Modification, validation and implementation of a protocol for post-thyroidectomy hypocalcaemia.

Introduction The management of post-thyroidectomy hypocalcaemia should facilitate early discharge, and reduce risks of hypocalcaemia, readmission and treatment related hypercalcaemia. This paper describes the implementation, evaluation and revision a protocol for the optimal management of this condition. Methods Day 1 parathyroid hormone (PTH) measurements in addition to calcium measurements were commenced following review of the unit's outcomes and literature on post-thyroidectomy hypocalcaemia. Outcomes from a three-year cohort of patients undergoing thyroid surgery helped amend this protocol (revision 1) to reduce biochemical tests, stipulate the need, nature and dose of vitamin D/calcium supplements, and encourage early discharge. This was further validated over seven months to assess compliance, episodes of hyper and/or hypocalcaemia after discharge, readmissions and need for treatment changes. Further revisions were made (revision 2) and implemented. Results The temporary and long-term postoperative hypocalcaemia rates were 29.1% and 3.2% respectively. Repeat calcium measurements on the first day altered management in only 1.4% of cases. The revised protocol was adhered to in 90% of cases. One patient had hypocalcaemia (due to non-compliance) and one had hypercalcaemia. Revision 2 involved reducing the dose of calcium. Conclusions This is a good example of a unit protocol for post-thyroidectomy hypocalcaemia being developed and modified on the basis of the literature and local experience. Day 1 PTH and calcium levels determine the need for treatment and frequency of follow-up visits, facilitate early discharge, reduce risk of over and/or undertreatment, and are good indicators of permanent hypocalcaemia.

Geographic Information Systems to Assess External Validity in Randomized Trials.

INTRODUCTION: To support claims that RCTs can reduce health disparities (i.e., are translational), it is imperative that methodologies exist to evaluate the tenability of external validity in RCTs when probabilistic sampling of participants is not employed. Typically, attempts at establishing post hoc external validity are limited to a few comparisons across convenience variables, which must be available in both sample and population. A Type 2 diabetes RCT was used as an example of a method that uses a geographic information system to assess external validity in the absence of a priori probabilistic community-wide diabetes risk sampling strategy. METHODS: A geographic information system, 2009-2013 county death certificate records, and 2013-2014 electronic medical records were used to identify community-wide diabetes prevalence. Color-coded diabetes density maps provided visual representation of these densities. Chi-square goodness of fit statistic/analysis tested the degree to which distribution of RCT participants varied across density classes compared to what would be expected, given simple random sampling of the county population. Analyses were conducted in 2016. RESULTS: Diabetes prevalence areas as represented by death certificate and electronic medical records were distributed similarly. The simple random sample model was not a good fit for death certificate record (chi-square, 17.63; p=0.0001) and electronic medical record data (chi-square, 28.92; p<0.0001). Generally, RCT participants were oversampled in high-diabetes density areas. CONCLUSIONS: Location is a highly reliable "principal variable" associated with health disparities. It serves as a directly measurable proxy for high-risk underserved communities, thus offering an effective and practical approach for examining external validity of RCTs.

The use of electronic medical records for recruitment in clinical trials: findings from the Lifestyle Intervention for Treatment of Diabetes trial.

BACKGROUND: The use of the electronic medical record (EMR) system in recruitment in clinical trials has the potential for providing a very reliable and cost-effective recruiting methodology which may improve participant recruitment in clinical trials. We examined a recruitment approach centered on the use of the EMR, as well as other traditional methods, in the Lifestyle Intervention for Treatment of Diabetes (LIFT Diabetes) trial. METHODS: LIFT Diabetes is a randomized controlled trial designed to investigate the effects of two contrasting interventions on cardiovascular disease risk: a community-based intensive lifestyle program aimed at achieving weight loss and a clinic-based enhanced diabetes self-management program. Eligible participants were overweight/obese (body mass index, BMI ≥25 kg/m2) patients with type 2 diabetes who were aged 21 years or older. Recruitment strategies included the use of the EMR system (primary), direct referrals, media advertisements, and community screenings. RESULTS: A total of 1102 telephone screens were conducted, resulting in randomization of 260 participants (61.5 % from EMR, mean age 56.3 years, 66.2 % women, 48.1 % non-Hispanic blacks) over a 21-month period, with a yield of 23.6 %. Recruitment yields differed by recruitment method, with referrals having the highest yield (27.5 %). A history of cardiovascular disease was the main health reason for exclusion from the study (16.5 %). An additional 8.9 % were excluded for BMI <25 kg/m2 (<27 kg/m2 for insulin users), 5.4 % could not exercise, 5.2 % had an HbA1c >11 %, and 34.9 % were excluded for other non-medical reasons. Exclusion criteria did not appear to differentially affect enrollment in terms of race or ethnicity. CONCLUSIONS: Future clinical studies should tailor their recruitment strategies based on the participant demographics of interest. Efficient methods such as using the EMR system and referrals should be prioritized over labor-intensive, low-yielding methods such as community screenings and mass mailings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01806727 . Registered on 5 March 2013.

