Trauma and defense style as response predictors of pharmacological treatment in panic patients

Background

As panic disorder (PD) has a chronic course, it is important to identify predictors that might be related to non-remission. The aim of this study is to verify whether history of trauma and defense style are predictors to pharmacological treatment response in PD patients.

Method

The sample was composed by 47 PD patients according to DSM-IV who were treated with sertraline for 16 weeks. Evaluations were assessed by the C.G.I. (Clinical Global Impression), the Hamilton-Anxiety Scale, the Hamilton-Depression Scale, the Panic Inventory and the DSQ-40 (Defense Style Questionnaire) at baseline and after treatment.

Results

Full remission was observed in 61.7% of the sample. The predictors significantly associated with non-remission were: severity of PD (p = 0.012), age of onset (p = 0.02) and immature defenses (p = 0.032). In addition, the history of trauma was associated with early onset of PD (p = 0.043).

Conclusion

Panic patients had as predictors of worse response to pharmacological treatment the early onset and the severity of PD symptoms as well as the use of immature defenses at baseline. This finding corroborates the relevance of the evaluation of factors that might affect the response so as to enable the development of appropriate treatment for each patient.

Resilience and coping strategies in cognitive behavioral group therapy for patients with panic disorder

BACKGROUND

Although resilience and coping are important factors associated with mental health, they are rarely investigated in the treatment of patients with panic disorder (PD).

OBJECTIVE

To evaluate the response to four resilience and coping strategy sessions added to the standard cognitive behavioral group therapy (CBGT) protocol for PD.

DESIGN

Controlled clinical trial.

METHODS

The control group (n = 50) attended 12 CBGT sessions, while the intervention group (n = 50) received four additional resilience and coping strategy sessions, i.e., 16 in total. Symptom severity, resilience, coping strategies, and quality of life were assessed at baseline and post-CBGT.

RESULTS

Symptom severity and maladaptive coping strategies decreased significantly in both groups. However, the intervention group had increased resilience and improvement in the environment domain of quality of life.

CONCLUSIONS

Additional sessions have potential benefits for coping skills and resilience in PD patients, but these benefits should be evaluated in further long-term studies.

What can HPA axis-linked genes tell us about anxiety disorders in adolescents?

Introduction: Anxiety disorders (AD) share features of both anxiety and fear linked to stress response. The hypothalamic-pituitary-adrenal (HPA) axis is considered the core biological pathway of the stress system and it is known that an inappropriate response to environmental stimuli may be related to individual genetic vulnerability in HPA-linked genes. Despite the biological plausibility of a relationship between the HPA axis and AD, few studies have investigated associations between genetic polymorphisms linked to the HPA axis and this complex disorder. Objective: To investigate whether AD are associated with genetic polymorphisms in HPA-linked genes in adolescents. Methods: Our study consisted of a cross-sectional evaluation of a community sample comprising a total of 228 adolescents (131 cases of AD). We extracted DNA from saliva and genotyped polymorphisms in HPA-linked genes (FKBP5: rs3800373, rs9296158, rs1360780, rs9470080 and rs4713916; NR3C1: rs6198; CRHR1: rs878886; and SERPINA6: rs746530) with real time polymerase chain reaction (PCR). The instruments used to diagnose and assess the severity of AD were the Schedule for Affective Disorder and Schizophrenia for School-Age Children - Present and Lifetime (K-SADS-PL) and the Screen for Child and Anxiety related Emotional Disorders (SCARED). Results: We failed to detect any associations between AD and genetic polymorphisms in HPA-linked genes (p > 0.05). Conclusion: To our knowledge, this is the first study evaluating these specific polymorphisms in relation to AD in adolescents, which encourages us to design further research on the subject.

Association between anxiety symptoms and problematic alcohol use in adolescents

BACKGROUND

Anxiety disorders are highly prevalent, affecting approximately 10% of individuals throughout life; its onset can be detected since early childhood or adolescence. Studies in adults have shown that anxiety disorders are associated with alcohol abuse, but few studies have investigated the association between anxiety symptoms and problematic alcohol use in early ages.

OBJECTIVE

To evaluate if anxiety symptoms are associated with problematic alcohol use in young subjects.

METHODS

A total of 239 individuals aged 10-17 years were randomly selected from schools located in the catchment area of Hospital de Clínicas de Porto Alegre. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) was used to evaluate the presence of anxiety symptoms, and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), to evaluate alcohol use.

RESULTS

One hundred twenty-seven individuals (53.1% ) reported having already used alcohol. Of these, 14 individuals showed problematic alcohol use (5.8% ). There was no association between lifetime use of alcohol and anxiety symptoms, but mean SCARED scores in individuals with problematic alcohol use was higher if compared to those without problematic use, even after adjustment for age and gender (29.9±8.5 vs. 23.7±11.8, p < 0.001).

CONCLUSIONS

Despite the limitation of a cross-sectional design, our study suggests that anxiety symptoms are associated with problematic alcohol use early in life.

Mineralocorticoid receptor genotype moderates the association between physical neglect and serum BDNF

The objective of this study is to investigate if a polymorphism in the NR3C2 gene moderates the association between childhood trauma on serum levels of brain derived neurothrophic factor (sBDNF). sBDNF was used here as a general marker of alteration in brain function. This is a community cross sectional study comprising 90 adolescents (54 with anxiety disorders). DNA was extracted from saliva in order to genotype the MR-2G/C (rs2070951) polymorphism using real time PCR. Blood was collected for sBDNF Elisa immunoassay. The Childhood Trauma Questionnaire (CTQ) was used to evaluate childhood abuse and neglect. Main effects and gene environment interactions were tested using linear regression models. Anxiety disorders were not associated with the MR-2G/C polymorphism or with sBDNF levels, but the number of C alleles of the MR-2G/C polymorphism was significantly associated with higher sBDNF levels (b = 8.008; p-value = 0.001). Subjects with intermediate and high exposure to physical neglect showed higher sBDNF levels if compared to subjects non-exposed (b = 11.955; p = 0.004 and b = 16.186; p = 0.009, respectively). In addition, we detected a significant physical neglect by MR-2G/C C allele interaction on sBDNF levels (p = 0.005), meaning that intermediate and high exposure to childhood neglect were only associated with increased sBDNF levels in subjects with the CC genotype, but not in subjects with other genotypes. Our findings suggest that genetic variants in NR3C2 gene may partially explain plastic brain vulnerability to traumatic events. Further studies are needed to investigate the moderating effects of NR3C2 gene in more specific markers of alteration in brain function.

The human ortholog of acid-sensing ion channel gene ASIC1a is associated with panic disorder and amygdala structure and function

BACKGROUND

Individuals with panic disorder (PD) exhibit a hypersensitivity to inhaled carbon dioxide, possibly reflecting a lowered threshold for sensing signals of suffocation. Animal studies have shown that carbon dioxide-mediated fear behavior depends on chemosensing of acidosis in the amygdala via the acid-sensing ion channel ASIC1a. We examined whether the human ortholog of the ASIC1a gene, ACCN2, is associated with the presence of PD and with amygdala structure and function.

