Neurobiology of depression: an integrated view of key findings

AIMS

The objectives of the present review were to summarise the key findings from the clinical literature regarding the neurobiology of major depressive disorder (MDD) and their implications for maximising treatment outcomes. Several neuroanatomical structures in the prefrontal and limbic areas of the brain are involved in affective regulation. In patients with MDD, alterations in the dynamic patterns of activity among these structures have profound implications for the pathogenesis of this illness.

DISCUSSION

The present work reviews the evidence for the progressive nature of MDD along with associated changes in neuroanatomical structure and function, especially for the hippocampus. The role of glucocorticoids, inflammatory cytokines and brain-derived growth factors are discussed as mediators of these pathological alterations. From this integrated model, the role of antidepressant therapy in restoring normative processes is examined along with additional treatment guidelines.

CONCLUSION

Major depressive disorder is an illness with significant neurobiological consequences involving structural, functional and molecular alterations in several areas of the brain. Antidepressant pharmacotherapy is associated with restoration of the underlying physiology. Clinicians are advised to intervene with MDD using an early, comprehensive treatment approach that has remission as the goal.

The variability of the curvature of the labial surface of the upper anterior teeth along the facial axis of the clinical crown

OBJECTIVE

To mathematically assess the curvature of upper anterior teeth along the facial axis of the clinical crown (FACC) line to provide information valuable for assessment of enamel growth.

METHODS

Forty upper study models were chosen from the Orthodontic clinic at the Charles Clifford Dental Hospital, Sheffield, UK. The study model incisors and canines were sectioned longitudinally down the FACC line, using a Microslice II cutting machine. Images were captured that showed the proximal view of the tooth curvature from incisal edge/cusp tip to the gingival margin. The images were converted into silhouettes and saved as bitmap files. These were vectorised and converted to an outline of xy data points. The forty xy files were mathematically adjusted so the distance between incisal edge and gingival margin were of equal length. Non Rotational Principal Component Analysis (PCA) was then applied at 20 equal intervals along the curve of each xy file to describe the shape of the teeth.

RESULTS

Intra class correlation coefficient for intra-operator repeatability ranged from 0.821-0.998 showing good or excellent levels of reliability. PCA showed variation between tooth types.

CONCLUSIONS

The method proved reliable. All tooth types showed that the mid-point region had the greatest rise variable, indicating that the most-prominent point was central or incisal for central and lateral incisors. All were skewed towards the incisal end and had kurtosis at both ends. Central incisors showed least variability. Greater variability was seen within the incisal third than within the gingival third for all tooth types.

Management of vascular birthmarks: review of a multidisciplinary clinic

Vascular birthmarks comprise a diverse group of congenital lesions and represent a significant cosmetic and functional burden for patients. They remain a diagnostic and management challenge for physicians due to their extremely variable clinical presentation and often complex anatomical associations. As each type of vascular lesion has a treatment program individual to it, optimal functional and cosmetic outcomes require accurate diagnosis. Primary physicians readily diagnose and manage uncomplicated lesions, such as isolated haemangiomas and innocuous capillary malformations. However, given the complexity and relative rarity of many other vascular birthmarks, specialised multidisciplinary clinics are central to their management. In this review, we present our experience regarding the diagnostic range of vascular anomalies, associated symptomatology, and management of patients with vascular birthmarks attending the multidisciplinary Joint Vascular Birthmark Clinic at Our Lady's Children's Hospital, Crumlin. Vascular tumours represented 57% of cases reviewed, malformations accounting for 43%. Of patients not previously seen at the JVBC or by any of the individual consultants, the initial or referring diagnosis was incorrect in 42%. Significantly, 62% of vascular malformations were assigned an incorrect diagnosis, highlighting the need for a specialised clinic.

A high density barley microsatellite consensus map with 775 SSR loci

A microsatellite or simple sequence repeat (SSR) consensus map of barley was constructed by joining six independent genetic maps based on the mapping populations 'Igri x Franka', 'Steptoe x Morex', 'OWB(Rec) x OWB(Dom)', 'Lina x Canada Park', 'L94 x Vada' and 'SusPtrit x Vada'. Segregation data for microsatellite markers from different research groups including SCRI (Bmac, Bmag, EBmac, EBmag, HVGeneName, scsssr), IPK (GBM, GBMS), WUR (GBM), Virginia Polytechnic Institute (HVM), and MPI for Plant Breeding (HVGeneName), generated in above mapping populations, were used in the computer program RECORD to order the markers of the individual linkage data sets. Subsequently, a framework map was constructed for each chromosome by integrating the 496 "bridge markers" common to two or more individual maps with the help of the computer programme JoinMap 3.0. The final map was calculated by following a "neighbours" map approach. The integrated map contained 775 unique microsatellite loci, from 688 primer pairs, ranging from 93 (6H) to 132 (2H) and with an average of 111 markers per linkage group. The genomic DNA-derived SSR marker loci had a higher polymorphism information content value (average 0.61) as compared to the EST/gene-derived SSR loci (average 0.48). The consensus map spans 1,068 cM providing an average density of one SSR marker every 1.38 cM. Such a high-density consensus SSR map provides barley molecular breeding programmes with a better choice regarding the quality of markers and a higher probability of polymorphic markers in an important chromosomal interval. This map also offers the possibilities of thorough alignment for the (future) physical map and implementation in haplotype diversity studies of barley.

