Using Lithium in Children and Adolescents with Bipolar Disorder: Efficacy, Tolerability, and Practical Considerations

Lithium has been an intriguing treatment option in psychiatry for over a century. While seemingly just a simple elemental compound, it has powerful treatment effects for both depression and bipolar disorder. The evidence base for treatment of pediatric bipolar disorder is relatively small, but, in recent years, additional clinical trial data have enabled lithium to re-emerge as a valuable and, in many cases, preferred treatment. Pharmacologically, lithium is complex, with varied effects at both intracellular and extracellular levels. As a treatment for bipolar disorder in pediatrics, lithium is challenging, given its narrow therapeutic window and myriad of potential side effects. However, the efficacy of lithium continues to match that of newer pharmacologic agents, and its tolerability has been shown to be comparable with more commonly prescribed medications. Lithium is still one of few drugs that have been proven to reduce the risk of suicidality, and it may have utility in illnesses beyond affective disorders. Practically, as a primary agent or as an adjunct, lithium continues to claim a rightful place in the treatment armamentarium of child psychiatry. New dosing paradigms have improved tolerability and reduced potential side effects. Recent evidence affirms that lithium is effective for pediatric bipolar disorder in multiple phases of the illness.

The recycling endosome protein RAB-10 promotes autophagic flux and localization of the transmembrane protein ATG-9

Macroautophagy/autophagy involves the formation of an autophagosome, a double-membrane vesicle that delivers sequestered cytoplasmic cargo to lysosomes for degradation and recycling. Closely related, endocytosis mediates the sorting and transport of cargo throughout the cell, and both processes are important for cellular homeostasis. However, how endocytic proteins functionally intersect with autophagy is not clear. Mutations in the DAF-2/insulin-like IGF-1 (INSR) receptor at the permissive temperature result in a small increase in GFP::LGG-1 foci, i.e. autophagosomes, but a large increase at the nonpermissive temperature, allowing us to control the level of autophagy. In a RNAi screen for endocytic genes that alter the expression of GFP::LGG-1 in daf-2 mutants, we identified RAB-10, a small GTPase that regulates basolateral endocytosis. Loss of rab-10 in daf-2 mutants results in more GFP::LGG-1-positive foci at the permissive, but less GFP::LGG-1 or SQST-1::GFP foci at the nonpermissive temperature. As previously reported, loss of rab-10 alone resulted in an increase of GFP:LGG-1 foci. Exposure of rab-10 mutant animals to chloroquine, a known inhibitor of autophagic flux, failed to increase the number of GFP::LGG-1 foci. Moreover, colocalization between LMP-1::tagRFP and GFP::LGG-1 (the lysosome and autophagosome reporters) was decreased in daf-2; rab-10 dauers at the nonpermissive temperature. Intriguingly, RAB-10 was required to maintain the normal size of GFP::ATG-9-positive structures in daf-2 mutants at both the permissive and nonpermissive temperature. Finally, we found that RAB-10 GTPase cycling was required to control the size of GFP::ATG-9 foci. Collectively, our data support a model where rab-10 controls autophagic flux by regulating autophagosome formation and maturation.

Supporting families of critically ill children at home using videoconferencing

Home videoconferencing links for families of children recently discharged with complex congenital heart disease may be useful in monitoring potentially unstable patients. A randomized controlled trial was carried out comparing home videoconferencing with telephone contact. Patients were randomized to an interventional videoconferencing group (n= 14), or to one of two control groups: the first (n = 9) received the same ad hoc telephone support that was available to all patients; the second group (n = 1 3) received regular telephone calls with the same protocol as those in the videoconferencing group. The results from the trial are still being analysed. Our experience with commercial cable modem transmission quickly showed that this is an unsuitable modality. Preliminary results with ISDN videoconferencing are encouraging. Initial results and feedback from families strongly suggest that videoconferencing provides significant benefits over telephone follow-up.

Gender distribution, sexual size dimorphism and morphometric sexing in ballan wrasse Labrus bergylta

In wild ballan wrasse Labrus bergylta, mass-length relationships were not different between genders, and positive allometry was found in the mixed-gender population. Male-biased sexual size dimorphism was significant and the most effective morphometric method for sexing L. bergylta outside of the species spawning window used body mass (M(B) in g), total body length (L(T) in mm) and Fulton's condition factor (K) as discriminant variables to predict gender with 91% accuracy. The discriminant score (S(D)) of a specimen can be calculated as S(D)  = 0.01 M(B)- 0.016 L(T)- 3.835 K + 6.252 to predict its gender as female or male if S(D) is < 1.459 or S(D) is > 1.504, respectively. There was a potential trend towards earlier sexual inversion compared to previous studies at comparable latitudes. Sex change is a phenotypically plastic trait under social control in haremic fishes and should be monitored in increasingly exploited L. bergylta.