METHODS

We conducted a case-control analysis (n = 414 PD cases and 846 healthy controls) of ACCN2 single nucleotide polymorphisms and PD. We then tested whether variants showing significant association with PD are also associated with amygdala volume (n = 1048) or task-evoked reactivity to emotional stimuli (n = 103) in healthy individuals.

RESULTS

Two single nucleotide polymorphisms at the ACCN2 locus showed evidence of association with PD: rs685012 (odds ratio = 1.32, gene-wise corrected p = .011) and rs10875995 (odds ratio = 1.26, gene-wise corrected p = .046). The association appeared to be stronger when early-onset (age ≤ 20 years) PD cases and when PD cases with prominent respiratory symptoms were compared with controls. The PD risk allele at rs10875995 was associated with increased amygdala volume (p = .035) as well as task-evoked amygdala reactivity to fearful and angry faces (p = .0048).

CONCLUSIONS

Genetic variation at ACCN2 appears to be associated with PD and with amygdala phenotypes that have been linked to proneness to anxiety. These results support the possibility that modulation of acid-sensing ion channels may have therapeutic potential for PD.

Effect of cognitive-behavioral group therapy for panic disorder in changing coping strategies

BACKGROUND

Cognitive-behavioral group therapy (CBGT) is an efficient treatment for panic disorder (PD). However, the role of CBGT in enhancing strategies to cope with stressful events has not been established.

AIM

To evaluate the effect of CBGT on the choice of coping strategy by PD patients compared to a group of individuals without mental disorders.

METHODS

Forty-eight PD patients who completed a 12-session CBGT protocol were compared to 75 individuals without mental disorders regarding coping strategies as evaluated by the Coping Strategies Inventory (CSI). The severity of PD was assessed at baseline and after CBGT through the Clinical Global Impression (CGI) scale, the Hamilton Anxiety Scale (HAM-A), and the Panic Inventory (PI).

RESULTS

Treatment was effective in reducing PD severity in all outcome measures. Patients used significantly fewer confrontation, escape and avoidance strategies after CBGT. The use of more adaptive coping strategies was related to a decrease in panic attacks and anticipatory anxiety. Application of the CSI showed that the use of strategies was also significantly different in patients as compared to the control group, except for escape and avoidance, which became similar after the CBGT protocol.

CONCLUSIONS

Despite the changes observed after the CBGT protocol, the choice of coping strategy was still different in patients vs. controls. The current CBGT protocol was used specifically to assess PD symptoms. Other cognitive tools should be included to address maladaptive coping strategies.

Treating refractory obsessive-compulsive disorder: what to do when conventional treatment fails?

Obsessive-compulsive disorder (OCD) is a chronic and impairing condition. A very small percentage of patients become asymptomatic after treatment. The purpose of this paper was to review the alternative therapies available for OCD when conventional treatment fails. Data were extracted from controlled clinical studies (evidence-based medicine) published on the MEDLINE and Science Citation Index/Web of Science databases between 1975 and 2012. Findings are discussed and suggest that clinicians dealing with refractory OCD patients should: 1) review intrinsic phenomenological aspects of OCD, which could lead to different interpretations and treatment choices; 2) review extrinsic phenomenological aspects of OCD, especially family accommodation, which may be a risk factor for non-response; 3) consider non-conventional pharmacological approaches; 4) consider non-conventional psychotherapeutic approaches; and 5) consider neurobiological approaches.

Can psychopharmacological treatment change personality traits in patients with panic disorder?

OBJECTIVE

The aim of this study was to evaluate the effects that a particular psychopharmacological treatment has on personality patterns in patients with panic disorder.

METHOD

Forty-seven patients with panic disorder and 40 controls were included in the study. The Mini International Neuropsychiatric Interview and Minnesota Multiphasic Personality Inventory were used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses and personality traits, respectively. Patients were treated with sertraline for 16 weeks.

RESULTS

There was a significant decrease in the score on 8 of the 10 Minnesota Multiphasic Personality Inventory scales. In addition, neurotic triad and psychasthenia personality scores were higher among panic disorder patients, even during the posttreatment asymptomatic phase, than among controls.

CONCLUSION

In the asymptomatic phase of the disease, panic disorder patients present a particular neurotic/anxious personality pattern. This pattern, although altered in the presence of acute symptoms, could be a focus of research.

The multidimensional evaluation and treatment of anxiety in children and adolescents: rationale, design, methods and preliminary findings

OBJECTIVE: This study aims to describe the design, methods and sample characteristics of the Multidimensional Evaluation and Treatment of Anxiety in Children and Adolescents - the PROTAIA Project. METHOD: Students between 10 and 17 years old from all six schools belonging to the catchment area of the Primary Care Unit of Hospital de Clínicas de Porto Alegre were included in the project. It comprises five phases: (1) a community screening phase; (2) a psychiatric diagnostic phase; (3) a multidimensional assessment phase evaluating environmental, neuropsychological, nutritional, and biological factors; (4) a treatment phase, and (5) a translational phase. RESULTS: A total of 2,457 subjects from the community were screened for anxiety disorders. From those who attended the diagnostic interview, we identified 138 individuals with at least one anxiety disorder (apart from specific phobia) and 102 individuals without any anxiety disorder. Among the anxiety cases, generalized anxiety disorder (n = 95; 68.8%), social anxiety disorder (n = 57; 41.3%) and separation anxiety disorder (n = 49; 35.5%) were the most frequent disorders. CONCLUSION: The PROTAIA Project is a promising research project that can contribute to the knowledge of the relationship between anxiety disorders and anxiety-related phenotypes with several genetic and environmental risk factors.

Long-term outcome in pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: 5-year follow-up

Background

There is a limitation of data about factors associated with treatment response in panic disorder (PD) patients at long-term follow-up period. The aim of this study was to evaluate the long-term treatment response of pharmacotherapy-resistant patients with PD after 5 years of cognitive-behavior group therapy (CBGT) and to identify factors that predict this outcome.

Method

Sixty-four patients who completed 12 sessions of CBGT were followed for 5-year. Outcome measures were evaluated by the Clinical Global Impression (CGI) and quality of life (QoL) using WHOQOL-bref. Demographic and clinical features, stressful life events were the variables investigated as predictors of CBGT response across follow-up period.

Results

Treatment was associated with significant reduction in symptoms severity (agoraphobia, anticipatory anxiety and panic attacks) with maintenance of gains at 5-year of follow-up (p < 0.05). Twenty-four (40%) of the sample remained in remission after 5 years, 12 (20%) relapsed during the follow-up period and 24 (40%) were non-responder to CBGT. The poor CBGT response had an important negative impact in QoL. Regression analyzes showed that comorbidity with dysthymia (p = 0.017) and stressful life events (p = 0.012) as the most important predictors to worse response.

