Subtyping depression: testing algorithms and identification of a tiered model

We seek to distinguish psychotic, melancholic, and nonmelancholic depression by clinical features and to test varying algorithm models to determine optimal criteria sets. We report a study of 269 depressed inpatients and outpatients. A latent class analysis (LCA) of 16 clinical features allowed for specificity or overrepresentation of features to be examined across the three classes. Varying algorithm models for distinguishing melancholic and nonmelancholic depression, involving endogeneity symptoms and observer-rated psychomotor disturbance (PMD) were compared. Psychotic depression was readily distinguished by the specific presence of psychotic features, and PMD was most severe in this class. Melancholic depression was most clearly distinguished from the residual nonmelancholic class by the presence of PMD. Although some endogeneity symptoms were overrepresented in the melancholic class, their specificity was unimpressive. An algorithm involving PMD components alone was highly efficient in discriminating LCA classes and, more importantly, superior to DSM-IV decision rules when examined against a range of clinical validators of melancholia. Subtyping appears assisted by a hierarchical model, based on a small set of features. The move from nonmelancholic to melancholic depression appears defined by a tier of observably rated PMD, whereas the move from melancholic to psychotic depression is determined by a tier of psychotic features and contributed to by significantly higher levels of PMD.

Psychological predictors of single and recurrent major depressive episodes

AIM

To examine for differential psychological risk factors in a nonclinical sample having single or recurrent episodes of major depression.

METHODS

A cohort of 164 subjects was assessed initially in 1978 in their last year of teacher training, and at five-yearly intervals in 1983, 1988 and 1993. Experience of episodes of DSM major depression and anxiety disorders from each wave were summed and three groups (nil, one, and two or more episodes of major depression) were derived. The cohort also completed a series of self-report measures including neuroticism, state and trait depression, self-esteem, dependency, childhood parental environment and social support.

RESULTS

The group with two or more episodes were distinctly more likely to have met lifetime criteria for an anxiety disorder and to have had multiple anxiety disorder diagnoses over their lifetime. Groups with one or more episodes reported higher mean scores for trait depression, neuroticism and maternal overprotection and lower mean scores for paternal care and self esteem at baseline in 1978, but these variables did not predict differences between groups with single and recurrent episodes. At 1993, those with two or more episodes differed from those with none and single episodes in reporting lower trait depression scores and decreased perception of satisfactory social support over time, suggesting a psychological scarring effect for those with repeated episodes.

[Relation of necrosis to outcome and site of fracture in scaphoid pseudarthrosis]

Usually, untreated scaphoid fractures lead to non-union and partial or complete avascular necrosis. The purpose of our study was to examine the influence of location and fracture line on the pattern of necrosis. Therefore, 85 patients with scaphoid non-union were examined by enhanced highfield MRI. Fractures were classified by location and fracture line. A staging system based on signal intensity in T1-weighted spin-echo sequences in enhanced MRI was used to evaluate extent and location of avascular necrosis, which was found in 81% of our patients. In our patients, viability of the scaphoid was independent of the fracture line without dominance of vertical oblique fractures (2%). Based on our staging system, signal intensity as a sign of fragment viability was reduced in the proximal fragment in 46 patients, whereas in eight patients the distal fragment showed reduced viability. In 26 patients, no difference was found between proximal and distal fragments. Fractures proximal to the transition of middle to distal third showed less viability of the proximal fragment, not dependent of how proximal the fracture was seen. In triple fractures (6%) signal intensity of scaphoid bone was more reduced in enhanced MRI.

[Scaphoid pseudarthrosis of the proximal third--results of treatment with the Herbert screw]

Purpose of this study was to assess the value of the Herbert screw used with iliac crest cancellous bone graft for treatment of scaphoid nonunion in the proximal third. From 1986 to 1996, 75 patients underwent this procedure. We followed-up on 67 of them using the Martini score, which covers pain, grip strength and social activities, range of motion, X-ray results, individual, clinical and overall assessment. We found 57 patients (85.1%) with a good to excellent outcome, eight patients (11.9%) with satisfactory results and two patients with a poor result. We conclude that the Herbert screw with or without cancellous bone graft should be the first choice for surgical treatment of non-union located in the proximal third of the scaphoid bone.

