[Multi-family therapy for adolescents with anorexia nervosa]

Background Anorexia nervosa (AN) is a severe psychiatric disorder. Family based therapy is the most appropriate treatment. In recent decades, a particular form multi-family therapy (MFT) has been used. Aim To provide an overview of the scientific evidence regarding MFT in adolescents with AN. Method Literature search using PubMed, PsycInfo and Web of Knowledge. Literature was searched about the treatment of AN in adolescents through multi-family therapy in day therapy setting. Seven studies were included: one RCT with a strong methodology, two smaller controlled studies and four case series. Results After completing MFT, clear significant improvement is reported in terms of weight or BMI and eating disorder symptoms. Two studies suggest MFT is more effective in accelerating weight gain and achieving weight recovery. Depressive features, individual and family factors also improve. The low drop-out rate is remarkable. Conclusion MFT as an additional treatment for adolescents with AN is promising. Based on the available evidence, a good and at least equivalent outcome in comparison with family therapy is expected. In addition, it offers several unique benefits.

Bisphosphonate-related atypical femoral fractures: A novel strategy to improve patient outcomes

Background:

Atypical femoral fracture (AFF) is a serious adverse event associated with bisphosphonate therapy and prone to complications and delayed union. We propose a technique and management strategy to maximise bone healing and outcomes.

Methods:

We report on a cohort of patients with AFF using our novel technique of preparing the intramedullary canal and rigid fixation with cephalomedullary nailing. Patients were admitted under a multidisciplinary team with rehabilitation goals of early mobilisation and teriparatide initiation. Clinical and radiographic data were retrospectively reviewed.

Results:

Twenty-eight AFFs were treated with a mean follow-up of 58.5 weeks and a mean age of 75.2 years old. All cases achieved radiological union by a mean of 6 months and post-operative thigh pain experienced up to 8.7 weeks. No cases underwent revision or experienced intraoperative complication.

Conclusion:

Our surgical technique and multidisciplinary management are reproducible with excellent results in patients with this rare yet challenging injury.

Can psychiatric childhood disorders be due to inborn errors of metabolism?

Many patients who visit a centre for hereditary metabolic diseases remarkably also suffer from a child psychiatric disorder. Those child psychiatric disorders may be the first sign or manifestation of an underlying metabolic disorder. Lack of knowledge of metabolic disorders in child psychiatry may lead to diagnoses being missed. Patients therefore are also at risk for not accessing efficacious treatment and proper counselling. To search the literature for the co-occurrence of child psychiatric disorders, such as ADHD, autism, psychosis, learning disorders and eating disorders and metabolic disorders. A search of the literature was conducted by performing a broad search on PubMed, using the terms "ADHD and metabolic disorders", "autism and metabolic disorders", "psychosis and metabolic disorders", "learning disorders and metabolic disorders", and "eating disorders and metabolic disorders". Based on inclusion criteria (concerning a clear psychiatric disorder and concerning a metabolic disorder) 4441 titles and 249 abstracts were screened and resulted in 71 relevant articles. This thorough literature search provides child and adolescent psychiatrists with an overview of metabolic disorders associated with child psychiatric symptoms, their main characteristics and recommendations for further investigations.

Paediatric airway foreign body - The human factors influencing patient safety in our hospitals

Foreign bodies in the pediatric airway are an uncommon emergency with a high morbidity and mortality rate. Morbidity ranges from 10 to 20% worldwide and this pathology accounts for up to 7% of accidental deaths in children under 4. Dealing with this emergency safely and effectively is complex, requiring a tight coupling of procedures and processes and optimal anesthetic and operating conditions to prevent errors. These factors are recognized by the World Health Organization as 'Human Factors'. We perform a multi-center assessment of human factors pertinent to this emergency. Specifically, equipment provision and staff training in this emergency. Data was collected from 13 sites in the United Kingdom, using two questionnaires for medical and nursing staff. Information including equipment availability, location of equipment, and surgeon and nursing experience was recorded. Royal Manchester Children's Hospital (RMCH) set the study standard. Our study shows there is huge variability in equipment provision across units. There is a lack of experience, confidence and training amongst middle grade otolaryngology surgeons and emergency theatre staff in handling this emergency. Issues with equipment and inexperience of both middle grade doctors and nursing staff could result in significant patient morbidity and mortality. We suggest a standardized age appropriate equipment list and staff training in use of this equipment. Implementation of these simple changes could reduce preventable error in this rare but serious emergency.

