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Microsoft word - agm 2002 finance & agenda.doc

Christchurch Medical Research Society
AGM and Scientific Meeting
Wednesday 24 April 2002
5 pm - 7.30 pm in the Rolleston Lecture Theatre


5.00 ANNUAL GENERAL MEETING
5.15 ORAL PRESENTATIONS
5.15 VEGF-D expression is associated with lymph node status in primary human
breast carcinomas and regulated by estrogen in breast carcinoma cell lines
Margaret J Currie*, Sarah P Gunningham, Vickie Hanrahan, Helen R Morrin,
Prudence A E Scott, Bridget A Robinson, Stephen B Fox
5.30 Alcohol use and misuse among older people in the community: hidden
Nadim Khan*, Peter Davis, Tim J Wilkinson, Douglas J Sellman, Patrick Graham 5.45 REFRESHMENTS There will be no charge for refreshments as this is covered by the $10 subscription which will be gladly accepted by the Treasurer!! 6.10 POSTER PRESENTATIONS Gene expression of VEFG-A, VEGF-B, VEGF-C and their tyrosine kinase
receptors in human colorectal cancer
Vickie Hanrahan, Margaret J Currie, Sarah P Gunningham, Helen R Morrin,
Prudence AE Scott, Bridget A Robinson and Stephen B Fox
Patterns of alcohol use and misuse among elderly rest-home residents in
Christchurch, New Zealand
Nadim Khan, Tim J Wilkinson, Douglas J Sellman, Patrick Graham
6.15 ORAL PRESENTATIONS CONT. 6.15 Pressure controlled ventilation compared with volume controlled ventilation
in anaesthetised adult patients
R A French*
6.30 Oxidation of β2-agonists by peroxidases and its relevance to asthma control
Stephen J Hoskin*, Anthony J Kettle 6.45 Patient agitation and heart rate variability
Z H Lam*, S Hunt, J Geoffrey Chase, Dr Geoff Shaw 7.00 Sialic acid content of fibrinogen in pregnant women and in individuals on
fibrate therapy
G Maghzal*, S Brennan, P George
7.15 C-type natriuretic peptide (CNP) and amino terminal pro C-type natriuretic
peptide (NT-proCNP) in a sheep model of mild sepsis
Timothy C R Prickett*, Timothy G Yandle, Graham K Barrell, Martin Wellby, M Gary
Nicholls, Eric A Espiner, A Mark Richards

* Contestants for the CMRS Young Researcher Prize
Christchurch Medical Research Society
32nd Annual General Meeting, 24 April 2002
1. Apologies: Don Beaven, Jack Heinemann, David McGregor, Ross Bowie 2. Minutes of the 31st AGM held on 18 April 2001 (attached) 3. Chairperson's report – Richard Tremewan (attached) 4. Financial statement – Michael MacAskill (attached) 5. Election of Executive Geoff Shaw – Intensive Care Secretary/Treasurer Michael MacAskill – Medicine Dru Mason – Zoology, Canterbury University David McGregor – Nephrology Robyn Niven – Research Office Karl Sluis – Biorad Ltd Richard Tremewan – Medical Physics Elisabeth Wells – Public Health John Fink – Neurology* Chris Pemberton – Endolab** * Nominated Tim Anderson, seconded Michael MacAskill ** Nominated Chris Charles, seconded Michael MacAskill 6. General business Thanks to retiring Executive members: Barbara Peddie, Chris Charles, Tim Anderson, John Elliott, Steven Gieseg. Minutes of the 31st Annual General Meeting, 18 April 2001,
held in the Rolleston Theatre, Christchurch School of
Medicine at 5.15 pm.

