were commonly cited reasons for declining vaccination. Desire to prevent illness, physician recommendation, and a high perceived risk of infection were commonly identified motivating factors. Both groups of mothers had significant concerns about vaccine safety. Locus of control (e.g., mother or daughter) of health-related decisions arose as a novel factor influencing this decision that had not been previously described in the context of HPV vaccination. CONCLUSIONS: Addressing safety concerns, educating parents about the age-specific risk of HPV infection, and promoting strong physician recommendation for vaccination may be the most useful targets for future interventions to increase HPV vaccine utilization.

Protecting the public: state medical board licensure policies for active and inactive physicians.

OBJECTIVE: The purpose of this research was to explore state physician licensing board policies and regulation of active, inactive, and retired licenses. METHODS: We conducted structured telephone interviews from January to March 2007 with representatives of all 64 state allopathic and osteopathic medical licensing boards in the United States. All of the licensing boards participated. RESULTS: Only 34% of state licensing boards query physicians regarding clinical activity at both initial licensure and renewal. The majority of boards allow physicians to hold or renew an unrestricted active license to practice medicine, although they may not have cared for a patient in years. Only 1 board requires a minimum number of patient visits to maintain an active license. Five boards allow physicians with inactive licenses to practice some form of medicine, whereas 7 boards allow physicians with retired licenses to practice. Few states have any mechanism to assess the competency of clinically inactive physicians who return to active practice. CONCLUSIONS: The number of inactive physicians in the United States is growing. Currently, state medical board policies do not address the issue of continuing competence in license renewal. Greater medical safety concerns on the part of the public will likely lead to calls for greater accountability by state licensing authorities.

Guide to collagen characterization for biomaterial studies.

The structure and remodeling of collagen in vivo is critical to the pathology and healing of many human diseases, as well as to normal tissue development and regeneration. In addition, collagen matrices in the form of fibers, coatings, and films are used extensively in biomaterial and biomedical applications. The specific properties of these matrices, both in terms of physical and chemical characteristics, have a direct impact on cellular adhesion, spreading, and proliferation rates, and ultimately on the rate and extent of new extracellular matrix formation in vitro or in vivo. In recent studies, it has also been shown that collagen matrix structure has a major impact on cell and tissue outcomes related to cellular aging and differentiation potential. Collagen structure is complex because of both diversity of source materials, chemistry, and structural hierarchy. With such significant impact of collagen features on biological outcomes, it becomes essential to consider an appropriate set of analytical tools, or guide, so that collagens attained from commercial vendors are characterized in a comparative manner as an integral part of studies focused on biological parameters. The analysis should include as a starting point: (a) structural detail-mainly focused on molecular mass, purity, helical content, and bulk thermal properties, (b) chemical features-mainly focused on surface elemental analysis and hydrophobicity, and (c) morphological features at different length scales. The application of these analytical techniques to the characterization of collagen biomaterial matrices is critical in order to appropriately correlate biological responses from different studies with experimental outcomes in vitro or in vivo. As a case study, the analytical tools employed for collagen biomaterial studies are reviewed in the context of collagen remodeling by fibroblasts. The goal is to highlight the necessity of understanding collagen biophysical and chemical features as a prerequisite to (a) studies with cells and tissue formation, and (b) suggest modes to establish comparative outcomes for studies conducted in different laboratories.

Phagocytosis and remodeling of collagen matrices.

