Neurosteroids and translocator protein 18 kDa (TSPO) in depression: implications for synaptic plasticity, cognition, and treatment options

There is need for novel fast acting treatment options in affective disorders. 3α-reduced neurosteroids such as allopregnanolone are powerful positive allosteric modulators of GABAA receptors and target also extrasynaptic receptors. Their synthesis is mediated by the translocator protein 18 kDa (TSPO). TSPO ligands not only promote endogenous neurosteroidogenesis, but also exert a broad spectrum of functions involving modulation of mitochondrial activity and acting as anti-inflammatory and neuroregenerative agents. Besides affective symptoms, in depression cognitive impairment can be frequently observed, which may be ameliorated through targeting of extrasynaptic GABAA receptors either via TSPO ligands or exogenously administered 3α-reduced neurosteroids. Interestingly, recent findings indicate an enhanced activation of the complement system, e.g., enhanced expression of C1q, both in depression and dementia. It is of note that benzodiazepines have been shown to reduce long-term potentiation and to cause cognitive decline. Intriguingly, TSPO may be crucial in mediating the effects of benzodiazepines on synaptic pruning. Here, we discuss how benzodiazepines and TSPO may interfere with synaptic pruning. Moreover, we highlight recent developments of TSPO ligands and 3α-reduced neurosteroids as therapeutic agents. Etifoxine is the only clinically available TSPO ligand so far and has been studied in anxiety disorders. Regarding 3α-reduced neurosteroids, brexanolone, an intravenous formulation of allopregnanolone, has been approved for the treatment of postpartum depression and zuranolone, an orally available 3α-reduced neurosteroid, is currently being studied in major depressive disorder and postpartum depression. As such, 3α-reduced neurosteroids and TSPO ligands may constitute promising treatment approaches for affective disorders.

A Bayesian test for Hardy-Weinberg equilibrium of biallelic X-chromosomal markers

The X chromosome is a relatively large chromosome, harboring a lot of genetic information. Much of the statistical analysis of X-chromosomal information is complicated by the fact that males only have one copy. Recently, frequentist statistical tests for Hardy-Weinberg equilibrium have been proposed specifically for dealing with markers on the X chromosome. Bayesian test procedures for Hardy-Weinberg equilibrium for the autosomes have been described, but Bayesian work on the X chromosome in this context is lacking. This paper gives the first Bayesian approach for testing Hardy-Weinberg equilibrium with biallelic markers at the X chromosome. Marginal and joint posterior distributions for the inbreeding coefficient in females and the male to female allele frequency ratio are computed, and used for statistical inference. The paper gives a detailed account of the proposed Bayesian test, and illustrates it with data from the 1000 Genomes project. In that implementation, a novel approach to tackle multiple testing from a Bayesian perspective through posterior predictive checks is used.

Diagnostic and predictive value of urine PCA3 gene expression for the clinical management of patients with altered prostatic specific antigen

OBJECTIVE

Analyze the impact of the introduction of the study of PCA3 gene in post-prostatic massage urine in the clinical management of patients with PSA altered, evaluating its diagnostic ability and predictive value of tumor aggressiveness.

METHODS

Observational, prospective, multicenter study of patients with suspected prostate cancer (PC) candidates for biopsy. We present a series of 670 consecutive samples of urine collected post-prostatic massage for three years in which we determined the "PCA3 score" (s-PCA3). Biopsy was only indicated in cases with s-positive PCA3.

RESULTS

The s-PCA3 was positive in 43.7% of samples. In the 124 biopsies performed, the incidence of PC or atypical small acinar proliferation was 54%, reaching 68,6% in s-PCA3≥100. Statistically significant relationship between the s-PCA3 and tumor grade was demonstrated. In cases with s-PCA3 between 35 and 50 only 23% of PC were high grade (Gleason≥7), compared to 76.7% in cases with s-PCA3 over 50. There was a statistically significant correlation between s-PCA3 and cylinders affected. Both relationships were confirmed by applying a log-linear model.

