Combining Clinical With Cognitive or Magnetic Resonance Imaging Data for Predicting Transition to Psychosis in Ultra High-Risk Patients: Data From the PACE 400 Cohort

BACKGROUND

Multimodal modeling that combines biological and clinical data shows promise in predicting transition to psychosis in individuals who are at ultra-high risk. Individuals who transition to psychosis are known to have deficits at baseline in cognitive function and reductions in gray matter volume in multiple brain regions identified by magnetic resonance imaging.

METHODS

In this study, we used Cox proportional hazards regression models to assess the additive predictive value of each modality-cognition, cortical structure information, and the neuroanatomical measure of brain age gap-to a previously developed clinical model using functioning and duration of symptoms prior to service entry as predictors in the Personal Assessment and Crisis Evaluation (PACE) 400 cohort. The PACE 400 study is a well-characterized cohort of Australian youths who were identified as ultra-high risk of transitioning to psychosis using the Comprehensive Assessment of At Risk Mental States (CAARMS) and followed for up to 18 years; it contains clinical data (from N = 416 participants), cognitive data (n = 213), and magnetic resonance imaging cortical parameters extracted using FreeSurfer (n = 231).

RESULTS

The results showed that neuroimaging, brain age gap, and cognition added marginal predictive information to the previously developed clinical model (fraction of new information: neuroimaging 0%-12%, brain age gap 7%, cognition 0%-16%).

CONCLUSIONS

In summary, adding a second modality to a clinical risk model predicting the onset of a psychotic disorder in the PACE 400 cohort showed little improvement in the fit of the model for long-term prediction of transition to psychosis.

Polygenic risk scores and the prediction of onset of mood and psychotic disorders in adolescents and young adults

AIM

To examine whether polygenic risk scores (PRS) for neuroticism, depression, bipolar disorder and schizophrenia are higher in individuals manifesting trans-diagnostic risk factors for the development of major mental disorders and whether PRS enhance prediction of early onset full-threshold disorders.

METHODS

Using data from the Brisbane Longitudinal Twin Study, we examined individual PRS for neuroticism, depression, bipolar disorder and schizophrenia, recorded evidence of subthreshold syndromes and family history of mood and/or psychotic disorders and noted progression to trans-diagnostic clinical caseness (onset of major mental disorders) at follow-up. We undertook multivariate, receiver operating curve and logistic regression analyses that were adjusted for known variables of influence (age, twin status, and so on).

RESULTS

Of 1473 eligible participants (female = 866, 59%; mean age 26.3 years), 28% (n = 409) met caseness criteria for a mood and/or psychotic disorder. All PRS were higher in cases versus non-cases but associations with different levels of risk were inconsistent. The prediction of caseness (reported as area under the curve with 95% confidence intervals [CI]) improved from 0.68 (95% CI: 0.65, 0.71) when estimated using clinical risk factors alone up to 0.71 (95% CI: 0.69, 0.73) when PRS were added to the model. Logistic regression identified five variables that optimally classified individuals according to caseness: age, sex, individual risk characteristics, PRS for depression and mental health case status of cotwins or siblings.

CONCLUSIONS

The findings need replication. However, this exploratory study suggests that combining PRS with other risk factors has the potential to improve outcome prediction in youth.

Facilitators and barriers to attending postpartum screening in women with a recent pregnancy complicated by gestational diabetes mellitus: a qualitative study

OBJECTIVE

Pregnant women with gestational diabetes mellitus (GDM) are 50% more likely to develop type II diabetes (T2D) within 6 months to 2 years after giving birth. Therefore, international guidelines recommend it is best practice for women diagnosed with GDM to attend screening for T2D 6-12 weeks postpartum and every 1-3 years thereafter for life. However, uptake of postpartum screening is suboptimal. This study will explore the facilitators of and barriers to attending postpartum screening for T2D that women experience.

STUDY DESIGN

This was a prospective qualitative cohort study using thematic analysis.

METHODS

A total of 27 in-depth, semistructured interviews were conducted over the telephone with women who had recent GDM. Interviews were recorded and transcribed, and data were analysed using thematic analysis.

RESULTS

Facilitators of and barriers to attending postpartum screening were identified at three different levels: personal, intervention, and healthcare systems level. The most common facilitators identified were concern for their own health and having the importance of screening explained to them by a health professional. The most common barriers identified were confusion over the test and COVID-19.

CONCLUSION

This study identified several facilitators of and barriers to attending postpartum screening. These findings will help to inform research and interventions for improving rates of attendance at postpartum screening to reduce the subsequent risk of developing T2D.

125 STROKE SURVIVOR AND CARER EXPERIENCES OF NAVIGATION OF STROKE SERVICES AND INFORMATION IN IRELAND: AN EXPLORATORY QUALITATIVE INTERVIEW STUDY

Background

Patient navigation of stroke services is challenging, as survivors have diverse and complex needs, and clear care pathways are often lacking, particularly in the post-acute phase. Exploring the views of stroke survivors and main carers is critical to understanding these navigational challenges.

Methods

In-depth semi-structured interviews were conducted online or by phone with stroke survivors (n=16) and main carers (n=13) recruited through voluntary organisations and social media. Participants with communication or cognitive difficulties were included, and provided with accessible information materials. Interviews were audio-recorded and transcribed. Framework analysis was used, involving data familiarisation, coding, development of an analytic framework, charting and interpretation. Ryvicker’s (2018) behavioral-ecological conceptual framework for patient navigation was used to inform the analytic framework.