Present: Dr Richard Tremewan (in the chair) and 20 members
Apologies. Ian Town, Karl Sluis, Nancy Gould, Chris Charles, Mike Ardagh
(Accepted)
Minutes. The minutes of the 30th AGM held on April 12, 2000 were ratified.
Chairperson's report. Dr Richard Tremewan presented the chairperson's report
which was received with acclaim. There was some discussion about the annual
subscription ($50) which the CMRS pays to the CMRF. The question of using
income for advertising was raised.
Financial statement. The financial statement to 31 March 2001 was presented by
the Secretary/Treasurer (Dr Barbara Peddie) and accepted by the meeting.
Subscriptions were maintained at $10.00 for 2001/2002.
Election of officers. The Committee for 2001/2002 will be as follows:
Dr Richard Tremewan -Medical Physics Dr Barbara Peddie - Nephrology Dr Steven Geisig -Zoology, Canterbury University Dr Tim Anderson - Neurology Dr Chris Charles - Medicine Dr Dru Mason - Zoology, Canterbury University Dr Karl Sluis - Biorad Ltd Dr Elisabeth Wells - Public Health Dr John Elliott - Cardiology Dr Geoff Shaw - Intensive Care Dr Michael MaAskill - Medicine Dr David McGregor, Nephrology. General business.
There being no further business, the AGM closed at 5.20 pm.
CMRS Chair's 2001/02 Annual Report


This is the 32nd AGM of the Society. I am pleased to report that after 31 years the
CMRS remains in good health and well supported by the health research community.
Sponsorship from 3M has allowed us to continue the "young" researcher prize which
attracts consistently good presentations. My thanks to the judges Robin Fraser,
Martin Kennedy, Dru Mason and Geoff Shaw.
In 1979 Robin Carrell, the then Chair of the CMRS, wrote of the continuing need for
a broad interest society to provide an overall forum for the presentation of medical
research. This comment arose because of some loss of momentum caused by the
formation of specialist societies. Robin also spoke of how the society was helping
develop a sense of community amongst researchers. More than 20 years later the
concept of a broad interest society and the development of a sense of community
remain pertinent and I hope they will continue to invigorate the Society.
My thanks to the Research Office and especially Robyn Niven for her support.
Thank you also to the members of the CMRS executive who have so enthusiastically
supported the Society. Particular acknowledgment is due to retiring members
Barbara Peddie, Chris Charles, Steven Gieseg and Tim Anderson. Barbara, was
Secretary/Treasurer for many years and has kept the Society in splendid order. Chris
Charles was secretary/treasurer from 1993-96, has been the victualler and often
managed the audio-visuals for more years than any other executive member can
remember.
And of course thank you to all members of the Society for helping to create a sense of
community amongst health researchers.
Richard Tremewan
Chair
24 April 2002
Christchurch Medical Research Society
Annual Financial Statement to 31 March 2002
Balance brought forward (as at 31.03.01) $2909.99 Expenditure
Meals (including drinks) Membership, CMRF Income over expenditure
($185.60)
Current balance as at 31.03.01
$2724.99

Recommendations:
1 - that the report be received
2 - that the annual subscription remain at $10 for 2002-2003

Michael R. MacAskill (Secretary/Treasurer)
VEGF-D expression is associated with lymph node status in
primary human breast carcinomas and regulated by estrogen
in breast carcinoma cell lines.
Margaret J. Currie1, Sarah P. Gunningham1, Vickie Hanrahan1, Helen R.
Morrin1, Prudence A.E Scott2, Bridget A. Robinson2, Stephen B. Fox3.

1Angiogenesis Research Group, University of Otago, Christchurch School of
Medicine, P.O.Box 4345, Christchurch, New Zealand.
2Oncology Department, Canterbury Health, Christchurch Hospital, Christchurch,
New Zealand.
3Nuffield Department Clinical Laboratory Sciences, University of Oxford, John
Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom.
Angiogenesis, the formation of new blood vessels from existing vasculature, is
essential for tumour growth and metastasis. Vascular Endothelial Growth Factor-D
(VEGF-D), a recently identified VEGF family member, is a potent angiogenic factor
in vivo and stimulates endothelial cell proliferation and migration in vitro. Although
overexpression of VEGF-D has been shown to promote tumour cell metastases in
animal studies, its contribution to tumour neovascularization and metastasis in human
breast tumours is unknown. We therefore measured the level of VEGF-D mRNA by
relative RT-PCR in 10 normal and 53 invasive breast cancers and correlated their
level of expression with standard clinicopathological parameters. Tumours expressed
more VEGF-D than normal breast tissue, and VEGF-D gene expression was
significantly associated with tumour size (p=0.05), nodal status (p=0.008), and the
number of involved nodes (p=0.0053), but not with patient age, estrogen receptor
(ER)(p=0.209), progesterone receptor (p=0.193), tumour histology (p=0.136), grade
(p=0.796), vascular invasion (p=0.645), or expression of VEGF-D receptors KDR
(p=0.935) and flt-4 (p=0.589). Since VEGF family members have been shown to be
estrogen regulated we assessed the effect of 17β-estradiol on VEGF-D mRNA
expression in a panel of ER positive (MCF-7, T47D) and ER negative (MDA231,
MDA453, MDA435, MDA468, BT20, SkBR3) breast carcinoma cell lines. We
observed that physiological amounts of estrogen (1nM) significantly upregulated
VEGF-D in T47D cells at 18 hours (p<0.01). These data suggest that VEGF-D
expression may provide a surrogate marker of nodal metastasis that may be used to
stratify patients for adjuvant chemotherapy, and give additional support for targeting
VEGF receptors as an anti-cancer therapy.
Alcohol use and misuse among older people in the community:
hidden problem
Nadim Khan1, Peter Davis3, Tim J Wilkinson1, Douglas J Sellman2, Patrick
Graham3