Sub-grouping non-melancholic depression from manifest clinical features

AIM

To determine whether clinical symptoms manifested during an episode of major depression are sufficient to allow meaningful sub-groups of non-melancholic depression to be identified.

METHODS

A sample of 178 non-melancholic patients with a major depressive episode was studied. The initial set of clinical variables was refined to 38 (21 depression, 17 anxiety) items and a cluster analysis undertaken.

RESULTS

A four-cluster solution identified 'anxiety', 'irritability', 'depressed mood' and 'residual' clusters, with these labels clarified by reference to a large data bank of non-symptomatic variables. These analyses suggested that members of the first two clusters could be viewed as having spectrum conditions (whereby Axis I symptom states are able to be linked with precursor or prodromal states and personality).

CONCLUSIONS

We confirm the long-standing suggestion that the non-melancholic depressive class contains sub-groups of those with manifest states of anxious depression and of an irritable or 'hostile' depression, and that such manifest symptoms are likely to be rooted in and fed by temperament and personality characteristics. The delineation of such sub-groups should assist studies designed to identify underlying neurobiological underpinnings and clinical management of the non-melancholic depressive disorders.

Sub-grouping non-melancholic major depression using both clinical and aetiological features

OBJECTIVE

In previous papers we have considered the extent to which two contrasting analytic approaches, examining reported clinical symptom variables alone and aetiological variables alone, assist definition of subgroups of non-melancholic major depression. Here, we address the same objective but combine both sets of variables, and contrast the combined solution with each of the contributing ones.

METHOD

We study a sample of 185 subjects with a putative non-melancholic major depressive disorder, with analyses involving 13 aetiological and 38 symptom variables.

RESULTS

A four-class subgrouping was derived by use of a cluster analytic technique, with 'neurotic depression', non-anxious 'depressed', 'situational' and 'residual' groups. The largest group comprised 'neurotic depression' subjects, with characteristics compatible with a spectrum disorder encompassing both clinical features as well as an underlying temperament and personality style marked by anxiety.

CONCLUSIONS

Comparative advantages and properties of the three differing analytic approaches to defining 'meaningful' non-melancholic major depressive subgroupings are considered. As a 'neurotic depressive' class has been consistently identified across those three approaches, but with quite varying numbers of subjects circumscribed, it is clearly a 'fuzzy' entity which may benefit from a dimensional approach to its measurement. As many of the non-melancholic groupings appear secondary to a substantive predisposing factor such as anxiety or disordered personality functioning, the clinical importance and treatment utility in identifying and circumscribing such classes are clearly supported.

The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy

We assessed the value of three-compartment magnetic resonance (MR) wrist arthrography in comparison with non-enhanced magnetic resonance imaging (MRI) for the evaluation of 13 individual wrist ligaments in 35 patients with refractory wrist pain. In 20 of these patients MR findings were correlated with the findings from multiportal wrist arthroscopy. For MR imaging (1.5-T magnet) a three-dimensional volume acquisition with a gradient-recalled echo sequence and 0.6-1.0 mm effective slice thickness was used. The delineation of individual wrist ligaments was rated as "good" in 10% of non-enhanced MR and 90% of MR arthrography images. Ligament evaluation was possible with high diagnostic confidence in 11% by non-enhanced MR imaging and 90% by MR arthrography. With wrist arthroscopy as the standard of reference, average sensitivities/specificities/accuracies for the diagnosis of full-thickness ligamentous defects were 0.81/0.75/0.77 for non-enhanced MR imaging and 0.97/0.96/0.96 for MR arthrography. Our findings suggest that MR arthrography is more accurate than standard MRI in delineating and evaluating the ligaments of the wrist.