The Healthy Primary School of the Future: study protocol of a quasi-experimental study

BACKGROUND

Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined.

METHODS

In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019.

DISCUSSION

A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society.

TRIAL REGISTRATION

The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

Cytogenetic Nomenclature: Changes in the ISCN 2013 Compared to the 2009 Edition

The latest edition of the International System for Human Cytogenetic Nomenclature, ISCN 2013, has recently been published following a thorough revision of the 2009 issue and the incorporation of suggestions from the community by the current standing committee. This review will highlight the multiple nomenclature changes in the respective chapters of the 2013 version compared to the previous version of the ISCN published in 2009. These highlights are meant as a guide for the cytogeneticist to assist in the transition in the use of this updated nomenclature for describing cytogenetic and molecular cytogenetic findings in both clinical and research reports.

[Early-onset eating disorders: a review of the literature]

BACKGROUND

The incidence of anorexia nervosa (AN) in adolescents has increased significantly in recent years. In several studies and in the media it has been suggested that AN has recently become more prevalent in the pre-adolescence. In view of the impact that an eating disorder can have on a child, it is important to diagnose and start treating the illness as early as possible.

AIM

To review the literature on the characteristics and susceptibilities of patients with eating disorders because this information can be important for early diagnosis, prevention and identification of susceptibilities to early-onset eating disorders.

METHOD

We searched the literature for articles relating to early-onset eating disorders. We based our search on PubMed and on related relevant articles listed in the references. We selected 34 relevant articles published between 1987 and 2014.

RESULTS

The literature lists characteristics and susceptibilities at various levels. Many types of factors are involved; examples of 'biological' factors are prior streptococcal infection, previous consultations with GP and a patients medical history; psychological factors include comorbidity, temperament, a particular personality profile, maturation-anxiety; environmental factors such as family history, family functioning and/or stressful events can play a role in the development of eating disorders. CONCLUSION The literature indicates that the early development of AN in children is related to a complex combination of etiological factors. However, there is a need for more research into this group of patients.

Bilateral femoral neck insufficiency fractures secondary to vitamin D deficiency and concurrent corticosteroid use--a case report

We present a rare case of a 67-year-old Indian female who was found to have bilateral insufficiency of the neck of femur fractures secondary to osteomalacia from vitamin D deficiency, with her symptoms exacerbated by a course of oral steroids prescribed for suspected polymyalgia rheumatica.

INTRODUCTION

Bilateral femoral neck fractures are rare and are known to be associated with a variety of conditions such as parathyroid or renal dysfunction.

METHOD

We present a rare case of a 67-year-old Indian female who was found to have bilateral insufficiency of the neck of femur fractures secondary to osteomalacia from vitamin D deficiency, with her symptoms exacerbated by a course of oral steroids prescribed for suspected polymyalgia rheumatica.

RESULT

In patients with severe bilateral hip pain and a normal pelvic radiograph, it is important to consider magnetic resonance imaging early to avoid missing this important diagnosis.

CONCLUSION

Osteomalacia and vitamin D deficiency is an important differential diagnosis in any patient presenting with bone and muscle pain. Vitamin D levels are easily available and deficiency is easily treated.