1Health Care of the Elderly, Department of Medicine, 2Department of Psychological
Medicine and 3Department of Public Health and General Practice, Christchurch
School of Medicine and Health Sciences, University of Otago
To determine patterns of alcohol use and misuse among community-dwelling people
aged 65 years and over in Christchurch and to assess how often this comes to medical
attention, a cross-sectional survey of alcohol use and misuse was conducted followed
by a self-administered postal survey among non- respondents. GPs of the respondents
completed a self-administered questionnaire on patients' alcohol use and misuse.
The response rate was 58% (141/243). The prevalence of hazardous alcohol
consumption in the past 12 months (AUDIT cut-off score 8 or more) was 9.9% (95%
CI = 4.9-14.9) and the prevalence of lifetime alcohol dependence using DSM-IV
diagnostic criteria was 24.8% (95% CI = 17.6-32.0). Men were more likely than
women to report lifetime dependency and current hazardous patterns. The response
rate among GPs was 77.7% (108/139).
None of the GPs who responded identified or diagnosed any alcohol problems in the
past 12 months among this group and reported a history of alcohol problems in only 4
(4.0%) patients. Those with current hazardous patterns of alcohol use were twice as
likely to be admitted to hospital (RR=2.4; 95% CI 1.2-5.1) but significantly less
likely to visit their GPs in the previous 12 months (RR=0.55; 95% CI 0.7-1.1).
A significant proportion of community-dwelling elderly people reported patterns of
alcohol consumption that put them at risk of future damage to physical or mental
health. Hazardous drinkers were less likely to visit their GPs and only in a few cases,
were GPs aware of such potential problems.
Gene expression of VEGF-A, VEGF-B, VEGF-C and their
tyrosine kinase receptors in human colorectal cancer.
Vickie Hanrahan1, Margaret J. Currie1, Sarah P. Gunningham1, Helen R.
Morrin1, Prudence A.E. Scott2, Bridget A. Robinson2 and Stephen B. Fox3.

1Angiogenesis Research Group, University of Otago, Christchurch School of
Medicine, P.O.Box 4345, Christchurch, New Zealand.
2Oncology Services, Christchurch Hospital, Christchurch, New Zealand.
3Nuffield Department Clinical Laboratory Sciences, University of Oxford, John
Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom.