Conclusions

The improvement in all evaluations suggested that brief CBGT for pharmacotherapy-resistant patients could be an alternative as next-step strategy for residual symptoms with maintenance of the gains after 5 years as assessed across follow-up period. New strategies should be tried for resistant patients, such as those with dysthymia comorbidity, and some specific tool in order to cope with adverse events.

The Functional c.-2G>C Variant of the Mineralocorticoid Receptor Modulates Blood Pressure, Renin, and Aldosterone Levels

The mineralocorticoid receptor (MR) is essential in the regulation of volemia and blood pressure. Rare mutations in the MR gene cause type 1 pseudohypoaldosteronism and hypertension. In this study we characterized the common MR polymorphism c.-2G>C (rs2070951) in vitro and tested its influence on parameters related to blood pressure regulation and the renin-angiotensin system. In vitro studies showed that the G allele was associated with decreased MR protein levels and reduced transcriptional activation compared with the C allele. Association studies were performed with several outcome variables in 3 independent cohorts: a mild hypertensive group subjected to a salt-sensitivity test, a healthy normotensive group included in a crossover study to receive both a high and low Na/K diet, and a large cohort (The Netherlands Study of Depression and Anxiety), in which blood pressure was measured. Subjects with the GG genotype had significantly higher plasma renin levels both in the mild hypertensive group and in normal volunteers compared with homozygous C carriers. The GG genotype was also correlated with higher plasma aldosterone levels in healthy subjects. In both the mild hypertensive group and The Netherlands Study of Depression and Anxiety cohort the genotype GG was associated with higher systolic blood pressure in males. In conclusion, the G allele of the common functional genetic polymorphism c.-2G>C in the MR gene associates with increased activation of the renin-angiotensin-aldosterone axis and with increased blood pressure, probably related to decreased MR expression.

Panic disorder and serotonergic genes (SLC6A4, HTR1A and HTR2A): Association and interaction with childhood trauma and parenting

OBJECTIVE

The aim of this study is to evaluate the association between HTR1A, HTR2A and the 5-HTTLPR in panic disorder (PD) patients and controls. In addition, this study also aims to evaluate the interaction between these genes and two environmental factors previously associated with PD: childhood trauma and parental bonding.

METHODS

This is a case-control candidate gene association study (107 PD patients and 125 controls). Genes were analyzed using a gene-based test in PLINK followed by single marker association tests and haplotype test only for genes that reached experiment-wide significance in the gene-based test in order to minimize multiple testing. Logistic regression was used to test the relationships between genotype in the additive model, trauma, optimal paternal parenting and optimal maternal parenting and their interactions.

RESULTS

Only HTR1A was associated with PD in gene-based test after correction for multiple tests (p(corrected)=0.027) and one HTR1A haplotype comprising four SNPs was associated with PD (p(corrected)=0.032). In the interaction analysis, no significant gene-environment interaction was found with the genes evaluated.

CONCLUSION

This study reinforces the association between HTR1A and PD. No major evidence of gene-environment interaction in PD with parenting or trauma was found. Further studies are necessary in order to confirm these findings.

Predictors of relapse in the second follow-up year post cognitive-behavior therapy for panic disorder

OBJECTIVE: To investigate predictors of relapse two years after a brief cognitive-behavior group therapy in patients with panic disorder who had failed to respond to pharmacologic treatment. METHOD: A total of 56 patients with panic disorder were followed who had met remission criteria at 1 year evaluation after 12 sessions of cognitive-behavior group therapy. Demographic and clinical features and life stressors were investigated as predictors of relapse. RESULTS: At the 2 year assessment, 39 (70%) patients maintained remission status and use of medication was reduced significantly, such that 36 (64%) patients were not undergoing any psychiatric treatment. Among all independent variables investigated, only "conflict" as a stressful life event, RR = 3.20 (CI95% 1.60; 7.20 - p = 0.001), and the severity or residual anxiety symptoms, RR = 3.60 for each scale point (CI95% 1.02; 1.08 - p < 0.001), emerged as nonredundant predictors. CONCLUSION: In spite of the high treatment gains across two years of follow-up, clinicians should pay attention to stress management and to the role of residual symptoms during this period. Results were discussed in the context of treatment cost-efficacy and potential strategies to prolong treatment gains from cognitive-behavior group therapy.

Gender differences in the associations between childhood trauma and parental bonding in panic disorder

OBJECTIVE: The aim of this study is to evaluate the association between childhood trauma and the quality of parental bonding in panic disorder compared to non-clinical controls. METHOD: 123 patients and 123 paired controls were evaluated with the Mini International Neuropsychiatric Interview, the Childhood Trauma Questionnaire and the Parental Bonding Instrument. RESULTS: The Parental Bonding Instrument and the Childhood Trauma Questionnaire were highly correlated. Panic disorder patients presented higher rates of emotional abuse (OR = 2.54, p = 0.001), mother overprotection (OR = 1.98, p = 0.024) and father overprotection (OR = 1.84, p = 0.041) as compared to controls. Among men with panic disorder, only mother overprotection remained independently associated with panic disorder (OR = 3.28, p = 0.032). On the other hand, higher father overprotection (OR = 2.2, p = 0.017) and less father warmth (OR = 0.48, p = 0.039) were independently associated with panic disorder among female patients. CONCLUSION: Higher rates of different types of trauma, especially emotional abuse, are described in panic disorder patients as compared to controls. The differences regarding gender and parental bonding could be explained in the light of the psychodynamic theory.

Preliminary evidence of association between EFHC2, a gene implicated in fear recognition, and harm avoidance

Genetic variation at the EF-hand domain containing 2 gene (EFHC2) locus has been associated with fear recognition in Turner syndrome. The aim of this study was to examine whether EFHC2 variants are associated with non-syndromic anxiety-related traits [harm avoidance (HA) and behavioral inhibition (BI)] and with panic disorder (PD). Our sample comprised 127 PD patients and 132 controls without psychiatric disorder. We genotyped nine SNPs within the EFHC2 locus and used PLINK to perform association analyses. An intronic SNP (rs1562875) was associated with HA (permuted p=0.031) accounting alone for over 3% of variance in this trait. This same SNP was nominally, but not empirically, associated with BI (r(2)=0.022; nominal p=0.022) and PD (OR=2.64; nominal p=0.009). The same association was found in a subsample of only females. In sum, we observed evidence of association between a variant in EFHC2, a gene previously associated with the processing of fear and social threat, and HA. Larger studies are warranted to confirm this association.