Characteristics of depressed patients who report childhood sexual abuse

OBJECTIVE

Depressed patients who had and had not been exposed to childhood sexual abuse were studied to determine differences in severity of depressed mood, lifetime histories of anxiety and depression, childhood environment, and disordered personality function.

METHOD

Data were obtained from 269 inpatients and outpatients with major depression (171 women and 98 men) by means of structured clinical interviews and self-report questionnaires.

RESULTS

Forty-six of the 269 patients reported childhood sexual abuse; 40 of these were women. These 40 women were compared with the 131 who did not report childhood sexual abuse. The patients who experienced abuse did not differ from those who had not on psychiatrist-rated mood severity estimates, but they did have higher self-report depression scores. They also evidenced more self-destructive behavior, more personality dysfunction, and more overall adversity in their childhood environment. Childhood sexual abuse status was associated with more borderline personality characteristics independently of other negative aspects of the patients' earlier parenting. Childhood sexual abuse status was linked strongly to adult self-destructiveness, as was early exposure to maternal indifference.

CONCLUSIONS

Multivariate analyses suggest that depression is unlikely to be a direct consequence of childhood sexual abuse. Childhood sexual abuse appears to be associated with a greater chance of having experienced a broadly dysfunctional childhood home environment, a greater chance of having a borderline personality style, and, in turn, a greater chance of experiencing depression in adulthood.

Solar wind outflow and the chromospheric magnetic network

Observations of outflow velocities in coronal holes (regions of open coronal magnetic field) have recently been obtained with the Solar and Heliospheric Observatory (SOHO) spacecraft. Velocity maps of Ne7+ from its bright resonance line at 770 angstroms, formed at the base of the corona, show a relationship between outflow velocity and chromospheric magnetic network structure, suggesting that the solar wind is rooted at its base to this structure, emanating from localized regions along boundaries and boundary intersections of magnetic network cells. This apparent relation to the chromospheric magnetic network and the relatively large outflow velocity signatures will improve understanding of the complex structure and dynamics at the base of the corona and the source region of the solar wind.

[MRI diagnosis of cardiac myxomas: sequence evaluation and differential diagnosis]

PURPOSE

To evaluate native and contrast enhanced T1-weighted spin (T1-SE), cine gradient echo (Cine-GE), and T2-weighted turbo spin (T2-TSE) sequences in the diagnosis and differential diagnosis of cardiac myxomas.

METHODS

15 patients with echocardiographically suspected cardiac atrial myxomas underwent 0.5 T-MR imaging of the heart with native T1-SE, contrast-enhanced T1-SE, Cine-GE, and T2-TSE sequences. MR images were evaluated for signal intensity (SI) and lesion's conspicuity. Results were confirmed histologically (14 x) or by follow-up (1 x).

RESULTS

MRI revealed myxomas in 9 patients, sarcomas in three patients, and thrombi in three patients. Lesion conspicuity was better in Cine-GE and T2-TSE compared with native and contrast-enhanced T1-SE sequences. Myxomas were characterized by an intermediate SI similar to myocardium in T1-SE, high SI similar to water in T2-TSE, and low to moderately high enhancement (range 19-75%, mean 48%).

CONCLUSION

Distinct SI characteristics together with anatomical-topographical features (attachment to the interatrial septum, no infiltration of myocardium and vessels) are diagnostic for cardiac myxomas. Cine-GE and T2-TSE sequences are the sequences of choice for detection of myxomas and other atrial masses. T2-TSE and contrast-enhanced T1-weighted sequences are most useful for mass characterisation and differentiation between myxomas, malignant tumors, and thrombi.

