Emerging biosignature of brain function and intervention in pediatric bipolar disorder

Pediatric bipolar disorder (PBD) is a complex illness with a chronic course, requiring multiple medications over the longitudinal course of illness, with limited recovery and high relapse rate. Beyond the placebo controlled trials of monotherapy, there is an increased need to understand how each medication influences regions of affective and cognitive circuitry function by normalization or deployment of alternative circuitry regions. Functional studies are beginning to unravel the improved function in the fronto-limbic and fronto-temporal affective circuitry, and based on the paradigm administered, also in the interfacing cognitive fronto-striato-temporo-parietal regions. Treatment studies illustrated a pattern of improvement in functional activity consistently among the affective ventrolateral and medial prefrontal regions, and variably in the cognitive dorsolateral prefrontal cortex. While there is decreased activity in amygdala with treatment for mania or depression among patients with PBD, there appears to be residual increased amygdala activity regardless of response, relative to healthy controls, suggesting a trait-like abnormality. Parallel biochemical abnormalities in magnetic resonance spectroscopic studies and fronto-limbic activity in magnetic resonance imaging studies of brain function at baseline provide maiden data on predicting outcome. This preliminary cohort of studies that probed the hypothesized circuitries underlying specific symptom constructs, coupled with futuristic paradigms and analytic methods, serve as a guidepost to generate the next generation of studies and build on the emerging biosignature towards specific treatment targets for personalized medicine in PBD.

Modification and validation of the Revised Diabetes Knowledge Scale

OBJECTIVES

To develop a simplified true/false response format of the Revised Diabetes Knowledge Scale and assess scaling assumptions, reliability and validity of the binary response format (the Simplified Diabetes Knowledge Scale) and compare with a multiple-choice version.

METHODS

Ninety-nine respondents attending an outpatient clinic completed the multiple-choice version of the Revised Diabetes Knowledge Scale and the simplified version of the Revised Diabetes Knowledge Scale. The response patterns and psychometric properties of both questionnaires were assessed in order to test the construct validity of the simplified version.

RESULTS

The mean age of the respondents was 57 years (range 21-83 years) and 64% were men. Respondents attained an average score of 65% on the Simplified Diabetes Knowledge Scale, compared with 62% on the Revised Diabetes Knowledge Scale. Overall, the Simplified Diabetes Knowledge Scale appeared to be somewhat easier to complete compared with the Revised Diabetes Knowledge Scale, as indicated by the number of missing responses.

CONCLUSIONS

The Simplified Diabetes Knowledge Scale provides researchers with a brief and simple diabetes knowledge questionnaire with favourable psychometric properties. The scale may require further updating to include other items relevant to diabetes education. This simplified version will now undergo translation and validation for use among minority ethnic groups resident in the UK.

Characterization of Thin PtSI/p-Si Schottky Diodes

A series of PtSi on p-type Si diodes have been characterized in order to establish correlations among processing parameters, metallurgical features and electrical properties. Characterization techniques include analytical (TED, TEM), electrical (current-voltage characteristics), and optical (photoemission and absorption). The fabrication techniques involve e-beam evaporation of platinum layers at UHV levels onto VLSI grade (100) p-type silicon substrates. The silicide layers are formed via sub-eutectic solid state diffusion at 350°C. The main trends with thickness as well as possible interrelationships are described. An unexpected result is the presence of unreacted polycrystalline Pt and Pt2Si at the interface.

Is it safe to prescribe clomiphene citrate without ultrasound monitoring facilities?

The majority of triplet and higher order multiple pregnancies now result from ovulation induction/superovulation rather than in vitro fertilisation. However, clomiphene citrate is still widely prescribed by gynaecologists and general practitioners who do not have access to ultrasound monitoring. The objective of our study was to determine the prevalence of multifollicular development with different doses of clomiphene citrate. A retrospective review of transvaginal ultrasound monitoring of 425 cycles in 182 women receiving clomiphene citrate from January 2002 to December 2003, was studied. Three or more follicles of >or= 14 mm were identified in 58 cycles (14%). Patients received 50 mg of clomiphene citrate in 52 of these 58 cycles and 25 mg in the remaining six. One patient was noted to have developed five follicles and 10 patients developed four follicles. One patient developed six follicles, despite receiving only 25 mg clomiphene citrate daily. It was concluded that a significant number of women (14%) developed three or more follicles, despite receiving low doses of clomiphene citrate.

