Common and dissociable regional cerebral blood flow differences associate with dimensions of psychopathology across categorical diagnoses

The high comorbidity among neuropsychiatric disorders suggests a possible common neurobiological phenotype. Resting-state regional cerebral blood flow (CBF) can be measured noninvasively with magnetic resonance imaging (MRI) and abnormalities in regional CBF are present in many neuropsychiatric disorders. Regional CBF may also provide a useful biological marker across different types of psychopathology. To investigate CBF changes common across psychiatric disorders, we capitalized upon a sample of 1042 youths (ages 11-23 years) who completed cross-sectional imaging as part of the Philadelphia Neurodevelopmental Cohort. CBF at rest was quantified on a voxelwise basis using arterial spin labeled perfusion MRI at 3T. A dimensional measure of psychopathology was constructed using a bifactor model of item-level data from a psychiatric screening interview, which delineated four factors (fear, anxious-misery, psychosis and behavioral symptoms) plus a general factor: overall psychopathology. Overall psychopathology was associated with elevated perfusion in several regions including the right dorsal anterior cingulate cortex (ACC) and left rostral ACC. Furthermore, several clusters were associated with specific dimensions of psychopathology. Psychosis symptoms were related to reduced perfusion in the left frontal operculum and insula, whereas fear symptoms were associated with less perfusion in the right occipital/fusiform gyrus and left subgenual ACC. Follow-up functional connectivity analyses using resting-state functional MRI collected in the same participants revealed that overall psychopathology was associated with decreased connectivity between the dorsal ACC and bilateral caudate. Together, the results of this study demonstrate common and dissociable CBF abnormalities across neuropsychiatric disorders in youth.

Right frontal gamma and beta band enhancement while solving a spatial puzzle with insight

Solving a problem with an "a-ha" effect is known as insight. Unlike incremental problem solving, insight is sudden and unique, and the question about its distinct brain activity, intrigues many researchers. In this study, electroencephalogram signals were recorded from 12 right handed, human participants before (baseline) and while they solved a spatial puzzle known as the '10 coin puzzle' that could be solved incrementally or by insight. Participants responded as soon as they reached a solution and reported whether the process was incremental or by sudden insight. EEG activity was recorded from 19 scalp locations. We found significant differences between insight and incremental solvers in the Gamma and Beta 2 bands in frontal areas (F8) and in the alpha band in right temporal areas (T6). The right-frontal gamma indicates a process of restructuring which leads to an insight solution, in spatial problems, further suggesting a universal role of gamma in restructuring. These results further suggest that solving a spatial puzzle via insight requires exclusive brain areas and neurological-cognitive processes which may be important for meta-cognitive components of insight solutions, including attention and monitoring of the solution.

Recovery entails bridging the multiple realms of best practice: towards a more integrated approach to evidence-based clinical treatment and psychosocial disability support for mental health recovery

While mental health recovery is a very personal process, the approach also offers possibilities as a meta-framework for improving quality of services to support people with severe and enduring mental illness. This paper explores how a recovery paradigm offers opportunities to better understand how efforts within the personal, clinical, and psychosocial disability domains of well-being relate and need bridging and integration with an evidence-based framework of practice to optimise outcomes. Recovery from a severe and persisting mental illness such as schizophrenia is optimised by a holistic approach integrating the domains of clinical treatment and psychosocial rehabilitation with the personal efforts of individuals. For service providers, a monolithic or single paradigm approach with an exclusive or predominant biological, psychological, social, or cultural focus is unable to offer effective guidance on the treatment and rehabilitation support needed to enable community participation and ameliorate the impact which problems associated with mental illness have on individuals, their families, and their wider communities. Moreover, recovery-oriented services need to be effective, embracing evidence-based policy, practice and service delivery by providing treatment and support which actually work to improve outcomes for consumers and families.