[Independent radiologic prognostic factors for fatal outcome of ambulatory-acquired pneumonia requiring inpatient treatment]

PURPOSE

To evaluate the independent prognostic impact of the chest radiograph for mortality from community-acquired pneumonia requiring hospitalization.

METHODS

Chest radiographs of 67 patients with hospital-treated community-acquired pneumonia were analyzed with regard to the prognostic implications of radiographic patterns, extent and density of infiltrates, and its evolution during treatment.

RESULTS

Non-survivors had a significantly higher extent of infiltrates (p = 0.008), density of infiltrates (p = 0.05), and radiographic spread during follow-up within 48-75 hours (p = 0.0001). In multivariate analysis, persistent or progressive infiltrates were associated with a 47-fold increase, and persistent or progressive density of infiltrates with an 18-fold increase in risk of mortality. The presence of both parameters could correctly predict 96% of survivors and 90% of non-survivors.

CONCLUSIONS

The chest radiograph is an independent predictor of the severity of pneumonia. Both persistent or progressive infiltrates and persistent or progressive density of infiltrates are independently associated with mortality from community-acquired pneumonia.

[Variants of the hepatic artery: detection with color--coded sonography pre and post levovist injection]

PURPOSE

Detection of hepatic artery variants is of great clinical importance, for instance, pre liver transplantation, pre intraarterial chemotherapy or for measurement of the Doppler perfusion index. We therefore investigated how accurate variants of the hepatic artery can be detected using color-coded sonography pre and post Levovist injection.

MATERIALS AND METHODS

52 patients (21-78 years) were examined using color-coded sonography pre and post Levovist injection. After the sonographic examination, intraarterial digital subtraction angiography was performed and the results were compared.

RESULTS

Using angiography 14 variants of the hepatic artery were detected in 13 patients. The most common variant in 10 patients were hepatic arteries originating from the superior mesenteric artery. This could be detected with unenhanced color-coded sonography in 8 and with enhanced sonography in 9 patients. In one patient in addition, a hepatogastric trunk was noted by angiography, this was not recognized by sonography. In 2 patients with a hepatogastric trunk, this variant was sonographically seen after Levovist injection in both but with unenhanced sonography in only 1 patient.

CONCLUSION

Most variants of the arterial hepatic blood supply can be diagnosed using conventional color-coded sonography. In some cases enhanced sonography provides additional information, but even with these techniques all variations cannot be detected.

"Acting out" and "acting in" as behavioral responses to stress: a qualitative and quantitative study

In a sample of 270 depressed patients, we describe some behaviors in response to stress. One third acknowledged "acting out" behaviors--angry, destructive acts and "out of control" behaviors. Four fifths acknowledged "acting in" behaviors--most commonly withdrawal. As a percentage of subjects acknowledged both response styles (with alternate expression influenced by situation), we developed a dimensional self-report measure within a subsample of 177 who attended a follow-up reassessment. Assignment to four groups with contrasting expressions of "acting out" and "acting in" scores demonstrated differences in age, diagnostic status, age of onset of depression, and self-injurious behaviors.

Cognitive function in depression: a distinct pattern of frontal impairment in melancholia?

BACKGROUND

Although depressed patients demonstrate impaired performance on a range of neuropsychological tests, there is little research that examines either frontal cognitive deficits or possible differences in test performance between melancholic and non-melancholic subtypes.

METHODS

Depressed subjects were administered a broad neuropsychological battery. In an overall analysis, 77 depressed subjects were compared with 28 controls. In a second set of analyses, the depressed sample was divided into melancholic and non-melancholic subsets according to DSM-III-R, the CORE system and the Newcastle scale. These depressed subsets were contrasted to controls and with each other using ANCOVA controlling for age, IQ, simple reaction time and Hamilton Depression scores where appropriate.