Transtorno do pânico

OBJETIVOS: Revisar o transtorno do pânico (TP), considerando seus aspectos clínicos, epidemiológicos, diagnósticos e etiológicos, bem como os avanços no tratamento, uma vez que o TP é uma entidade nosológica acompanhada de importante prejuízo psíquico e funcional. MÉTODO: Foi realizada uma revisão narrativa da literatura nas principais bases de dados existentes (MEDLINE, PsychINFO e SciELO) e em livros-textos atualizados. RESULTADOS: Devido à sintomatologia predominantemente física desse transtorno, os pacientes geralmente procuram vários atendimentos clínicos até que o diagnóstico seja feito. Em função desses aspectos e da sua cronicidade, o TP está associado a elevados custos econômicos. O tratamento do TP pode ser feito com psicoterapia e/ou psicofármacos. As diversas abordagens terapêuticas são apresentadas com o nível de evidência de cada recomendação. Em virtude da cronicidade e morbidade do TP, pesquisas têm se voltado para o estudo de estratégias de prevenção já na infância. CONCLUSÕES: O TP é um transtorno crônico e com baixas taxas de remissão dos sintomas em longo prazo. Sendo assim, sugere-se que sejam delineados novos estudos para tratamento precoce dos transtornos de ansiedade ou mesmo para prevenção em crianças de risco.

Assessing Response to Cognitive-behavioral Group Therapy for Panic Disorder with Comorbid Mood Disorders

Objective:

To evaluate the response to group cognitive-behavioral therapy (CBGT) for panic disorder (PD) in patients with and without comorbid mood disorders (MD).

Method:

A total of 113 patients took part in 12 CBGT sessions for PD. the diagnoses of PD and comorbid MD (depression and/or dysthymia) were established using the Mini International Neuropsychiatric Interview (MINI). Outcome measures were assessed by Clinical Global Impression (CGI), Hamilton-Anxiety and Panic Inventory. Remission was considered when CGI ≤ 2 and there was absence of panic attacks.

Results:

One-hundred patients (91%) completed the CBGT protocol and 37(32.7%) patients had PD with comorbid MD. at the end of the treatment, 41 (36.3%) patients met criteria for symptom remission. the remission rates were 47.4% in patients without MD versus 13.5% in patients presenting with comorbid MD (RR = 3.50; IC95%[1.5 to 8.19]; p < 0.001). both groups showed significant improvement on all clinical outcomes throughout treatment. A differential effect was identified between those with and those without comorbid MD both in the CGI (pgroup x time = 0.020) and in anticipatory anxiety (pgroup x time = 0.017).

Conclusions:

Panic patients without MD improved better to CBGT than those with MD. Maybe more sessions regarding depression should be added to the protocol in this subgroup of patients with MD. However, given that there is a general reduction of PD symptoms in all patients, CBGT must not be excluded.

Harm avoidance and self-directedness as essential features of panic disorder patients

OBJECTIVE

The purpose of the study is to compare the personality traits assessed with the Temperament and Character Inventory (TCI) between patients with panic disorder (PD) and a control group in a Brazilian sample.

METHODS

One hundred thirty-five patients with PD paired according to sex and age with 135 controls without any psychiatric disorders were assessed with the Mini International Neuropsychiatric Interview (MINI), a structured interview. Temperament and character were assessed with the TCI.

RESULTS

Consistently, patients with PD presented higher scores on the harm avoidance (HA) temperament scale (23.20 +/- 5.41 vs 15.21 +/- 4.92; P < .001) and lower scores on the self-directedness (SD) (27.81 +/- 7.25 vs 35.16 +/- 5.47; P < .001) if compared to the control group and has been associated independently from other TCI scales and confounders with PD. The multivariate logistic model containing HA and SD explains 38.6% to 51.4% of the differences between PD and controls.

CONCLUSIONS

Harm avoidance could be a good candidate to be heritable because it appears to be a consistent finding across current literature in anxious and depressed patients independent of their cultural context. Also, SD seems to be a key character characteristic of PD patients. The dimensional assessment is an interesting alternative for understanding the relationship between the psychobiologic bases of temperament and character and is highly related to the development of psychiatric syndromes.

Lack of association between the Serotonin Transporter Promoter Polymorphism (5-HTTLPR) and Panic Disorder: a systematic review and meta-analysis

BACKGROUND

The aim of this study is to assess the association between the Serotonin Transporter Promoter Polymorphism (5-HTTLPR) and Panic Disorder (PD).

METHODS

This is a systematic review and meta-analysis of case-control studies with unrelated individuals of any ethnic origin examining the role of the 5-HTTLPR in PD according to standard diagnostic criteria (DSM or ICD). Articles published in any language between January 1996 and April 2007 were eligible. The electronic databases searched included PubMed, PsychInfo, Lilacs and ISI. Two separate analyses were performed: an analysis by alleles and a stratified analysis separating studies by the quality of control groups. Asymptotic DerSimonian and Laird's Q test were used to assess heterogeneity. Results of individual studies were combined using the fixed effect model with respective 95% confidence intervals.

RESULTS

Nineteen potential articles were identified, and 10 studies were included in this meta-analysis. No statistically significant association between 5-HTTLPR and PD was found, OR = 0.91 (CI95% 0.80 to 1.03, p = 0.14). Three sub-analyses divided by ethnicity, control group quality and Agoraphobia comorbidity also failed to find any significant association. No evidence of heterogeneity was found between studies in the analyses.

CONCLUSION

Results from this systematic review do not provide evidence to support an association between 5-HTTLPR and PD. However, more studies are needed in different ethnic populations in order to evaluate a possible minor effect.

Defense mechanisms after brief cognitive-behavior group therapy for panic disorder: one-year follow-up

Changes in defense mechanisms have been shown in long-term psychodynamic treatment. The aim of this study was to examine the changes that occurred after brief cognitive-behavior group therapy in the defense style of panic disorder patients that had failed to respond to pharmacotherapy. Forty-seven patients participated in the study and severity of panic disorder was evaluated by Clinical Global Impression. Defense mechanisms were evaluated by the Defense Style Questionnaire. Patients decreased the use of maladaptive defenses after cognitive-behavior group therapy, and the change in immature defenses was maintained at 1-year follow-up evaluation (p = 0.022). These modifications were associated with reduction of symptoms (F = 0.359; p = 0.047). These findings are consistent with the hypothesis that defense styles are malleable in short-term treatment and are, at least partially, symptom-state dependent.

The efficacy of milnacipran in panic disorder: an open trial

The aim of this study is to evaluate the efficacy of milnacipran in the acute treatment of patients with panic disorder. Thirty-one patients who met Diagnostic and statistical manual of mental disorders-IV criteria for panic disorder with or without agoraphobia were included in the study. Patients were initially treated with milnacipran 25 mg twice daily and then 50 mg twice daily until the 10th week. The treatment outcome and panic disorder severity were determined by the Panic Disorder Severity Scale, Panic Inventory, Clinical Global Impression and Hamilton Anxiety Scale, all of which were applied during every evaluation interview. Quality of life (WHOQOL-bref) was evaluated at baseline and at the end of the study. Missing data were handled by using the last observation carried forward for all participants who had taken at least one dose of study medication. Intention-to-treat was used in the analyses. Pharmacological treatment resulted in a clinically and statistically significant mean reduction in all severity measures. Remission (Clinical Global Impression < or = 2) was obtained in 58.1% of the sample. Regarding WHOQOL, we found a significant improvement (P<0.05) across treatment in all the domains studied. Although results may be influenced by the open design of this pilot study and by the small sample size, our findings suggest that milnacipran may be effective for the treatment of panic disorder and justify further research.