A compact high-performance low-field NMR apparatus for measurements on fluids at very high pressures and temperatures

We discuss an innovative new high-performance apparatus for performing low-field Nuclear Magnetic Resonance (NMR) relaxation times and diffusion measurements on fluids at very high pressures and high temperatures. The apparatus sensor design and electronics specifications allow for dual deployment either in a fluid sampling well logging tool or in a laboratory. The sensor and electronics were designed to function in both environments. This paper discusses the use of the apparatus in a laboratory environment. The operating temperature and pressure limits, and the signal-to-noise ratio (SNR) of the new system exceed by a very wide margin what is currently possible. This major breakthrough was made possible by a revolutionary new sensor design that breaks many of the rules of conventional high pressure NMR sensor design. A metallic sample holder capable of operating at high pressures and temperatures is provided to contain the fluid under study. The sample holder has been successfully tested for operation up to 36 Kpsi. A solenoid coil wound on a slotted titanium frame sits inside the metallic sample holder and serves as an antenna to transmit RF pulses and receive NMR signals. The metal sample holder is sandwiched between a pair of gradient coils which provide a linear field gradient for pulsed field gradient diffusion measurements. The assembly sits in the bore of a low-gradient permanent magnet. The system can operate over a wide frequency range without the need for tuning the antenna to the Larmor frequency. The SNR measured on a water sample at room temperature is more than 15 times greater than that of the commercial low-field system in our laboratory. Thus, the new system provides for data acquisition more than 200 times faster than was previously possible. Laboratory NMR measurements of relaxations times and diffusion coefficients performed at pressures up to 25 Kpsi and at temperatures up to 175 °C with crude oils enlivened with dissolved hydrocarbon gases (referred to as "live oils") are shown. This is the first time low-field NMR measurements have been performed at such high temperatures and pressures on live crude oil samples. We discuss the details of the apparatus design, tuning, calibration, and operation. NMR data acquired at multiple temperatures and pressures on a live oil sample are discussed.

Thought disorder in the meta-structure of psychopathology

BACKGROUND

Dimensional models of co-morbidity have the potential to improve the conceptualization of mental disorders in research and clinical work, yet little is known about how relatively uncommon disorders may fit with more common disorders. The present study estimated the meta-structure of psychopathology in the US general population focusing on the placement of five under-studied disorders sharing features of thought disorder: paranoid, schizoid, avoidant and schizotypal personality disorders, and manic episodes as well as bipolar disorder.

METHOD

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions, a face-to-face interview of 34 653 non-institutionalized adults in the US general population. The meta-structure of 16 DSM-IV Axis I and Axis II psychiatric disorders, as assessed by the Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM-IV version (AUDADIS-IV), was examined using exploratory and confirmatory factor analysis.

RESULTS

We document an empirically derived thought disorder factor that is a subdomain of the internalizing dimension, characterized by schizoid, paranoid, schizotypal and avoidant personality disorders as well as manic episodes. Manic episodes exhibit notable associations with both the distress subdomain of the internalizing dimension as well as the thought disorder subdomain. The structure was replicated for bipolar disorder (I or II) in place of manic episodes.

CONCLUSIONS

As our understanding of psychopathological meta-structure expands, incorporation of disorders characterized by detachment and psychoticism grows increasingly important. Disorders characterized by detachment and psychoticism may be well conceptualized, organized and measured as a subdimension of the internalizing spectrum of disorders. Manic episodes and bipolar disorder exhibit substantial co-morbidity across both distress and thought disorder domains of the internalizing dimension. Clinically, these results underscore the potential utility of conceptualizing patient treatment needs using an approach targeting psychopathological systems underlying meta-structural classification rubrics.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

PURPOSE

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.

METHOD

A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.

RESULTS

Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).

DISCUSSION

Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

The predictive validity of Cluster C personality disorders on the persistence of major depression in the national epidemiologic survey on alcohol and related conditions

The present study examined the predictive validity of Cluster C personality disorders (CCPDs) on major depressive disorder (MDD), using Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, N = 34,653; time interval equals 3 years). Multiple logistic regression analyses were utilized to compare respondents with MDD and a concurrent CCPD to those with MDD only. Findings demonstrated that individuals with MDD and a comorbid CCPD were significantly more likely than those with MDD only to have MDD at Time 2. The presence of comorbid CCPD in individuals with MDD also predicts the subsequent occurrence of suicide attempts at Time 2 and the new onset of Axis I anxiety disorders. The chronic and enduring personality styles and interpersonal difficulties that characterize individuals with a CCPD likely lead to the exacerbation of MDD symptoms. Clinicians should be aware of the impact that CCPDs have on the outcome of MDD.

Breast Specialist Nurses – Expensive Hand Holding or Cost-Effective Counselling?