Results

Barriers to successful patient navigation at the healthcare system level included complex and unclear eligibility criteria for services and entitlements, including arbitrary age limits; geographical variation; and waiting times for services, particularly rehabilitation. Having a skilled or knowledgeable advocate, such as a family member with experience of the healthcare system, was a key enabling factor. Survivors and carers had to be pro-active and “push” or “battle” for needed services and information. Navigation often involved a substantial administrative burden, which survivors and caregivers had to manage in addition to the demands of the stroke itself, the recovery process, and in many cases other co-morbidities. Healthcare provider factors that supported navigation included clear communication with survivors/carers about services and the stroke itself. Staff who specifically supported care co-ordination were helpful, but this tended to be ad-hoc and limited in availability.

Conclusion

Dedicated staff to support patient navigation across the care continuum could make a significant difference to stroke survivor access to services and consequently outcomes. Clearer, standardised and more person-centred referrals pathways, that are widely publicised and understood, would also improve access.

119 ENHANCING THE QUALITY OF STROKE CARE IN IRELAND - DEVELOPMENT OF AN IRISH NATIONAL STROKE AUDIT

Background

Population ageing, stroke treatment advances, changing models of care, and between-hospital heterogeneity in stroke outcomes demonstrate the necessity of continual audit of stroke care to support quality improvement at local and national levels, and to enhance patient recovery and wellbeing. This project aims to identify the core minimum datasets for acute and non-acute stroke care, and Patient-Reported Outcome Measures (PROMs), for integration in to the newly-developed Irish National Audit of Stroke (INAS), in addition to identifying resourcing needs and implementation procedures.

Methods

In Phase 1, a minimum dataset for acute stroke care was identified based on a scoping review of international practice and available guidelines. Phase 2 (ongoing) involves identifying datasets for non-acute rehabilitative and follow-up care based on a scoping review of international practice, iterative cycles of qualitative stakeholder engagement, and systematic review of PROMs. In Phase 3, a review of resourcing and data collection procedures used in stroke audits internationally will be used to produce an implementation strategy for data collection, contextualised to the Irish healthcare system.

Results

Twenty-one eligible international stroke registries were identified from the scoping review. Within Phase 1, core clinical and thrombectomy items in the Irish registry were benchmarked against internationally-collected items to identify common items and to generate an inventory of items that other registries collect that Ireland does not. Based on consensus agreement on the most frequently-occurring international items, as reviewed by key stakeholders, a core minimum dataset for audit of acute stroke care was delivered.

Conclusion

These minimum datasets shall act as the “gold standard” for evaluating stroke care in Ireland, by not only incorporating structure, process, and care quality outcome indicators, but also PROMs. The resultant datasets may inform policy and quality improvement initiatives, and shape health service delivery across the trajectory of stroke care, from hyper-acute care, to rehabilitation, and return to the community.

Lifetime prevalence and correlates of perinatal depression in a case-cohort study of depression

OBJECTIVES

This study sought to evaluate the prevalence, timing of onset and duration of symptoms of depression in the perinatal period (PND) in women with depression, according to whether they had a history of depression prior to their first perinatal period. We further sought to identify biopsychosocial correlates of perinatal symptoms in women with depression.

DESIGN AND SETTING

The Australian Genetics of Depression Study is an online case cohort study of the aetiology of depression. For a range of variables, women with depression who report significant perinatal depressive symptoms were compared with women with lifetime depression who did not experience perinatal symptoms.

PARTICIPANTS

In a large sample of parous women with major depressive disorder (n=7182), we identified two subgroups of PND cases with and without prior depression history (n=2261; n=878, respectively).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was a positive screen for PND on the lifetime version of the Edinburgh Postnatal Depression Scale. Descriptive measures reported lifetime prevalence, timing of onset and duration of PND symptoms. There were no secondary outcome measures.

RESULTS

The prevalence of PND among parous women was 70%. The majority of women reported at least one perinatal episode with symptoms both antenatally and postnatally. Of women who experienced depression prior to first pregnancy, PND cases were significantly more likely to report more episodes of depression (OR=1.15 per additional depression episode, 95% CI 1.13 to 1.17, p<0.001), non-European ancestry (OR 1.5, 95% CI 1.0 to 2.1, p=0.03), severe nausea during pregnancy (OR 1.3, 95% CI 1.1 to 1.6, p=0.006) and emotional abuse (OR 1.4, 95% CI 1.1 to 1.7, p=0.005).

CONCLUSIONS

The majority of parous women with lifetime depression in this study experienced PND, associated with more complex, severe depression. Results highlight the importance of perinatal assessments of depressive symptoms, particularly for women with a history of depression or childhood adverse experiences.

54 EXWELL: OUTCOMES FROM A SIX-WEEK COMMUNITY EXERCISE REHABILITATION PROGRAM FOR PEOPLE LIVING WITH CHRONIC ILLNESS

Background

Chronic diseases (CD) are long-term conditions, which often require ongoing medical treatment and have the potential to limit the quality of life of the people who live with them. Exercise rehabilitation has been shown to improve physical functioning and health related quality of life (HRQoL) in this cohort.

ExWell is a community-based exercise rehabilitation (CBER) program that offers group exercise rehabilitation classes to individuals with a range of CD. The purpose of this study was to investigate the impact of 6 weeks of participation in the ExWell Medical program on physical functioning and HRQoL in a diverse CD population.

Methods

Participants with a range of CD were referred by healthcare practitioners to the HSE-funded ExWell Medical program based in a community setting. Outcome variables included measurements of body composition, functional capacity and health related quality of life. Assessments were taken at baseline and 6 weeks. Participants were encouraged to attend ExWell Medical classes twice weekly for the duration of the study. Each forty-five minute class included a warm up, aerobic, resistance, core and balance exercises and a cool-down.