The contribution of vascular endothelial growth factor (VEGF) family members to
neovascularisation and metastasis in human colorectal carcinoma (CRC) is unclear.
We therefore measured the mRNA levels of VEGF-A isoforms (VEGF-A189, VEGF-
A165, VEGF-A121), VEGF-B, VEGF-C, and their tyrosine kinase receptors VEGFR1
(Flt-1), VEGFR2 (KDR), and VEGFR3 (Flt-4) in normal colon (n=20), adenoma (n=10), and invasive colorectal carcinoma (n=71) samples by RNase protection assay (RPA), and correlated expression levels with standard clinicopathological variables. VEGF-A and VEGF-C mRNA levels were positively correlated with tumour grade and tumour size (p<0.05), but not patient age, sex, presence of infiltrative margin, lymphocytic response, vascular invasion, Duke's stage, or node involvement (p>0.05). VEGF-B mRNA abundance showed a positive association with the presence of an infiltrative margin (p=0.044). Gene expression studies demonstrated differential regulation of VEGF ligands during adenoma-carcinoma progression. VEGF-A mRNA abundance was greater in adenoma and carcinoma samples compared with normal tissue (p<0.05), and VEGF-B mRNA levels were highest in adenoma samples (p=0.012). In contrast, VEGF-C mRNA abundance was higher in carcinoma than normal or adenoma tissue (p=0.003), with expression levels highest in invasive adenocarcinomas with lymph node metastases (Duke's Stage C). Flt-1 and KDR receptor mRNA levels were higher in adenoma and carcinoma compared to normal tissue (p≤0.001), whereas Flt-4 mRNA levels appeared lower in carcinoma samples. These data support the hypothesis that VEGF ligands undergo an angiogenic switch at different stages during progression from normal colon to invasive CRC: VEGF-A and VEGF-B initiate and sustain angiogenic responses, whereas VEGF-C promotes invasive tumour growth and lymph node metastasis. Patterns of alcohol use and misuse among elderly rest home
residents in Christchurch, New Zealand
Nadim Khan1, Tim J Wilkinson1, Douglas J Sellman2, Patrick Graham3

1Health Care of the Elderly, Department of Medicine, 2Department of Psychological
Medicine and 3Department of Public Health and General Practice, Christchurch
School of Medicine and Health Sciences, University of Otago, New Zealand
To determine the prevalence of alcohol use and misuse among elderly rest home
residents in Christchurch, a cross-sectional prevalence survey was conducted among
175 residents aged 65 and over, randomly selected from 30 rest homes in
Christchurch, New Zealand, in 1998. Hazardous patterns of alcohol consumption in
the past 12 months were determined by the Alcohol Use Disorders Identification Test
(AUDIT) questionnaire and alcohol dependence in the past 12-months and lifetime
was determined by a structured clinical interview using DSM-IV criteria.
Of 246 eligible participants, 175 (71.1%) residents were interviewed, 115 women and
60 men. The mean age of participating residents was 82.6 years (SD=7.8) compared
with 83.2 years (SD=6.3) for non-participants in the study.
The prevalence of hazardous patterns of alcohol consumption in the past 12 months
by the AUDIT (cut-off score 8) was 5.1% (95% CI=1.8-8.4). According to DSM-IV
criteria, the prevalence of lifetime alcohol dependence was 20.5% (95% CI = 13.5-
27.6). The prevalence of alcohol dependence in the past 12 months was 0.5% (95%
CI = 0-1.7). The prevalence of lifetime alcohol dependence was significantly higher
in men 36.7% (95%CI = 23.2-50.1) than women 12.2% (95% CI = 5.6-18.8)
(p=0.0001).
In spite of advanced age, a small proportion of elderly rest home residents consumed
quantities of alcohol that puts them at risk of future damage to physical or mental
health. Lifetime prevalence of alcohol dependence was comparable to the general
population estimates and was higher in men than women.
Pressure controlled ventilation compared with volume
controlled ventilation in anaesthetised adult patients
RA French

Department of Anaesthesia, Christchurch Hospital, Christchurch, New Zealand
Ventilators for use in the Intensive Care Unit have been able to offer a variety of
ventilatory modes for some years. The introduction of anaesthesia "work-stations"
now allows the anaesthetist a choice of ventilatory mode, principally volume vs.
pressure control ventilation. No comparative study of these modes of ventilation
appears to have been performed in the anaesthetic setting.
This study examined patients undergoing general anaesthesia with the use of
intermittent positive pressure ventilation. Ethics committee approval was gained and
twelve patients studied. Pressure control (PCV) and volume control (VCV) modes
(Datex Anaesthesia Delivery Unit) were used within the same patients in situations of
stable respiratory mechanics. VCV and PCV modes were used sequentially and
pressure, flow and volume waveforms, as recorded by sidestream spirometry (Datex
AS/3), were captured using an analogue to digital converter and a computer.
Pressure control ventilation and volume controlled ventilation delivered a clinically
equivalent tidal volume and peak airway pressure in all patients studied. In the
majority of patients (11 of 12), PCV delivered a slightly greater tidal volume per
cmH20 applied peak pressure. The mean difference was 2.2 ml per cm H20 applied
(p<0.001, 95% CI 1.1 to 3.3 ml/cm H20). Pressure control ventilation offers a satisfactory mode of providing intermittent positive pressure ventilation in anaesthetised adults. It possesses a small advantage over volume control ventilation when considering the tidal volume delivered per unit of peak pressure. This may be of benefit when attempting to limit peak airway pressures whilst maximising tidal volume. Oxidation of β2-agonists by peroxidases and its relevance to
asthma control
Stephen J. Hoskin, Anthony J. Kettle.