[Paroxysmal events after anxiety treatment with fluoxetine in a child with autism spectrum disorder]

Anxiety is common in children and adolescents with autism spectrum disorders and can cause severe dysfunction and suffering. An 11-year-old boy with an autism spectrum disorder and suffering from anxiety and mood problems responded positively to treatment with fluoxetine. After four weeks he developed clinically observable paroxysmal events accompanied by absence and confusion.

Chronic psychosocial stressors and salivary biomarkers in emerging adults

We investigated whole saliva as a source of biomarkers to distinguish individuals who have, and who have not, been chronically exposed to severe and threatening life difficulties. We evaluated RNA and DNA metrics, expression of 37 candidate genes, and cortisol release in response to the Trier Social Stress Test, as well as clinical characteristics, from 48 individuals stratified on chronic exposure to psychosocial stressors within the last year as measured by the Life Events and Difficulties Schedule. Candidate genes were selected based on their differential gene expression ratio in circulating monocytes from a published genome-wide analysis of adults experiencing different levels of exposure to a chronic stressor. In univariate analyses, we observed significantly decreased RNA integrity (RIN) score (P = 0.04), and reduced expression of glucocorticoid receptor-regulated genes (Ps < 0.05) in whole saliva RNA from individuals exposed to chronic stressors, as compared to those with no exposure. In those exposed, we observed significantly decreased BMI (P < 0.001), increased ever-smoking and increased lifetime alcohol abuse or dependence (P ≤ 0.03), and a reduction of cortisol release. In post hoc multivariate analyses including clinical and biospecimen-derived variables, we consistently observed significantly decreased expression of IL8 (Ps<0.05) in individuals exposed, with no significant association to RIN score. Alcohol use disorders, tobacco use, a reduced acute stress response and decreased salivary IL8 gene expression characterize emerging adults chronically exposed to severe and threatening psychosocial stressors.

Onset of alcohol or substance use disorders following treatment for adolescent depression

OBJECTIVE

This study tested whether positive response to short-term treatment for adolescent major depressive disorder (MDD) would have the secondary benefit of preventing subsequent alcohol use disorders (AUD) or substance use disorders (SUD).

METHOD

For 5 years, we followed 192 adolescents (56.2% female; 20.8% minority) who had participated in the Treatment for Adolescents with Depression Study (TADS; TADS Team, 2004) and who had no prior diagnoses of AUD or SUD. TADS initial treatments were cognitive behavior therapy (CBT), fluoxetine alone (FLX), the combination of CBT and FLX (COMB), or clinical management with pill placebo (PBO). We used both the original TADS treatment response rating and a more restrictive symptom count rating. During follow-up, diagnostic interviews were completed at 6- or 12-month intervals to assess onset of AUD or SUD as well as MDD recovery and recurrence.

RESULTS

Achieving a positive response to MDD treatment was unrelated to subsequent AUD but predicted a lower rate of subsequent SUD, regardless of the measure of positive response (11.65% vs. 24.72%, or 10.0% vs. 24.5%, respectively). Type of initial MDD treatment was not related to either outcome. Prior to depression treatment, greater involvement with alcohol or drugs predicted later AUD or SUD, as did older age (for AUD) and more comorbid disorders (for SUD). Among those with recurrent MDD and AUD, AUD preceded MDD recurrence in 24 of 25 cases.

CONCLUSION

Effective short-term adolescent depression treatment significantly reduces the rate of subsequent SUD but not AUD. Alcohol or drug use should be assessed prior to adolescent MDD treatment and monitored even after MDD recovery.

A rare cause of pneumoperitoneum

Gas under the diaphragm can be due to like perforation in stomach, duodenum due to peptic ulcer disease, in jejunum or illeum by inflammatory bowel disease or cancer can lead to pneumoperitoneum. We present a rare cause of pneumoperitoneum following abdominal hysterectomy.