Results

Three hundred and ten people (mean age 70.7 ± 7.7 years, 48.3% Female) participated. Statistically and clinically significant improvements were found in cardiorespiratory fitness, lower body strength, balance, co-ordination, body composition and health related quality of life. The greatest improvements were observed in those with the lowest levels of fitness at baseline, and the oldest participants. Improvements in cardiorespiratory fitness and lower body strength matched the recognized clinically meaningful differences in the entire group sample and greatly exceeded them in those in the lowest tertile of fitness at baseline.

Conclusion

The ExWell mixed CD CBER program is an effective approach to rehabilitation delivery in clinical practice. Clinically meaningful improvements can be achieved within 6 weeks of participation, and older and frail participants show greatest improvements overall.

Can network analysis of self-reported psychopathology shed light on the core phenomenology of bipolar disorders in adolescents and young adults?

OBJECTIVES

Network analysis is increasingly applied to psychopathology research. We used it to examine the core phenomenology of emerging bipolar disorder (BD I and II) and 'at risk' presentations (major depression with a family history of BD).

METHODOLOGY

The study sample comprised a community cohort of 1867 twin and nontwin siblings (57% female; mean age ~26) who had completed self-report ratings of (i) depression-like, hypomanic-like and psychotic-like experiences; (ii) family history of BD; and (iii) were assessed for mood and psychotic syndromes using the Composite International Diagnostic Interview (CIDI). Symptom networks were compared for recent onset BD versus other cohort members and then for individuals at risk of BD (depression with/without a family history of BD).

RESULTS

The four key symptoms that differentiated recent onset BD from other cohort members were: anergia, psychomotor speed, hypersomnia and (less) loss of confidence. The four key symptoms that differentiated individuals at high risk of BD from unipolar depression were anergia, psychomotor speed, impaired concentration and hopelessness. However, the latter network was less stable and more error prone.

CONCLUSIONS

We are encouraged by the overlaps between our findings and those from two recent publications reporting network analyses of BD psychopathology, especially as the studies recruited from different populations and employed different network models. However, the advantages of applying network analysis to youth mental health cohorts (which include many individuals with multimorbidity) must be weighed against the disadvantages including basic issues such as judgements regarding the selection of items for inclusion in network models.

Alzheimer's disease genetic risk and sleep phenotypes in healthy young men: association with more slow waves and daytime sleepiness

STUDY OBJECTIVES

Sleep disturbances and genetic variants have been identified as risk factors for Alzheimer's disease (AD). Our goal was to assess whether genome-wide polygenic risk scores (PRS) for AD associate with sleep phenotypes in young adults, decades before typical AD symptom onset.

METHODS

We computed whole-genome PRS for AD and extensively phenotyped sleep under different sleep conditions, including baseline sleep, recovery sleep following sleep deprivation, and extended sleep opportunity, in a carefully selected homogenous sample of 363 healthy young men (22.1 years ± 2.7) devoid of sleep and cognitive disorders.

RESULTS

AD PRS was associated with more slow-wave energy, that is, the cumulated power in the 0.5-4 Hz EEG band, a marker of sleep need, during habitual sleep and following sleep loss, and potentially with larger slow-wave sleep rebound following sleep deprivation. Furthermore, higher AD PRS was correlated with higher habitual daytime sleepiness.

CONCLUSIONS

These results imply that sleep features may be associated with AD liability in young adults, when current AD biomarkers are typically negative, and support the notion that quantifying sleep alterations may be useful in assessing the risk for developing AD.

Short communication: Self-reported sleep-wake disturbances preceding onset of full-threshold mood and/or psychotic syndromes in community residing adolescents and young adults

BACKGROUND

Insomnia may predict onset of mental disorders in adults. However, it is unclear whether the same directional relationship exists during the peak age range for the onset of major mental disorders and/or whether other types of sleep-wake disturbance, such as hypersomnia, show similar associations.

METHODS

Longitudinal follow-up of >1800 community residing twins and non-twin siblings (mean age ~26; 57% female). Adjusted relative risk ratios and 95% confidence intervals (Adj RR and 95% CI) were estimated for onset of depression, hypomania and psychosis in individuals with prior self-reported exposure to Insomnia and/or Hypersomnia or proxies for insomnia disorder (Insomnia and Daytime Impairment) and atypical symptom profile (Hypersomnia and Anergia).

RESULTS

Risk of onset differed somewhat according to type of syndrome and the nature of sleep-wake disturbance (e.g. Insomnia alone increased risk of first onset of psychosis). Overall, the risk for onset of any syndrome was best identified using composite measures (Adj RR were ~1.5-2.5) such as Insomnia and Hypersomnia, Insomnia and Daytime Impairment, or Hypersomnia and Anergia, rather than singular items describing night-time disruption only.

CONCLUSIONS

The magnitude of risk of onset of major mental health problems and the availability of effective, low-cost, individual and population-based interventions for sleep-wake disturbances, suggest that it is justifiable to introduce screening for and strategies to overcome sleep problems in youth.

'A melting pot of cultures' -challenges in social adaptation and interactions amongst international medical students

BACKGROUND

The internationalisation of higher level education and the profiles - nationalities, ethnicities and cultural identities - of students who migrate to undertake higher level education programmes in a different country are increasingly complex. This article explores the way in which cultural backgrounds impact the student's experiences of an international medical school, and how these experiences have the potential to inform the development and design of student support services for those students who are not coping well with the transition.

METHODS

Thirty one first year students were interviewed by sixteen second year students who were trained and supervised by an experienced researcher. Three focus group discussions were also held.