IntroductionCounselling breast cancer patients for reconstruction is complex and time consuming. Post-reconstruction satisfaction has been shown to be related to the quality of information provided to patients. Decisions regarding the type of breast reconstruction suitable for each patient is multi-factorial, including the autologous tissue available, general health, patient lifestyle and suitability, as well as patient preference. In our institution we offer a full range of reconstruction techniques. Initial pre-operative counselling is performed by a breast reconstruction specialist nurse at a consultation lasting at least 1 hour. During this time, all reconstructive options are discussed.Implications of surgery, photographs of post-operative results and the details of the procedures are explained and written information is provided. The option to meet a patient advocate at a later date is offered. An indication of the suitable reconstructive options available to the individual is given, however the surgeon, at a separate consultation lasting 10 minutes, performs the formal assessment of reconstructive type.MethodA comparison was made of patient satisfaction with pre-operative counselling and information giving, between those patients who were counselled by the operative surgeon alone and those counselled by the Breast Reconstruction Specialist nurse. A questionnaire to assess patient satisfaction with the reconstruction counselling was designed in conjunction with the Clinical Psychology team. This questionnaire was posted retrospectively to all patients who had undergone reconstruction counselling irrespective of whether they had subsequently undergone breast reconstruction. Patients were asked to respond to questions on a 5 point Likert scale. Patients were divided into 2 groups dependent on the person performing the counselling, ie. surgeon or nurse. All questionnaires were anonymous.ResultsQuestionnaires were allocated a random number and the data were analyzed independently by 2 separate clinical psychologists, blinded to which group the patients belonged to. Group 1 was counselled by the operative surgeon alone and Group 2 by the Breast Reconstruction Nurse. There was a very high response rate in both groups (70% in Group 1 and 71% in Group 2). Qualitative and quantitative data were analyzed separately. There was a high satisfaction rating in both groups with responses to all questions having a mean rating of above 4 out of 5. Patient satisfaction between the 2 groups was compared using the Mann-Whitney U test. There was no significant reported difference between how useful each of the groups found the contact.ConclusionEmploying a Specialist Nurse to perform the time-consuming pre-operative counselling for breast reconstruction is a cost effective measure, allowing Surgeons time to assess more patients or perform more appropriate skilled tasks instead. Patient satisfaction with the counselling service and information-giving was equal in both groups suggesting that nurse-led counselling, even for complex surgical procedures, is acceptable to patients. Having someone, other than the operative surgeon, give an independent and unbiased perspective on reconstructive options may be important in patient decision making.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1075.

Combination immunochemotherapy followed by reduced dose (rd) whole brain radiation therapy (WBRT) in an expanded cohort of patients with newly diagnosed primary central nervous system lymphoma (PCNSL)

2072

Background: High-dose methotrexate (M)-based chemotherapy combined with WBRT has improved survival in patients with PCNSL. However, disease recurrence and treatment-related neurotoxicity are significant problems. We conducted a prospective trial incorporating rituximab (R) and rdWBRT and previously demonstrated this was feasible. This study was extended to assess the long-term outcome of this approach in an expanded cohort. Methods: Patients were treated with R-MPV (d1 R 500mg/m2; d2 M 3.5gm/m2; vincristine 1.4mg/m2; d1–7 procarbazine 100 mg/m2/d on odd-cycles). Patients with a PR after five cycles received two additional cycles. Patients with a CR received rdWBRT (2340cGy), otherwise patients received standard WBRT (4500cGy). Patients then received two cycles of Ara-C 3gm/m2. Prospective neuropsychological evaluations were performed at baseline, before WBRT, and every 6 months thereafter. Results: From October 2002 to September 2008, 50 patients were enrolled (22 female, 28 male), median age 59.5 years (range 30–79 years). Due to neutropenia in two of the first five patients, all subsequent patients received G-CSF. 42 patients are assessable for response (4 patients died from progressive disease prior to completing the first cycle of treatment, 4 patients - treatment ongoing). 33 patients (79%) had a CR, of whom 29 received rdWBRT (3 refused, 1 died). At median follow-up of 3 years for survivors the median OS has not been reached and the estimated 2-year OS is 68%. Patients treated with rdWBRT have a median follow up of 38 months: 21 (72%) are alive with no evidence of disease, seven (24%) relapsed, and one died of unknown causes. Eight of 21 (38%) who are alive with no evidence of disease were age 60+ at diagnosis. The number of patients treated with rdWBRT alive with no evidence of disease at 3, 4, and 5 years is 12, 8, and 4 respectively. 9 patients have completed neuropsychological evaluations 24 months after rdWBRT with no significant cognitive decline detectable. Conclusions: Prolonged follow-up of an expanded cohort of patients treated with immunochemotherapy followed by rdWBRT for patients with an initial CR continues to support our initial conclusions that this approach results in excellent disease control with no observed treatment-related neurotoxicity.

[Table: see text]

Assisting the transition from hospital to home for children with major congenital heart disease by telemedicine: a feasibility study and initial results

Parents of children hospitalized with major congenital heart disease often state that the weeks following discharge from hospital are particularly difficult. There is a sudden change from 24-h medical supervision and care to outpatient reviews. Videoconferencing not only gives the family an opportunity to have visual and audio contact with staff but also allows clinicians to visually assess the patient. We have investigated the feasibility of using videoconferencing to provide support for families at home. We also report the early results of a randomized control trial comparing videoconference support with regular telephone support and the current clinic review follow-up.

Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients

Current recommendations for management of obese patients post-extubation are based on clinical experience and expert opinions. It was hypothesised that the application of noninvasive ventilation (NIV) during the first 48 h after extubation in severely obese patients would reduce post-extubation failure and avert the need for reintubation. Following protocol-driven weaning trials, 62 consecutive severely obese patients (body mass index > or =35 kg x m(-2)) were assigned to NIV via nasal mask immediately post-extubation and compared with 62 historically matched controls who were treated with conventional therapy. The primary end-point was the incidence of respiratory failure in the first 48 h post-extubation. Compared with conventional therapy, the institution of NIV resulted in 16% (95% confidence interval 2.9-29.3%) absolute risk reduction in the rate of respiratory failure. There was a significant difference in the intensive care unit and lengths of hospital stay between the two groups. Subgroup analysis of hypercapnic patients showed reduced hospital mortality in the NIV group compared with the control group. In conclusion, noninvasive ventilation may be effective in averting respiratory failure in severely obese patients when applied during the first 48 h post-extubation. In selected patients with chronic hypercarbia, early application of noninvasive ventilation may confer a survival benefit.