Stress, glucocorticoids and liquorice in human pregnancy: programmers of the offspring brain

A suboptimal prenatal environment may induce permanent changes in cells, organs and physiology that alter social, emotional and cognitive functioning, and increase the risk of cardiometabolic and mental disorders in subsequent life ("developmental programming"). Although animal studies have provided a wealth of data on programming and its mechanisms, including on the role of stress and its glucocorticoid mediators, empirical evidence of these mechanisms in humans is still scanty. We review the existing human evidence on the effects of prenatal maternal stress, anxiety and depression, glucocorticoids and intake of liquorice (which inhibits the placental barrier to maternal glucocorticoids) on offspring developmental outcomes including, for instance, alterations in psychophysiological and neurocognitive functioning and mental health. This work lays the foundations for biomarker discovery and affords opportunities for prevention and interventions to ameliorate adverse outcomes in humans.

Recovery and recurrence following treatment for adolescent major depression

CONTEXT

Major depressive disorder in adolescents is common and impairing. Efficacious treatments have been developed, but little is known about longer-term outcomes, including recurrence.

OBJECTIVES

To determine whether adolescents who responded to short-term treatments or who received the most efficacious short-term treatment would have lower recurrence rates, and to identify predictors of recovery and recurrence.

DESIGN

Naturalistic follow-up study.

SETTING

Twelve academic sites in the United States.

PARTICIPANTS

One hundred ninety-six adolescents (86 males and 110 females) randomized to 1 of 4 short-term interventions (fluoxetine hydrochloride treatment, cognitive behavioral therapy, their combination, or placebo) in the Treatment for Adolescents With Depression Study were followed up for 5 years after study entry (44.6% of the original Treatment for Adolescents With Depression Study sample).

MAIN OUTCOME MEASURES

Recovery was defined as absence of clinically significant major depressive disorder symptoms on the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version interview for at least 8 weeks, and recurrence was defined as a new episode of major depressive disorder following recovery.

RESULTS

Almost all participants (96.4%) recovered from their index episode of major depressive disorder during the follow-up period. Recovery by 2 years was significantly more likely for short-term treatment responders (96.2%) than for partial responders or nonresponders (79.1%) (P < .001) but was not associated with having received the most efficacious short-term treatment (the combination of fluoxetine and cognitive behavioral therapy). Of the 189 participants who recovered, 88 (46.6%) had a recurrence. Recurrence was not predicted by full short-term treatment response or by original treatment. However, full or partial responders were less likely to have a recurrence (42.9%) than were nonresponders (67.6%) (P = .03). Sex predicted recurrence (57.0% among females vs 32.9% among males; P = .02).

CONCLUSIONS

Almost all depressed adolescents recovered. However, recurrence occurs in almost half of recovered adolescents, with higher probability in females in this age range. Further research should identify and address the vulnerabilities to recurrence that are more common among young women.

The Treatment for Adolescents With Depression Study (TADS): outcomes over 1 year of naturalistic follow-up

OBJECTIVE

The Treatment for Adolescents With Depression Study (TADS) evaluates the effectiveness of fluoxetine, cognitive-behavioral therapy (CBT), and their combination in adolescents with major depressive disorder. The authors report effectiveness outcomes across a 1-year naturalistic follow-up period.

METHOD

The randomized, controlled trial was conducted in 13 academic and community sites in the United States. Stages I, II, and III consisted of 12, 6, and 18 weeks of acute, consolidation, and continuation treatment, respectively. Following discontinuation of TADS treatments at the end of stage III, stage IV consisted of 1 year of naturalistic follow-up. The participants were 327 subjects between the ages of 12 and 17 with a primary DSM-IV diagnosis of major depressive disorder. No TADS treatment was provided during the follow-up period; treatment was available in the community. The primary dependent measures, rated by an independent evaluator blind to treatment status, were the total score on the Children's Depression Rating Scale-Revised and the rate of response, defined as a rating of much or very much improved on the Clinical Global Impressions improvement measure.

RESULTS

Sixty-six percent of the eligible subjects participated in at least one stage IV assessment. The benefits seen at the end of active treatment (week 36) persisted during follow-up on all measures of depression and suicidality.