RESULTS

While many international students had lived in more than one country and region and spoke several languages, most reported difficulties in forming intercultural friendships, especially interactions outside of the academic setting. Some of the challenges faced were similar to what has been reported in the literature, such as difficulties with language and loss of established friendship networks. Other challenges to emerge in this study were the complex interrelatedness of the daily life challenges facing international students regarding the forming and importance of intercultural relations, which is impacted by gender, the presence of alcohol, languages spoken (in addition to English, which was the language used for medical education), and the dominance of the regional grouping the student belongs to.

CONCLUSION

The challenges of adaptation and intercultural relations are increasing in complexity and it is important for higher level institutions who enrol international students to understand the nature of the pressures these students experience, outside as well as within the academic environment, and to support them in managing these transitions.

A Cross-Sectional Study of Antibiotic Prescribing for Childhood Upper Respiratory Tract Infections in Irish General Practice

Introduction This study aimed to analyse antibiotic prescribing in cases of upper respiratory tract infection (URTI) in children under 6 years attending Irish daytime and out-of-hours General Practice (GP) services. There have been large scale changes in entitlements for free GP care for this group in recent years. Methods A cross-sectional study of children under 6 years with URTI presentations was performed, over a two-week period for three years from 2015 to 2017. Factors associated with antibiotic prescription and preferred antibiotic compliance were examined using multivariate logistic regression. Results 1,007 Under-6 patients presented with an URTI in our sample over the study period. Following introduction of free GP care, patients were 50% less likely to receive an antibiotic prescription. Overall antibiotic prescribing fell from 70% to 50% in daytime services and from 72% to 60% in the out-of-hours setting. Patients presenting to out-of-hours services were more likely to receive an antibiotic (OR: 1.42) and less likely to receive a deferred antibiotic (OR: 0.53). One quarter to one third of all prescriptions were for deferred antibiotics. Year-on-year trends showed a 13% decrease in prescriptions and 13% increase in preferred antibiotic use. Conclusion The introduction of free GP care led to significant reductions in antibiotic prescribing, which may be due to changes in health seeking behaviour by parents or other reasons. Antibiotic prescribing was more commonplace in the out-of-hours setting, and rates remains high by international standards. This study underlines the importance of ongoing work around GP antimicrobial stewardship, particularly in the out-of-hours setting.

The creative turn in evidence for public health: community and arts-based methodologies

Background

We propose that arts based methodologies can be of value in the production and exchange of evidence in supporting public health related policy. This article reports on a collaborative piece of work resulting from two projects which took place in a former coal mining town in South Wales.

Methods

We used a participatory framework whereby researchers, community members and artists co-produced 'evidence' through the creative arts to inform public policy. We collected a range of data using a number of different techniques, including interviews, focus groups and observation, but also included an extensive range of creative activities.

Results

The data provided a diverse range of perspectives on how people of different ages live their lives. The People's Platform was a performance-based debate which was the culmination of the collaboration. The show involved a series of short performances with time for facilitated discussion in-between. It was felt that the show facilitated knowledge exchange on health and wellbeing issues that are usually difficult to express and understand through traditional forms of evidence.

Conclusion

Whilst arts-based approaches are not free from risk, they offer an alternative form of knowledge as a necessary complement to the range of data available to policy makers.

Measuring choice for adults with an intellectual disability - a factor analysis of the adapted daily choice inventory scale

BACKGROUND

For most people, choice making is an everyday occurrence, but for adults with an intellectual disability (ID), such opportunities are often limited, if not, absent. Defining choice, and related opportunity capacity and supports continue to feature prominently in academic, practice and policy discourse within the field of ID as reflected in the range of measures available. This paper examines the factor analytic properties of an adapted 14-item choice inventory scale.

METHOD

Presence and type of choice were recorded in wave 1 of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing using a choice inventory scale adapted for the Irish context for 753 participants with ID over age 40 years. Analysis included both an exploratory and confirmatory factor analysis. Descriptive statistics on choice by type of living arrangement, type of interview (proxy, self or supported) and level of ID are presented.

RESULTS

Exploratory factor analysis indicates good model fit when using both a 3-item and 4-item response with the 4-item version suggesting a two-factor model. Further exploration of this two-factor model through confirmatory factor analysis highlighted an improved fit for the 4-item model. Further improvement in model fit is found when four item pairs are co-varied within the model.

CONCLUSION

Two broad types of choice were found to exist for adults with ID - everyday decisions and key life decisions. In addition, the factor analysis support for the inclusion of a 'no choice' response may help reduce the potential for missing data.

The Use of Recombinant Tissue Plasminogen Activator (rTPA) in The Treatment of Fibrinous Pleuropneumonia in Horses: 25 Cases (2007-2012)

Background

Information about treatment protocols, adverse effects and outcomes with intrapleural recombinant tissue plasminogen activator (rTPA) use in horses with fibrinous pleuropneumonia is limited.

Hypothesis/Objectives

Describe factors that contribute to clinical response and survival of horses treated with rTPA intrapleurally.

Animals

Horses with bacterial pneumonia and fibrinous pleural effusion diagnosed by ultrasonography, that were treated with rTPA intrapleurally.

Methods

Retrospective multicenter case series from 2007–2012. Signalment, history, clinical and laboratory evaluation, treatment, and outcome obtained from medical records. Regression analysis used to identify associations between treatments and outcomes.