Do defense mechanisms vary according to the psychiatric disorder?

OBJECTIVE

The aim of this study was to evaluate the defense mechanisms used by depressive and anxious patients without comorbidities compared to those used by controls and to determine whether these patterns differ between diagnoses.

METHOD

The sample was composed of 167 psychiatric patients and 36 controls that were evaluated using the Defense Style Questionnaire 40. All subjects were evaluated through a clinical interview, and each evaluation was confirmed through the application of the Mini International Neuropsychiatric Interview, a structured psychiatric interview. We used ANOVA and discriminant analysis to assess differences between groups.

RESULTS

Neurotic defense mechanisms discriminated controls from all patients except those with social anxiety. Immature defense mechanisms differentiated controls from all patients, as well as distinguished depressive patients from panic disorder and obsessive disorder patients. The discriminant analysis indicated that depressive patients are characterized by projection, panic disorder patients by sublimation and obsessive-compulsive patients by acting out.

CONCLUSIONS

Depressive and anxious patients differ from other individuals in their use of defense mechanisms, and each diagnosis has a particular pattern. These findings could lead to the development of specific psychotherapeutic interventions.

Quality of life and treatment outcome in panic disorder: cognitive behavior group therapy effects in patients refractory to medication treatment

BACKGROUND

Improvements in quality of life (QoL) as well as symptomatic relief are important outcomes for the treatment of panic disorder (PD). The aim of this study is to assess the impact of brief cognitive behavior group therapy (CBGT) for panic disorder on QoL and to identify the clinical features associated with these changes.

METHODS

Thirty-six patients with PD refractory to pharmacological treatment took part in a treatment protocol consisting of 12 sessions of CBGT. To evaluate the changes in QoL, the WHOQOL-bref was administered before and after treatment.

RESULTS

Thirty-two patients completed the treatment. Significant improvement in all domains of QoL was observed (p< 0.001), which was associated with reductions in general and anticipatory anxiety (p = 0.018) and agoraphobic avoidance (p = 0.046). Consistent with previous findings, associations between QoL and panic-free status did not reach significance in this small study (p = 0.094).

CONCLUSIONS

CBGT was efficacious in the treatment of PD; the symptoms of anticipatory anxiety and avoidance appear to be more important than episodic panic episodes in affecting QoL.

Evaluation of defense mechanisms in adult patients with panic disorder: before and after treatment

Patients with acute panic disorder (PD) use a more maladaptive pattern of defense mechanisms. This study investigated the use of defense mechanisms by patients with acute symptomatic PD and those in complete remission. Thirty-three patients and 33 controls were evaluated by the Mini International Neuropsychiatric Interview. The defense mechanisms were evaluated by the Defense Style Questionnaire at the beginning of the study and after 16 weeks of sertraline treatment. Panic disordered patients used more neurotic (4.6 vs. 3.6; p = 0.003) and immature (3.6 vs. 3.0; p = 0.024) defenses at baseline. Patients who achieved complete remission (N=25) differed from the control group in the use of neurotic defenses at the baseline (4.4 vs. 3.6; p = 0.033). After treatment, they showed a reduction in the use of neurotic (4.4 vs. 3.7; p=0.014) and immature (3.4 vs. 3.1; p = 0.019) defenses. Defense mechanisms in PD are influenced by the presence of symptoms, severity, and outcome of the disease.

One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of remission

Non-response to pharmacotherapy for panic disorder (PD) is a well-documented problem. However, little information exists to guide next-step strategies for these non-responders. In addition to pharmacologic augmentation strategies, several studies support the efficacy of cognitive-behavior therapy (CBT) for these patients, although data on long-term outcomes has been lacking. In this study, we provide one-year outcomes on a sample of 63 patients who completed group CBT for PD after failing to respond adequately to previous pharmacotherapy. Sustained significant benefit was found for all dimensional outcome scores, and nearly two-thirds of the sample met remission criteria. This occurred with reductions in medication use over the follow-up period. Negative predictors of remission status included comorbid dysthymia, social phobia, and generalized anxiety disorder. These results provide additional evidence for the efficacy of CBT for medication non-responders with PD.

Behavioral inhibition and history of childhood anxiety disorders in Brazilian adult patients with panic disorder and social anxiety disorder

PURPOSE

To evaluate the presence of behavioral inhibition and anxiety disorders during childhood in Brazilian adult patients with panic disorder and social anxiety disorder compared to a control group.

METHODS

Fifty patients with panic disorder, 50 patients with social anxiety disorder, and 50 control subjects were included in the study. To assess the history of childhood anxiety, the Schedule for Affective Disorders and Schizophrenia for School Age Children, Epidemiologic Version (K-SADS-E), and the Diagnostic Interview for Children and Adolescents-Parent Version (DICA-P) were used. The presence of behavioral inhibition in childhood was assessed by the self-reported scale of Behavioral Inhibition Retrospective Version (RSRI-30).

RESULTS

Patients showed significantly higher prevalence of anxiety disorders and behavioral inhibition in childhood compared to the control group. Patients with social anxiety disorder also showed significantly higher rates of avoidance disorder (46% vs. 18%, p = 0.005), social anxiety disorder (60% vs. 26%, p = 0.001), presence of at least one anxiety disorder (82% vs. 56%, p = 0.009) and global behavioral inhibition (2.89 +/- 0.61 vs. 2.46 +/- 0.61, p < 0.05) and school/social behavioral inhibition (3.56 +/- 0.91 vs. 2.67 +/- 0.82, p < 0.05) in childhood compared to patients with panic disorder.

CONCLUSION

Our data are in accordance to the literature and corroborates the theory of an anxiety diathesis, suggesting that a history of anxiety disorders in childhood is associated with an anxiety disorder diagnosis, mainly social anxiety disorder, in adulthood.

[Brazilian-Portuguese version of the Defense Style Questionnaire (DSQ-40) for defense mechanisms measure: a preliminary study]

The aim of this study is to describe the translation and adaptation process of the Defense Style Questionnaire (DSQ-40) into Brazilian-Portuguese version. The instrument has also contended validation evaluation.

METHODS

The first version of the scale was presented to five individuals with different schooling for language adaptation. Afterwards the instrument was presented to three experts that evaluated its content validation. The final version was back-translated and accepted by the original author.

RESULTS

Vocabulary adjustments were needed in 9 items and language adaptation in 4 items in order to render the final DSQ-40 Brazilian-Portuguese version. The mean of experts' correlation to each defense was 89%, being 100% to mature, neurotic and immature factors.

CONCLUSION

The adaptation of DSQ-40 by different individuals and the group of experts enabled the necessary adjustment to the Brazilian socio-cultural reality.