A randomised trial to evaluate the self-administered standardised chronic respiratory questionnaire

The original chronic respiratory questionnaire (CRQ), one of the most widely used measures of health-related quality of life (HRQL) in chronic respiratory disease (CRD), is traditionally interviewer administered (IA) and includes an individualised dyspnoea domain. The present authors studied the impact of self-administered (SA) and standardised dyspnoea questions on CRQ measurement properties. In a factorial design multicentre trial, 177 patients with CRD (mean age 67.7 yrs; mean forced expiratory volume in one second per cent predicted 44.6%) were randomised to CRQ-IA (n = 86) or CRQ-SA (n = 91), and to initially complete the standardised or individualised items before and after respiratory rehabilitation. While maintaining validity, the CRQ-SA proved more responsive to changes in HRQL than the CRQ-IA in all domains. Compared with the standardised dyspnoea domain, the individualised dyspnoea domain indicated greater responsiveness. The correlations of baseline scores and change scores with other HRQL instruments indicated good validity of the CRQ-SA. In conclusion, self-administration and standardisation of the chronic respiratory questionnaire maintains validity and responsiveness relative to the interviewer-administered chronic respiratory questionnaire. These results challenge the assumption that interviewer-administered questionnaires are superior to self-administered questionnaires in older patients with chronic respiratory disease.

Telemedicine applications for the regional paediatric cardiology service in Northern Ireland

The regional paediatric cardiology centre in Northern Ireland has a telemedicine network linking the neonatal units of three district general hospitals using ISDN and IP-compliant equipment. We have previously reported the use of ISDN transmission at 128 kbit/s for remote echocardiography. In a series of 61 patients, a total of 59 transmitted scans were of sufficient diagnostic quality to confirm or exclude the presence of major congenital heart disease (CHD). There were three diagnostic errors (7%). Subsequently, we have examined the use of ISDN transmission at 384 kbit/s. Echocardiographic studies were carried out on 21 patients and all were followed up. Fourteen patients (67%) had CHD confirmed. There were two diagnostic errors (10%). Our experience of transmitting live echocardiographic images suggests that ISDN at 384 kbit/s provides the optimum balance between the clarity of the transmitted images and costs. We expect that IP videoconferencing will offer similar quality but at a lower running cost, and are currently assessing it in a pilot study. All sites within our network will remain capable of ISDN transmission until the efficacy and reliability of IP transmission has been demonstrated in a controlled trial. The clinical telemedicine service has led to the earlier diagnosis of and instigation of appropriate treatment for CHD.

Immuno-EM localization of GFP-tagged yolk proteins in C. elegans using microwave fixation

Because of the presence of a low-permeability cuticle covering the animal, fixation of C. elegans tissue for immunoelectron microscopy has proved very difficult. Here we applied a microwave fixation protocol to improve penetration of fixatives before postembedding immunogold labeling. Using this technique, we were able to successfully localize several components of yolk (YP170) trafficking in both wild-type and transgenic strains expressing a vitellogenin::green fluorescent protein fusion (YP170::GFP). Green fluorescent protein (GFP) and its variants are commonly used as markers to localize proteins in transgenic C. elegans using fluorescence microscopy. We have developed a robust method to localize GFP at the EM level. This procedure is applicable to the characterization of transgenic strains in which GFP is used to mark particular proteins or cell types and will undoubtedly be very useful for high-resolution analysis of marked structures.

Cognitive functioning in the last year of life as a function of age, gender, and race

Research has shown that many factors affect cognitive functioning. In this study cognitive functioning was analyzed using proxy reports concerning 17,135 decedents included in the 1993 National Followback Mortality Study conducted for the National Center for Health Statistics. These responses form a representative sample of all U.S. residents over age 15 who died in 1993 (except for those in South Dakota, which did not participate). Decedents had more difficulty understanding where they were than remembering what year it was or in recognizing family members. Logistic regression models found that age, gender, and race were the most important predictors of these basic cognitive functions. Although increasing age was associated with more cognitive difficulties, men had fewer deficits than women and Black Americans tended to have fewer deficits than White Americans. Possible reasons for these findings are discussed as well as some general implications for health service provision.

RME-8, a conserved J-domain protein, is required for endocytosis in Caenorhabditis elegans

By genetic analysis of Caenorhabditis elegans mutants defective in yolk uptake, we have identified new molecules functioning in the endocytosis pathway. Here we describe a novel J-domain-containing protein, RME-8, identified by such genetic analysis. RME-8 is required for receptor-mediated endocytosis and fluid-phase endocytosis in various cell types and is essential for C. elegans development and viability. In the macrophage-like coelomocytes, RME-8 localizes to the limiting membrane of large endosomes. Endocytosis markers taken up by the coelomocytes rapidly accumulate in these large RME-8-positive endosomes, concentrate in internal subendosomal structures, and later appear in RME-8-negative lysosomes. rme-8 mutant coelomocytes fail to accumulate visible quantities of endocytosis markers. These observations show that RME-8 functions in endosomal trafficking before the lysosome. RME-8 homologues are found in multicellular organisms from plants to humans but not in the yeast Saccharomyces cerevisiae. These sequence homologies suggest that RME-8 fulfills a conserved function in multicellular organisms.