Results

Thirty three hemithoraces were treated in 25 horses, with 55 separate treatments. Recombinant tissue plasminogen activator (375–20,000 μg/hemithorax) was administered 1–4 times. Sonographically visible reduction in fibrin mat thickness, loculations, fluid depth, or some combination of these was seen in 32/49 (65%) treatments. Response to at least 1 treatment was seen in 17/20 (85%) horses with sonographic follow‐up evaluation after every treatment. Earlier onset of rTPA treatment associated with increased survival odds. No association was found between cumulative rTPA dose or number of rTPA doses and survival, development of complications, duration of hospitalization or total charges. Clinical evidence of hypocoagulability or bleeding was not observed. Eighteen horses (72%) survived to discharge.

Conclusions and clinical importance

Treatment with rTPA appeared safe and resulted in variable changes in fibrin quantity and organization within the pleural space. Recombinant tissue plasminogen activator could be a useful adjunct to standard treatment of fibrinous pleuropneumonia, but optimal case selection and dosing regimen remain to be elucidated.

International students' experience of a western medical school: a mixed methods study exploring the early years in the context of cultural and social adjustment compared to students from the host country

BACKGROUND

Few studies have addressed the challenges associated with international students as they adapt to studying medicine in a new host country. Higher level institutions have increasing numbers of international students commencing programmes. This paper explores the experiences of a cohort of students in the early years of medical school in Ireland, where a considerable cohort are from an international background.

METHODS

A mixed exploratory sequential study design was carried out with medical students in the preclinical component of a five year undergraduate programme. Data for the qualitative phase was collected through 29 semi-structured interviews using the peer interview method. Thematic analysis from this phase was incorporated to develop an online questionnaire combined with components of the Student Adaptation to College Questionnaire and Student Integration Questionnaire. First year students were anonymously surveyed online. The Mokken Scaling procedure was used to investigate the students' experiences, both positive and negative.

RESULTS

Three main themes are identified; social adjustment, social alienation and cultural alienation. The response rate for the survey was 49% (467 Respondents). The Mokken Scaling method identified the following scales (i) Positive experience of student life; (ii) Social alienation, which comprised of negative items about feeling lonely, not fitting in, being homesick and (iii) Cultural alienation, which included the items of being uncomfortable around cultural norms of dress and contact between the sexes. With the threshold set to H = 0.4. Subscales of the positive experiences of student life scale are explored further.

CONCLUSIONS

Overall student adjustment to a western third level college was good. Students from regions where cultural distance is greatest reported more difficulties in adjusting. Students from these regions also demonstrate very good adaptation. Some students from the host country and more similar cultural backgrounds were also struggling. Acculturation is more complex than being associated with cultural distance and worthy of further exploration.

Hypermethylation in the ZBTB20 gene is associated with major depressive disorder

BACKGROUND

Although genetic variation is believed to contribute to an individual's susceptibility to major depressive disorder, genome-wide association studies have not yet identified associations that could explain the full etiology of the disease. Epigenetics is increasingly believed to play a major role in the development of common clinical phenotypes, including major depressive disorder.

RESULTS

Genome-wide MeDIP-Sequencing was carried out on a total of 50 monozygotic twin pairs from the UK and Australia that are discordant for depression. We show that major depressive disorder is associated with significant hypermethylation within the coding region of ZBTB20, and is replicated in an independent cohort of 356 unrelated case-control individuals. The twins with major depressive disorder also show increased global variation in methylation in comparison with their unaffected co-twins. ZBTB20 plays an essential role in the specification of the Cornu Ammonis-1 field identity in the developing hippocampus, a region previously implicated in the development of major depressive disorder.

CONCLUSIONS

Our results suggest that aberrant methylation profiles affecting the hippocampus are associated with major depressive disorder and show the potential of the epigenetic twin model in neuro-psychiatric disease.

Genome-wide association analysis of coffee drinking suggests association with CYP1A1/CYP1A2 and NRCAM

Coffee consumption is a model for addictive behavior. We performed a meta-analysis of genome-wide association studies (GWASs) on coffee intake from 8 Caucasian cohorts (N=18 176) and sought replication of our top findings in a further 7929 individuals. We also performed a gene expression analysis treating different cell lines with caffeine. Genome-wide significant association was observed for two single-nucleotide polymorphisms (SNPs) in the 15q24 region. The two SNPs rs2470893 and rs2472297 (P-values=1.6 × 10(-11) and 2.7 × 10(-11)), which were also in strong linkage disequilibrium (r(2)=0.7) with each other, lie in the 23-kb long commonly shared 5' flanking region between CYP1A1 and CYP1A2 genes. CYP1A1 was found to be downregulated in lymphoblastoid cell lines treated with caffeine. CYP1A1 is known to metabolize polycyclic aromatic hydrocarbons, which are important constituents of coffee, whereas CYP1A2 is involved in the primary metabolism of caffeine. Significant evidence of association was also detected at rs382140 (P-value=3.9 × 10(-09)) near NRCAM-a gene implicated in vulnerability to addiction, and at another independent hit rs6495122 (P-value=7.1 × 10(-09))-an SNP associated with blood pressure-in the 15q24 region near the gene ULK3, in the meta-analysis of discovery and replication cohorts. Our results from GWASs and expression analysis also strongly implicate CAB39L in coffee drinking. Pathway analysis of differentially expressed genes revealed significantly enriched ubiquitin proteasome (P-value=2.2 × 10(-05)) and Parkinson's disease pathways (P-value=3.6 × 10(-05)).