Chewing as a social act: cultural displacement and khat consumption in the East African communities of Melbourne

In this paper we present a review of practices surrounding the consumption of khat (Catha edulis) within recent migrant communities in Melbourne from East Africa. Cultures in East Africa and the Arabian Peninsular have used khat as a stimulant since the seventh century and the practice of coming together to chew the leaves of the khat plant has acquired unique cultural importance. Based on focus-group interviews the research examines transformations taking place in the meaning of khat for East African communities within their experiences of displacement and considers how the arrival of khat might be managed in the Australian context. Emphasis is given to indigenous models and the cultural context of practices surrounding khat. This anthropology of khat use in Melbourne summarizes issues such as who chews it, traditional settings for khat gatherings, culturally defined effects of the leaf, health effects, beliefs and attitudes, levels of use, gendered attitudes and questions of dependence. These issues raise questions regarding the reception of indigenous substance use within a state that claims to be multicultural.

Evidence for articular cartilage regeneration in MRL/MpJ mice

OBJECTIVE

A major clinical problem in Orthopaedics is the repair of traumatic articular cartilage lesions. The MRL/MpJ strain of mice has the remarkable ability to regenerate ear hole punch wounds seamlessly including the scarless replacement of multiple tissues. The objective of this study was to assess whether articular cartilage defects repair or regenerate in the MRL/MpJ 'healer' strain of mice.

METHOD

Full thickness and partial thickness lesions were introduced into trochlear groove articular cartilage of MRL/MpJ and C57Bl/6 mice, a control strain that does not undergo ear hole regeneration. The wound sites were assessed 6 weeks and 12 weeks post-surgery using a histological scoring scheme and immunohistochemistry for markers of articular cartilage including proteoglycan, collagen II and collagen VI.

RESULTS

The partial thickness lesions did not repair in either strain. However, at both 6 weeks and 12 weeks timepoints the MRL/MpJ mice had a superior healing response of full thickness lesions with abundant chondrocytes and an extracellular matrix rich in proteoglycan, collagen II and collagen VI at the wound site. At the 12 week timepoint the enhanced cartilage healing was restricted to male MRL/MpJ mice. In contrast, the C57Bl/6 control strain produced an extracellular matrix at the wound site that, overall, had significantly less matrix proteoglycan and collagen II.

CONCLUSIONS

Male MRL/MpJ mice appear to possess an intrinsic ability to 'regenerate' articular cartilage. Understanding the biochemical and genetic basis for articular cartilage regeneration may open up new treatment options for traumatic articular cartilage defects.

Repair in the central nervous system

The subject of central nervous system damage includes a wide variety of problems, from the slow selective 'picking off' of characteristic sub-populations of neurons typical of neurodegenerative diseases, to the wholesale destruction of areas of brain and spinal cord seen in traumatic injury and stroke. Experimental repair strategies are diverse and the type of pathology dictates which approach will be appropriate. Damage may be to grey matter (loss of neurons), white matter (cutting of axons, leaving neurons otherwise intact, at least initially) or both. This review will consider four possible forms of treatment for repair of the human central nervous system.

Combined modality therapy of locally advanced adenocarcinoma of the rectum: Update of a phase I trial of preoperative radiation (RT) with concurrent capecitabine (Cap) and irinotecan (Ir)

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Background: We previously reported the combination of preoperative radiation (RT) with concurrent Irinotecan and 5-FU in locally advanced rectal cancer, was well tolerated and had an excellent pathologic complete response rate (CR) of 25%, but with catheter related infections and thromboses as major toxicities (Proc Am Soc Clin Onc 22: 2003). With the potential benefits of capecitabine (Cap) and no need for an implanted catheter, a phase I study was initiated to determine the toxicity and maximum tolerated dose (MTD) of Cap with concurrent Ir and RT. Methods: Eligible patients (pts) had primary or recurrent Stage II or III rectal adenocarcinoma, without a history of prior RT or chemotherapy. The treatment regimen was as follows: external beam RT at 1.8Gy daily M-F, to a total dose of 50.4 or 54 Gy; Ir 50 mg/m2 IV, d 1, 8, 15, 22; dose escalating Cap starting at 825 mg/m2 PO divided in 2 doses, Q 12h. Surgical resection occurred at 6–10 weeks. Dose limiting toxicity is defined as Gr4 heme or non-heme Gr3. Results: A total of 16 pts have enrolled on the study, 10 male and 6 female;the median age was 57 (range 44–77). All are evaluable for toxicity. The Table reviews the maximum toxicities. Grade three diarrhea is the only dose-limiting toxicity to date. There has also been 3 pts with Gr 3 hematologic toxicity. There has been no Gr 4 toxicity. Patients are currently accruing on the 4th dose level of capecitabine. A total of 13 pts have completed the preoperative phase and three are currently on treatment. Eleven pts have had surgical resection. One pt refused surgery due to a biopsy proven CR to chemoradiation. One pt refused surgery and died of disease. Of the 11 pts undergoing surgical resection, there have been 3 pathologic CR. Conclusions: The preoperative combination of capecitabine, irinotecan and radiation in locally advanced rectal cancer pts is feasible and well tolerated. The study continues to accrue, and the MTD has not been achieved. [Table: see text]