Thermoelectricity in polymer composites due to fluctuation-induced tunneling.

Transport in heavily-doped polymer composites, characterized by localized charge regions, is examined in light of the recent interest in polymers for thermoelectric applications. The developed fundamental transport theory describes carrier tunneling between charged localizations by taking into account thermally induced fluctuations of the applied potential. A range of characteristic behaviors corresponding to experimental data are described. Deviations from the Wiedemann-Franz law are also identified. This novel theory enables the determination of factors dominating the transport in polymers and a comparison to tunneling without thermal fluctuations is also provided. The obtained asymptotic expressions for the conductivity, Seebeck coefficient, and carrier thermal conductivity are particularly useful for elucidating possible routes for thermoelectric transport control and optimization.

Low-fat oxidation may be a factor in obesity among men with schizophrenia.

OBJECTIVE: Obesity associated with atypical antipsychotic medications is an important clinical issue for people with schizophrenia. The purpose of this project was to determine whether there were any differences in resting energy expenditure (REE) and respiratory quotient (RQ) between men with schizophrenia and controls. METHOD: Thirty-one men with schizophrenia were individually matched for age and relative body weight with healthy, sedentary controls. Deuterium dilution was used to determine total body water and subsequently fat-free mass (FFM). Indirect calorimetry using a Deltatrac metabolic cart was used to determine REE and RQ. RESULTS: When corrected for FFM, there was no significant difference in REE between the groups. However, fasting RQ was significantly higher in the men with schizophrenia than the controls. CONCLUSION: Men with schizophrenia oxidised proportionally less fat and more carbohydrate under resting conditions than healthy controls. These differences in substrate utilisation at rest may be an important consideration in obesity in this clinical group.

Endocytosis in different lifestyles of protozoan parasitism: role in nutrient uptake with special reference to Toxoplasma gondii.

A fundamental property of any eukaryotic cell is endocytosis, that is the ability to take up external fluid, solutes and particulate matter into membrane-bound intracellular vesicles by various mechanisms. Toxoplasma gondii is an intracellular protozoan parasite of the phylum Apicomplexa with a wide geographical and host range distribution. Significant progress in studying the cell biology of this parasite has been accomplished over the last few years. Only recently endocytic compartments and endocytic trafficking have come to a closer dissection in T. gondii. In this review, we discuss the evidence for an endocytic compartment and present a model for an endocytic pathway in Toxoplasma against a background of endocytosis in kinetoplastida and the extensive insights gained from mammalian and yeast cells.

Toxoplasma gondii ADP-ribosylation factor 1 mediates enhanced release of constitutively secreted dense granule proteins.

Toxoplasma gondii dense granules are morphologically similar to dense matrix granules in specialized secretory cells, yet are secreted in a constitutive, calcium-independent fashion. We previously demonstrated that secretion of dense granule proteins in permeabilized parasites was augmented by the non-hydrolyzable GTP analogue guanosine 5'-3-O-(thio)triphosphate (GTPgammaS) (Chaturvedi, S., Qi, H., Coleman, D. L., Hanson, P., Rodriguez, A., and Joiner, K. A. (1998) J. Biol. Chem. 274, 2424-2431). As now demonstrated by pharmacological and electron microscopic approaches, GTPgammaS enhanced release of dense granule proteins in the permeabilized cell system. To investigate the role of ADP-ribosylation factor 1 (ARF1) in this process, a cDNA encoding T. gondii ARF1 (TgARF1) was isolated. Endogenous and transgenic TgARF1 localized to the Golgi of T. gondii, but not to dense granules. An epitope-tagged mutant of TgARF1 predicted to be impaired in GTP hydrolysis (Q71L) partially dispersed the Golgi signal, with localization to scattered vesicles, whereas a mutant impaired in nucleotide binding (T31N) was cytosolic in location. Both mutants caused partial dispersion of a Golgi/trans-Golgi network marker. TgARF1 mutants inhibited delivery of the secretory reporter, Escherichia coli alkaline phosphatase, to dense granules, precluding an in vivo assessment of the role of TgARF1 in release of intact dense granules. To circumvent this limitation, recombinant TgARF1 was purified using two separate approaches, and used in the permeabilized cell assay. TgARF1 protein purified on a Cibacron G3 column and able to bind GTP stimulated dense granule secretion in the permeabilized cell secretion assay. These results are the first to show that ARF1 can augment release of constitutively secreted vesicles at the target membrane.

