Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial

Background

Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes.

Methods

StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals.

Results

The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (− 0.08% (− 0.31 to 0.16) (IFCC − 0.82 mmol/mol (− 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was − 0.71% (− 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful.

Conclusions

Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes.

Trial registration

Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11874-7.

Association between overcrowded households, multigenerational households, and COVID-19: a cohort study

OBJECTIVES

The role of overcrowded and multigenerational households as a risk factor for COVID-19 remains unmeasured. The objective of this study is to examine and quantify the association between overcrowded and multigenerational households and COVID-19 in New York City (NYC).

STUDY DESIGN

Cohort study.

METHODS

We conducted a Bayesian ecological time series analysis at the ZIP Code Tabulation Area (ZCTA) level in NYC to assess whether ZCTAs with higher proportions of overcrowded (defined as the proportion of the estimated number of housing units with more than one occupant per room) and multigenerational households (defined as the estimated percentage of residences occupied by a grandparent and a grandchild less than 18 years of age) were independently associated with higher suspected COVID-19 case rates (from NYC Department of Health Syndromic Surveillance data for March 1 to 30, 2020). Our main measure was an adjusted incidence rate ratio (IRR) of suspected COVID-19 cases per 10,000 population. Our final model controlled for ZCTA-level sociodemographic factors (median income, poverty status, White race, essential workers), the prevalence of clinical conditions related to COVID-19 severity (obesity, hypertension, coronary heart disease, diabetes, asthma, smoking status, and chronic obstructive pulmonary disease), and spatial clustering.

RESULTS

39,923 suspected COVID-19 cases were presented to emergency departments across 173 ZCTAs in NYC. Adjusted COVID-19 case rates increased by 67% (IRR 1.67, 95% CI = 1.12, 2.52) in ZCTAs in quartile four (versus one) for percent overcrowdedness and increased by 77% (IRR 1.77, 95% CI = 1.11, 2.79) in quartile four (versus one) for percent living in multigenerational housing. Interaction between both exposures was not significant (β_interaction = 0.99, 95% CI: 0.99-1.00).

CONCLUSIONS

Overcrowdedness and multigenerational housing are independent risk factors for suspected COVID-19. In the early phase of the surge in COVID cases, social distancing measures that increase house-bound populations may inadvertently but temporarily increase SARS-CoV-2 transmission risk and COVID-19 disease in these populations.

Comparison of speech production in upright and supine position

Speech is usually produced in an upright sitting or standing posture. Measurements and judgments of speech may be made in conditions requiring a supine position, however. These conditions include MRI recordings, and oral procedures, such as, adjustments to dental appliances, medical and surgical procedures. It is of interest, therefore, to see whether gravity has strong or systematic effects on tongue behavior. In the present study, 13 subjects repeated several words, which contained extreme consonant and vowel tongue positions, during upright and supine condition. Ultrasound imaging provided midsagittal tongue contours, in each condition, for comparison. A neck brace was used to stabilize transducer placement and the palate was used as a physiological reference to register the data sets. Results showed a significant subject effect. In supine position the tongue was more posterior than upright for seven subjects, more anterior for two subjects and varied by phoneme for four subjects. However, there was no significant phoneme effect. The direction of change and the amount of change were not directly related. Most subjects had small upright-supine differences. The largest differences, less than 3 mm on average, were in the posterior tongue.

Antiproliferative activity and induction of apoptosis in human colon cancer cells treated in vitro with constituents of a product derived from Pistacia lentiscus L. var. chia

In this report, we demonstrate that a 50% ethanol extract of the plant-derived product, Chios mastic gum (CMG), contains compounds which inhibit proliferation and induce death of HCT116 human colon cancer cells in vitro. CMG-treatment induces cell arrest at G(1), detachment of the cells from the substrate, activation of pro-caspases-8, -9 and -3, and causes several morphological changes typical of apoptosis in cell organelles. These events, furthermore, are time- and dose-dependent, but p53- and p21-independent. Apoptosis induction by CMG is not inhibited in HCT116 cell clones expressing high levels of the anti-apoptotic protein, Bcl-2, or dominant-negative FADD, thereby indicating that CMG induces cell death via a yet-to-be identified pathway, unrelated to the death receptor- and mitochondrion-dependent pathways. The findings presented here suggest that CMG (a) induces an anoikis form of cell death in HCT116 colon cancer cells that includes events associated with caspase-dependent pathways; and (b) might be developed into a chemotherapeutic agent for the treatment of human colon and other cancers.

Fibrinolysis of loculated pleural effusion in malignant mesothelioma

Surgical resection is not feasible in most cases of malignant mesothelioma and palliation of symptoms remains the mainstay of treatment. When a pleural effusion is loculated, the standard treatment methods of intercostal tube drainage and pleurodesis may not be helpful. We report a 49-year-old man with malignant mesothelioma in whom intrapleural fibrinolysis was performed using streptokinase. It was successful in breaking the locules and draining the effusion. Intrapleural fibrinolysis should be considered in cases of loculated pleural effusion due to malignant mesothelioma, as it may provide symptom relief and palliation.