Brazilian patients with panic disorder: the use of defense mechanisms and their association with severity

This study aims to evaluate the defense mechanisms most frequently used by Brazilian patients with panic disorder when compared with a control group. The study also examines the association between severity of disease and comorbidity and the use of specific defense mechanisms. Sixty panic-disordered patients and 31 controls participated in the study. The Mini International Neuropsychiatric Interview was used to confirm the panic disorder diagnosis and to establish the comorbid diagnosis. The Clinical Global Impression (CGI) was used to assess severity and the Defensive Style Questionnaire (DSQ-40) was used to evaluate the defense mechanisms. Panic patients used more neurotic (mean = 4.9 versus 3.6; p < 0.001) and immature (mean = 3.9 versus 2.8; p < 0.001) defenses as compared with controls. Panic patients with severe disease (n = 37; CGI>4) had more depression comorbidity and used more immature defenses than patients with CGI<or=4 (n = 23; mean = 4.2 versus 3.5; p < 0.001). It was concluded that the panic severity and depression comorbidity found in Brazilian panic-disordered patients are associated with the use of maladaptive mechanisms, namely immature defenses.

Relationship between adult social phobia and childhood anxiety

OBJECTIVE

The aim of this study was to evaluate the prevalence of traumas and the presence of childhood anxiety disorders in adult patients with social phobia and investigate their influence on the presentation of the disorder.

METHODS

Twenty-four adult patients with social phobia were asked about the presence of trauma before the age of 16. The K-SADS-E and the DICA-P interviews were used to assess these patients regarding childhood anxiety disorders.

RESULTS

Twelve (50%) patients reported a history of trauma before the age of 16. The presence of trauma did not influence the presentation of the disorder. Seventy-five percent of patients had a history of anxiety disorders in childhood. Patients with a history of at least 2 childhood anxiety disorders had an increased lifetime prevalence of major depression (10 vs. 3; p=.04) and family history of psychiatric disorders (13 vs. 6; p=.02).

CONCLUSION

Anxiety disorder in childhood is associated with family history of psychiatric disorders. The presence of more than one diagnosis of anxiety disorder in childhood can be considered a risk factor for the development of depression in adult patients with social phobia.

Treating medication-resistant panic disorder: predictors and outcome of cognitive-behavior therapy in a Brazilian public hospital

BACKGROUND

In Brazil, treatment of panic disorder is most frequently initiated with pharmacotherapy, but only half of the patients can be expected to be panic free after medication. Studies have suggested that individual or group cognitive-behavior therapy (CBT) is an effective treatment strategy for panic patients who have failed to respond to pharmacotherapy.

METHODS

Thirty-two patients diagnosed with panic disorder with agoraphobia having residual symptoms despite being on an adequate dose of medication were treated with 12 weeks of group CBT. The outcome was evaluated for panic frequency and severity, generalized anxiety, and global severity. Comorbid conditions, a childhood history of anxiety, and defense mechanism styles were assessed as potential predictors of treatment response.

RESULTS

Twenty-nine patients completed the 12-week protocol. Treatment was associated with significant reductions in symptom severity on all outcome measures (p < 0.001). Patients with depression had a poorer outcome of the treatment (p = 0.01) as did patients using more neurotic (p = 0.002) and immature defenses (p = 0.05).

CONCLUSION

Consistent with previous reports, we found that CBT was effective for our sample of treatment-resistant patients. Among these patients, depression as well as neurotic defense style was associated with a poorer outcome. The use of CBT in Brazil for treatment-resistant and other panic patients is encouraged.

Estudo retrospectivo da associação entre transtorno de pânico em adultos e transtorno de ansiedade na infância

OBJETIVO: A etiologia do transtorno do pânico (TP) é provavelmente multifatorial, incluindo fatores genéticos, biológicos, cognitivo-comportamentais e psicossociais que contribuem para o aparecimento de sintomas de ansiedade, muitas vezes durante a infância. O objetivo deste estudo foi avaliar a relação entre história de transtornos de ansiedade na infância e transtorno do pânico na vida adulta. MÉTODOS: Foram avaliados retrospectivamente 84 pacientes adultos com transtorno do pânico quanto à presença de história de transtornos de ansiedade na infância, por meio de uma entrevista estruturada (K-SADS-E e DICA-P). A presença de comorbidades com outros transtornos de ansiedade e de humor foi avaliada por uma revisão de registros médicos. RESULTADOS: Observou-se que 59,5% dos pacientes adultos com TP apresentavam história de ansiedade na infância. Encontrou-se uma associação significativa entre a presença de história de transtorno de ansiedade generalizada na infância e a presença de comorbidades com o TP na vida adulta, como agorafobia (p=0,05) e depressão (p=0,03). CONCLUSÕES: Este estudo sugere que a história de transtorno de ansiedade na infância pode ser considerada um preditor de maior gravidade para o transtorno do pânico na vida adulta.

Ex vivo expansion of umbilical cord blood (UCB) CD34(+) cells alters the expression and function of alpha 4 beta 1 and alpha 5 beta 1 integrins

We have investigated the influence of ex vivo expansion of human CD34(+) cord blood cells on the expression and function of adhesion molecules involved in the homing and engraftment of haematopoietic progenitors. Ex vivo expansion of umbilical cord blood CD34(+) cells for 6 d in the presence of interleukin 3 (IL-3), IL-6 and stem cell factor (SCF) or IL-11, SCF and Flt-3L resulted in increased expression of alpha 4, alpha 5, beta 1, alpha M and beta 2 integrins. However, a significant decrease in the adhesion of progenitor cells to fibronectin was observed after the ex vivo culture (adhesion of granulocyte-macrophage colony-forming units (CFU-GM) was 22 +/- 4% in fresh cells versus 5 +/- 2% and 2 +/- 2% in each combination of cytokines). Incubation with the beta 1 integrin-activating antibody TS2/16 restored adhesion to fibronectin. Transplantation of ex vivo expanded umbilical cord blood CD34(+) cells was associated with an early delayed engraftment in non-obese diabetic/severe combined immunodeficient (NOD/SCID) mice. Incubation of cells with the monoclonal antibody TS2/16 before transplantation almost completely abrogated NOD/SCID repopulating ability of both fresh and expanded CD34(+) cells. The seeding efficiency of fresh and expanded CD34(+) cells was similar, but markedly reduced after incubation with the TS2/16 monoclonal antibody. Our results show that functional activation of beta 1 integrins could overcome the decreased very late antigen (VLA)-4- and VLA-5-mediated adhesion observed after ex vivo expansion of haematopoietic progenitors. However, in vivo, these effects induced an almost complete abrogation of the homing and repopulating ability of CD34(+) UCB cells.