Anti-Yo positive paraneoplastic cerebellar degeneration: a report of three cases and review of the literature

Anti-Yo is an anti-Purkiney cell cytoplasmic antibody found in approximately 50% of patients with parancoplastic cerebellar degeneration (PCD). We report three patients with anti-Yo positive PCD (one ovarian carcinoma and two poorly differentiated adenocarcinomas consistent with breast origin). Two were treated with chemotherapy and plasmapheresis but died within months of the diagnosis from progressive neurological disease. The other was given gamma-globulin and has remained table at 6 months follow up. Anti-Yo antibodies are highly specific with almost all patients having breast or gynaecological malignanies. Commonly the tumour is of small volume and asymptomatic. Attempts at treatment are usually unsuccessful but there are a number of reports of stabilisation or improvement when treatment is begun before the development of severe neurological disability. The detection of anti-Yo antibodies is very useful for the diagnosis of PCD allowing early tumour detection and prompt institution of treatment.

Comparison of laparoscopic adjustable gastric banding (LAGB) with other bariatric procedures; a systematic review of the randomised controlled trials

BACKGROUND

Bariatric surgery can provide efficient weight loss and improvement in obesity-related co-morbidities in adults. Laparoscopic adjustable gastric banding (LAGB) comprised 30.3% of all bariatric procedures between 2009 and 2010 in the UK. This review evaluates the level 1 evidence for change in co-morbidities, quality of life (QoL) and weight provided by LAGB compared with other bariatric procedures.

METHOD

Systematic literature search of MEDLINE, EMBASE and CENTRAL (1988 to May 2011) was performed. Only randomised controlled trials (RCTs) were included. Studies with non-surgical comparators, open gastric banding procedures or adolescent participants were excluded. Primary outcome was change in co-morbidities. Secondary outcomes included QoL, weight loss, complications, operation time and length of stay.

RESULTS

Five RCTs met the inclusion criteria. Vertical banded gastroplasty, sleeve gastrectomy and gastric bypass were compared to LAGB. Co-morbidities were reported in two studies and QoL in one. LAGB was comparable to other procedures for both of these outcomes. All five trials showed LABG to be effective in weight loss, however all comparative procedures resulted in greater weight loss. Operative time and length of hospital stay were significantly shorter with LAGB. Short-term complications were found to be consistently lower in the LAGB group. Evidence was divided with respect to long-term complications.

CONCLUSION

Co-morbidities and QoL are poorly reported and showed no difference between LAGB and other bariatric procedures. Evidence suggests that LAGB is not the most effective surgical procedure to reduce weight. LAGB is associated with lower early complications and shorter operative time and length of stay, and therefore may be preferable to patients.

Diagnostic screening of mitochondrial DNA mutations in Australian adults 1990-2001

BACKGROUND

Many diverse pathogenic mitochondrial DNA (mtDNA) mutations have been described since 1988. The Melbourne Neuromuscular Research Institute (MNRI) has undertaken diagnostic detection of selected mtDNA mutations since 1990. MtDNA mutations screened have included point mutations associated with Leber's hereditary optic neuropathy (LHON; G3460A, G11778A and T14484C), mitochondrial encephalopathy lactic acidosis and stroke-like episodes (MELAS; A3243G), myoclonus epilepsy and ragged red fibres (MERRF; A8344G) and Leigh's syndrome/neuropathy ataxia retinitis pigmentosa (LS/NARP; T8993C/G). Samples have also been screened for deletions/ rearrangements associated with Kearns-Sayre syndrome (KSS) and chronic progressive external ophthalmoplegia (CPEO).

AIMS

To present an audit of the MNRI mtDNA diagnostic service between 1990 and 2001, encompassing 1725 referred patients.

METHODS

The detection techniques carried out included polymerase chain reaction amplification of mtDNA combined with restriction fragment length polymorphism analysis for mtDNA point mutation detection, supplemented with selected sequence analysis and Southern blots for the detection of deletions/ rearrangements. Tissues tested included blood, hair and skeletal muscle.

RESULTS

Of the 1184 patients screened for MELAS A3243G, 6.17% were positive for the mutation, whereas for MERRF A8344G, 2.21% carried the mutation and for LS/NARP T8993C/G, 0.32% carried the mutation. The outcomes for the LHON mutations were G11778A, 6.60%, T14484C, 5.76% and G3460A, 0.29%. Of the patients referred for KSS and CPEO, 17.72% had deletions/rearrangements.

CONCLUSIONS

Overall, the detection rate of mtDNA point mutations was low. The protean clinical features of mitochondrial disorders and the frequency of partial phenotypes lead to requests for tests in many patients with a relatively low likelihood of mtDNA mutations. An improved algorithm could involve mutation screening appropriate to the phenotype using sequencing of selected mtDNA regions in patients with a high likelihood of mtDNA disease. Features increasing the likelihood of mtDNA mutations include the following: (i) a typical phenotype, (ii) a maternal inheritance pattern and (iii) histochemical evidence of mitochondrial abnormality in the muscle biopsy. Efficient laboratory diagnosis of mtDNA disease involves good communication between the physician and laboratory scientists, coupled with screening of the appropriate tissue.

Idiopathic granulomatous myositis: does the clinical spectrum include polymyalgia rheumatica?

Granulomatous inflammation restricted to muscle is an uncommon cause of myopathic syndromes. Two patients were diagnosed with idiopathic granulomatous polymyositis after appropriate investigations failed to reveal a systemic or alternative explanation for the granulomas seen in their muscle biopsy. One patient presented with a syndrome indistinguishable from polymyalgia rheumatica but both patients manifested disabling myalgias which were strikingly corticosteroid responsive. The two cases underscore the potential importance of muscle biopsy in polymyalgic states, the non-specificity of polymyalgia rheumatica as a syndrome which can be simulated by other disorders including granulomatous myositis, and the potential corticosteroid responsiveness of prominent, functionally limiting myalgias which can be seen in this disorder. Some controversy continues regarding the correct nosology of this disease, largely perpetuated by an awareness of the inherent limitations of current non-invasive evaluation techniques to confirm occult granulomatous involvement of non-myogenous organs.