RESULTS

The total depressed sample was impaired on most mnemonic tasks, simple reaction time and Trails B. Similar findings applied to DSM-III-R melancholic and non-melancholic subjects. When defined by the CORE and Newcastle (narrower definitions of melancholia), melancholic patients were additionally impaired on WCST (perseverative response) and (for Newcastle) digit symbol substitution. In contrast, the cognitive performance of the CORE and Newcastle-defined non-melancholic patients was largely unimpaired.

CONCLUSIONS

Using narrower definitions of melancholia, i.e. CORE and (in particular) Newcastle, melancholic patients were impaired on mnemonic tasks and tasks of selective attention, and set-shifting while non-melancholic subjects were largely unimpaired in their cognitive performance. These differences may be due to impairment of specific neuroanatomical regions in narrowly defined melancholic patients, in particular the anterior cingulate.

The influence of anxiety as a risk to early onset major depression

OBJECTIVE

we seek to identify and quantify any risk provided by several expressions of "anxiety" to major depression overall, and to separate melancholic and non-melancholic sub-types.

METHOD

a sample of 269 patients with a current major depressive episode was assessed for rates of separate formalised anxiety disorders, both for lifetime and prior to the initial depressive episode. We also sought for evidence of familial anxiety and, early childhood expression of anxiety forerunners, measured both state and trait anxiety levels as well as anxiety at a "personality" level, and assessed use of anxiolytic medications. Depressive sub-typing was undertaken using DSM-IV criteria, while "early onset" (EO) depression was defined as an initial onset at 25 years or less, and subsequently re-examined with a cut-off age of 20 years or less.

RESULTS

overall. 42% of our sample were assigned as having EO depression, with there being a higher representation of non-melancholic than melancholic EO subjects (i.e., 51% vs. 29%), arguing for sub-type status being respected in the analyses. For both melancholic and non-melancholic subjects two trait anxiety items ("tense"; "keyed up/on edge") were over-represented, suggesting that such a tense anxiety style may provide an antecedent risk to depression (of either sub-type) or be a consequence of depression. Specificity was most evident in the non-melancholic sub-sample, where EO depression was associated with a family history of anxiety, early childhood expressions of anxiety and with two lifetime anxiety disorders (social phobia and obsessive-compulsive disorder). Broadly similar results were returned when "EO" definition was reduced to 20 years or less.

CONCLUSIONS

our study is consistent with previous research in identifying anxiety in the form of social inhibition or social avoidance as being particularly likely to precede and perhaps be a conduit to early onset non-melancholic major depression. This conclusion both sharpens risk factor research and indicates an important fulcrum that could be used to assist primary prevention of the depressive disorders.

On modelling personality disorders: are personality style and disordered functioning independent or interdependent constructs?

Current descriptors of personality disorder (PD) are an amalgam of two constructs, personality style and/or disorder. We seek to determine whether their intrinsic personality style descriptors are proxy measures of, or independent of, disordered personality functioning. In a sample of depressed patients, psychiatrists rated 16 differing PD personality style vignettes and assessed eight differing manifestations of disordered functioning. When "personality" vignettes and identified personality clusters were intercorrelated with "disorder" variables, interdependence was generally evident, suggesting that the personality descriptors underpinning current definition of the PDs actually act as proxy criteria for assessing disorder because they are, in and of themselves, descriptors of pathological functioning. The obsessional personality vignette provided an exception, seeming to be independent of disordered function. Such results assist consideration of how best to model, define and measure the personality disorders.

Qualitative and quantitative analyses of a 'lock and key' hypothesis of depression

BACKGROUND

We examine a 'lock and key' ('L-K') hypothesis to depression which posits that early adverse experiences establish locks that are activated by keys mirroring the earlier adverse experience to induce depression.

METHODS

Two-hundred and seventy clinically depressed patients were examined with open-ended and pre-coded interview questions to ascertain both early adverse experiences and precipitating life events. Qualitative and quantitative data analyses examined for any associations between developmental 'locks' and precipitating 'keys'.