A computerised third molar surgery simulator--results of supervision by different professionals

The purpose of the study was to investigate which supervisory approach afforded the most efficient learning method for undergraduate students in oral and maxillofacial surgery (OMS) using a computerised third molar surgery simulator. Fifth year dental students participated voluntarily in a randomised experimental study using the simulator. The amount of time required and the number of trials used by each student were evaluated as a measure of skills development. Students had the opportunity to practise the procedure until no further visible improvements were achieved. The study assessed four different types of supervision to guide the students. The first group was where they were supported by a teacher/specialist in OMS, the second by a teaching assistant, the third group practised without any supervision and the fourth received help from a simulator technician/engineer. A protocol describing assessment criteria was designed for this purpose, and a questionnaire was completed by all participating students after the study. The average number of attempts required to virtually remove a third molar tooth in the simulator was 1.44 times for the group supervised by an OMS teacher; 1.5 times for those supervised by a teaching assistant; 2.8 times for those who had no supervision; and 3.6 times when support was provided only by a simulator technician. The results showed that the most efficient experience of the students was when they were helped by an OMS teacher or a teaching assistant. In a time and cost-effective perspective, supervision by a teaching assistant for a third molar surgery simulator would be the optimal choice.

Nasogastric vs. intravenous rehydration in children with gastroenteritis and refusal to drink: a randomized controlled trial

BACKGROUND

Nasogastric rehydration therapy (NGRT) is the recommended therapy in moderately dehydrated children with gastroenteritis and refusal to drink, since it is supposed to be as effective if not better than intravenous rehydration therapy (IVRT). However, in clinical practice IVRT is often favored. We conducted a clinical trial to determine whether IVRT is not inferior to NGRT.

PATIENTS AND METHODS

Children 3 months to 6 years of age with moderate dehydration and refusal to drink secondary to gastroenteritis were recruited. After clinical assessment of the degree of dehydration, patients were assigned randomly to receive either IVRT or NGRT over 6 h on the hospital ward.

RESULTS

Recruitment did not yield the estimated number of patients. Mainly, non-enrollment was due to failure to obtain parental consent because IVRT was expected. 97 patients were enrolled in the study, 46 were randomized to NGRT and 51 to IVRT. There was no difference between IVRT and NGRT groups concerning length of hospital stay (2.2±1.1 days vs. 2.4±1.1 days), success of rehydration (78 vs. 76%) and adverse events.

DISCUSSION

Since we had to terminate the study ahead of schedule due to a low recruiting rate, our results are not reliable. However, data from the literature shows that the widespread described superiority of NGRT over IVRT is seriously influenced by studies from developing countries questioning the applicability of the results to a setting available in high-income countries nowadays.

CONCLUSION

Our study demonstrates the difficulties performing such a study in a high-income country to come to an objective and clearly evident final conclusion.

Long-term successful healing of ulcerated necrobiosis lipoidica after topical therapy with becaplermin

We report a case of chronic leg ulceration occurring in a patient with necrobiosis lipoidica (NL). After many topical treatments had failed to achieve healing, treatment with topical becaplermin was started, which resulted in rapid improvement and ultimately complete healing of the ulceration. Treatment of ulcerated NL is often disappointing. Many topical and systemic drugs have been tried. Becaplermin is a platelet-derived growth factor indicated for the treatment of neuropathic diabetic ulcers measuring < 50 mm in size. To our knowledge, this is only the second case reported in the literature of ulcerated NL successfully treated with becaplermin.

MR spectroscopy for assessment of memantine treatment in mild to moderate Alzheimer dementia

OBJECTIVES

Magnetic Resonance Spectroscopy (MRS) may provide a precise and reliable assessment of the extent and severity of neural tissue loss caused by various diseases. In particular, the N-Acetyl Aspartate (NAA) and Creatine (Cr) ratio has been found to be an indicator of the degree of neuronal loss in Alzheimer's disease (AD). Memantine is thought to benefit the AD brain by stabilizing the NMDA receptors on neurons in turn reducing excitotoxicity. Despite its effectiveness in treating moderate to severe AD, memantine has not had similar success in the treatment of mildly demented AD patients. The objective of this study was to test whether memantine would slow or prevent the loss of neurons in mild to moderate AD patients.

METHODS

A double-blind placebo-controlled study was designed to measure the effect of a year-long course of memantine in patients with a probable AD diagnosis with mild to moderate dementia. The primary outcome measure was stipulated to be change in MRS NAA/Cr ratio in inferior parietal cortex in memantine relative to the placebo treatment condition. The secondary outcome measures were changes in cognitive and function scale scores.

RESULTS

This pilot study failed to demonstrate a benefit of memantine on the primary outcome measure, the inferior parietal NAA/Cr ratio, or the secondary outcome measures.