CONCLUSIONS

In contrast to earlier reports on short-term treatments, in which worsening after treatment is the rule, the longer treatment in the TADS was associated with persistent benefits over 1 year of naturalistic follow-up.

HPA-axis Function and Depression in Adolescence: Are they Related to Prenatal Early Life Stress?

Early-life exposure to adverse environmental cues during critical windows of time in the prenatal and/or early postnatal life period could predispose the individual for somatic andmental diseases. This especially holds for stress-related disorders such as depression in which HPA-axis dysregulation plays a pathophysiological role. This is in line with the ‘fetal (or developmental) programming-hypothesis’ which has been tested in numerous preclinical experimental. We tested this hypothesis in humans in a prospective longitudinal study in which maternal emotional state was measured during each pregnancy trimester and after pregnancy. When the offspring was 14-15 years old, HPA-axis function was measured through establishing a saliva day-time cortisol profile. Severity of depressive symptoms was measured with the Children's Depression Inventory. Repeated measurements regression analysis and ordinary least-squares regression analyses indicated that maternal anxiety at 12-22 weeks of pregnancy was in female and male offspring associated with a diurnal cortisol profile that was attenuated due to elevated cortisol secretion in the evening. Moreover, in female adolescents this flattened cortisol curve was associated with depressive symptoms. Our results indicate that maternal anxiety during pregnancy enhances neurobiological vulnerability to depressive symptoms, possibly by altering (or ‘programming") foetal physiology. If our results can be replicated in future research they may lead to a re-orientation of the target of primary prevention and treatment of depressive symptoms. Preliminary results of a study on the association between prenatal exposure to maternal anxiety and cortisol stress responsivity during inoculation in the four month old will be presented.

Heterogeneous patterns of amplification of the NUP214-ABL1 fusion gene in T-cell acute lymphoblastic leukemia

Episomes with the NUP214-ABL1 fusion gene have been observed in 6% of T-ALL. In this multicentric study we collected 27 cases of NUP214-ABL1-positive T-ALL. Median age was 15 years with male predominance. Outcome was poor in 12 patients. An associated abnormality involving TLX1 or TLX3 was found in all investigated cases. Fluorescent in situ hybridization revealed a heterogeneous pattern of NUP214-ABL1 amplification. Multiple episomes carrying the fusion were detected in 24 patients. Episomes were observed in a significant number of nuclei in 18 cases, but in only 1-5% of nuclei in 6. In addition, intrachromosomal amplification (small hsr) was identified either as the only change or in association with episomes in four cases and two T-ALL cell lines (PEER and ALL-SIL). One case showed insertion of apparently non-amplified NUP214-ABL1 sequences at 14q12. The amplified sequences were analyzed using array-based CGH.These findings confirm that the NUP214-ABL1 gene requires amplification for oncogenicity; it is part of a multistep process of leukemogenesis; and it can be a late event present only in subpopulations. Data also provide in vivo evidence for a model of episome formation, amplification and optional reintegration into the genome. Implications for the use of kinase inhibitors are discussed.

Pseudonormalisation of the T wave: old wine?: A fresh look at a 25-year-old observation

A 74-year-old woman with documented coronary artery disease presented with symptoms of angina at rest. During these episodes of angina, the initial abnormal terminal negative T waves converted to normal positive T waves. In this article the significance of pseudonormalisation as a sign of ischaemia is reviewed. The underlying electropathological basis of this phenomenon is discussed as well. (Neth Heart J 2007;15:257-9.).

Remission and residual symptoms after short-term treatment in the Treatment of Adolescents with Depression Study (TADS)

OBJECTIVE

To ascertain remission rates in depressed youth participating in the Treatment for Adolescents With Depression Study (TADS), a multisite clinical trial that randomized 439 adolescents with major depressive disorder (MDD) to a 12-week treatment of fluoxetine (FLX), cognitive-behavioral therapy (CBT), their combination (COMB), or clinical management with pill placebo (PBO).