Congenital subglotic haemingiomas

Congenital subglottic haemingomas are rare however they are important treatable cause of infantile stridor and can be fatal unless treated. They present in a range of ways most noticeably with stridor in infancy period and as they enlarge they can threaten the airway. Thus they require urgent assessment and treatment. We present three cases of subglottic haemingiomas all of which represented different clinical management strategies. We review this interesting topic with discussion on presentation, treatment options and outcome.

6. DYADIC PERSPECTIVES ON SUPPORT FOR WOMEN LIVING WITH HIV/AIDS IN AUSTRALIA: AN EXPLORATORY STUDY

There are more women than ever living with HIV/AIDS in Australia and this relatively small heterogenous population has received scant research attention. Women living with HIV/AIDS, face many complex and compelling challenges in managing this stigmatised illness in their everyday lives. This study sought to gain an understanding of these women's support needs. Semi-structured, in-depth interviews were conducted with two groups: women living with HIV/AIDS (Sydney and Melbourne, involved and not in advocacy); and HIV specialists (Sydney and Melbourne) treating women living with HIV/AIDS. There was a consensus view among both specialists and women that women: have limited knowledge of HIV/AIDS; have no collective or historical understanding of HIV/AIDS; are more likely to present late with HIV; experience diagnosis as extremely distressing; are not aware of the resources available including medical treatments; and are more likely to experience social isolation. Both groups recognised the need for psychological and social support. HIV specialists questioned the effectiveness of community based peer support, while women identified this as one of the most important forms of support. HIV specialists differed in their knowledge and views of CBOs, and this influenced their decisions on recommending these to their female patients. The unique nature of this stigmatised illness calls for the recognition of the contributions of all parties in efforts to address these support needs; the women living with HIV/AIDS, HIV specialists and community based organisations. Particularly in light of the potential for social isolation, inquiries into social structures that provide the opportunity to access social resources are arguably a future direction to advance knowledge in this area.

Successful ex utero intrapartum treatment (EXIT) procedure for congenital high airway obstruction syndrome (CHAOS) owing to a large oropharyngeal teratoma

Large fetal neck masses can present a major challenge to securing an airway at birth, with associated risks of hypoxia, brain injury and death. The authors report a case of a giant oropharyngeal teratoma diagnosed in a fetus of 19 weeks gestation. The fetus was delivered by the ex utero intrapartum treatment procedure allowing sufficient time on placental support for bronchoscopy and tracheostomy to secure the airway. A multidisciplinary team approach combined with an accurate prenatal diagnosis obtained through fetal ultrasound was the key to a successful outcome. Unfortunately due to the large size of tumour and intracranial extension, the lesion was unresectable and the baby died 6 days after birth.

Individualized exercise program for the treatment of severe fatigue in patients after allogeneic hematopoietic stem-cell transplant: a pilot study

Chronic cancer-related fatigue in otherwise asymptomatic post-allogeneic hematopoietic stem cell transplant (HSCT) patients is common and debilitating. This pilot study investigated whether patients with no clinical or psychological abnormalities but severe fatigue would respond to an individually adapted aerobic exercise program. Participants were 12 patients (eight male, and four female patients), median age 47 years and 41 months post-HSCT with a variety of hematopoietic cancer diagnoses. All underwent a 12-week individualized mild aerobic exercise program, preceded by a 4-week introduction and baseline testing phase. Psychological measures included fatigue, mood and depression. Exercise-related physiological outcomes included power output at ventilatory threshold 2 (VT2) and associated changes in stroke volume, heart rate, blood lactate concentration and ratings of perceived exertion. Patients were assessed for fatigue before, immediately after and at 3, 6, 9 and 12 months post-program. Significant improvements were found on both measures of fatigue (both P<0.001), with a very large effect size of 1.82 on the The Functional Assessment of Cancer Therapy - Fatigue Module, which were maintained over the follow-up period. Exercise testing revealed a mean increase (P<0.001) of 28% in power output at VT2 with an increase (P<0.001) in stroke volume and a decrease (P<0.001) in heart rate, blood lactate and perceived exertion at pre-intervention VT2 power output.