CONCLUSIONS

The incorporation of PCA3 can avoid the need for biopsies in 54% of patients. s-PCA3 positivity increases the likelihood of a positive biopsy, especially in higher s-PCA3 100 (68.6%). s-PCA3 is also an indicator of tumor aggressiveness and provides essential information in making treatment decisions.

Fluorescent in situ hybridization as a predictor of relapse in urothelial carcinoma

OBJECTIVE

To assess the value of the study of chromosomal alterations by fluorescent in situ hybridization in a series of patients diagnosed of urothelial carcinoma and a minimum follow up of twenty four months, as well as evaluate its putative predictive potential.

MATERIAL AND METHODS

The overall series includes 338 samples from 98 patients with 84 episodes of urothelial carcinoma. A subgroup of 24 patients who had at least one recurrence during the follow up was used to evaluate the predictive potential of the test. Three categories were considered (positive coherent episode, negative coherent episode, and incoherent episode) depending on the relationship between the fluorescent in situ hybridization result in the concomitant study of the new episode and those of the preceding samples.

RESULTS

Fluorescent in situ hybridization showed higher sensitivity regardless of grade, negative predictive value and accuracy, while specificity and positive predictive value were superior with conventional cytology. In the recurrence, series 19/29 episodes were coherent, 11/19 were positive coherent with urothelial carcinoma all high grade and 8/19 negative coherent, most low grade.

CONCLUSIONS

Fluorescent in situ hybridization test shows good sensitivity during a follow up of twenty four months and is able to predict recurrence, especially in cases of high grade. Our data demonstrate the existence of urothelial carcinomas without detectable chromosomal abnormalities by currently available methodology. The results support a multidisciplinary follow up combining fluorescent in situ hybridization, cytology and cystoscopy.

The impact of avoidable mortality on life expectancy at birth in Spain: changes between three periods, from 1987 to 2001

Objective:

To evaluate the impact of avoidable mortality on the changes in life expectancy at birth in Spain.

Methods:

Standard life table techniques and the Arriaga method were used to calculate and to decompose life expectancy (LE) changes by age, effects and groups of causes of avoidable mortality among three periods (1987–91, 1992–6 and 1997–2001). A list of causes of avoidable mortality reached by consensus and previously published in Spain was used.

Main results:

Life expectancy increased in all ages and both sexes. The main contribution to the increase of LE at birth was due to people over 50. Mortality in young adults produced a reduction in LE between the first two periods, but there was an important increase in LE between the last two periods; in both cases, this was the result of factors amenable to health policy interventions. The highest improvement in LE was due to non-avoidable causes, but avoidable mortality through health service interventions showed improvements in LE in those younger than 1 year and in those aged 45–75 years.

Conclusions:

Making a distinction between several groups of causes of avoidable mortality and using decomposition by causes, ages and effects allowed us to better explain the impact of avoidable mortality on the LE of the whole population and gave a new dimension to this indicator that could be very useful in public health.

Impact of Mycophenolate Mofetil Dose Posttransplantation on 12-Month Renal Function: Analysis of the MOST Database

INTRODUCTION

Mycophenolate mofetil (MMF) has greatly reduced the risk of acute rejection episodes (ARE) after renal transplantation, but dose reductions/withdrawals could jeopardize long-term results.

METHODS

The MOST database of "de novo" patients treated with MMF at month 1 and functioning grafts at month 12 were divided into 2 groups: groups 1, 2 g MMF at month 1 and month 12; and group 2, 2 g MMF at month 1 but MMF <2 g at month 12 to evaluate renal function glonerular filtration rate (GFR).