METHOD

Using an end-of-treatment Children's Depression Rating Scale-Revised (CDRS-R) total score of 28 or below as the criterion for remission, rates of remission were examined with logistic regression, controlling for site. Loss of MDD diagnosis and residual symptoms in responders (defined as Clinical Global Impressions-Improvement (CGI-I) score of 1 (very much improved) or 2 (much improved) were also examined across treatment groups.

RESULTS

After 12 weeks of treatment, 102 (23%) of 439 youths had reached remission. The remission rate was significantly higher in the COMB group (37%) relative to the other treatment groups (FLX, 23%; CBT, 16%; PBO, 17%), with odds ratios of 2.1 for COMB versus FLX, 3.3 for COMB versus CBT, and 3.0 for COMB versus PBO. In addition, 71% of subjects across treatment groups no longer met criteria for MDD at the end of acute treatment. Fifty percent of the youths who responded by CGI-I criteria continued to have residual symptoms, such as sleep or mood disturbances, fatigue, and poor concentration.

CONCLUSIONS

The combination of FLX and CBT was superior to both monotherapy and PBO in terms of remission rates, but overall rates of remission remain low and residual symptoms are common at the end of 12 weeks of treatment.

Functioning and quality of life in the Treatment for Adolescents with Depression Study (TADS)

OBJECTIVE

To test whether 12-week treatment of major depression improved the level of functioning, global health, and quality of life of adolescents.

METHOD

The Treatment for Adolescents With Depression Study was a multisite, randomized clinical trial of fluoxetine, cognitive-behavioral therapy (CBT), their combination (COMB), or clinical management with placebo in 439 adolescents with major depression. Functioning was measured with the Children's Global Assessment Scale (CGAS), global health with the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), and quality of life with the Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q). Random-effects regression models were applied to the data.

RESULTS

Compared with placebo, COMB was effective on the CGAS (p < .0001), HoNOSCA (p < .05), and PQ-LES-Q (p < .001), whereas fluoxetine was superior to placebo on the CGAS only (p < .05). COMB was superior to fluoxetine on the CGAS (p < .05) and PQ-LES-Q (p = .001). Fluoxetine was superior to CBT on the CGAS (p < .01). CBT monotherapy was not statistically different from the placebo group on any of the measures assessed. Treatment effects were mediated by improvement in depressive symptoms measured on the Child Depression Rating Scale-Revised.

CONCLUSIONS

The combination of fluoxetine and CBT was effective in improving functioning, global health, and quality of life in depressed adolescents. Fluoxetine monotherapy improved functioning.

Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS)

OBJECTIVE

To identify predictors and moderators of response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive-behavioral therapy (CBT), both fluoxetine and CBT, or clinical management with pill placebo in the Treatment for Adolescents With Depression Study (TADS).

METHOD

Potential baseline predictors and moderators were identified by a literature review. The outcome measure was a week 12 predicted score derived from the Children's Depression Rating Scale-Revised (CDRS-R). For each candidate moderator or predictor, a general linear model was conducted to examine main and interactive effects of treatment and the candidate variable on the CDRS-R predicted scores.

RESULTS

Adolescents who were younger, less chronically depressed, higher functioning, and less hopeless with less suicidal ideation, fewer melancholic features or comorbid diagnoses, and greater expectations for improvement were more likely to benefit acutely than their counterparts. Combined treatment, under no condition less effective than monotherapy, was more effective than fluoxetine for mild to moderate depression and for depression with high levels of cognitive distortion, but not for severe depression or depression with low levels of cognitive distortion. Adolescents from high-income families were as likely to benefit from CBT alone as from combined treatment.