Effect of complete response pre- and post- autologous stem cell transplantation in multiple myeloma

7604

Background: The value of achieving a complete response (CR) pre or post high dose therapy and autologous stem cell transplant (HDT-ASCT) in multiple myeloma is still uncertain. Knowing the impact of achieving a CR prior to HDT-ASCT on survival, may lead to the incorporation of novel therapeutic agents into the front line treatment of this disease. The aim of our study was to determine whether achieving a CR before or after HDT-ASCT affects overall survival (OS) in multiple myeloma patients. Methods: We performed a retrospective analysis of 88 consecutive myeloma patients receiving HDT-ASCT at our center from 1993 to 2004. The OS of patients achieving at least 90% reduction in their M-protein, i.e. complete response and very good partial response (CR/VGPR), pre or post HDT-ASCT, was compared to that of patients achieving a partial response or less (<90% reduction in M-protein). OS, defined as the number of months from HDT-ASCT to death or last follow up, was estimated by the Kaplan-Meier method. Response status was evaluated pre and at 100 days post HDT-ASCT. Results: Prior to HDT-ASCT, twenty-two (25%) patients achieved a CR/VGPR. Median follow-up time was 39 months for patients in CR/VGPR and 18 months for non-CR/VGPR group. OS at 5 years was 58% (95% CI: 21%-82%) for patients in CR/VGPR, compared to 69% (95% CI: 51%-81%) for all patients in PR or less prior to stem cell collection. Post HDT-ASCT, 48 (55%) patients achieved a CR/VGPR. Their OS estimate at 5 years was 67% (95% CI: 44%-82%) compared to 71% (95% CI: 27%-92%) for all other patients. Overall, 30% more patients achieved CR/VGPR post HDT-ASCT. However, the survival curves did not differ by response status pre or post HDT-ASCT (log-rank test p=0.58 and 0.57 respectively). Conclusions: Our results suggest that achieving a clinical CR/VGPR pre or post HDT-ASCT does not appear to impact OS. These results might have been influenced by the small sample size and the possible need for a longer follow-up time. A more robust definition of CR at the molecular level, plus the use of novel therapeutic agents in front-line treatment, may better define the impact of achieving CR in multiple myeloma.

No significant financial relationships to disclose.

Mechanisms underlying the anti-inflammatory actions of boswellic acid derivatives in experimental colitis

Recent clinical trials of the gum resin of Boswellia serrata have shown promising results in patients with ulcerative colitis. The objective of this study was to determine whether a semisynthetic form of acetyl-11-keto-beta-boswellic acid (sAKBA), the most potent anti-inflammatory component of the resin, also confers protection in experimental murine colitis induced by dextran sodium sulfate (DSS) to compare its effects with those standard medications of ulcerative colitis like steroids and to examine whether leukocyte-endothelial cell adhesion is a major target of action of sAKBA. Clinical measurements of disease activity and histology were used to assess disease progression, and intravital microscopy was employed to monitor the adhesion of leukocytes and platelets in postcapillary venules of the inflamed colon. sAKBA treatment significantly blunted disease activity as assessed both grossly and by histology. Similarly, the recruitment of adherent leukocytes and platelets into inflamed colonic venules was profoundly reduced in mice treated with sAKBA. Because previous studies in the DSS model have shown that P-selectin mediates these blood cell-endothelial cell interactions, the expression of P-selectin in the colonic microcirculation was monitored using the dual-radiolabeled antibody technique. The treatment of established colitis with sAKBA largely prevented the P-selectin upregulation normally associated with DSS colitis. All of the protective responses observed with sAKBA were comparable to that realized in mice treated with a corticosteroid. Our findings demonstrated an anti-inflammatory effect of sAKBA and indicated that P-selectin-mediated recruitment of inflammatory cells is a major site of action for this novel anti-inflammatory agent.

Narrative methods in quality improvement research

This paper reviews and critiques the different approaches to the use of narrative in quality improvement research. The defining characteristics of narrative are chronology (unfolding over time); emplotment (the literary juxtaposing of actions and events in an implicitly causal sequence); trouble (that is, harm or the risk of harm); and embeddedness (the personal story nests within a particular social, historical and organisational context). Stories are about purposeful action unfolding in the face of trouble and, as such, have much to offer quality improvement researchers. But the quality improvement report (a story about efforts to implement change), which is common, must be distinguished carefully from narrative based quality improvement research (focused systematic enquiry that uses narrative methods to generate new knowledge), which is currently none. We distinguish four approaches to the use of narrative in quality improvement research--narrative interview; naturalistic story gathering; organisational case study; and collective sense-making--and offer a rationale, describe how data can be collected and analysed, and discuss the strengths and limitations of each using examples from the quality improvement literature. Narrative research raises epistemological questions about the nature of narrative truth (characterised by sense-making and emotional impact rather than scientific objectivity), which has implications for how rigour should be defined (and how it might be achieved) in this type of research. We offer some provisional guidance for distinguishing high quality narrative research in a quality improvement setting from other forms of narrative account such as report, anecdote, and journalism.