The Influence of Twin Pair Permutation on Likelihood-Based-Estimates of Genetic Variance That Require Ordering of Twin-Pairs

Results from analyses of twin data that use models assuming a bivariate distribution of twin values will change when twins within pairs are reordered. We examined the effect of twin pair ordering on additive genetic variance estimates and hypothesis tests, from a bivariate normal model, both via simulation and through examination of real twin data. The simulations generated twin data for varying sample sizes and amounts of additive genetic and common environmental variance. The real data sets had sample sizes of 60 or less per zygosity. The results indicate that for moderate or large size studies, the effects of twin pair ordering are unlikely to greatly change the results of the data analysis; but for small studies the results can be sensitive to twin pair ordering. We therefore suggest that methods, not sensitive to within twin-pair differences be compared to the results obtained from twin-pair ordering. Methods not influenced by twin-pair ordering include least squares methods or covariance matrices approaches as described by Carey (2005, Behav Genet 35:667-670) or Guo and Wang (2002, Behav Genet 32:37-49).

A new dominant distal myopathy affecting posterior leg and anterior upper limb muscles

OBJECTIVE

To report a dominant, slowly progressive early onset distal myopathy with sparing of the tibialis anterior.

METHODS

Twelve affected and two possibly affected members from an Australian kindred were examined and investigated by EMG, imaging studies, histopathology, and genetic analysis.

RESULTS

Affected patients had a slowly progressive condition with symmetric, distal weakness and wasting of the anterior upper and posterior lower limbs, with sparing of tibialis anterior, even in advanced disease. All patients remained ambulant and there was no evidence of cardiac or respiratory muscle involvement. Serum creatine kinase levels were either normal or mildly elevated. Imaging studies showed widespread involvement of the posterior and lateral leg compartments. Proximal muscles were radiologically abnormal only in advanced disease. Muscles that were mildly affected clinically appeared normal on imaging. EMG in nine patients showed widespread myopathic changes. Muscle histopathology in four patients showed either end stage muscle or nonspecific myopathic findings without inflammation or vacuoles. Microsatellite markers for distal myopathy loci were analyzed and all known distal myopathy phenotype genes and linkage regions were formally excluded by multipoint analysis.

CONCLUSIONS

The affected patients in this kindred display a clinically distinct myopathy, with selective involvement of posterior lower and anterior upper limb muscles. The genetic analysis suggests the existence of one more distal myopathy locus.

Patient self-efficacy and health locus of control: relationships with health status and arthritis-related expenditure

OBJECTIVE

To explore the relationship between measures of self-efficacy, health locus of control, health status and direct medical expenditure among community-dwelling subjects with rheumatoid arthritis (RA) and osteoarthritis (OA).

METHODS

This analysis is part of a larger ongoing study of the costs and outcomes of arthritis and its treatments. Community-dwelling RA and OA respondents completed questionnaires concerning arthritis-related expenditure, health status, arthritis related self-efficacy and health locus of control.

RESULTS

Data were obtained from 70 RA respondents and 223 OA respondents. The majority of respondents were female with a mean age of 63 yr for RA respondents and 68 yr for OA respondents. Among the RA respondents, those with higher self-efficacy reported better health status and lower overall costs. Health locus of control was not consistently correlated with health status. OA respondents with higher self-efficacy reported better health status and lower costs. Health locus of control had more influence. OA respondents with higher external locus of control reported worse pain and function. A higher belief in chance as a determinant of health was correlated with more visits to general practitioners and a higher cost to both the respondent and the health system.

CONCLUSION

Higher self-efficacy, which is amenable to change through education programmes, was associated with better health status and lower costs to the respondent and the health system in this cross-sectional study. Locus of control had less of an influence; however, the tendency was for those with higher external locus of control to have higher costs and worse health status. As the measurement of these constructs is simple and the outcome potentially affects health status, these results have implications for future intervention studies to improve quality of life and reduce the financial impact of arthritis on both the health-care system and patients.

Quantitative measure of muscle strength and size in chronic alcoholism: an early indication of tissue damage

We measured quadriceps strength and thickness in 101 male alcoholic patients and in 58 controls in order to investigate the force-size relationships of skeletal muscle in an alcoholic population. The relationship of these parameters with the duration of alcoholism, nutritional status and biochemical and haematological markers of heavy chronic alcohol use was investigated. Alcohol consumption of more than 42 standard drinks (420 g alcohol) per week for at least 5 years is associated with muscle weakness and wasting. There was no evidence of under-nutrition in these alcoholic subjects and muscle wasting occurred independently of peripheral neuropathy, a history of muscle pain, abnormalities of liver enzymes and elevation of mean red cell corpuscular volume. Quantitation of muscle size and strength in heavy drinkers may provide a useful early indicator of health impairment in alcoholics.

Musculoskeletal assessment of general medical in-patients--joints still crying out for attention

OBJECTIVES

The aim of this study was to assess the extent of musculoskeletal assessment (history and examination) amongst medical in-patients and to determine the effects that GALS (gait, arms, legs, spine) teaching has had on this.

METHODS

General medical in-patients were interviewed and examined. Case notes were reviewed to determine diagnoses and assess documentation of clinical signs and/or symptoms. Doctors were interviewed to determine whether they had been taught the GALS locomotor screen, assess their confidence in examining the musculoskeletal system and explore their attitudes to musculoskeletal problems.

