Reboxetine augmentation of SSRI treatment for depression: Six-week naturalistic outcomes

Introduction

Antidepressants that combine serotonergic (SSRI) and noradrenergic (NaRI) actions may have greater efficacy in treating depression than SSRI monotherapy. This theory has not been tested in any trials examining augmentation of SSRIs with a NaRI.

Objectives

Does augmenting SSRIs with reboxetine, a NaRI, in depressed patients unresponsive to first line treatment, result in improved antidepressant efficacy?

Methods

In a naturalistic observational study, 30 patients with moderate to severe depression (ICD-10) who failed to respond to at least 20 mg of a SSRI, were augmented with reboxetine (4 mg increased to 8 mg if tolerated). BDI-II was measured before and 6 weeks after introduction of reboxetine. Changes in BDI scores were analysed using paired t-test.

Results

20 out of 30 patients were able to tolerate the combination of SSRI and reboxetine treatment for at least 6 weeks. There was a significant reduction in mean BDI-II scores from 36.6 at baseline to 27.2 at six weeks follow-up (t = 4.13, df = 29, p < 0.001). 13 out of 30 previously unresponsive patients showed a response (reduction in BDI score of at least 10 points) to combination treatment, with 5 patients achieving remission (BDI < 12) over the six weeks.

Conclusions

Reboxetine augmentation of SSRIs can be tolerated by a majority of patients and results in a significant increase in response rates. It is a treatment strategy that should be considered in patients with moderate to severe depression who fail to respond to first line treatment with an SSRI.

Litylenchus coprosma gen. n., sp. n. (Tylenchida: Anguinata), from leaves of Coprosma repens (Rubiaceae) in New Zealand

Abstract

A new genus and species of anguinid nematode, Litylenchus coprosma gen. n., sp. n., was recovered from leaves of Coprosma repens A. Rich. from an amenity planting in Wellington, New Zealand. The genus is characterised by having slender males and slender or semi-obese females, pharynx with a weak non-muscular median bulb, a terminal bulb containing the pharyngeal glands, female with a single gonad having a quadricolumella and post-uterine sac; male with arcuate spicules and the bursa arising 1-2 anal body diam. anterior to the cloacal aperture and extending nearly to the tail tip, and does not induce galls, only foliar chlorosis. The species is characterised by having a short, robust stylet with conus forming ca 40% of stylet length and three well developed rounded knobs, secretory/excretory pore opening posterior to the nerve ring, terminal bulb abutting the intestine, and tail tip of variable form. Molecular phylogeny of near full length small subunit, D2/D3 expansion segments of the large subunit and internal transcribed spacer rRNA genes support the description of L. coprosma gen. n., sp. n. as a new genus and species.

Teratodiplogaster fignewmani gen. nov., sp. nov. (Nematoda: Diplogastridae) from the syconia of Ficus racemose in Australia

During the course of a survey of fig-associated nematodes in eastern Australia, we discovered an unusual diplogastrid nematode that we describe herein as Teratodiplogaster fignewmani gen. nov., sp. nov. This nematode was isolated as adults and juveniles from the syconia of Ficus racemose in Queensland and Western Australia. It is presumed to be associated with the agaonid fig wasp, Ceratosolen fusciceps, for dispersion to new phase-B sycones. Teratodiplogaster fignewmani gen. nov., sp. nov. was inferred to be the sister taxon to the genus Parasitodiplogaster based upon molecular phylogeny using nearly full-length sequences of the SSU and D2/D3 LSU ribosomal RNA genes. It is sufficiently distinct in morphology (with many autapomorphies) to justify a new monotypic genus with the hypothesis that further species of Teratodiplogaster gen. nov. will be discovered when sycones from other Ficus from tropical Australasia and possibly Africa are sampled.