The biodegradation of collagen and the deposition of new collagen-based extracellular matrices are of central importance in tissue remodeling and function. Similarly, for collagen-based biomaterials used in tissue engineering, the degradation of collagen scaffolds with accompanying cellular infiltration and generation of new extracellular matrix is critical for the integration of in vitro grown tissues in vivo. In earlier studies we observed significant impact of collagen structure on primary lung fibroblast behavior in vitro in terms of collagen uptake and matrix remodeling. Therefore, in the present work, the response of human fibroblasts (IMR-90) to the structural state of collagen was studied with respect to phagocytosis in the presence and absence of inhibitors. Protein content and transcript levels for collagen I (Col-1), matrix metalloproteinase 1 (MMP-1), matrix metalloproteinase 2 (MMP-2), tissue inhibitor of matrix metalloproteinase 1 (TIMP-1), tissue inhibitor of matrix metalloproteinase 2 (TIMP-2), and heat shock protein 70 (HSP-70) were characterized as a function of collagen matrix concentration, structure and cell culture time to assess effects on cellular collagen matrix remodeling processes. Phagocytosis of collagen was assessed quantitatively by the uptake of collagen-coated fluorescent beads incorporated into the collagen matrices. Significantly higher levels of collagen phagocytosis were observed for the cells grown on the denatured collagen versus native collagen matrices. Significant reduction in collagen phagocytosis was observed by blocking several phagocytosis pathways when the cells were grown on denatured collagen versus non-denatured collagen. Collagen phagocytosis inhibition effects were significantly greater for PDL57 IMR-90 cells versus PDL48 cells, reflecting a reduced number of collagen processing pathways available to the older cells. Transcript levels related to the deposition of new extracellular matrix proteins varied as a function of the structure of the collagen matrix presented to the cells. A four-fold increase in transcript level of Col-1 and a higher level of collagen matrix incorporation were observed for cells grown on denatured collagen versus cells grown on non-denatured collagen. The data suggest that biomaterial matrices incorporating denatured collagen may promote more active remodeling toward new extracellular matrices in comparison to cells grown on non-denatured collagen. A similar effect of cellular action toward denatured (wound-related) collagen in the remodeling of tissues in vivo may have significant impact on tissue regeneration as well as the progression of collagen-related diseases.

Extracellular matrix remodeling--methods to quantify cell-matrix interactions.

Tissue turnover during wound healing, regeneration or integration of biomedical materials depends on the rate and extent of materials trafficking into and out of cells involved in extracellular matrix (ECM) remodeling. To exploit these processes, we report the first model for matrix trafficking in which these issues are quantitatively assessed for cells grown on both native collagen (normal tissue) and denatured collagen (wound state) substrates. Human fibroblasts more rapidly remodeled denatured versus normal collagen type I to form new ECM. Fluxes to and from the cells from the collagen substrates and the formation of new ECM were quantified using radioactively labeled substrates. The model can be employed for the systematic and quantitative study of the impact of a broad range of physiological factors and disease states on tissue remodeling, integrating extracellular matrix structures and cell biology.

Impact of collagen structure on matrix trafficking by human fibroblasts.

Biodegradation of collagen biomaterial matrices and the deposition of new collagen extracellular matrix (ECM) are critical to the integration of in vitro bioengineered materials and tissues in vivo. In previous studies, we observed significant impact of collagen matrix structure on primary lung fibroblast behavior in vitro. In the present work, to begin to understand the mechanistic basis for our previous observation, the response of human fibroblasts (IMR-90) to the structural state of collagen matrices was studied with respect to cell proliferation, cell morphology, beta-galactosidase level, and transcript content for collagen (Col-1), matrix metalloproteinases (MMP-1, MMP-2), tissue inhibitors of matrix metalloproteinase (TIMP-1 and TIMP-2). Collagen digestion was assessed quantitatively by uptake of collagen-coated fluorescent beads incorporated in the preformed collagen matrix. Transcript levels related to the deposition of new ECM proteins varied as a function of the structure of the collagen matrix presented to the cells. Col-1 expression was 2-fold higher and expression for MMP-1, MMP-2, TIMP-1, and TIMP-2 increased for cells when grown on 156 microg/cm2 denatured collagen compared with cells grown on tissue culture (TC) plastic. On 156 microg/cm2 nondenatured (native) collagen, Col-1 expression was decreased by half and MMP-2 was increased by 2.5-fold compared with cells grown on TC plastic. On 78 microg/cm2 denatured collagen, Col-1 expression was 80% whereas the MMPs and TIMPs were increased by 1.25- to 2-fold compared with cells grown on TC plastic. On 78 microg/cm2 nondenatured collagen expression of all 5 transcripts was reduced 60-90% of the levels determined for the cells grown on TC plastic. Cell viability, based on cell morphology and beta-galactosidase activity, was improved on the denatured collagen. A higher level of collagen matrix incorporation was observed for cells grown on denatured collagen than on nondenatured collagen or TC plastic. These data suggest that tissue engineering matrices incorporating denatured collagen may promote more active remodeling toward new ECM in comparison to cells grown on nondenatured collagen or cells grown on TC plastic.