[Table: see text]

Bilateral objective tinnitus secondary to congenital middle-ear myoclonus

Subjective tinnitus (heard only by the patient) is a common otological complaint. Objective tinnitus (heard by the examiner as well as the patient) is extremely rare. There are only a few cases of objective tinnitus, secondary to middle-ear myoclonus, described in the literature.

We present the case of a child with bilateral, congenital, objective tinnitus, secondary to middle-ear myoclonus, with otherwise normal hearing thresholds (250Hz-8kHz), and with no evidence of intra-cerebral or systemic disorders. No similar case has been reported in the world literature.

A comparison of MR cholangiopancreatography at 1.5 and 3.0 Tesla

Clinical MR systems operating at 3.0 Tesla have the potential to significantly improve spatial resolution due to the boost in intrinsic signal to noise ratio. However, body imaging at these field strengths presents a number of technical challenges. We performed a prospective pilot study in which 10 patients underwent an MR cholangiopancreatography (MRCP) examination consecutively on 1.5 and 3.0 Tesla systems (both Philips Intera). An axial half Fourier segmented turbo spin echo (HASTE) sequence and a coronal thick-slab 2D turbo-spin echo (TSE) sequence were compared on both systems. A reader measured the signal intensity (SI) ratios of common bile duct (CBD): liver, and CBD: fat on HASTE images and CBD: liver on the TSE images. A second reader performed a qualitative analysis of the intrahepatic and extrahepatic biliary anatomy. Quantitative data was compared using the paired t-test and qualitative data with the paired Wilcoxon signed rank test with p < 0.05. The quantitative analysis of the HASTE sequences showed a slightly higher signal intensity ratio (CBD:liver) at 3.0 Tesla compared with 1.5 Tesla (8.1 vs 5.6, p = 0.002). No significant difference was found between the SI ratios of (CBD:fat) on HASTE images or (CBD:liver) on TSE images. The qualitative analysis showed superior image quality of 3.0 Tesla over 1.5 Tesla images on both HASTE (31 vs 25, p = 0.032), and TSE sequences (34 vs 28, p = 0.043). This pilot study shows that MRCP is feasible at 3.0 Tesla with some improvement in image quality and signal characteristics. Further development may be achieved with sequence optimization and improved coil design.

Dental disease in children with chronic illness

This article aims to raise awareness among paediatricians and specialist paediatric services that poor oral health, in particular children with chronic illness, is a major cause of morbidity and can be a risk factor for severe, even life threatening complications. Good oral health and dentition is important for efficient mastication, speaking and of course, cosmetically for smiling. If left untreated, dental caries can lead to pain and infection. Chronic infection around one or more teeth can result in damage to localised structures, such as the developing permanent teeth. Children who are medically compromised (such as being immunocompromised from disease and/or therapy) however are at increased risk of developing systemic complications from dental infections, which may prove fatal. We focus on the role of the general paediatrician in promoting the importance of good dental health for all children and in particular those children "at risk". We present preventive measures, evidence based where available, that may improve dental care and promote the role of paediatric dental services in the multidisciplinary management of chronic disease.

Use of antihypertensive agents in the management of patients with acute ischemic stroke

BACKGROUND

To protect the ischemic penumbra, guidelines have recommended against treating all but the severest elevations in blood pressure during acute ischemic stroke.

OBJECTIVE

To determine how often antihypertensive agents were used in routine clinical practice and whether this use was consistent with guideline recommendations.

METHODS

The records of patients discharged with ischemic stroke in 2000 at Baystate Medical Center in Springfield, MA, were reviewed. Adherence was evaluated by examining the use of antihypertensive agents in the context of daily blood pressure recordings during the first 4 days of hospitalization. Therapy was considered appropriate in the setting of severe hypertension (systolic blood pressure of >220 mm Hg or mean arterial blood pressure of >130 mm Hg) and potentially harmful in the setting of relative (systolic blood pressure of <120 mm Hg or mean arterial blood pressure of <85 mm Hg) or absolute (systolic blood pressure of <90 mm Hg or mean arterial blood pressure of <60 mm Hg) hypotension.