Schistonchus (Aphelenchoididae) from Ficus (Moraceae) in Australia, with description of S. aculeata sp. n

Abstract

A checklist of Schistonchus collected from Ficus spp. in Australia and stored in the Waite Nematode Collection at the University of Adelaide is presented. Within Australia, Schistonchus contains 12 morphospecies and four nominal species, based on a combination of the following characters: body shape when heat-relaxed, position of excretory pore, length of post-uterine sac, spicule form, and number and position of caudal papillae. Up to four morphospecies of Schistonchus have been collected from one species of Ficus and, in several cases, one morphospecies of Schistonchus has been collected from more than one host fig species. A phylogenetic tree based on D2/D3 sequences showed that Australian collections of Schistonchus fall into two clades, suggestive of endemic and introduced lineages with host switching. Schistonchus aculeata sp. n. is described from F. aculeata and F. opposita and differentiated from other species of Schistonchus by having the excretory pore opening near the lips, a short post-uterine sac, rosethorn-shaped spicules, arcuate gubernaculum or thickening of dorsal wall, amoeboid sperm, and three pairs of caudal papillae (one pair adcloacal, one just posterior to mid-tail, and one near the tail tip), association with Kradibia spp. pollinating wasps and apparent biogeographical range. A key to the known species and morphospecies of Schistonchus from Australia is presented.

Schistonchus virens sp. n. (Aphelenchoididae) and Parasitodiplogaster australis sp. n. (Diplogastridae) from Ficus virens (Moraceae) in Australia

Abstract

A new species each of Schistonchus and Parasitodiplogaster were recovered from the sycones of Ficus virens from St Lucia, Brisbane, QLD, Australia. This is also the first record of Parasitodiplogaster from Australia. The species are described here as Schistonchus virens sp. n. and Parasitodiplogaster australis sp. n. Schistonchus virens sp. n. is differentiated from other species of the genus by a combination of morphological characters, including C-shaped females and males, excretory pore opening located near the head, a short post-vulval uterine sac, rose-thorn-shaped spicule, amoeboid sperm, no gubernaculum, three pairs of subventral papillae on the male tail, DNA sequence data; biogeographical range and host wasp and Ficus species affiliation. Parasitodiplogaster australis sp. n. is differentiated from all other species of the genus by having females with only one gonad, males with C-shaped spicules with an arcuate, slender gubernaculum, characteristic arrangement of the male caudal papillae and DNA sequence data. The generic diagnosis of Parasitodiplogaster is emended to include loss of a female gonad.

Ficotylus congestae gen. n., sp. n. (Anguinata), from Ficus congesta (Moraceae) sycones in Australia

Abstract

A new monotypic genus of tylenchid nematode, Ficotylus n. gen., was recovered from sycones of Ficus congesta L. from Mourilyan, Mission Beach and Cairns, Queensland, Australia. The genus is characterised by having slender nematodes with a long stylet, a sub-cylindrical pharynx lacking a terminal bulb, pharyngeal glands overlapping the intestine for a short distance, secretory/excretory pore opening posterior to the nerve ring, female with a single gonad and post-vulval sac and male with slender, arcuate, cephalated spicules with the bursa arising near the proximal level of the retracted spicule and supported by a pair of papilla-like structures at its widest point. This is the first record of a tylenchid occurring within Ficus sycones. Ficotylus congestae gen. n., sp. n. is distinguished by possessing a long stylet (29-39 μm) with conus forming ca 40% of stylet length and three well developed bifid knobs at the base of the shaft, a degenerate pharynx with a vestigial metacorpus (no valve) and no basal bulb, females with a post-vulval uterine sac and males with a characteristic bursa supported by a pair of papilla-like structures at its widest point, then narrowing rapidly and just enveloping tail. Ficotylus congestae gen. n., sp. n. is a putative member of the Anguinata (sensu Siddiqi, 1985), based on molecular phylogeny of near full length SSU and D2/D3 expansion segments of the large subunit (LSU) rDNA. Morphologically, it has affinities with the superfamily Sphaerularioidea, family Neotylenchidae, where it is tentatively placed.

Phase I evaluation of CDP791, a PEGylated di-Fab' conjugate that binds vascular endothelial growth factor receptor 2

PURPOSE

Specific blocking of vascular endothelial growth factor receptor 2 (VEGFR-2) is a novel therapeutic approach. Here, we report the first phase I clinical trial evaluation of CDP791, a PEGylated di-Fab' conjugate that binds VEGFR-2.