An open-label, dose-ranging study of atomoxetine in children with attention deficit hyperactivity disorder

OBJECTIVE

The goal of this study was to evaluate the tolerability and effectiveness of the experimental, noradrenergic specific reuptake inhibitor atomoxetine in the treatment of children with attention deficit hyperactivity disorder (ADHD).

METHODS

This was an open, prospective, dose-ranging study of atomoxetine monotherapy in the treatment of 30 children with ADHD between the ages of 7 and 14 years. Atomoxetine was started at 10-20 mg/day and titrated weekly up to 90 mg over 11 weeks, depending on response and adverse effects. Twenty-two children completed the full 11 weeks. We assessed efficacy with weekly clinician and parent ratings of ADHD and oppositional symptoms and monitored adverse effects, laboratory findings, and cardiovascular parameters.

RESULTS

Treatment with atomoxetine (mean final, total daily dose of 1.9 mg/kg/day) was very well tolerated without meaningful adverse effects. Atomoxetine significantly reduced core symptoms of ADHD (ADHD-Rating Scale-IV; 38.6% decrease vs. baseline, p < 0.001) with significant improvement (p < 0.05) in all but 1 of the 18 individual items in the ADHD-Rating Scale-IV. More than 75% of subjects who completed 10 weeks of treatment showed > 25% decrease in ADHD symptoms.

CONCLUSIONS

These findings extend to children the positive results previously reported in adults diagnosed with ADHD who were treated with atomoxetine. These results support additional controlled trials of atomoxetine in cases of pediatric ADHD.

A retrospective study of citalopram in adolescents with depression

Recent evidence suggests that the selective serotonin reuptake inhibitors are safe and efficacious in treating juveniles with depression. However, citalopram has not been reported in adolescents with depression. This study assessed the effectiveness and tolerability of citalopram in all adolescents with depressive disorders treated naturalistically in a community mental health center during a 1-year interval. Medical charts were retrospectively reviewed for 21 adolescents treated with citalopram for major depression (n = 14), bipolar depression (n = 4), or dysthymia (n = 3). An independent rater compared last visit to baseline depression using the Clinical Global Impression (CGI) Severity and Improvement scales. Adolescents received citalopram for an average of 128.5 +/- 84 days at a final average dose of 26.5 +/- 13.1 mg/day. Sixteen of these 21 adolescents (76%) exhibited much to very much improvement as measured by the CGI, and severity of depression diminished significantly (z = 3.007, p < 0.0026). Mild side effects, including headaches, dizziness, nausea, sedation, agitation, and sweating were reported by 7 (33%) of the patients. These data suggest that citalopram may be effective, safe, and well tolerated in the treatment of adolescents with depressive disorders and that controlled trials are warranted in this population.

Aggressive interactions between freshwater turtle, Chelodina oblonga, hatchlings and freshwater crayfish, Cherax spp.: implications for the conservation of the critically endangered western swamp turtle, Pseudemydura umbrina

Interactions between turtle hatchlings of Chelodina oblonga and the marron, Cherax tenuimanus, the gilgie, C. quinquecarinatus, the koonac, C. preissii (freshwater crayfish native to Western Australia) and the introduced yabby, Cherax. sp., were observed in laboratory-based trials in uncluttered aquaria. Marron, koonacs and yabbies, but not gilgies, showed aggressive and predatory behaviour towards the hatchlings. In total, 59 attacks were observed in 26 of the 80 trials. On 12 occasions, crayfish captured hatchlings in their chelae. On two occasions, the attack of the crayfish was so quick that the hatchling was killed instantly. Compared with movement when alone, movement of hatchlings was significantly greater in the presence of koonacs and yabbies, but significantly less in the presence of marron and gilgies. The range of non-native yabbies currently is expanding into Ellen Brook Nature Reserve which harbours the last naturally persisting population of the critically endangered western swamp turtle, Pseudemydura umbrina. No native crayfish occur in the habitat of P. umbrina in this reserve. The possible invasion by the ecological generalist yabby poses a new threat to the survival of P. umbrina.