Chemokine stromal cell-derived factor-1alpha modulates VLA-4 integrin-dependent adhesion to fibronectin and VCAM-1 on bone marrow hematopoietic progenitor cells

Stromal cell-derived factor-1alpha (SDF-1alpha) is a potent chemoattractant for hematopoietic progenitor cells (HPC), suggesting that it could play an important role during their migration within or to the bone marrow (BM). The integrin VLA-4 mediates HPC adhesion to BM stroma by interacting with CS-1/fibronectin and VCAM-1. It is required during hematopoiesis and homing of HPC to the BM. As HPC migration in response to SDF-1alpha might require dynamic regulation of integrin function, we investigated if SDF-1alpha could modulate VLA-4 function on BM CD34(hi) cells.CD34(hi) BM cells and hematopoietic cell lines were tested for the effect of SDF-1alpha on VLA-4-dependent adhesion to CS-1/fibronectin and VCAM-1, as well as to BM stroma. CD34(hi) BM cells that adhered to VLA-4 ligands after SDF-1alpha treatment were characterized in colony-forming and long-term culture-initiating cell (LTC-IC) assays.SDF-1alpha rapidly (1 minute) and transiently upregulated the adhesion of CD34(hi) BM cells and hematopoietic cell lines to both CS-1/fibronectin and VCAM-1, and to BM stromal cells. The upregulation of VLA-4-dependent cell adhesion by SDF-1alpha targeted primitive LTC-IC as well as committed CD34(hi) cells. SDF-1alpha-triggered enhancement in VLA-4 function was inhibited by pertussis toxin (PTx) and cytochalasin D, indicating the involvement of G(i) protein downstream signaling and an intact cytoskeleton. Instead, activation of p44/42 MAP kinases by SDF-1alpha did not functionally correlate with enhancement of VLA-4-dependent cell adhesion. Modulation of VLA-4-mediated CD34(hi) BM cell adhesion by SDF-1alpha could play a key role in their migration within and to the BM and therefore influence their proliferation and differentiation.

Consensus and variable region PCR analysis of Helicobacter pylori 3' region of cagA gene in isolates from individuals with or without peptic ulcer

The clinical outcome of Helicobacter pylori infection may be associated with the cagA bacterial genotype. To investigate the cagA status of H. pylori-infected patients and the relationship between cagA and peptic ulcer disease, gastric biopsy specimens from 103 Caucasian patients in Brazil were analyzed by PCR. Since allelic variation in cagA exists and distinct H. pylori subgenotypes may circulate in different regions, PCR using primers for a variable 3' region of the cagA gene according to a Japanese methodology and for a consensus cagA 3' region used in Western methods was used for cagA detection. cagA was present in 53 (71%) of 75 H. pylori-positive cases when analyzed by the consensus region method and was associated with duodenal ulcer disease (P = 0.02), but not with gastric ulcer (P = 0.26), when compared to patients with duodenitis or gastritis. The variable region PCR method was able to detect 43 (57%) cagA-positive cases within the same group of H. pylori-positive patients and showed three subtypes of cagA (A, B/D, and C) that were not associated with clinical outcome. However, in 8 (18%) of the cases, more than one subtype was present, and an association between patients with multiple subtypes and disease outcome was observed when compared to patients with isolated subtypes (P = 0.048). cagA was a marker of H. pylori strains for duodenal ulcer disease in our population, and in spite of the differences in the 3' region of the cagA gene, the Japanese methodology was able to detect the cagA status in most cases. The presence of multiple subgenotypes of cagA was associated with gastric ulcer.

The role of serum liver enzymes in the diagnosis of choledocholithiasis

BACKGROUND/AIMS

The introduction of laparoscopic cholecystectomy has increased the need for preoperative diagnosis of common bile duct stones. The purpose of this study is to verify the sensitivity of the liver function tests in the detection of duct stones.

METHODOLOGY

We evaluated 438 patients (223 retrospectively and 215 prospectively) who underwent endoscopic papillotomy for bile duct stones in two different services. In every case, blood samples for liver function tests levels were collected prior to endoscopic retrograde cholangiopancreatography.

RESULTS

The most sensitive test was gamma-glutamyl transpeptidase, that was abnormal in 92.2% of the cases. Alkaline phosphatase was elevated in 74.7% of the patients with choledocholithiasis. The least sensitive parameter was AST, altered in only 50.8% of times. The sensitivity of all liver tests for the diagnosis of choledochal stones taken together was 94.3%.

CONCLUSIONS

Liver function tests are very sensitive in the detection of common bile duct stones, however these blood tests are in the normal range of about 5% of endoscopically treated patients.

High power setting argon plasma coagulation for the eradication of Barrett's esophagus

OBJECTIVE

The term Barrett's esophagus refers to a premalignant condition that is characterized by the replacement of the esophageal squamous mucosa by a columnar-lined one. Preliminary studies have demonstrated reversal of Barrett's mucosa after endoscopic coagulation with different techniques associated with acid inhibition. However, most of these studies have shown that residual Barrett's glands are found underneath the new squamous epithelium in up to 40% of patients. The goal of our study is to verify whether complete restoration of Barrett's mucosa can be achieved by the combination of high power setting argon plasma coagulation and omeprazole.

METHODS

A total of 33 patients (mean age: 55.2 yr, range: 21-84 yr; 21 men and 12 women) with histologically demonstrated Barrett's esophagus (mean length: 4.05 cm, range: 0.5-7 cm) were treated. Fourteen cases presented with low-grade dysplasia and one with high-grade dysplasia. All of the extent, or until a maximum of 4 cm, of the Barrett's mucosa was cauterized in each session using argon beam coagulation at a power setting of 65-70 W. All patients received 60 mg omeprazole during the treatment period.

RESULTS

Complete restoration of squamous mucosa was obtained in all 33 cases after a mean of 1.96 sessions (range, 1-4). Endoscopic results were histologically confirmed. Nineteen (57.5%) patients experienced moderate to severe chest pain and odyno-dysphagia lasting for 3-10 days after the procedure. Five of these cases experienced high fever and a small volume of pleural effusion, and three patients developed esophageal strictures that needed to be dilated. Another patient developed pneumomediastinum and subcutaneous emphysema without evidences of perforation. After a mean follow-up of 10.6 months there was one endoscopic, as well as histological, recurrence of Barrett's mucosa in a patient with an ineffective laparoscopic fundoplication.

CONCLUSIONS

High power setting argon plasma coagulation combined with intensive acid suppression is an effective treatment for the total endoscopic ablation of Barrett's esophagus, at least in the short term. Long-term follow-up of treated patients in whom gastroesophageal reflux is surgically or medically alleviated seems mandatory before drawing definitive conclusions about this therapy.