CONCLUSIONS

More studies are needed to determine the effect of memantine on regions of the brain significantly affected by AD pathology.

Severe encephalopathy, lactic acidosis, vegetative instability and neuropathy with 5-Fluorouracil treatment - pyrimidine degradation defect or beriberi?

We present the case of a 19-year-old female with nasopharyngeal carcinoma, who received two courses of chemotherapy with 5-fluorouracil (5-FU) in combination with folic acid and cisplatin. Upon developing esophageal strictures in the course of her radiotherapy, she required total parenteral nutrition. In the course of therapy, the patient developed severe multisystem failure with encephalopathy, lactic acidosis, vegetative instability and neuropathy. The treatment with 5-FU can lead to severe toxicity due to enzyme deficiencies in the degradation of pyrimidines, but it can also lead to thiamine deficiency with the classic symptoms of beriberi. Beriberi is a rare disorder, usually attributed to malnutrition or alcoholism. 5-FU has been shown to induce thiamine depletion. Reduced food intake or total parenteral nutrition devoid of vitamin supplements may aggravate symptoms. We were unable to find a genetic cause for increased 5-FU toxicity in our patient, ruling out deficiencies of dihydropyrimidine dehydrogenase, dihydropyrimidinase or β-ureidopropionase and double-strand break repair deficits. We come to the conclusion that, even without any definable enzyme deficiency, treatment with 5-FU can lead to high toxicity due to thiamine deficiency if vitamin supplementation is not undertaken.

Long-term outcome of loose seton for complex anal fistula: a two-centre study of patients with and without Crohn's disease

OBJECTIVE

Complex anal fistulas traverse a significant portion of the external sphincter muscle, making their treatment a surgical challenge. Several surgical options are used with conflicting results. The aim of this study was to analyse the results of permanent loose seton in the management of high anal fistulas in Crohn's disease (CD) patients and two-stage seton fistulotomy in patients without CD.

METHOD

We retrospectively reviewed the clinical records of 77 patients with complex anal fistula treated by loose seton over a 4-year period, in two medical centres. Recorded parameters included demographics, medical history, type of fistula, disease duration, previous surgery, morbidity, recurrence and mortality.

RESULTS

Sixty patients without CD underwent 107 fistula-related surgical procedures, and 17 CD patients underwent 29 procedures. Early postoperative complications were recorded in eight (10%) patients. Perioperative complications, mainly local sepsis or bleeding, were recorded in eight (10%) patients. Long-term complications were observed in nine non-CD and four CD patients. During a median follow-up period of 24 months, the recurrence rate was 40% in CD patients and 47% in patients without CD. Five patients (four non-CD patients and one CD patient) developed some degree of faecal incontinence.

CONCLUSION

The fistula recurrence rate following two-stage seton fistulotomy in non-CD patients was high. In CD patients the use of permanent loose seton is effective in controlling local sepsis in about half of patients and has low rates of subsequent incontinence.

Autoantigens in systemic autoimmunity: critical partner in pathogenesis

Rosen A, Casciola-Rosen L (Johns Hopkins University School of Medicine, Baltimore, MD, USA). Autoantigens in systemic autoimmunity: critical partner in pathogenesis (Review). J Intern Med 2009; 265: 625-631.Understanding the mechanisms of human autoimmune rheumatic diseases presents a major challenge, due to marked complexity involving multiple domains, including genetics, environment and kinetics. In spite of this, the immune response in each of these diseases is largely specific, with distinct autoantibodies associated with different disease phenotypes. Defining the basis of such specificity will provide important insights into disease mechanism. Accumulating data suggest an interesting paradigm for antigen selection in autoimmunity, in which target tissue and immune effector pathways form a mutually reinforcing partnership. In this model, distinct autoantibody patterns in autoimmunity may be viewed as the integrated, amplified output of several interacting systems, including: (i) the specific target tissue, (ii) the immune effector pathways that modify antigen structure and cause tissue damage and dysfunction, and (iii) the homeostatic pathways activated in response to damage (e.g. regeneration/differentiation/cytokine effects). As unique antigen expression and structure may occur exclusively under these amplifying circumstances, it is useful to view the molecules targeted as 'neo-antigens', that is, antigens expressed under specific conditions, rather than ubiquitously. This model adds an important new dynamic element to selection of antigen targets in autoimmunity, and suggests that the amplifying loop will only be identified by studying the diseased target tissue in vivo.