Distribution and transport of cholesterol in Caenorhabditis elegans

Cholesterol transport is an essential process in all multicellular organisms. In this study we applied two recently developed approaches to investigate the distribution and molecular mechanisms of cholesterol transport in Caenorhabditis elegans. The distribution of cholesterol in living worms was studied by imaging its fluorescent analog, dehydroergosterol, which we applied to the animals by feeding. Dehydroergosterol accumulates primarily in the pharynx, nerve ring, excretory gland cell, and gut of L1-L3 larvae. Later, the bulk of dehydroergosterol accumulates in oocytes and spermatozoa. Males display exceptionally strong labeling of spermatids, which suggests a possible role for cholesterol in sperm development. In a complementary approach, we used a photoactivatable cholesterol analog to identify cholesterol-binding proteins in C. elegans. Three major and several minor proteins were found specifically cross-linked to photocholesterol after UV irradiation. The major proteins were identified as vitellogenins. rme-2 mutants, which lack the vitellogenin receptor, fail to accumulate dehydroergosterol in oocytes and embryos and instead accumulate dehydroergosterol in the body cavity along with vitellogenin. Thus, uptake of cholesterol by C. elegans oocytes occurs via an endocytotic pathway involving yolk proteins. The pathway is a likely evolutionary ancestor of mammalian cholesterol transport.

Rme-1 regulates the distribution and function of the endocytic recycling compartment in mammalian cells

RME-1 is an Eps15-homology (EH)-domain protein that was identified in a genetic screen for endocytosis genes in Caenorhabditis elegans. When expressed in a CHO cell line, the worm RME-1 protein and a mouse homologue are both associated with the endocytic recycling compartment. Here we show that expression of a dominant-negative construct with a point mutation near the EH domain results in redistribution of the endocytic recycling compartment and slowing down of transferrin receptor recycling. The delivery of a TGN38 chimaeric protein to the trans-Golgi network is also slowed down. The function of Rme-1 in endocytic recycling is evolutionarily conserved in metazoans as shown by the protein's properties in C. elegans.

Evidence that RME-1, a conserved C. elegans EH-domain protein, functions in endocytic recycling

In genetic screens for new endocytosis genes in Caenorhabditis elegans we identified RME-1, a member of a conserved class of Eps15-homology (EH)-domain proteins. Here we show that RME-1 is associated with the periphery of endocytic organelles, which is consistent with a direct role in endocytic transport. Endocytic defects in rme-1 mutants indicate that the protein is likely to have a function in endocytic recycling. Evidence from studies of mammalian RME-1 also points to a function for RME-1 in recycling, specifically in the exit of membrane proteins from recycling endosomes. These studies show a conserved function in endocytic recycling for the RME-1 family of EH proteins.

Incidence of blindness due to diabetic eye disease in Fife 1990-9

AIMS

In the light of goals for reducing blindness due to diabetes, published in the St Vincent Declaration, 1989, the aim of this study was to find the incidence and prevalence of blindness in the diabetic population of Fife.

METHODS

All blind registrations for the period 1990-9 were studied. Those with diabetes as the first or main diagnosis were included as new diabetic blind. The prevalence of diabetes was studied in a large sample population and extrapolated to the estimated population of Fife.

RESULTS

The incidence of blindness due to diabetes was 64 (SD 24, 95% CI 49-79) per 100 000 diabetic population/year. The point prevalence of blindness due to diabetes on 31 December 1999 was 210 per 100 000 diabetic population.

CONCLUSION

The incidence of blindness due to diabetes, in a diabetic population, is now known. Without this benchmark it is impossible to assess the implementation of the St Vincent Declaration.

Caenorhabditis elegans auxilin: a J-domain protein essential for clathrin-mediated endocytosis in vivo

The budding of clathrin-coated vesicles is essential for protein transport. After budding, clathrin must be uncoated before the vesicles can fuse with other membranous structures. In vitro, the molecular chaperone Hsc70 uncoats clathrin-coated vesicles in an ATP-dependent process that requires a specific J-domain protein such as auxilin. However, there is little evidence that either Hsc70 or auxilin is essential in vivo. Here we show that C. elegans has a single auxilin homologue that is identical to mammalian auxilin in its in vitro activity. When RNA-mediated interference (RNAi) is used to inhibit auxilin expression in C. elegans, oocytes show markedly reduced receptor-mediated endocytosis of yolk protein tagged with green fluorescent protein (GFP). In addition, most of these worms arrest during larval development, exhibit defective distribution of GFP-clathrin in many cell types, and show a marked change in clathrin dynamics, as determined by fluorescence recovery after photobleaching (FRAP). We conclude that auxilin is required for in vivo clathrin-mediated endocytosis and development in C. elegans.

Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use

Postoperative wound infection after laminectomy is uncommon. In February 1997, 3 patients were confirmed to have postlaminectomy deep wound infections due to Candida albicans. No similar case had been seen during the previous 10 years. The infections were indolent, with a mean time from initial operation to diagnosis of 54 days (range, 26-83 days). All patients were successfully treated. Pulsed-field gel electrophoresis revealed the Candida isolates to be identical. A case-controlled study and medical record review revealed that a single operating room technician scrubbed on all 3 infected case patients but on only 32% of the uninfected controls. The technician had worn artificial nails for a 3-month period that included the dates of laminectomy site infections, and C. albicans was isolated from her throat. She was treated with fluconazole and removed from duty. No subsequent cases have occurred during the ensuing 3 years. Artificial nails are known to promote subungual growth of gram-negative bacilli and yeast. This may be clinically relevant, and hospitals should enforce policies to prevent operating room personnel from wearing artificial nails.

Diurnal fluxes and the isotopomer ratios of N(2)O in a temperate grassland following urine amendment

There is an urgent need to provide an accurate, up-to-date estimate of N(2)O fluxes in order that national policies can be developed to reduce emissions of N(2)O from soils. There are only limited data on temporal and diurnal patterns of N(2)O fluxes to the atmosphere, mainly due to constraints in the measurement techniques. In this paper we present the first terrestrial source values of N(2)O isotopomers and have measured and quantified the temporal and diurnal variability in N(2)O fluxes following urine addition to a grassland system in the UK. The experiment was carried out over a 2-week period on an artificially drained grassland system at the Institute of Grassland and Environmental Research (IGER), North Wyke, UK. Duplicate samples of urine, each of 2 L, were collected from dairy cows and applied to chambers (of area 0.16 m(2)). The N(2)O diurnal fluxes from urine and control (no urine) plots were measured by an automatic closed chamber technique. The isotopomers of N(2)O were obtained by analysing the gas samples collected during a peak emission phase. Soil and meteorological data were also collected. The results showed strong diurnal variations in N(2)O fluxes with minimum fluxes generally occurring between 7:00 and 14:00 hrs. The total cumulative flux of N(2)O for the whole experimental period was higher by a factor of >2 compared with estimates based on the daytime (between 10.00-16.00 hrs) measurements only. Therefore, measurements of N(2)O fluxes based on daily single exposure and expressed on a 24-h basis could impose a considerable bias and inaccuracy to the emission estimates, depending on when it was taken. The measured site preference values (difference between the centre (delta(15)Nalpha) and the end (delta(15)Nbeta) N atom of the N(2)O molecule) for soil-emitted N(2)O measured during our study were always lower than the tropospheric value. This work confirms that the enhanced tropospheric N(2)O site preference value could be the result of the back injection from the stratosphere. The intramolecular isotope ratios of nitrogen (delta(15)N) and oxygen (delta(18)O) and the site preference of the emitted N(2)O indicated that there was a shift of processes during the measurement period.

Platelet adenylyl cyclase activity as a trait marker of alcohol dependence. WHO/ISBRA Collaborative Study Investigators. International Society for Biomedical Research on Alcoholism

BACKGROUND

There is compelling evidence that genetic factors play a major role in the development of alcohol dependence. Platelet adenylyl cyclase (AC) activity has been proposed as a biochemical marker for differentiating alcohol-dependent and nondependent subjects, but the sensitivity and specificity of this marker have not been ascertained. The objective of this study was to determine the sensitivity and specificity of platelet AC activity in identifying alcohol-dependent subjects and to ascertain the effect of medical/ psychiatric variables, drinking and smoking history, and age and body weight on AC activity.

METHODS

The cross-sectional study was conducted from 1995 to 1998. Participants were 210 Australian White men who were community volunteers and alcohol treatment inpatients in Sydney, Australia. There were 41 nondrinkers, 140 drinkers, and 29 men who were entering alcohol treatment. The main outcome measure was platelet AC activity. Classification variables were plasma ethanol, gamma-glutamyltransferase, aspartate aminotransferase, serum carbohydrate-deficient transferrin (CDT), and urinary 5-hydroxytryptophol/5-hydroxyindoleacetic acid (5-HTOL/5-HIAA) levels, and World Health Organization/International Society for Biomedical Research on Alcoholism Interview Schedule variables, which included alcohol use and dependence criteria.

RESULTS

Among subjects who reported abstinence for at least 4 days, both cesium fluoride (CsF)- and forskolin-stimulated platelet AC activities were significantly lower in those with a lifetime history of alcohol dependence compared with those with no such history (p < 0.005 and p < 0.05, respectively). The sensitivity and specificity of CsF-stimulated AC activity to discriminate individuals with a lifetime history of alcohol dependence were 75% and 79%, respectively. Similar values for sensitivity and specificity for CsF-stimulated AC activity were calculated when discriminating current alcohol dependence in the subjects in our sample. Irrespective of the history of alcohol dependence, persons who had consumed alcohol recently (within the last 3-4 days) showed significantly higher mean basal, CsF-stimulated, and forskolin-stimulated AC activity (p < 0.001), as did those who had elevated 5-HTOL/5-HIAA ratios or CDT levels, indicative of recent (heavy) drinking. The "normalization" of platelet AC activity to baseline levels after an individual stops drinking may be related to the generation of new platelets during the abstinence period. Conduct disorder and antisocial personality disorder were not associated with low AC activity, but low forskolin-stimulated AC activity was associated with major depression.

CONCLUSIONS

We found that CsF- and forskolin-stimulated platelet AC activity discriminates between subjects with and without alcohol dependence in a population of subjects who had not consumed significant quantities of ethanol recently. Recent alcohol consumption is a confounding variable that can alter the measured levels of AC activity. Forskolin-stimulated platelet AC activity also may be influenced by a history of major depression.