EXPERIMENTAL DESIGN

Cohorts of patients received CDP791 at doses between 0.3 and 30 mg/kg every 3 weeks for the initial two doses.

RESULTS

The compound was well tolerated with no dose-limiting toxicity. Dose-related hypertension was observed in patients receiving CDP791 10 mg/kg or more and several patients on the higher doses developed infusion-related cutaneous hemangiomata arising 28 to 106 days after the first drug administration and resolving 3 weeks after cessation. Biopsy and histologic evaluation showed that CDP791-bound VEGFR-2 is non-phosphorylated, suggesting that the drug is biologically active. Concentrations of CDP791 considered biologically relevant were sustained for 3 weeks when doses of 10 mg/kg or more were administered. Although no reductions in vascular permeability were recorded using dynamic contrast enhanced magnetic resonance imaging (DCE-MRI), there was a significant dose level-related reduction in tumor growth. While challenging the recent dogma that active VEGF inhibitors should modulate DCE-MRI measurements of vascular permeability, this highlights the potential of serial three-dimensional tumor measurements to detect tumor growth arrest. Twelve patients received drug for more than two treatments, although no partial or complete responses were seen.

CONCLUSION

The data show that CDP791 is biologically active and well tolerated, achieving appropriate plasma concentrations when administered at 10 mg/kg or more every 3 weeks.

Surveillance of primary antibiotic resistance of Helicobacter pylori at centres in England and Wales over a six-year period (2000-2005)

Antibiotic resistance is a key factor in the failure of Helicobacter pylori eradication therapy, yet few sentinel schemes exist to monitor trends in resistance at local, national or international levels. This study aimed, over a six-year period, to monitor resistance levels of H. pylori in England and Wales to the four antibiotics used in its treatment. A total of 1,310 isolates from Gwynedd in north Wales and from mid-Essex in south-east England were collected from 2000 to 2005 and tested for susceptibilities to metronidazole, clarithromycin, amoxicillin and tetracycline. Overall, metronidazole and clarithromycin resistance rates were 28.6% and 8.3% in Gwynedd and significantly higher (36.3%, p=0.0031, and 12.7%, p=0.0112) in mid-Essex. Rates of resistance to metronidazole and clarithromycin increased in both areas over this six-year period. Resistance rates were higher in female compared with male patients (38.1% vs 26.6% for metronidazole, p<0.0001, and 12.9% vs 7.5% for clarithromycin, p=0.0024), and were higher in patients <45 years compared with those ?45 years (44.0% vs 29.0% for metronidazole, p=0.0002, and 15.0% vs 9.4% for clarithromycin, p=0.0233). This study highlights the importance of antibiotic resistance surveillance in H. pylori for providing information on local resistance rates for test and treat strategies.

An investigation of the decontamination of Siqveland matrix bands

OBJECTIVES

This study investigated blood contamination of artificially and clinically contaminated Siqveland matrix bands and retainers. A modified version of the recognised Kastle-Meyer test for blood was used to compare the efficacy of enzymatic agents, a washer-disinfector and an instrument washer for pre-sterilisation cleaning of Siqveland matrix bands and retainers.

METHODS

Assembled Siqveland matrix bands were contaminated either artificially with horse blood or clinically during dental treatment. Contaminated assembled matrix bands and retainers were subjected to immersion in an enzymatic agent, automated processing in a washer-disinfector or instrument washer, or a combination of pre-soaking and automatic cleaning. Residual blood contamination from each band and retainer was measured and compared to the volume of blood recovered from an unprocessed control group of contaminated assembled matrix bands or retainers.

RESULTS

Residual blood was recovered from every clinically contaminated assembled Siqveland matrix band and retainer. The volume of blood recovered from assembled Siqveland matrix bands ranged from 0.13-7.1 microl and from retainers, following removal of the matrix band, from 0.001-1.523 microl. The most effective method of pre-sterilisation cleaning for artificially contaminated assembled matrix bands was processing in the washer-disinfector. Conversely, the most effective method for cleaning clinically contaminated assembled matrix bands and retainers was pre-soaking in an enzymatic agent followed by a heavy-duty cycle in an instrument washer.