RESULTS

In this study, 1136 patients were receiving 2 g MMF at month 1. On month 12, 645 were on 2 g (56.8%, group 1) and 431 were on <2 g (43.2%, group 2). Group 1 included younger recipients of younger donors with fewer patients with delayed graft function (DGF). Group 1 showed more ARE during month 1 and more patients who received induction. Mean Neoral daily doses at month 1/month 12 were 5.3/3.0 and 5.3/3.1 mg/kg in group 1 and group 2, respectively (P = .05 at month 12). GFR in group 1 and group 2 were 59.06 (CI 57.10-60.60) and 53.81 (CI 52-55.7) at month 1 (P < .001); 63.7 (CI 62.1-65.30) and 55.9 (CI 54.1-57.7) mL/min*1.73 m(2) at month 12 (P < .001). The mean increases in GFR between month 1 and month 12 were 4.64 and 1.94 mL/min*1.73 m(2), respectively (P < .05). A multivariate analysis also included 795 patients from the "maintenance" patient database with retrospective detailed information. The following parameters were highly predictive for good renal function at month 12: donor age younger than 60 years, recipient age younger than 60 years, immediate graft function, 12-month MMF dose = 2 g, absence of CMV infection, and 12-month Neoral dose <3 mg/kg/d.

CONCLUSIONS

Maintenance of MMF dose at 2 g/d during the first year appears to facilitate the attainment of optimal renal function at 12-months after kidney transplantation.

[Importance of 5569G/A polymorphism in intron 4 of HFE gene in the diagnosis of hereditary hemochromatosis]

BACKGROUND

The presence of the 5569A polymorphism may lead to misdiagnosis of patients susceptible of hereditary hemochromatosis (HH). For that reason, samples containing the Cys282Tyr mutation were revised and the frequency of this polymorphism in our environment was assessed.

PATIENTS AND METHOD

Twenty samples were retested and 56 controls were included. The study was performed by PCR-RFLP.

RESULTS

The diagnosis was confirmed in 8 cases susceptible of error. However, an amplification deficiency of normal alleles was detected in 2 heterozygous (17%). The allelic frequency of the 5569A polymorphism in the control population was 14.3%.

CONCLUSIONS

Although misdiagnosis was not committed, we recommend changing to any primer that does not include the 5569G/A polymorphism in the study of HH.

BMI-1 gene amplification and overexpression in hematological malignancies occur mainly in mantle cell lymphomas

The BMI-1 gene is a putative oncogene belonging to the Polycomb group family that cooperates with c-myc in the generation of mouse lymphomas and seems to participate in cell cycle regulation and senescence by acting as a transcriptional repressor of the INK4a/ARF locus. The BMI-1 gene has been located on chromosome 10p13, a region involved in chromosomal translocations in infant leukemias, and amplified in occasional non-Hodgkin's lymphomas (NHLs) and solid tumors. To determine the possible alterations of this gene in human malignancies, we have examined 160 lymphoproliferative disorders, 13 myeloid leukemias, and 89 carcinomas by Southern blot analysis and detected BMI-1 gene amplification (3- to 7-fold) in 4 of 36 (11%) mantle cell lymphomas (MCLs) with no alterations in the INK4a/ARF locus. BMI-1 and p16INK4a mRNA and protein expression were also studied by real-time quantitative reverse transcription-PCR and Western blot, respectively, in a subset of NHLs. BMI-1 expression was significantly higher in chronic lymphocytic leukemia and MCL than in follicular lymphoma and large B cell lymphoma. The four tumors with gene amplification showed significantly higher mRNA levels than other MCLs and NHLs with the BMI-1 gene in germline configuration. Five additional MCLs also showed very high mRNA levels without gene amplification. A good correlation between BMI-1 mRNA levels and protein expression was observed in all types of lymphomas. No relationship was detected between BMI-1 and p16INK4a mRNA levels. These findings suggest that BMI-1 gene alterations in human neoplasms are uncommon, but they may contribute to the pathogenesis in a subset of malignant lymphomas, particularly of mantle cell type.

[Relationship between quality and cost of the drug prescription in primary care]

OBJECTIVES

With a system of qualitative indicators, to analyse the pharmaceutical prescription of general practitioners (GPs), and to evaluate the relationship of these indicators to the overall pharmaceutical prescription expenditure per inhabitant.

DESIGN

Retrospective descriptive study.

SETTING

Primary care.