CONCLUSIONS

Younger and less severely impaired adolescents are likely to respond better to acute treatment than older, more impaired, or multiply comorbid adolescents. Family income level, cognitive distortions, and severity of depression may help clinicians to choose among acute interventions, but combined treatment proved robust in the presence of moderators.

Application of One Sided t-tests and a Generalized Experiment Wise Error Rate to High-Density Oligonucleotide Microarray Experiments: An Example Using Arabidopsis

MOTIVATION: A formidable challenge in the analysis of microarray data is the identification of those genes that exhibit differential expression. The objectives of this research were to examine the utility of simple ANOVA, one sided t tests, natural log transformation, and a generalized experiment wise error rate methodology for analysis of such experiments. As a test case, we analyzed a Affymetrix GeneChip microarray experiment designed to test for the effect of a CHD3 chromatin remodeling factor, PICKLE, and an inhibitor of the plant hormone gibberellin (GA), on the expression of 8256 Arabidopsis thaliana genes. RESULTS: The GFWER(k) is defined as the probability of rejecting k or more true null hypothesis at a given p level. Computing probabilities by GFWER(k) was shown to be simple to apply and, depending on the value of k, can greatly increase power. A k value as small as 2 or 3 was concluded to be adequate for large or small experiments respectively. A one sided t-test along with GFWER(2)=.05 identified 43 genes as exhibiting PICKLE-dependent expression. Expression of all 43 genes was re-examined by qRT-PCR, of which 36 (83.7%) were confirmed to exhibit PICKLE-dependent expression.

Is objective cure of mild undifferentiated incontinence more readily achieved than that of moderate incontinence? Costs and 2-year outcome

Because the prognostic value of 1-h pad testing has received scant attention, we tested the hypothesis that mild incontinence of any etiology is more readily cured than moderate incontinence. A consecutive series of 150 patients with mild (2-9.9 g) to moderate (10-49.9 g) incontinence (as judged by weight gain on 1-h pad testing) [1] attending a urogynecology unit were recruited, of whom 145 completed all baseline objective measures: 110 completed 12 weeks of conservative therapy, with follow-up data at 2 years available for 51 subjects. At 12 weeks 81% of 'mild' patients became 'dry' on the 1-h pad test versus 36.8% in the moderate group (chi2<0.0001). Interestingly the post-treatment changes seen in all other outcomes demonstrated equally positive responses for the mild and moderate groups. At 2-year follow-up 29/71 (40.8%) of patients with mild incontinence and 22/74 (29.7%) of patients with moderate incontinence were satisfied and had no requirement for further therapy, the remainder having sought other treatments (chi2=1.963 P=0.161). Of the responders, (11/29) (37.9%) of mildly incontinent patients and (8/22 (36.4%)) of moderately affected subjects remained continent (on 20-point incontinence score < or =2 m, chi2=0.013, P=0.9087). Improvements in quality of life persisted to an equal degree in both groups.

Randomised controlled trial of nurse continence advisor therapy compared with standard urogynaecology regimen for conservative incontinence treatment: efficacy, costs and two year follow up

OBJECTIVE

To compare the efficacy and labour costs of nurse continence advisors and urogynaecologists in conservative management of urinary incontinence.

DESIGN

Single centre randomised controlled trial of patients with mild or moderate leakage.

SETTING

Tertiary urogynaecology unit.

SAMPLE

One hundred and forty-five consecutive patients with stress and/or urge incontinence.

METHODS

Standardised conservative therapy regimens, provided by nurse continence advisors and urogynaecologists.

MAIN OUTCOME MEASURE

One-hour pad test, frequency volume charts, a 20-point incontinence score and two quality of life tests, staff treatment times and costs.