CONCLUSIONS

It is not possible to clean assembled Siqveland matrix bands using any method currently available to dental practitioners. Matrix bands should be discarded after use on one patient. Once the band is removed, all detectable blood can be removed from the retainer by pre-soaking in an enzymatic detergent followed by processing in an instrument washer.

Cosegregation of a novel homozygous CYP11B1 mutation with the phenotype of non-classical congenital adrenal hyperplasia in a consanguineous family

We report a novel missense mutation of CYP11B1 causing non-classical 11beta-hydroxylase deficiency in 3 members of a consanguineous Turkish family. Two siblings presented with clinical evidence of precocious pseudopubarche. Biochemistry suggested 11beta-hydroxylase deficiency and genetic analysis revealed that they were homozygous for the missense mutation L489S within exon 9 of the CYP11B1 gene. The unaffected parents were heterozygotes for the same mutation. In addition, a paternal aunt of the affected siblings presenting with primary infertility and mild hirsutism was found to have the same homozygous mutation. This is the first report of a homozygous mutation in non-classical congenital adrenal hyperplasia that cosegregates with clinical phenotype. The significance of the missense mutation L489S in CYP11B1 is further supported by the conservation of leucine at position 489 in CYP11 genes in eleven other species. Molecular modelling of the enzyme suggests that the mutation L489S in CYP11B1 may alter the enzyme's substrate-binding affinity. These findings suggest that this homozygous mutation affects 11beta-hydroxylase function, resulting in the clinical features of non-classical adrenal hyperplasia in this family.

Joint hypermobility syndrome in childhood. A not so benign multisystem disorder?

OBJECTIVES

Joint hypermobility (JH) or "ligamentous laxity" is felt to be an underlying risk factor for many types of musculoskeletal presentation in paediatrics, and joint hypermobility syndrome (JHS) describes such disorders where symptoms become chronic, often more generalized and associated with functional impairment. Clinical features are felt to have much in common with more severe disorders, including Ehlers-Danlos syndrome (EDS), osteogenesis imperfecta and Marfan syndrome, although this has not been formally studied in children. We defined the clinical characteristics of all patients with joint hypermobility-related presentations seen from 1999 to 2002 in a tertiary referral paediatric rheumatology unit.

METHODS

Patients were identified and recruited from paediatric rheumatology clinic and ward, and a dedicated paediatric rheumatology hypermobility clinic at Great Ormond Street Hospital. Data were collected retrospectively on the patients from the paediatric rheumatology clinics (1999-2002) and prospectively on patients seen in the hypermobility clinic (2000-2002). Specifically, historical details of developmental milestones, musculoskeletal or soft tissue diagnoses and symptoms, and significant past medical history were recorded. Examination features sought included measurements of joint and soft tissue laxity, and associated conditions such as scoliosis, dysmorphic features, cardiac murmurs and eye problems.

RESULTS

One hundred and twenty-five children (64 females) were included on whom sufficient clinical data could be identified and who had clinical problems ascribed to JH present for longer than 3 months. Sixty-four were from the paediatric rheumatology clinic and 61 from the hypermobility clinic. No differences were found in any of the measures between the two populations and results are presented in a combined fashion. Three-quarters of referrals came from paediatricians and general practitioners but in only 10% was hypermobility recognized as a possible cause of joint complaint. The average age at onset of symptoms was 6.2 yr and age at diagnosis 9.0 yr, indicating a 2- to 3-yr delay in diagnosis. The major presenting complaint was arthralgia in 74%, abnormal gait in 10%, apparent joint deformity in 10% and back pain in 6%. Mean age at first walking was 15.0 months; 48% were considered "clumsy" and 36% as having poor coordination in early childhood. Twelve per cent had "clicky" hips at birth and 4% actual congenital dislocatable hip. Urinary tract infections were present in 13 and 6% of the female and male cases, respectively. Thirteen and 14%, respectively, had speech and learning difficulties diagnosed. A history of recurrent joint sprains was seen in 20% and actual subluxation/dislocation of joints in 10%. Forty per cent had experienced problems with handwriting tasks, 48% had major limitations of school-based physical education activities, 67% other physical activities and 41% had missed significant periods of schooling because of symptoms. Forty-three per cent described a history of easy bruising. Examination revealed that 94% scored > or =4/9 on the Beighton scale for generalized hypermobility, with knees (92%), elbows (87%), wrists (82%), hand metacarpophalangeal joints (79%), and ankles (75%) being most frequently involved.