MEASUREMENTS AND MAIN RESULTS

The drugs prescription of 285 GPs from 32 primary care teams was evaluated, with the individual prescription of each doctor as the unit of analysis. The prescription was classified in 3 categories according to its intrinsic value (IV): low (< or = 75%), medium (76-79%) and high (> or = 80%). Selected as tracers of over-prescription were: daily dose per inhabitant (DDI) of antibiotics (AB), DDI of non-steroid anti-inflammatory drugs (NSAID), and DDI of ulcer drugs (ULC). Selected as tracers of selection were: % DDI third-generation cephalosporins/DDI total cephalosporins; % DDI broad-spectre quinolones/DDI total quinolones; and % DDI NSAID/DDI NSAID plus analgesics. Quantitative indicators studied were: total expenditure per allocated population, cost per drugs prescription of doubtful efficacy, and cost per daily dose of AB, NSAID and ULC. Variance analysis, including the Scheffe test for multiple comparisons and Pearson's linear correlation, was applied. 26% of the prescriptions had an IV below 75%, and 34% had an IV above 80%. The means of DDI of AB among the categories of IV were different (p < 0.0001), as were those of DDI of NSAID (p < 0.0001) and of ULC (p = 0.007). Lower consumption of AB, NSAID and ULC was found in prescriptions with the highest IV %. The third-generation cephalosporins and the NSAID + analgesics showed significant differences in the three IV categories (p < 0.0001 and p = 0.041), unlike broad-spectrum quinolones (p = 0.18). The total expenditure per allocated population was less for GPs whose prescriptions had the highest IV %; whereas the cost per prescription and cost per daily dose showed no significant differences for IV categories.

CONCLUSIONS

The doctors with the best qualitative profile on these indicators had less expenditure per inhabitant. However, no differences were found in the cost per prescription or cost per treatment between doctors. Therefore, interventions must prioritize improving drug prescription quality rather than just promoting changes to lower-cost drugs.

Systemic capillary leak syndrome

Systemic capillary leak syndrome is a rare, severe disorder with a high mortality rate. It consists of the shift of fluid and proteins from the intravascular to the extravascular compartment with subsequent hypovolemic shock. We describe a 34-year-old-woman who had several episodes of generalized edema that evolved to hypovolemic shock. During the acute phase, laboratory investigations revealed marked hypoproteinemia, leukocytosis, and high levels of hematocrit and hemoglobin. A paraprotein IgG kappa chain was detected. Although different therapeutic trials were used, the patient continued to have similar episodes and she died during an acute episode 2 1/2 years after the first symptom of this disorder. The cause of systemic capillary leak syndrome is unknown. The presence of a paraprotein IgG is frequent in this group of patients.

[Malignant pleural mesothelioma. A diagnostic and therapeutic challenge]

Malignant pleural mesothelioma is a tumor very difficult to diagnose and with a very controversial therapy. We describe an illustrative case with development of pleural overflow and detection of high adenosine-deaminase levels. Surgical resection combined with radiotherapy and/or chemotherapy is the current therapeutics. We describe the state-of-the-art advances in the immunohistochemical diagnosis and therapeutics and we stress the need to conduct cooperative studies in order to achieve a better knowledge of the prognosis factors, an effective step-by-step approach and innovative therapy strategies.

Bronchial stump aspergillosis four years after lobectomy

Bronchial stump aspergillosis (BSA) is an unusual entity. We report a case presenting hemoptysis four years after right upper lobe resection because of lung cancer. Simple removal of the silk suture is most likely the treatment of choice. No additional local or systemic antifungal therapy is needed.

Nifedipine in the treatment of renal colic

A double-blind randomized, clinical trial was conducted in 43 patients to evaluate the efficacy of sublingual nifedipine in the treatment of pain in renal colic. Comparison was made with a combination of dipyrone, pitofenone and fenpipramide, which is usually administered intravenously in Spain. With nifedipine, pain completely disappeared in 44% of the cases, and with the combination of drugs, in 89% (p less than 0.005). More adverse effects were noted with the combination than with nifedipine. Both treatments brought about a slight drop in arterial pressure without leading to hypotension in any case. There was no change in heart rate. The possible causes of the relatively low level of success with nifedipine were analyzed. The possibility of using nifedipine under certain circumstances in which other drugs are contraindicated or when their administration is unfeasible is suggested.