A gap approach to exploring quality of life in mental health.

Improving quality of life (QoL) is an important treatment outcome for the serious mentally ill. There is, however, a need for an instrument which both captures consumers own assessments and gives direct information for intervention. A useful approach is to define QoL as the gap between actual and ideal life circumstances, which is weighted by importance. In this paper we detail how we developed and evaluated a QoL instrument which follows this model. This instrument, the 'QoL-GAP', is based on self-appraised items within various life domains. For each item respondents firstly identify what they have (actual) and then what they would like (ideal). They then rate the item for its importance and make any comments. A weighted gap score for each item is subsequently derived from the ideal actual gap being weighted by the importance rating. This weighted gap score is then related to domain satisfaction ratings, while their average from each domain is related to overall satisfaction and well-being. We surveyed 120 individuals with a serious and enduring mental illness living in different types of residences, such as psychiatric hospitals, hostels, or their own homes, in a largely urban part of Queensland. Sixty-eight percent were males, and 92% had schizophrenia or related disorders. We found that our approach demonstrated good psychometric properties, and that the model-based predictions were borne out: weighted gap measures were consistently more strongly related to domain satisfaction than were the actual circumstances alone. While further work is being undertaken--in such matters as short-forms and further evaluation of the QoL-GAP in a longitudinal study--our results suggest that this 'gap' approach helps consumers state their own goals and give their opinions and so is particularly relevant for consumer-focused mental health delivery and research.

The perceived utility of six selected measures of consumer outcomes proposed for routine use in Australian mental health services.

OBJECTIVE: This paper aims to assess the utility of six measures of consumer outcomes: the Behaviour and Symptom Identification Scale, the Mental Health Inventory (MHI), the Medical Outcomes Study 36-Item Short-Form Survey, the Health of the Nation Outcome Scales, the Life Skills Profile (LSP) and the Role Functioning Scale previously recommended for the routine assessment in Australian mental health services. METHOD: Consumers and service providers were invited through focus group discussions and surveys to describe the perceived utility of these selected measures. RESULTS: All six measures were rated favourably. The qualitative and quantitative findings suggest that the MHI elicited the most positive results of the consumer measures. No observer-rated scale was clearly preferred. CONCLUSION: The qualitative feedback obtained indicated that process and context issues may be as important to the successful use of routine instruments for the measurement of consumer outcomes in clinical practice as the choice of instrument.

Choosing negative symptom instruments: issues of representation and redundancy.

Assuming that the negative syndrome in schizophrenia may be multidimensional, this study examines how conclusions about the structure of negative symptoms may be influenced by the particular rating scale used, the level of data reduction used (such as total, subscale and individual item scores), and also the type of data analyses used to compare scales. Forty-seven subjects with RDC schizophrenia were rated on three instruments: the negative symptom subscale of the BPRS (BPRS-WR); the negative symptom subscale of the PANSS (PANSS-NS); and the SANS. Comparisons were made of different levels of data reduction and different methods of analysis, which included bivariate correlation, bi-multivariate canonical correlation and redundancy analysis. We found that while the total scores from all three scales were highly correlated and therefore highly redundant, both the individual items and subscale scores from the SANS contained information independent of the BPRS-WR, and also, to a lesser extent, of the PANSS-NS. When the BPRS-WR was correlated with either the SANS or the PANSS-NS, one strong canonical variate (CV) emerged, on which all or most items loaded, particularly the affective items. When the SANS and PANSS-NS were correlated, this component again emerged along with three less strong but interpretable components. When examining the non-symmetrical redundancy, we found that the BPRS-WR variates explained 40% of the SANS variance, while conversely the SANS variates explained 80% of the BPRS-WR variance. The PANSS-NS variates were found to explain 58% of the SANS variance, while the SANS variates explained 85% of the PANSS-NS variance. Finally, the PANSS-NS variates explained 79% of the BPRS-WR variance, while conversely the BPRS-WR variates explained 54% of the PANSS-NS variance. AH three scales appear to measure a single general 'affective' component of the negative syndrome, while the PANSS-NS and the SANS also cover additional components which identify cognitive, anergic and social dimensions. This extra information is lost, however, if inappropriate data reduction and/or statistical analyses are used. The fact that the three instruments predicted the various dimensions of the negative syndrome to different degrees suggests that the best choice of a negative scale depends on the type of information required. Nevertheless, further examination of how negative symptom scales cover the multi-dimensional nature of the negative syndrome is required.