CONCLUSIONS

JHS is poorly recognized in children with a long delay in the time to diagnosis. Although there is a referral bias towards joint symptoms, a surprisingly large proportion is associated with significant neuromuscular and motor development problems. Our patients with JHS also show many overlap features with genetic disorders such as EDS and Marfan syndrome. The delay in diagnosis results in poor control of pain and disruption of normal home life, schooling and physical activities. Knowledge of the diagnosis and simple interventions are likely to be highly effective in reducing the morbidity and cost to the health and social services.

Final adult height and body mass index after cure of paediatric Cushing's disease

OBJECTIVE

Linear growth data after cure of paediatric Cushing's disease (CD) have been reported infrequently. We evaluated final adult height (FH) and body mass index (BMI) in a cohort of paediatric patients treated successfully for CD.

PATIENTS AND METHODS

Fourteen patients (10 male, age range 6.4-16.6 years) fulfilled the diagnostic criteria for CD. All had had transsphenoidal surgery (TSS), combined with pituitary irradiation (RT) (45 Gy in 25 fractions) in six. All were cured (post-TSS cortisol < 50 nmol/l or mean cortisol post-RT < 150 nmol/l). Subjects analysed had bone ages at diagnosis of < 15 'years' (male) and < 13 'years' (female).

RESULTS

At diagnosis, height SDS was [mean (range)]-2.5 (-4.2 to -0.8) and body mass index (BMI) SDS +2.7 (0.8-5.1). Following cure, 13 patients had GH deficiency (peak GH < 20 mU/l) and were treated with hGH (+ GnRH analogue in four). Height SDS at FH (n = 10) or latest assessment (n = 4) was -1.3 (-3.9-0.2) and increased compared to diagnosis (P < 0.01). The difference between final or latest height SDS and target height SDS was -1.2 (-3.3-0.5), that is less (P < 0.01) than the difference between the height SDS at diagnosis and target height SDS of -2.4 (-3.9 to -0.5). At final height or latest assessment, BMI SDS was +1.7 (0.4-6.2), being decreased compared to diagnosis (P < 0.05) but greater than the normal population (P < 0.01).

CONCLUSION

Catch-up growth was demonstrated in paediatric patients cured from CD, with the majority achieving FH within target height range. Early diagnosis and treatment of GH deficiency is recommended to achieve optimal long-term growth. Excess adiposity remains a potential long-term complication.

Joint hypermobility syndrome in childhood. A not so benign multisystem disorder?

OBJECTIVES

Joint hypermobility (JH) or "ligamentous laxity" is felt to be an underlying risk factor for many types of musculoskeletal presentation in paediatrics, and joint hypermobility syndrome (JHS) describes such disorders where symptoms become chronic, often more generalized and associated with functional impairment. Clinical features are felt to have much in common with more severe disorders, including Ehlers-Danlos syndrome (EDS), osteogenesis imperfecta and Marfan syndrome, although this has not been formally studied in children. We defined the clinical characteristics of all patients with joint hypermobility-related presentations seen from 1999 to 2002 in a tertiary referral paediatric rheumatology unit.

METHODS

Patients were identified and recruited from paediatric rheumatology clinic and ward, and a dedicated paediatric rheumatology hypermobility clinic at Great Ormond Street Hospital. Data were collected retrospectively on the patients from the paediatric rheumatology clinics (1999-2002) and prospectively on patients seen in the hypermobility clinic (2000-2002). Specifically, historical details of developmental milestones, musculoskeletal or soft tissue diagnoses and symptoms, and significant past medical history were recorded. Examination features sought included measurements of joint and soft tissue laxity, and associated conditions such as scoliosis, dysmorphic features, cardiac murmurs and eye problems.