Granzyme B: evidence for a role in the origin of myasthenia gravis

PURPOSE OF RESEARCH

Although the pathogenesis of myasthenia gravis (MG) as an antibody mediated disorder of acetylcholine receptors (AChRs) at neuromuscular junctions is well understood, the origin of the autoimmune response is unclear. The thymus is intimately involved in initiation of the autoimmune response; the antigen, AChR, is present in the thymus, but how the autoimmune response is triggered is not known. Granzyme B (GrB), a proteolytic enzyme present in cytolytic T cells and natural killer (NK) cells, selectively cleaves many potential autoantigens (but few non-autoantigens), generating novel fragments that trigger autoreactive responses. This protease has been strongly implicated in the pathogenesis of several autoimmune diseases including lupus, rheumatoid arthritis, dermatomyositis, and others. In the studies described in this manuscript, we examined the ability of GrB to cleave the AChR subunits, and performed biochemical, immunohistochemical and molecular studies on thymus glands from myasthenic patients and controls to assess GrB expression.

MAIN RESULTS

GrB efficiently and specifically cleaves subunits of AChR, especially the epsilon subunit. GrB is present in thymus glands from myasthenia patients, but is absent in control thymuses.

CONCLUSIONS

Our results provide evidence supporting a potential role for GrB in the process of initiation of MG, and are consistent with the concept of an immunodominant epsilon epitope.

Malignant Fibrous Histiocytoma, Aggressive Fibromatosis and Benign Fibrous Tumors Express mRNA for the Metalloproteinase Inducer EMMPRIN and the Metalloproteinases MMP-2 and MT1-MMP

PURPOSE

Extracellular matrix metalloproteinase inducer (EMMPRIN) has been shown to stimulate fibroblasts to production of matrix metalloproteinases (MMPs). MMPs comprise a family of proteolytic enzymes implicated in the degradation of extracellular matrix which has been proposed to be one of the essential steps in tumor invasion and metastases. In the present study we investigated the expression and location of mRNAs for EMMPRIN, matrix metalloproteinase-2 (MMP-2), and membrane-type 1 matrix metalloproteinase (MT1-MMP) in mesenchymal tumors with different tendencies to recur or metastasize.

SUBJECTS

Eight malignant fibrous histiocytomas (MFH), seven aggressive fibromatosis (AF), and six benign fibrous tumors (BF).

METHOD

The mRNA-expression of EMMPRIN, MMP-2 and MT1-MMP were studied using mRNA in situ hybridization technique.

RESULTS

The mRNA-expression of EMMPRIN, MMP-2 and MT1-MMP respectively were found at varying frequency and level in all tumor types. The mRNAs corresponding to EMMPRIN and MMP-2 were seen in neoplastic cells as well as in endothelial cells both inside and outside the tumor pseudo-capsule, whereas MT1-MMP was seen only within the tumors. The estimated mRNA levels of EMMPRIN and MMP-2 covariated significantly. Overall, the highest expression was found in the MFH tumors and the lowest levels in the BF tumors.

DISCUSSION

These findings suggest that the MMP-inducer EMMPRIN and the extracellular matrix degrading system involving the metalloproteinases MMP-2 and MT1-MMP is frequently activated in mesenchymal tumors. The covariation between EMMPRIN and MMP-2 support previous findings that EMMPRIN may be an inducer of MMP-2. The high levels of MMP-2 mRNA in MFH indicate a relationship between the proteolytic activity of MMP-2 and the tumor aggressiveness.

Prospects for prediction: ethics analysis of neuroimaging in Alzheimer's disease

This article focuses on the prospects and ethics of using neuroimaging to predict Alzheimer's disease (AD). It is motivated by consideration of the historical roles of science in medicine and society, and considerations specifically contemporary of capabilities in imaging and aging, and the benefits and hope they bring. A general consensus is that combinations of imaging methods will ultimately be most fruitful in predicting disease. Their roll-out into translational practice will not be free of complexity, however, as culture and values differ in terms of what defines benefit and risk, who will benefit and who is at risk, what methods must be in place to assure the maximum safety, comfort, and protection of subjects and patients, and educational and policy needs. Proactive planning for the ethical and societal implications of predicting diseases of the aging brain is critical and will benefit all stakeholders-researchers, patients and families, health care providers, and policy makers.