The HSP70 gene family in Pneumocystis carinii: molecular and phylogenetic characterization of cytoplasmic members.

Pneumocystis carinii, a major opportunistic lung pathogen of AIDS patients, is found in a number of mammals and is proposed to be a member of the fungi. In this work, several members of the highly conserved HSP70 multigene family were characterized from rat-derived P. carinii. Previously, we reported characterization of the ER resident HSP70 homolog known as BiP from prototype (P.c. carinii) and variant (P. c. rattus) strains of the organism. We report here, from P. c. carinii, characterization of Pcsa1, an HSP70 homolog that encodes a cognate/stress-induced HSP70 homolog of the SSA subfamily in Saccharomyces cerevisiae. We also identify, from both rat strains and from a human isolate of P. carinii (P.c. hominis), a third set of HSP70 homologs that apparently encode a ribosome-associated cytoplasmic HSP70 homologous to the S. cerevisiae SSB subfamily. Our data indicate that Pcsal mRNA, like Pcbip mRNA, bears an intron in the 5' untranslated region, is induced by heat shock, and suggest that this gene undergoes alternative transcription and splicing. The SSB homologs display significant sequence heterogeneity between P. carinii source strains, supporting the genetic divergence and likely speciation of P. carinii isolates within and between host species. Phylogenetic analysis with the PcSA1 protein supports inclusion of P. carinii among the higher fungi.

Neuropsychological, neurological and symptom correlates of impaired olfactory identification in schizophrenia.

Impaired olfactory identification has been reported in samples of schizophrenic patients. Little is known about the associations between these impairments and neuropsychological deficits, neurological deficits and olfaction-related symptoms. Forty-six subjects (37 men and 9 women) with schizophrenia were examined with the University of Pennsylvania Smell Identification Test (UPSIT), a selection of neuropsychological tests and standardised neurological and symptom evaluations. Eighty-five per cent of the subjects scored below the published norms' 10th percentile on the UPSIT. Stepwise multiple regression found that WAIS-R Information score and Wisconsin Card Sort Test Failure to Maintain Set score (WCST-FMS) were the only significant predictors of the UPSIT percentile scores, accounting for 41% of the variance. Neurological signs did not contribute to the prediction of impaired olfactory identification. Although 26% of subjects reported olfactory hallucinations, there was no association between this symptom and olfactory impairment. The results suggest that general knowledge or general intelligence may have some influence on olfactory identification in subjects with schizophrenia; however, olfactory identification deficit could not be explained by gross impairments of sustained attention, memory or conceptual ability.

Chirality of reduced haloperidol in humans.

In vitro, cytosolic human ketone reductases catalyse the stereospecific (i.e. >99%) formation of S(-) reduced haloperidol (RHP) from haloperidol (HP). Whether this situation is reflected in patients taking the drug is unknown. In this study in nine patients taking HP, only 73.2+/-18.2% of the RHP excreted in urine was the S(-) enantiomer. Thus, enzymes other than cytosolic ketone reductases must be responsible for the formation of the minor enantiomer.

Two pyridinium metabolites of haloperidol are present in the brain of patients at post-mortem.