RESULTS

One hundred and twenty-five children (64 females) were included on whom sufficient clinical data could be identified and who had clinical problems ascribed to JH present for longer than 3 months. Sixty-four were from the paediatric rheumatology clinic and 61 from the hypermobility clinic. No differences were found in any of the measures between the two populations and results are presented in a combined fashion. Three-quarters of referrals came from paediatricians and general practitioners but in only 10% was hypermobility recognized as a possible cause of joint complaint. The average age at onset of symptoms was 6.2 yr and age at diagnosis 9.0 yr, indicating a 2- to 3-yr delay in diagnosis. The major presenting complaint was arthralgia in 74%, abnormal gait in 10%, apparent joint deformity in 10% and back pain in 6%. Mean age at first walking was 15.0 months; 48% were considered "clumsy" and 36% as having poor coordination in early childhood. Twelve per cent had "clicky" hips at birth and 4% actual congenital dislocatable hip. Urinary tract infections were present in 13 and 6% of the female and male cases, respectively. Thirteen and 14%, respectively, had speech and learning difficulties diagnosed. A history of recurrent joint sprains was seen in 20% and actual subluxation/dislocation of joints in 10%. Forty per cent had experienced problems with handwriting tasks, 48% had major limitations of school-based physical education activities, 67% other physical activities and 41% had missed significant periods of schooling because of symptoms. Forty-three per cent described a history of easy bruising. Examination revealed that 94% scored > or =4/9 on the Beighton scale for generalized hypermobility, with knees (92%), elbows (87%), wrists (82%), hand metacarpophalangeal joints (79%), and ankles (75%) being most frequently involved.

CONCLUSIONS

JHS is poorly recognized in children with a long delay in the time to diagnosis. Although there is a referral bias towards joint symptoms, a surprisingly large proportion is associated with significant neuromuscular and motor development problems. Our patients with JHS also show many overlap features with genetic disorders such as EDS and Marfan syndrome. The delay in diagnosis results in poor control of pain and disruption of normal home life, schooling and physical activities. Knowledge of the diagnosis and simple interventions are likely to be highly effective in reducing the morbidity and cost to the health and social services.

Blockade of platelet-derived growth factor receptor-beta by CDP860, a humanized, PEGylated di-Fab', leads to fluid accumulation and is associated with increased tumor vascularized volume

PURPOSE

CDP860 is an engineered Fab' fragment-polyethylene glycol conjugate, which binds to and blocks the activity of the beta-subunit of the platelet-derived growth factor receptor (PDGFR-beta). Studies in animals have suggested that PDGFR-beta inhibition reduces tumor interstitial fluid pressure, and thus increases the uptake of concomitantly administered drugs. The purpose of this study was to determine whether changes in tumor vascular parameters could be detected in humans, and to assess whether CDP860 would be likely to increase the uptake of a concurrently administered small molecule in future studies.

PATIENTS AND METHODS

Patients with advanced ovarian or colorectal cancer and good performance status received intravenous infusions of CDP860 on days 0 and 28. Patients had serial dynamic contrast-enhanced magnetic resonance imaging studies to measure changes in tumor vascular parameters.

RESULTS

Three of eight patients developed significant ascites, and seven of eight showed evidence of fluid retention. In some patients, the ratio of vascular volume to total tumor volume increased significantly (P < .001) within 24 hours following CDP860 administration, an effect suggestive of recruitment of previously non-functioning vessels.

CONCLUSION

These observations suggest that inhibition of PDGFR-beta might improve delivery of a concurrently administered therapy. However, in cancer patients, further exploration of the dosing regimen of CDP860 is required to dissociate adverse effects from beneficial effects. The findings challenge the view that inhibition of PDGF alone is beneficial, and confirm that effects of PDGFR kinase inhibition mediate, to some extent, the fluid retention observed in patients treated with mixed tyrosine kinase inhibitors.