Free Radical Research Group, Department of Pathology, Christchurch School of
Medicine and Health Sciences, PO Box 4345, Christchurch, New Zealand
β2-agonists are useful for dilating airways in acute episodes of asthma but regular use
may worsen asthma and cause tolerance. The aim of this study was to investigate a
biochemical mechanism that could explain such findings.
Using absorbance spectroscopy, we investigated whether β2-agonists act as substrates
for peroxidases – the enzymes released by eosinophils and neutrophils during
inflammatory processes like asthma. Fenoterol, isoproterenol, terbutaline, salbutamol
and formoterol, were all capable of reacting with myeloperoxidase (MPO) and
eosinophil peroxidase (EPO.) Fenoterol and isoproterenol showed highest affinity
whereas salbutamol was a very poor peroxidase substrate.
Oxidised terbutaline formed several new products which we detected using high
performance liquid chromatography (HPLC.) Some products were fluorescent and
showed an absorbance spectrum characteristic of phenol dimers. Oxidation of
terbutaline also produced a terbutaline peroxide, measured using the ferrous oxidation
of xylenol (FOX) assay. Isolated neutrophils and eosinophils oxidised terbutaline to
form the same range of products as isolated enzyme.
In conclusion, β2-agonists are oxidised by peroxidases in the presence of hydrogen
peroxide. Drug affinity for peroxidase roughly correlates with adverse effects.
Closer investigation of terbutaline revealed that oxidation occurs via a free radical
pathway to produce multiple products including phenol dimers and peroxide. β2-
agonist administration into the inflammatory environment of an asthmatic airway
could result in products capable of increasing inflammatory damage in the lung. The
β2-agonist could also be inactivated. Our investigations confirm that inflammatory
cells are capable of oxidising terbutaline. Further studies are needed to identify
whether β2-agonist oxidation occurs in vivo.
Patient agitation and heart rate variability
ZH Lam, S. Hunt, J. Geoffrey Chase1, Geoff Shaw2

1 University of Canterbury, Department. of Mechanical Engineering, PO Box 4800,
Christchurch, New Zealand
2 Departmment of Intensive Care Medicine, Christchurch Hospital, Christchurch,
New Zealand
The dynamics of agitated patients are not understood and the resulting over-sedation
has a high social cost and risk to the patient. This research aims to develop sensor
arrays and signal processing systems to quantify the agitation response of sedated and
ambulatory patients.
Data from continuously monitored electrocardiographs ECG's were taken from a
lightly sedated, mildly agitated critically ill patient, and from two normal ambulatory
subjects. The normal subjects also underwent a cold compress test in order to
simulate physiological effects of agitation. The signal ‘noise' of the ECG was
reduced with the use of a moving average filter before determining the RR-intervals.
The RR-intervals were then analysed for heart rate variability (HRV).
Our results show that although the overall heart rate does not increase significantly
with agitation, the RR-intervals have higher power content in the 0.4-0.5Hz high
frequency range. During the cold pressor test spectral power around the low
frequency (0.05Hz) band reduces approximately 5dB transferring to peaks over 10dB
greater in the high frequency (0.4-0.5Hz) band. These results show the potential for
determining the state of agitation employing Fourier analysis and Autoregressive
modelling of the RR-interval.
It is hoped this research will enable better patient care, create commercial opportunity
in medical devices and systems and provide a quantifiable technology platform for
assessing the efficacy of a wide range of sedation therapeutics.
Sialic acid content of fibrinogen in pregnant women and in
individuals on fibrate therapy
G. Maghzal, S. Brennan and P. George