The importance of anti-HLA-specific antibody strength in monitoring kidney transplant patients

Approximately 25% of patients who undergo kidney transplantation develop HLA-specific antibodies, the strength of which has not been previously correlated with graft failure. The strength of these de novo antibodies is investigated in this study. Serial dilution of strong HLA-specific allo-antibodies (up to 1:25,600) and testing with HLA-antigen-coated beads showed that the titer of the reaction to different HLA antigens is directly correlated to maximum fluorescence values and the molecules of equivalent soluble fluorochrome (MESF) values obtained by Luminex machines. Thus, the strength of antibodies can be measured utilizing maximum fluorescence and MESF. The strength of antibodies in the sera from 39 patients who subsequently had graft failure were markedly higher than those in the sera of 26 patients who continued to have good graft function (p = 0.0084). A clear increase in the strength of antibodies was identified in nine patients with a subsequent increase in serum creatinine levels. If analyzed for donor specificity, a strong association was noted for donor-specific MESF and failure (p = 0.00000027). Our results suggest that it is important to monitor the strength of antibodies when evaluating patient sera posttransplant.

The Australian experience of deinstitutionalization: interaction of Australian culture with the development and reform of its mental health services

OBJECTIVE

To describe the Australian experience of deinstitutionalization of the Australian National Mental Health Strategy in the context of the history of mental health services in Australia, and of Australian culture.

METHOD

The development of Australian Mental Health Services is described with reference to developments in both psychiatric intervention research and Australian culture. The effects and achievements of national mental health reforms are described and critically examined.

RESULTS

The relationship in Australia between the development of mental health services and the development of Australian society includes the stories of colonization, gold rush, suppression of indigenous peoples' rights, incarceration of mentally ill people, and incompatible state service systems. Mental health services required reform to provide consistent services and support for full citizenship and rights for such individuals who are still on the margins of society. Recent national developments in service models and service system research have been driven by the Australian National Mental Health Strategy. The translation of national policy into state/territory mental health service systems has led to a 'natural' experiment between states. Differing funding and implementation strategies between states have developed services with particular strengths and limitations.

CONCLUSION

The effects of competition for limited resources between core mental health service delivery and the shift to a population-based public health approach (to prevention of mental illness and promotion of mental health), leaves our services vulnerable to doing neither particularly well. The recent loss of momentum of these reforms, due to failure of governments to continue to drive and fund them adequately, is causing the erosion of their considerable achievements.

Distinct recognition of antibodies to centromere proteins in primary Sjogren's syndrome compared with limited scleroderma

BACKGROUND

Anticentromere antibodies are characteristically observed in scleroderma but have recently been reported in other autoimmune rheumatic disorders, including Sjögren's syndrome. It is not known whether distinct centromere proteins (CENP) are targeted in primary Sjögren's syndrome (pSS) and scleroderma.

OBJECTIVE

To determine whether antibodies to CENP-B and CENP-C are present in these two disorders.

METHODS

Sera from 45 patients with pSS and 33 with limited scleroderma were studied. All patients met classification criteria for pSS and scleroderma, respectively. Sera were used to immunoprecipitate in vitro translated CENP-B and CENP-C. The proportions recognising CENP-B or CENP-C were compared.

RESULTS

10 of 45 patients (22%) with pSS and 18 of 33 (55%) with scleroderma had antibodies recognising CENPs (p = 0.004). Seven of 10 (70%) CENP positive patients with pSS recognised CENP-C alone, compared with one of 18 (6%) CENP positive patients with scleroderma (odds ratio (OR) = 40 (95% confidence interval (CI), 3.5 to 450) (p = 0.003). In contrast, the majority (15 of 18 (83%)) of CENP positive scleroderma sera recognised both CENP-B and CENP-C, compared with none of 10 pSS sera (OR = 93 (95% CI, 4.4 to 1979) (p = 0.0001).

CONCLUSIONS

The pattern of CENP recognition differs markedly in pSS and limited scleroderma. While patients with pSS predominantly recognise CENP-C alone, dual recognition of CENP-B and CENP-C is most frequent in scleroderma. These findings suggest that obtaining antibodies to specific centromere antigens is useful diagnostically, and imply that distinct mechanisms underlie the unique patterns of centromere autoreactivity in pSS and scleroderma.