RESULTS

Qualitative assessment suggested 'L-K' links in almost one-third of the sample, and examples are provided. While quantitative analyses indicated significant associations between several identical 'lock' and 'key' constructs, evidence of specificity was rare. When individual 'locks' and 'keys' were consolidated into three higher-order constructs, variable models were suggested, including a non-specific link, a specific link and absence of any link. 'L-K' links appeared more likely in those with 'non-melancholic' (versus 'melancholic') depression, with the seemingly greater relevance to 'reactive' (versus 'neurotic') depression in the quantitative analyses inviting speculation that that 'disorder' may be more a reaction to a salient rather than a severe stressor.

CONCLUSIONS

This exploratory study suggests that early adverse experiences may variably establish specific and non-specific patterns of vulnerability to having depression triggered by exposure to salient mirroring life event stressors.

[Visualization of renal arteries and value of color-coded duplex sonography in renal artery stenoses using an ultrasound signal enhancing agent]

PURPOSE

To assess whether the use of an echo-enhancing agent reliably allows the diagnosis of renal artery stenosis with colour-coded Doppler sonography.

MATERIALS AND METHODS

We examined the main, segmental, and, if present, the accessory renal arteries of 31 patients before and after intravenous injection of Levovist using colour-coded Doppler sonography and compared the results with digital subtraction angiography. A rise in peak systolic velocity in the main renal artery and a reduction of the acceleration index in segmental arteries were used as parameters to detect renal artery stenosis.

RESULTS

After i.v. administration of Levovist the main stem of the renal arteries could be well delineated in 36 of 62 cases (58%) during colour-coded Doppler sonography against 31 cases without Levovist. Taking only the visible cases in account the sensitivity of native as well as of enhanced colour-coded Doppler sonography of the renal main stem was 100%, the specificity was 96% and 94%, respectively. Only one of 11 accessory renal arteries was identified after echo enhancement. The segmental arteries were seen only after echo enhancement in 12 cases so that 60 of the total of 62 renal arteries (95%) could be evaluated. The sensitivity and specificity of the native examination were 67% and 70%. After echo enhancement sensitivity was 75% and specificity was 81%.

CONCLUSION

Using an echo-enhancing agent the sensitivity and specificity for detection of relevant renal artery stenosis could only be slightly improved compared to the native examination.

Neural network subtyping of depression

OBJECTIVE

To examine the applicability of a neural network classification strategy to examine the independent contribution of psychomotor disturbance (PMD) and endogeneity symptoms to the DSM-III-R definition of melancholia.

METHOD

We studied 407 depressed patients with the clinical dataset comprising 17 endogeneity symptoms and the 18-item CORE measure of behaviourally rated PMD. A multilayer perception neural network was used to fit non-linear models of varying complexity. A linear discriminant function analysis was also used to generate a model for comparison with the non-linear models.

RESULTS

Models (linear and non-linear) using PMD items only and endogeneity symptoms only had similar rates of successful classification, while non-linear models combining both PMD and symptoms scores achieved the best classifications.

CONCLUSIONS

Our current non-linear model was superior to a linear analysis, a finding which may have wider application to psychiatric classification. Our non-linear analysis of depressive subtypes supports the binary view that melancholic and non-melancholic depression are separate clinical disorders rather than different forms of the same entity. This study illustrates how non-linear modelling with neural networks is a potentially fruitful approach to the study of the diagnostic taxonomy of psychiatric disorders and to clinical decision-making.

Non-melancholic depression: the contribution of personality, anxiety and life events to subclassification

BACKGROUND

We sought to develop a clinically useful subtyping system for the non-melancholic depressive disorders, and here we assess one weighted to central aetiological factors.

METHODS

We studied 185 patients meeting DSM-III-R and/or clinical criteria for non-melancholic depression. Data were obtained by self-report, interview of patients and from corroborative witnesses. We developed a set of variables for class definition, assessing: (i) 'P', disordered personality as a vulnerability factor; (ii) 'A', meeting criteria for a lifetime anxiety disorder or positive on probe questions about trait anxiety characteristics, so assessing anxiety as a vulnerability factor; and (iii) 'L', psychiatrist and consensually-rated life event stress prior to depression onset.