RESULTS

The presence or absence of locomotor symptoms was recorded in 50% of the 100 patients, whilst signs were recorded in 20%; 63% of all the patients had locomotor symptoms and/or signs. Relevant musculoskeletal history was missed in 49% of the patients, whilst signs were missed in 78%; 42% of those with musculoskeletal conditions would have benefited from additional treatment. Teaching of the GALS screen significantly increased doctors' confidence in examination of the locomotor system.

CONCLUSIONS

Active musculoskeletal problems are seen frequently amongst medical in-patients. There is a significant discrepancy between the number of patients with clinical symptoms and signs and the frequency with which they are detected and treated.

CD45 fraction bone marrow cells as potential delivery vehicles for genetically corrected dystrophin loci

Targeted correction of mutations in muscle can be delivered by direct i.m. injection of corrective DNA to the dystrophic muscle or by autologous injection of cells that have been genetically corrected after isolation from the individual with the dystrophic muscle. The successful application of chimeraplasty and short fragment homologous replacement to correct the exon 23 nonsense mdx transition at the mouse dys locus has opened up the possibility that with further development, targeted gene correction may have some future application for the treatment of muscular dystrophies. In vitro, application of targeted gene correction at the mdx dys locus results in better correction efficiencies than when applied directly to dystrophic muscle. This suggests that at least for the time being, a strategy involving ex vivo correction may be advantageous over a direct approach for delivery of gene correction to dystrophic muscle. This, particularly in view of recent developments indicating that bone-marrow-derived cells are able to systemically remodel dystrophic muscle, whilst penetration of DNA introduced to muscle is limited to individually injected muscles. Application of targeted gene correction to Duchenne dystrophy needs to account for the fact that about 65% of Duchenne muscular dystrophy cases involve large frame-shift deletion of gene sequence at the dys locus. Traditionally, whilst targeted gene correction is able to restore point mutations entirely, it remains to be seen as to whether a strategy for the 'correction' of frame shift deletions may be engineered successfully. This communication discusses the possibility of applying targeted gene correction to dystrophic muscle in Duchenne dystrophy.

Clinicopathological features of genetically confirmed Danon disease

BACKGROUND

Danon disease is due to primary deficiency of lysosome-associated membrane protein-2.

OBJECTIVE

To define the clinicopathologic features of Danon disease.

METHODS

The features of 20 affected men and 18 affected women in 13 families with genetically confirmed Danon disease were reviewed.

RESULTS

All patients had cardiomyopathy, 18 of 20 male patients (90%) and 6 of 18 female patients (33%) had skeletal myopathy, and 14 of 20 male patients (70%) and one of 18 female patients (6%) had mental retardation. Men were affected before age 20 years whereas most affected women developed cardiomyopathy in adulthood. Muscle histology revealed basophilic vacuoles that contain acid phosphatase-positive material within membranes that lack lysosome-associated membrane protein-2. Heart transplantation is the most effective treatment for the otherwise lethal cardiomyopathy.

CONCLUSIONS

Danon disease is an X-linked dominant multisystem disorder affecting predominantly cardiac and skeletal muscles.

Targeted gene correction in the mdx mouse using short DNA fragments: towards application with bone marrow-derived cells for autologous remodeling of dystrophic muscle

In muscle, mutant genes can be targeted and corrected directly by intramuscular (i.m.) injection of corrective DNA, or by ex vivo delivery of DNA to myogenic cells, followed by cell transplantation. Short fragment homologous replacement (SFHR) has been used to repair the exon 23 nonsense transition at the Xp21.1 dys locus in cultured cells and also, directly in tibialis anterior from male mdx mice. Whilst mdx dys locus correction can be achieved in up to 20% of cells in culture, much lower efficiency is evident by i.m. injection. The major consideration for application of targeted gene correction to muscle is delivery throughout relevant tissues. Systemically injected bone marrow (BM)-derived cells from wt C57BL/10 ScSn mice are known to remodel mdx muscle when injected into the systemic route. Provided that non muscle-derived cell types most capable of muscle remodeling activity can be more specifically identified, isolated and expanded, cell therapy seems presently the most favorable vehicle by which to deliver gene correction throughout muscle tissues. Using wt bone marrow as a model, this study investigates systemic application of bone marrow-derived cells as potential vehicles to deliver corrected (ie wt) dys locus to dystrophic muscle. Intravenous (i.v.) and intraperitoneal (i.p.) injections of wt BM were given to lethally and sub-lethally irradiated mdx mice. Despite both i.v. and surviving i.p. groups containing wt dys loci in 100% and less than 1% of peripheral blood nuclei, respectively, both groups displayed equivalent levels of wt dys transcript in muscle RNA. These results suggest that the muscle remodeling activity observed in systemically injected BM cells is not likely to be found in the hemopoietic fraction.

A novel clinical phenotype of myopathy, sensorimotor neuropathy, infertility, and hypogonadism with multiple mitochondrial DNA deletions

We describe a patient with myopathy, sensorimotor neuropathy, hypogonadism, and infertility with abnormal sperm mobility and morphology. Analysis of the deltoid muscle DNA revealed a G to A change at nt 1102 in the twinkle gene and multiple mitochondrial DNA deletions. Histochemistry revealed "ragged-red" fibers and many cytochrome-c oxidase negative fibers (32%) that lacked the mitochondrial encoded respiratory chain subunits I and II and the nuclear encoded subunit VIc. Respiratory chain enzyme analysis showed severe deficiency of complex I, III, and IV. This patient has no documented family history of progressive external ophthalmoplegia, which suggests either a sporadic or autosomal-recessive syndrome. This case is a novel phenotype for twinkle gene mutations and multiple mitochondrial DNA deletion syndromes, as these syndromes generally follow an autosomal-dominant inheritance pattern.