Withdrawal and tolerance: prognostic significance in DSM-IV alcohol dependence

OBJECTIVE

The clinical and research importance of tolerance and/or withdrawal in the diagnosis of substance dependence has been identified as a key area needing clarification. Earlier longitudinal studies did not identify whether diagnoses of alcohol dependence were current or lifetime. In this study, the prognostic significance of the DSM-IV physiological specifier was investigated among cases of alcohol dependence current at the baseline interview. The role of tremors, required in DSM-III and DSM-III-R, was investigated as well.

METHOD

Household residents (N = 130; 57% men) meeting full criteria for current DSM-IV alcohol dependence in a baseline interview were re-interviewed a year later and DSM-IV alcohol dependence was again evaluated. Reliable structured interviews were used to make the diagnoses. The DSM-IV physiologic specifier and its components were tested as predictors of outcome of DSM-IV alcohol dependence, and included an additional definition of alcohol withdrawal that required tremors. Chi-square tests and adjusted odds ratios indicated statistical significance of group differences on outcome.

RESULTS

The DSM-IV physiological specifier (tolerance or withdrawal) did not predict 1-year chronicity of DSM-IV alcohol dependence, nor did tolerance when considered separately. However, withdrawal predicted poor outcome (e.g., 1-year chronicity of DSM-IV alcohol dependence). The effect of withdrawal was strengthened when tremors were required as part of the withdrawal syndrome.

CONCLUSIONS

In contrast to earlier longitudinal research, this study supports the prognostic relevance of one component of the present DSM-IV physiological specifier--withdrawal. Withdrawal appears to have stronger prognostic meaning when the DSM-III-R version, in which tremors were required, is used. Further studies of the physiological subtype may benefit from studying subjects who have been clearly identified at the baseline evaluation as having a current diagnosis of dependence.

Effects of dung and urine amendments on the isotopic content of N(2)O released from grasslands

The temporal and diurnal changes in nitrous oxide (N(2)O) fluxes were measured between 29(th) September and 2(nd) November 1999 from urine and dung patches from cattle deposited on grazed grassland. The delta(15)N and delta(18)O values of the N(2)O emitted from soil from both treatments were examined on four occasions during this period. The diurnal fluxes of N(2)O were measured by a chamber technique that provides hourly measurement of N(2)O fluxes. The (15)N and (18)O analysis of N(2)O were determined by isotope ratio mass spectrometry. N(2)O fluxes from the excreta patches were large, with peak emissions up to 1893 ng N m(-2) s(-1) occurring after heavy precipitation, measured one month after the treatment applications. Emissions from the urine patches were significantly greater than from the dung. The results showed that excretal patches are an important source of atmospheric N(2)O. The flux pattern showed a strong diurnal variation with maximum fluxes generally occurring in late afternoon or early morning, and generally not in phase with the soil temperature changes. The isotopic content of (15)N and (18)O in the N(2)O showed a similar trend to that of the N(2)O flux. The (15)N and (18)O values of the N(2)O emitted from the soil indicated that denitrification was the major process involved. After heavy precipitation on the 6(th) October, the larger delta(15)N and delta(18)O values suggested a consumption of the N(2)O by total denitrification.

Receptor-mediated endocytosis in the Caenorhabditis elegans oocyte

The Caenorhabditis elegans oocyte is a highly amenable system for forward and reverse genetic analysis of receptor-mediated endocytosis. We describe the use of transgenic strains expressing a vitellogenin::green fluorescent protein (YP170::GFP) fusion to monitor yolk endocytosis by the C. elegans oocyte in vivo. This YP170::GFP reporter was used to assay the functions of C. elegans predicted proteins homologous to vertebrate endocytosis factors using RNA-mediated interference. We show that the basic components and pathways of endocytic trafficking are conserved between C. elegans and vertebrates, and that this system can be used to test the endocytic functions of any new gene. We also used the YP170::GFP assay to identify rme (receptor-mediated endocytosis) mutants. We describe a new member of the low-density lipoprotein receptor superfamily, RME-2, identified in our screens for endocytosis defective mutants. We show that RME-2 is the C. elegans yolk receptor.

The validity of DSM-IV alcohol abuse: drunk drivers versus all others

OBJECTIVE

Prior research in a community sample indicated that almost half the individuals receiving a diagnosis of DSM-IV alcohol abuse did so on the basis of only one symptom, driving after drinking too much. While this is certainly unwise behavior, it may not be a psychiatric disorder. Therefore, we investigated the differential validity of this subgroup of abuse cases by testing the association of a set of external validating criterion variables with three groups: those who met criteria for abuse just for drinking-driving, those who met criteria by other means and those with no alcohol diagnosis. Present status of past cases of abuse was also investigated.

METHOD

Subjects were 22,204 U.S. household residents (a subset of a national probability sample) interviewed in 1992 with the Alcohol Use Disorders and Associated Disabilities Interview Schedule. The generalized logit model was the principal means of analysis.

RESULTS

Subjects who met criteria for DSM-IV alcohol abuse just for drinking-driving differed from subjects with no diagnosis on about half the variables tested, while those who met criteria for abuse in other ways differed from subjects with no diagnosis on all variables tested. The two abuse groups differed from each other on some but not all variables. Past cases of abuse for drinking-driving and past cases of other abuse were equally likely to have remitted in the last 12 months, and slightly less likely to meet criteria for current dependence.