We have shown in patients taking the antipsychotic drug haloperidol (HP) that two pyridinium metabolites (HPP+ and RHPP+) are present in blood and urine in nM concentrations. These metabolites are structurally analogous to MPP+, the neurotoxic metabolite of the well-known parkinsonian-producing protoxin, MPTP. In this study we measured the concentrations of HPP+ and RHPP+ in seven regions of the brain (putamen, substantia nigra, globus pallidus, caudate, hippocampus, cerebellum and occipital cortex) obtained at post-mortem from three patients who were taking HP before death. Blood, urine, and bile from one patient were analysed as well. HPP+ was present in all regions (except for substantia nigra in one patient and globus pallidus in another); the amount/g ranged from 1.6-8.3 pMol but there was no preferential sequestration of the metabolite in dopaminergic regions. Similarly, RHPP+ was present relatively uniformly in all regions; the amount/g ranged from 1.1-7.6 pMol. The concentrations of HPP+ and RHPP+ in one patient were 24 and 13 nM in blood, 660 and 230 nM in urine, and 13.0 and 1.4 microM in bile, respectively. The presence of these pyridinums in brain adds another important piece of information to the case that, at least for HP, metabolite-induced neurotoxicity could contribute to the extrapyramidal side-effects in patients receiving long-term therapy.

Approaches to measuring quality of life and their relevance to mental health.

OBJECTIVES: This paper describes the 'sociological' and health-related approaches to the measurement of quality of life and aims to describe their major findings, shortcomings and potential uses with mental health problems. METHOD: The literature is selectively reviewed to illustrate the major developments and conclusions. RESULTS: Despite the lack of an accepted definition of quality of life, sociological approaches have repeatedly shown in general populations, the mentally ill and the elderly that subjective assessments are more influential in determining expressions of happiness, wellbeing and life satisfaction than are the objective circumstances of a person's life. This supports the use of subjective judgements as the basis for quality-of-life determinations.. CONCLUSIONS: The quality-of-life approaches can help to answer a broad range of questions of interest to psychiatry. Health-related quality-of-life approaches are potentially useful methods of demonstrating the impact of mental illness and the benefit of interventions. Further work is required to determine whether the commonly used measures are sensitive to change.

Identification, characterization, and expression of the BiP endoplasmic reticulum resident chaperonins in Pneumocystis carinii.

We have isolated, characterized, and examined the expression of the genes encoding BiP endoplasmic reticulum (ER) resident chaperonins responsible for transport, maturation, and proper folding of membrane and secreted proteins from two divergent strains of Pneumocystis carinii. The BiP genes, Pcbip and Prbip, from the P. c. carinii (prototype) strain and the P. c. rattus (variant) strain, respectively, are single-copy genes that reside on chromosomes of approximately 330 and approximately 350 kbp. Both genes encode approximately 72.5-kDa proteins that are most homologous to BiP genes from other organisms and exhibit the amino-terminal signal peptides and carboxyl-terminal ER retention sequences that are hallmarks of BiP proteins. We established short-term P. carinii cultures to examine expression and induction of Pcbip in response to heat shock, glucose starvation, inhibition of protein transport or N-linked glycosylation, and other conditions known to affect proper transport, glycosylation, and maturation of membrane and secreted proteins. These studies indicated that Pcbip mRNA is constitutively expressed but induced under conditions known to induce BiP expression in other organisms. In contrast to mammalian BiP genes but like other fungal BiP genes, P. carinii BiP mRNA levels are induced by heat shock. Finally, the Prbip and Pcbip coding sequences surprisingly exhibit only approximately 83% DNA and approximately 90% amino acid sequence identity and show only limited conservation in noncoding flanking and intron sequences. Analyses of the P. carinii BiP gene sequences support inclusion of P. carinii among the fungi but suggest a large divergence and possible speciation among P. carinii strains infecting a given host.

An arrayed bacteriophage P1 genomic library of Pneumocystis carinii.

We have constructed an arrayed, large insert, multiple coverage genomic library of Pneumocystis carinii DNA using the bacteriophage P1 cloning system. The library consists of approximately 4800 independent clones with an average insert size of approximately 55 kbp individually arrayed in 50 microtiter plates, and is readily screened on ten or fewer microtiter plate-sized filters using a high density colony replicating device. Screening of the library for unique P. carinii sequences detected an average of 4-5 positive clones for each, consistent with a several-fold coverage of the approximately 10-mbp P. carinii genome. Restriction and hybridization analyses demonstrated that the P1 clones in this library are quite stable and contain few, if any, chimeric inserts. Thus, this arrayed, large insert library of P. carinii genomic DNA will be a valuable tool in the future genetic dissection of this important pathogen.