Pharmacokinetics of oligodeoxynucleotides encapsulated in liposomes: effect of lipid composition and preparation method

1. The effect of the method employed to prepare liposomes and their lipid composition were evaluated in terms of the encapsulation efficiency and pharmacokinetic features of two oligodeoxynucleotides of a 21 mer: the normal (N-Odn) and the phosphorothioate (S-Odn) oligodeoxynucleotide. 2. Liposomes were prepared by the classical method of multilamellar vesicles (MV) and by the dehydration-rehydration method (DR). Two lipid mixtures were used to prepare liposomes--the predominant lipid being phosphatidylcholine (PC) and sphingomyelin (SM) respectively. 3. The DR method for liposome preparation provided the highest encapsulation efficiency, regardless of liposome lipid composition and the type of oligodeoxynucleotide involved (N-Odn or S-Odn). 4. The pharmacokinetics of free and liposome encapsulated oligodeoxynucleotides was studied in mouse following i.v. administration. Liposome encapsulated oligodeoxynucleotides exhibited a significantly lower plasma clearance and longer half-life and residence time than free oligodeoxynucleotides. The method used to obtain the liposomes affected plasma clearance, which was lower for liposomes elaborated by the DR method than for liposomes prepared with the MV method. The use of S-Odn in place of N-Odn decreased the plasma clearance of oligodeoxynucleotide when administered encapsulated in liposomes, regardless of the lipid composition and method used to obtain the liposomes.

Effect of the protein kinase inhibitors, 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine H-7 and N-(2-[methylamino]ethyl)-5-isoquinoline-sulfonamide H-8 on Lewis lung carcinoma tumor progression

The effects of 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine H-7 (a cAMP-dependent protein kinase and protein kinase C inhibitor), n-(2-[methylamino]ethyl)-5-isoquinoline-sulfonamide H-8 (a cAMP- and cGMP-dependent protein kinase inhibitor) and indomethacin (IND, a cyclooxygenase inhibitor) on both the spontaneous metastatic ability of 3LL (Lewis lung carcinoma) tumor cells and anti-tumor host response were studied. The study of tumor progression showed that H-7 and H-8 (2 mg kg(-1) day(-1) , i.p., for 8 days) significantly reduced the mean number of metastases (0.8 +/- 0.2 and 1.0 +/- 0.7, respectively, P < 0.05) with respect to the number of lung metastases (4.2 +/- 2.1) observed in the control group. In turn, the highest tumor-specific cytotoxicity response (50% increase vs. non-treated target cells) was observed when both animal and tumor cells were treated with H-8. This suggests that the protein kinase inhibitors could inhibit tumor progression toward lung metastases formation by blocking the immunosuppressor mechanism triggered by agents that increase intracellular cAMP.

Anti-interleukin 4 antibody and indomethacin synergistic effect on B16 melanoma tumor progression

B16 melanoma-bearing mice were treated with anti-interleukin 4 antibody, indomethacin or its combination to evaluate the ability of the primary tumor to induce lung metastasis and the antitumor host response. Flow cytometry of tumor cells incubated with sera from tumor-bearing mice showed B16 melanoma to induce a significant antitumor humoral response (39.0 +/- 1.1% positive cells versus 1.8 +/- 0.9% in the control). The treatment of tumor-bearing mice with antimouse anti-interleukin 4 monoclonal antibody plus indomethacin significantly increased (P < .01) the mean value of lung metastasis (from 6.1 +/- 3.0 in the controls to 50.8 +/- 21.8). Also, a significant increase in natural cytotoxicity against tumor cells was observed when both peripheral blood mononuclear cells and splenocytes were used as effector cells. In contrast, an antibody-dependent cellular cytotoxicity decrease was found with effector cells from both normal and tumor-bearing mice. In the former, the antibody-dependent cellular cytotoxicity decrease was 49.4% and 58.4% (P < .05) for peripheral blood mononuclear cells and splenocytes, whereas in the second case the decrease was 40.7% (P < .05) and 29.1% (P < .01), respectively. These results suggest that an efficient antibody-dependent cellular cytotoxicity response might be necessary to secure an effective host antitumor immune response.

Long-term expression of the human alpha1-antitrypsin gene in mice employing anionic and cationic liposome vectors

The efficiency of both anionic and cationic liposomes as vectors for in vivo human alpha1-antitrypsin (AAT) gene transfer was studied in mice with and without an associated partial hepatectomy. The pTG7101 plasmid, containing the full-length human AAT gene, was encapsulated in small liposomes bearing 10% of negatively (phosphatidylserine, PS) or positively (DOTAP) charged lipids. The results indicated that the DNA/lipid ratio was increased in cationic liposomes by inclusion of monosialoganglioside-GM1. The expression of human protein after in vivo gene transfer was quantified in mouse plasma by an ELISA procedure, and revealed that both anionic and cationic liposomes mediated the presence of human protein in mouse plasma for 2-3 weeks. This effect was prolonged (>5 months) when a partial hepatectomy was performed after treatment. In addition, it was observed that the efficacy of liposome-mediated gene transfer was more limited when the plasmid was externally associated to cationic liposomes.

Antimetastatic effect of immunization with liposome-encapsulated tumor cell-membrane proteins obtained from experimental tumors

Immunization of C57BL/6 mice with tumor-derived membrane-proteins encapsulated in sized liposomes (0.2 microgram/mouse) and composed by phosphatidylcholine or sphingomyelin, significantly reduced the mean values of spontaneous lung metastasis from both B16 (0.7 +/- 0.5 and 1.2 +/- 0.6, respectively) and 3LL (4.8 +/- 2.5 and 7.2 +/- 4.1, respectively) tumors, with respect to control (HEPES) groups (4.8 +/- 1.1 and 19.0 +/- 4.4, respectively). However, no significant antimetastatic effect was observed using free tumor-derived proteins (2 micrograms/mouse) or liposome vehicle alone. Specific humoral immune response after the vaccination was studied by flow cytometry of tumor cells incubated with a pooled sample from each group of immunized mice and FITC-conjugate antimouse immunoglobulins. The results showed that the highest number of positive tumor cells was identified using sera from immunized mice with sized liposomes encapsulating tumor-derived proteins whereas the immunization with the protein fraction in free form failed to induce this effect. In addition, an increased cytotoxicity towards 3LL and B16 tumor cells can also be observed when tumor cells were incubated with spleen effector cells plus specific immunosera. In conclusion, our results show that antitumor active vaccination, using sized liposomes as adjuvants, induces an antitumor host response and a significant inhibition of tumor progression.

Expression of human alpha 1-antitrypsin in mouse after in vivo gene transfer to hepatocytes by small liposomes

A plasmid (pTG7101) containing the full-length human alpha 1-antitrypsin gene was encapsulated in small liposomes and used for "in vivo" gene transfer to mouse hepatocytes, by i.v. injection (100 ng DNA/mouse and dose). The expression of human protein was evaluated by microspectrophotometry after human alpha 1-antitrypsin immunoperoxidase reaction on liver cryosections and the presence in mouse plasma of de novo synthesized protein was detected by ELISA analysis. Our results indicate that a single dose of encapsulated plasmid induces the expression of human alpha 1-antitrypsin in mouse hepatocytes and a large effect (70%) remains two weeks after treatment. However, no effect was observed when mice were treated with buffer or free plasmid (100 ng/mouse) plus an equivalent lipid dose of empty liposomes. In addition, whereas no additive effect was observed after repetitive treatment-doses, the partial hepatectomy three hours after a single treatment-dose, significantly increased the presence of human alpha 1-antitrypsin in mice plasma.