RESULTS

A latent class analysis generated a four-class solution for the P-A-L variables. Life event stressors had similar item probabilities across all four classes, and did not influence the four-class 'P-A' solution when deleted from the analysis, suggesting that life event stress may act more as a general provoking agent, rather than constituting any distinct 'reactive' or 'situational' depression class. Three classes generated clinically meaningful groupings, reflecting varying contributions of anxiety and disordered personality functioning, and with evidence of differential outcome over the following 12 months.

CONCLUSIONS

We suggest that a refined aetiologically-weighted model may assist definition of the non-melancholic depressive disorders, and provide the logic for exploring the comparative utility of differing treatments to identified vulnerability-based classes.

[Radiologic changes following cement-free implantation of hip prostheses. 5-year follow-up and clinical experience with the cement-free hip prosthesis Autophor-900-S]

PURPOSE

To evaluate early reliable radiographic signs of loosening in cementless total hip arthroplasty compared to clinical follow-up.

METHODS

Within a time interval of 5 years 89 patients with 101 hips underwent total hip arthroplasty using the Autophor 900 S-prosthesis. Clinical and radiographic follow-up were first performed retrospectively followed by a prospective investigation.

RESULTS

Radiographic evaluation showed prosthesis fixation in 93%. Loosening of the prosthesis was identified in 4 cases of the acetabular component and in 4 cases of the femoral stem. Pain was associated with radiographically detectable loosening of the cementless arthroplastic components in only two cases.

CONCLUSION

Within a follow-up period of up to five years, loosening of cementless total hip arthroplasty occurs in about 7%. The most reliable radiographic signs of loosening are complete radiolucent zones wider than 2 mm at the bone-component interface, progressive subsidence, migration, or tilt of the component. Pain and movement disorders are not specific symptoms and do not necessarily indicate a loosening of the prosthesis.

Pulmonary infiltrates in neutropenic patients with acute leukemia during chemotherapy: outcome and prognostic factors

STUDY OBJECTIVE

To determine predictors of mortality from pulmonary infiltrates in neutropenic patients with acute leukemia during chemotherapy, and the significance of those factors related to the underlying malignancy and its therapy as well as of those related to the severity of the illness associated with pulmonary infiltrates.

DESIGN

A historical cohort study.

SETTING

A university teaching hospital and tertiary referral center.

PATIENTS AND METHODS

Overall, 53 patients with neutropenia during chemotherapy and with first episodes of pulmonary infiltrates during a 4-year period were studied. Prognostic analysis included 38 variables. Multivariate analyses were performed by logistic regression.

RESULTS

The survival rate from pneumonia was 57% (30/53). The following eight parameters were significantly associated with death in univariate analysis: comorbidity present; development of "late" pulmonary infiltrates (> or = 14 days after hospital admission); heart rate > or = 100 beats/min; a ratio heart rate/systolic blood pressure (HR/SBP) > or = 1.2; urea nitrogen > 7 mmol/L; radiographic score > or = 3; neutropenia < 1.0x10(9)/L at the treatment end point; and failed complete remission. In a multivariate model including only parameters available at diagnosis of pulmonary infiltrates, the presence of a ratio HR/SBP > or = 1.2 and of a radiographic score > or = 3 remained independently associated with death. In a second model also including the evolutionary parameter neutropenia < or = 1.0x10(9)/L at the treatment end point, both parameters remained significant together with neutropenia <1.0x 10(9)/L at the treatment end point. The presence of a ratio HR/SBP > or = 1.2 was a strong marker of early death.