Molecular Pathology, Canterbury Health Laboratory, Christchurch, New Zealand
Fibrinogen is a plasma glycoprotein, which plays a pivotal role in blood coagulation,
and has been associated with a higher risk of cardiovascular disease and thrombosis.
A distinct correlation has been made between the sialic acid content of fibrinogen and
the thrombin clotting time (TCT) of plasma. For example, acquired
dysfibrinogenemias caused by liver disease have an increased sialic acid content of
fibrinogen and a significant delay in TCT.
We have studied the sialic acid content of fibrinogen in two populations: 1) pregnant
women, who reportedly have increased fibrinogen and sialic acid levels and an
increased risk of thrombosis; and 2) individuals on fibrates, which are used to control
dyslipidaemia and have been shown to decrease the functional level of fibrinogen.
Using electrospray ionisation mass spectrometry, we found a 5.4% increase in the
sialic acid content of fibrinogen (p < 0.01) in the fibrate population (n=12) compared
to normal controls (n=6). While in the pregnant women who were in the third
trimester (n=11), there was a 5.5% decrease in the sialic acid content of fibrinogen (p
< 0.05). Pregnant women also had significantly higher fibrinogen levels and lower
TCT. We also measured the thrombin-catalysed polymerisation rate of these
fibrinogens and found that the fibrates group had a significantly lower rate (Vmax)
compared to the controls (5.6 x 10-4 s-1 vs 6.6 x 10-4 s-1) while this rate was increased in the pregnant women. These findings strongly suggest that the sialic acid content of fibrinogen affects its clotting and may contribute to the increased risk of thrombosis in pregnant women and the decrease of functional fibrinogen during fibrate therapy. C-type natriuretic peptide (CNP) and amino terminal pro C-
type natriuretic peptide (NT-proCNP) in a sheep model of
mild sepsis
Timothy C.R. Prickett1, Timothy G. Yandle1, Graham K. Barrell2, Martin
Wellby2, M Gary Nicholls1, Eric A. Espiner1 and A. Mark Richards1.

1 Department of Medicine, Christchurch School of Medicine and Health Sciences,
Christchurch, New Zealand.
2 Animal & Food Sciences Division, Lincoln University, Canterbury, New Zealand.
CNP is a peptide hormone synthesised in the brain, vascular endothelium and bone,
where it functions as a neurotransmitter, vasorelaxant and stimulator of long bone
growth respectively. We have identified a circulating peptide from the amino
terminal end of the precursor proCNP in human and sheep plasma. This peptide has
an apparent molecular weight of 5 kDa, similar to that expected for NT-proCNP(1-
50) – a potential fragment released during processing of proCNP. However the
relation between the two forms, and the source of the immunoreactive forms found in
plasma are unknown. In health, plasma levels of CNP are close to detection limits
and only in the setting of sepsis has elevation of CNP been observed in vivo. Since
endothelial cells stimulated by lipopolysaccharide (LPS) release CNP in vitro we
aimed to see if CNP levels were raised in an animal model of mild sepsis and whether
plasma concentrations correlated with NT-proCNP.
Sixteen sheep received an i.v. bolus of LPS (800ng/kg live weight) or vehicle.
Changes in rectal temperature at 4 h were –0.2 + 0.1 0C (mean + sem) for control
sheep, and +1.1 + 0.2 0C for LPS treated sheep. LPS induced a rise in plasma CNP
at 2 h (P<0.005), and NT-proCNP at 3 h compared with control sheep. CNP and NT-
proCNP plasma concentrations were significantly correlated (R=0.44, P<0.0001).
These results support the hypothesis that CNP and NT-proCNP are released from the
same source during the processing of proCNP. Plasma measurements of the novel
peptide NT-proCNP, which circulate at higher levels than CNP, opens the possibility
of studying factors regulating CNP in vivo.

Source: http://hrsc.org.nz/archive/documents/proceedings/cmrs_meeting_agm_24_apr_2002.pdf

Microsoft word - 3ebff837-6870-18239e.doc

eBusiness Technologies and Trends in the Pharmaceutical industry Imran Qayyum BS, Computer Science, George Mason University, 1993 MS, Information Systems Technology, George Washington University, 1996 Submitted to the Sloan School of Management in Partial Fulfillment of the Requirements for the Degree of SM, Management of Technology

2003-09

ERIC Digest A Guide for Helping Professionals Robert L. Smith and Elda E. Garcia clinicians. After a comprehensive diagnostic evaluation, an individual treatment plan, based on any coexisting mental and physical conditions Certain mental disorders are caused by or accompanied by should be selected. Medications should not be considered as the first or