CONCLUSIONS

Further conceptual and empirical work is needed to resolve the difficulties with the DSM-IV alcohol abuse category.

Domiciliary post-operative assessment following cataract surgery carried out by specialist nurses

PURPOSE

To establish whether first day postoperative review by ophthalmic trained nurses following day case cataract surgery is a safe and effective practice.

METHODS

A prospective study was undertaken of all patients undergoing day case cataract surgery followed by a domiciliary visit in 1996. Principal outcome measures were: (1) incidence of problems diagnosed by the nurses at the first visit, (2) the rate of referral to the hospital for medical review, (3) incidence of problems identified at the first clinic review (10-14 days later), with particular attention paid to any that might be attributed to an event 'missed' by the nurse at the first day, and (4) visual acuity at 3 months, to allow comparison with previously published national outcome measures.

RESULTS

From 281 cases, although nurses identified a problem in 11%, only 4.2% required referral back to medical staff from the domiciliary visit; 2.1% required re-admission over the first 2 weeks. Only one case (0.35%) was found to have a missed pathology; this patient had no long-term adverse outcome. Visual acuity outcomes at 3 months compared favourably with results from the National Cataract Surgery Survey.

CONCLUSIONS

Domiciliary visits by ophthalmic trained nurses are a safe alternative to routine hospital review by medical staff.

Factor structures for DSM-IV substance disorder criteria endorsed by alcohol, cannabis, cocaine and opiate users: results from the WHO reliability and validity study

AIMS

The factor structure of DSM-IV substance disorder criteria is examined among alcohol, cannabis, cocaine and opiate users to determine the dimensionality of abuse and dependence criteria within each of these drug classes and whether a common construct can be generalized across drug classes.

DESIGN

12-month criterion prevalence was assessed as part of the World Health Organization's Study on the Reliability and Validity of the Alcohol and Drug Use Disorder Instruments in various settings at eight sites around the world using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). A majority of respondents were recruited from non-treatment settings. In addition to exploratory factor analysis, confirmatory factor analysis was used to analyse factor structures using weighted least square methods and tetrachoric correlation matrices. Multi-sample analysis techniques were used to model differences between drug-classes.

FINDINGS

In the full data analyses identified a single factor solution for each user population and across user populations. However, analyses of data from users reporting low to moderate symptomatology identified a two-dimensional construct among alcohol, cannabis and opiate users consisting of a major "dependence" factor and a lesser "abuse" factor. In addition, results showed that neither the abuse criterion "(A2) use in physical hazardous situations" or the dependence criterion "(D7) use despite knowledge of psychological/physical problems" were central to the latent construct in any of the user populations, except for D7 among alcohol users.

CONCLUSIONS

The multi-dimensional results found among users with low to moderate symptomatology indicate that: (1) previous results from relatively homogeneous populations may have been biased towards lesser order solutions, and that (2) the DSM-IV substance disorder criteria describe at least two distinct phenomena, supporting the current DSM-IV organization of substance disorder criteria. Further work needs to evaluate whether prevalent symptoms are present in random or predictable combinations, whether combinations reflecting a specific hierarchy of severity can be identified, and whether incident symptoms are accumulated in a predictable pattern, within specific user populations and across user populations.

Autophosphorylation of the catalytic subunit of cAMP-dependent protein kinase in Escherichia coli

When the catalytic (rC) subunit of cAMP-dependent protein kinase (cAPK) is expressed in Escherichia coli, it is autophosphorylated at four sites, Ser10, Ser139, Ser338 and Thr197 (49). Three of these sites, Ser10, Ser338 and Thr197, are also found in the mammalian enzyme. To understand the functional importance of these phosphorylation sites, each was replaced with Ala, Glu or Asp. The expression, solubility and phosphorylation state of each mutant protein was characterized by immunoprecipitation following in vivo labeling with 32Pi. When possible, isoforms were resolved and kinetic properties were measured. The two stable phosphorylation sites in the mammalian enzyme, Ser338 and Thr197, were shown to play different roles. Ser338, which stabilizes a turn near the C-terminus, is important for stability. Both rC(S338A) and rC(S338E) were very labile; however, the kinetic properties of rC(S338E) were similar to the wild-type catalytic subunit (C-subunit). Ser338 most likely helps to anchor the C-terminus to the surface of the small lobe. Thr197 is in the activation loop near the cleft interface. Mutagenesis of T197 caused a significant loss of catalytic activity with increases in Kms for both peptide and MgATP, as well as a small decrease in k(cat) indicating that this phosphate is important for the correct orientation of catalytic residues at the active site. Replacement of Ser139, positioned at the beginning of the E-helix, with Ala had no effect on the kinetic parameters, stability or phosphorylation at the remaining sites. In contrast, mutation of Ser10, located at the beginning of the A-helix, produced mostly insoluble, inactive, unphosphorylated protein, suggesting that this region, though far removed from the active site, is structurally important at least for the expression of soluble phosphoprotein in E.coli. Since the mutation of active site residues as well as deletion mutants generate underphosphorylated proteins, these phosphorylations in E.coli all result from autophosphorylation.