Immunosuppressive treatment options in renal transplantation

An overview of the first 4 decades of clinical kidney transplantation would characterize progress primarily in the development of new immunosuppressive agents designed to reduce the incidence and severity of acute rejection to improve short-term outcomes, but with less marked effects on long-term patient and graft survival. The new trend of immunosuppressive therapy is to facilitate long-term allograft and patient survival, and to help to maintain a good quality of life after renal transplantation. To achieve these goals, transplant physicians need to determine the immunosuppressive protocols that will best minimize risk factors associated with reduced allograft/patient survival and quality of life. Recent protocols and clinical experience with modern immunosuppression strategies, as well as the efficacy and safety of various combination protocols, will be reviewed.

Altered autoantigen structure in Sjögren's syndrome: implications for the pathogenesis of autoimmune tissue damage

The etiology and pathogenic mechanisms underlying Sjögren's syndrome (SS) remain unclear. Recent studies have emphasized that the specific autoantibodies that occur in a high proportion of patients with SS may provide important insights into the circumstances that initiate and propagate tissue damage in this disease. Although autoantigens targeted in systemic autoimmune diseases share little in common in terms of structure, subcellular distribution, or function in normal cells, these molecules are unified by becoming clustered and concentrated in the surface blebs of apoptotic cells. Furthermore, their structure is altered during some types of cell death to generate structures not previously generated during development and homeostasis. This review highlights the susceptibility of SS autoantigens to undergoing such structural changes during activation of immune effector pathways, and synthesizes a model of SS incorporating these concepts. An understanding of the mechanisms responsible for activating the specific immune response in SS, and the role of specific immune effector pathways in propagating both the autoimmune response and tissue damage, is of potential therapeutic importance. Abbreviations used in this paper are: CTL, cytotoxic T-lymphocytes; ER, endoplasmic reticulum; GluR3, subunit III of the glutamate receptor; GrB, granzyme B; M3R, type III muscarinic receptor; NK cells, natural killer cells; PARP, poly(ADP-ribose)polymerase; SS, Sjögren's syndrome; SLE, systemic lupus erythematosus; and UV, ultraviolet.

Recurrent transverse myelitis associates with anti-Ro (SSA) autoantibodies

Transverse myelitis (TM) is an idiopathic inflammatory disorder of the spinal cord. The authors observed cases of recurrent TM in patients where anti-Ro (SSA) antibodies were present and therefore performed a case-control study to examine the frequency of anti-Ro autoantibodies in patients with recurrent TM and control subjects. Antibodies to 52-kd Ro were demonstrated in 77% of cases (10/13) compared with only 33% of control subjects (4/12).

Effect of raloxifene on sexual function in postmenopausal women

OBJECTIVE

To determine the effects of raloxifene on sexual function in postmenopausal women with pre-existing vaginal atrophy treated with vaginal estrogen cream.

METHODS

A total of 187 naturally postmenopausal women, 42-80 years of age, with signs of genitourinary atrophy were enrolled in this 6-month, multicenter, parallel-group study. Subjects were randomized to oral raloxifene HCl 60 mg daily or matching placebo; the same subjects were also randomized to receive one application of either vaginal conjugated estrogen cream 0.5 g twice weekly for 6 months or non-hormonal vaginal moisturizer twice weekly for 3 months, followed by conjugated estrogen cream for 3 months. Both investigators and subjects were masked to the identity of the oral medication. The vaginal preparations were administered in an open-label fashion. The Sexual Activity Questionnaire (SAQ) was administered at baseline and at 3 and 6 months. Safety was assessed throughout the study.

RESULTS

A total of 102 women were sexually active at baseline and, of these, 82 were also sexually active at the 6-month end-point. At 6 months, raloxifene and placebo, in the presence of vaginal conjugated estrogen cream, were both associated with improvement from baseline in vaginal dryness and reduced discomfort during sexual activity. There were no significant differences between raloxifene and placebo groups in any SAQ item. Enjoyment of sexual activity significantly increased from baseline with raloxifene but not with placebo. No difference in adverse events was observed between groups.

CONCLUSION

Raloxifene had no negative effects on sexual function in postmenopausal women with vaginal atrophy who were treated concomitantly with vaginal estrogen cream.