RESULTS

Of 110 women who completed 12-week treatments, 64% of the women in the nurse continence advisor group (n = 58) and 52% of women treated by urogynaecologists (n = 52) were asymptomatic (dry pad test; OR 1.63, 95% CI 0.71-3.75). There was no significant difference between clinician groups for change in pad test result (P = 0.71), voids/day (0.43), incontinence score (P = 0.57) or quality of life scores (urogenital distress inventory, P = 0.27; Incontinence Impact Questionnaire, P = 0.41). Despite the expected longer consultation times for the advisor group (median 160 min, interquartile range [IQR] 130-210) versus the urogynaecologist group (median 90 min, IQR 60-120), the per capita labour cost for advisor treatment (median AU$59.20, IQR 48.10-77.70) was lower than for treatment given by urogynaecologists (median cost AU$ 189.70, IQR 120.60-250.70, Mann-Whitney U test, P < 0.0001). At 2.5 years, 23/58 patients (40%) treated by advisor and 27/52 patients (52%) treated by urogynaecologist group, who had been cured and discharged, were available for contact. Of these, 29% of women in the nurse continence advisor group and 41% of those treated by urogynaecologists remained continent (on 20-point score). Quality of life improvement persisted equally in both groups. These data should be interpreted cautiously due to a 24% dropout rate.

CONCLUSIONS

The reduction in urine leakage and improvement in quality of life observed in patients treated by nurse continence advisors and urogynaecologists were similar at 12 weeks and 2 years, but lower costs arose from treatment provided by nurse advisors. We suggest that conservative treatment by the nurse continence advisor could be used more widely in mild to moderate incontinence.

What does the Keane PTSD scale of the MMPI measure? Repeated measurements in a group of patients with major depression

We looked at a group of depressed patients in a treatment study, none of whom by study design had Posttraumatic Stress Disorder (PTSD). High scores on the PTSD (PK) scale could only be due to factors other than PTSD. Despite the absence of PTSD, we observed an extremely high false positive rate in a group given the MMPI on multiple occasions. 92% of the subjects had at least one T score at or above 65 on the PK scale. 44% of the men and the women had at least one score at or above the more conservative cutoff (a raw score of 28) recommended by Lyons and Keane. The PK scale is sensitive to depression as well as anxiety and PTSD. The PK scale showed multiple high correlations with clinical and validity scales. It was concluded, in agreement with Miller, Goldberg, and Streiner (1995) and Moody and Kish (1989), that the PK scale is primarily a measure of general dysphoria. In populations with considerable psychopathology, the PK scale does not appear to discriminate between patients with and without PTSD.

Recurrent miscarriage and variant alleles of mannose binding lectin, tumour necrosis factor and lymphotoxin alpha genes

Variant alleles of the mannose binding lectin (MBL) gene are associated with increased susceptibility to infection and polymorphisms of tumour necrosis factor and lymphotoxin alpha genes (TNF, LTA) are associated with increased severity of infection. Studies have associated recurrent miscarriage with low serum mannose binding lectin concentrations and premature membrane rupture and preterm delivery with elevated maternal and fetal levels of TNF and the TNF (- 308) polymorphism. In this study the frequencies of variant MBL, TNF and LTA alleles in 76 Caucasian couples with idiopathic recurrent miscarriage were compared with those in 69 Caucasian control couples with no history of miscarriage and at least one previous live birth. A new assay based on hybridization to immobilized sequence-specific oligonucleotides (SSO) was used to rapidly detect nine MBL, two TNF and two LTA sequence variants. The assay genotyped all the structural and promoter MBL variants known to influence serum MBL concentrations. This assay was more reliable than restriction digestion or nested allele-specific PCR for the structural variants at codon 54 or 52, respectively. Reliability for codon 57 alleles was not assessed because of the low frequency in this population. The MBL haplotype frequencies in antenatal controls were similar to those reported in other control populations. The frequencies of structural variant MBL genes and of low, medium and high MBL level haplotypes were similar in the recurrent miscarriage and control couples. The TNF and LTA haplotype frequencies were similar in the recurrent miscarriage and control couples. In this carefully defined population no association has been found between recurrent miscarriage and variant alleles of the MBL, TNF or LTA genes.