RESULTS

One hundred (65%) of the 154 ischemic stroke patients were treated with antihypertensive agents. Forty-two percent of those who had received therapy prior to admission had their regimen intensified, and 36% of previously untreated patients had therapy initiated. Sixteen (11%) patients had hypertension severe enough to warrant treatment upon arrival, and 34 (22%) had at least one episode of severe hypertension during the first 4 hospital days. Sixty-five (65%) patients developed relative hypotension on a day when antihypertensive agents were administered, and five (5%) developed absolute hypotension.

CONCLUSIONS

Most patients with acute ischemic stroke are treated with antihypertensive agents despite the absence of severe hypertension. Although low blood pressure is common among treated patients, frank hypotension is unusual.

Safety becomes danger: dilemmas of drug-use in public space

This paper provides a socio-spatial analysis of injecting drug-use in public space. It focuses on one urban district in Melbourne, Australia, which has become strongly identified with heroin sale and use in public space. Selling activities are camouflaged within a diverse street life while injecting sites are dispersed through a broad diversity of laneways, car parks and toilets. These injecting zones occupy liminal places which slide between categories of private and public, and which mediate complex and paradoxical relations between safety and danger. Those who inject in public space are caught in a dilemma--needing both privacy and exposure in the event of an overdose, safety from police becomes danger from an overdose. This empirical work, based on interview and spatial analysis, is presented as a basis for theorizing the socio-spatial construction of heroin use and for assessing the prospects for safe injecting.

Identification and quantification of anti-D, -C and -G in alloimmunized pregnant women

Our objectives were to investigate possible overestimation of maternal anti-D due to co-existing anti-C and/or anti-G, and to confirm the presence of anti-D in plasma presumed to contain anti-D+C. We investigated 96 samples (from 22 antenatal patients and 74 blood donors) initially identified as containing anti-D+C using routine investigation procedures. Anti-D quantification was performed using an Astoria Pacific International 300 (API 300) continuous flow analyser with R1R1 and R2R2 reagent red cells. Where possible, samples were tested manually using a rare D+, C-, G- cell, to confirm the presence of anti-D. Fifty-two of 96 samples (11/22 antenatal patients and 41/74 blood donors) gave >50% higher anti-D quantification results with R1R1 cells than with R2R2 cells. Anti-D was not detected using manual techniques in 16 of 73 samples tested (10/22 antenatal patients and 6/51 blood donors). Anti-D quantification using R1R1 reagent red cells may cause inaccurate estimation of anti-D levels, when anti-C and/or anti-G are present. Indeed, a significant number of cases, where apparent anti-D+C is identified, may contain only anti-C+G and lack an anti-D component. This may in turn lead to a failure to administer prophylactic anti-D immunoglobulin to RhD negative patients in cases where anti-D is not present, putting these patients at risk from immunization with possible consequences to future pregnancies.

Effect of motion on cardiac SPECT imaging: recognition and motion correction

Cardiac motion is likely to occur during long single photon emission computed tomography acquisitions or if there is considerable patient discomfort. Motion causes data misregistration and may decrease the accuracy of interpretation of cardiac single photon emission computed tomography by introducing image artifacts, such as smearing of counts around the ventricle ("hurricane sign"), distortion and discontinuities of the ventricular walls, nonanatomic defects, and hot spots. Although motion should be avoided during data acquisition, motion correction techniques have been developed to allow for manual or semiautomated compensation of cardiac displacement and should be used when motion cannot be eliminated.

Depression, cognitive impairment and function in Alzheimer's disease

Depression is very common in patients with dementia but the relationship is very complex. Depression is regarded as a cause of excess disability in persons with dementia and contributes to their functional decline. The assessment of depression in dementia patients, however, has been difficult in that the validity of self-reported depression in patients with dementia has been questioned. This study was done to investigate whether self-reported depression by persons with dementia (using the GDS) is related to their functional abilities as rated by a family caregiver (using the IADL scale) above and beyond demographic variables. This study was conducted at the Detroit Satellite of the Michigan Alzheimer's Disease Research Center. There were 141 participants, 67% were African American and 33% were European American. Statistical analyses included a correlational and multiple regression approach to determine the predictive relationships of cognitive and depressive symptoms above and beyond the influence of demographic variables and cognition. The results of the study further support the notion that depression in dementia is significantly related to functional decline but, more importantly, that self-reported depression in patients with dementia can be valuable information in understanding patients' functioning.