CONCLUSION

Both therapy- and malignancy-associated neutropenia as well as the severity of illness associated with pulmonary infiltrates are independent prognostic factors. Patients with a ratio HR/SBP > or = 1.2 at diagnosis of pulmonary infiltrates suffer from potentially reversible acute illness, are at risk for early death and, therefore, may be appropriate candidates for treatment in an ICU.

Radiometric Calibration Tracking of the Vacuum-Ultraviolet Spectrometer SUMER During the First Year of the SOHO Mission

Detailed radiometric calibration tracking of the vacuum-ultravioletspectrometer SUMER (from solar ultraviolet measurements of emittedradiation) was performed during the first year of the Solar andHeliospheric Observatory (SOHO) mission and will continue. Inview of the flight history of many previous solar UV instruments, thestability of calibration of the extreme-ultraviolet instruments on SOHOhas been a major concern. Results obtained during the first year ofoperation show that excellent radiometric stability has been achievedwith SUMER. These results were accomplished by stringentcleanliness and contamination-control procedures during all phases ofthe project. We describe the strategy and results of the in-flightcalibration tracking program performed with SUMER.

Male sterility and meiotic drive associated with sex chromosome rearrangements in Drosophila. Role of X-Y pairing

In Drosophila melanogaster, deletions of the pericentromeric X heterochromatin cause X-Y nondisjunction, reduced male fertility and distorted sperm recovery ratios (meiotic drive) in combination with a normal Y chromosome and interact with Y-autosome translocations (T(Y;A)) to cause complete male sterility. The pericentromeric heterochromatin has been shown to contain the male-specific X-Y meiotic pairing sites, which consist mostly of a 240-bp repeated sequence in the intergenic spacers (IGS) of the rDNA repeats. The experiments in this paper address the relationship between X-Y pairing failure and the meiotic drive and sterility effects of Xh deletions. X-linked insertions either of complete rDNA repeats or of rDNA fragments that contain the IGS were found to suppress X-Y nondisjunction and meiotic drive in Xh-/Y males, and to restore fertility to Xh-/T(Y;A) males for eight of nine tested Y-autosome translocations. rDNA fragments devoid of IGS repeats proved incapable of suppressing either meiotic drive or chromosomal sterility. These results indicate that the various spermatogenic disruptions associated with X heterochromatic deletions are all consequences of X-Y pairing failure. We interpret these findings in terms of a novel model in which misalignment of chromosomes triggers a checkpoint that acts by disabling the spermatids that derive from affected spermatocytes.

[Stress on the wrist joint in semilunar bone necrosis--a morphologic study in vivo]

The distribution of subchondral mineralization of the distal articular surface of the radius was examined by CT osteoabsorptiometry in both wrists of twelve patients showing different stages of Kienböck's disease. The pattern of density distribution had already been demonstrated in previous studies to be an adequate parameter for assessing axial loading across the wrist joint in the patients. Contrary to the anticipated presence of predominant stress in the lunate compartment, some patients showed identical stress in the compartment of the scaphoid, and the balanced loading of both compartments, as before. Even when in early stages of the disease the lunate type of mineralization appeared more often, it was still not possible to demonstrate general excessive stress on the lunate. We have therefore concluded that the main stress in the scaphoid compartment might be a secondary effect, which is to be regarded as the expression of the advancing destruction of the lunate and consequent loss of load transmission through this compartment. This hypothesis is also supported by the fact that, in progressive stages of Kienböck's disease, the density maximum in the fovea lunata, generally present in healthy people, is absent. Furthermore, in patients with necrosis of the lunate, the total mineralization in terms of the maximal density values in the distal joint surface of the radius is in the majority of cases less than in the normal subject. In two cases, even the density maximum was absent from the fovea lunata of the contralateral wrist joint, without there being any clinical signs suggesting a possible lunate necrosis on this side. We interpret these pathological changes in the unaffected wrist joint as a further indication that we are dealing with a congenital predisposition which affects both wrist joints.