Metabolic ecology of cockatoos in the south-west of Western Australia

This study examined the metabolic ecology of six cockatoo taxa endemic to the south-west of Western Australia. As the availability of food is one factor that may influence the abundance and distribution of these cockatoos, we document here their baseline energy requirements and feeding patterns. Evaporative waterloss was also measured as this may correlate with the aridity of the species’ environment. Basal metabolic rate was significantly lower at 0.62 ± 0.13 mL O2 g–1 h–1 for the inland red-tailed black cockatoo than 1.11 ± 0.16 mL O2 g–1 h–1 for the forest red-tailed black cockatoo, but there was no significant difference in metabolic rate between the two white-tailed black cockatoos (0.86 ± 0.18 for Carnaby’s and 0.81 ± 0.11 mL O2 g–1 h–1 for Baudin’s) or the two corellas (0.95 ± 0.12 for Butler’s and 0.70 ± 0.04 mL O2 g–1 h–1 for Muir’s). There were no significant differences between the two white-tailed black cockatoos, and between the two corellas, with respect to evaporative water loss. The inland red-tailed black cockatoo had a significantly lower rate of evaporative water loss (0.44 ± 0.07 mg g–1 h–1) than the forest red-tailed black cockatoo (0.70 ± 0.06 mg g–1 h–1), which is presumably an adaptation to its more arid habitat. The total energy content of assorted native and introduced food items that form significant proportions of the diets for these cockatoos varied from only 0.17 kJ for a 9-mg Emex australis seed to 63.9 kJ for a 3-g Banksia attenuata nut. The energy content of each food item and the estimated daily energy requirements of the cockatoos enabled the calculation of the numbers of nuts/cones/seeds required by each species for a day, which ranged from 11 B. attenuata nuts for a Carnaby’s cockatoo to 3592 Persoonia longifolia seeds for a forest red-tailed black cockatoo.

Efficacy of a mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder

BACKGROUND

We report on a controlled trial of a mixed amphetamine salts compound (Adderall, dextroamphetamine sulfate, dextro-, levoamphetamine sulfate, dextroamphetamine aspartate, levoamphetamine aspartate, and dextroamphetamine saccharate) in the treatment of adult attention-deficit/hyperactivity disorder (ADHD).

METHODS

This was a 7-week, randomized, double-blind, placebo-controlled, crossover study of Adderall in 27 well-characterized adults satisfying full DSM-IV criteria for ADHD of childhood onset and persistent symptoms into adulthood. Medication was titrated up to 30 mg twice a day. Outcome measures included the ADHD Rating Scale and the Clinical Global Impression Score. Comorbid psychiatric disorders were assessed to test for potential effects on treatment outcome.

RESULTS

Treatment with Adderall at an average oral dose of 54 mg (administered in 2 daily doses) was effective and well tolerated. Drug-specific improvement in ADHD symptoms was highly significant overall (42% decrease on the ADHD Rating Scale, P<.001), and sufficiently robust to be detectable in a parallel groups comparison restricted to the first 3 weeks of the protocol (P<.001). The percentage of subjects who improved (reduction in the ADHD rating scale of > or =30%) was significantly higher with Adderall treatment than with a placebo (70% vs 7%; P =.001).

CONCLUSIONS

Adderall was effective and well tolerated in the short-term treatment of adults with ADHD. More work is needed to evaluate the long-term effects of Adderall, or other amphetamine compounds, in the treatment of adults with ADHD.

A controlled clinical trial of bupropion for attention deficit hyperactivity disorder in adults

OBJECTIVE

Despite the increasing recognition of attention deficit hyperactivity disorder (ADHD) in adults, there is a paucity of controlled pharmacological trials demonstrating the effectiveness of compounds used in treatment, particularly nonstimulants. The authors report results from a controlled investigation to determine the anti-ADHD efficacy of bupropion in adult patients with DSM-IV ADHD.

METHOD

This was a double-blind, placebo-controlled, randomized, parallel, 6-week trial comparing patients receiving sustained-release bupropion (up to 200 mg b.i.d.) (N=21) to patients receiving placebo (N=19). The authors used standardized structured psychiatric instruments for diagnosis of ADHD. To measure improvement, they used separate assessments of ADHD, depression, and anxiety symptoms at baseline and each weekly visit.

RESULTS

Of the 40 subjects (55% male) enrolled in the study, 38 completed the study. Bupropion treatment was associated with a significant change in ADHD symptoms at the week-6 endpoint (42% reduction), which exceeded the effects of placebo (24% reduction). In analyses using a cutoff of 30% or better reduction to denote response, 76% of the subjects receiving bupropion improved, compared to 37% of the subjects receiving placebo. Similarly, in analyses using Clinical Global Impression scale scores, 52% of the subjects receiving bupropion reported being "much improved" to "very improved," compared to 11% of the subjects receiving placebo.

CONCLUSIONS

These results indicate a clinically and statistically significant effect of bupropion in improving ADHD in adults. The results suggest a therapeutic role for bupropion in the armamentarium of agents for ADHD in adults, while further validating the continuity of pharmacological responsivity of ADHD across the lifespan.

Systematic chart review of the pharmacologic treatment of comorbid attention deficit hyperactivity disorder in youth with bipolar disorder

The objective of this study was to evaluate pharmacological approaches for attention deficit hyperactivity disorder (ADHD) in children with bioplar disorder and comorbid ADHD. The medical charts of 38 patients with diagnoses of both Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised ADHD and bipolar disorder were reviewed over multiple visits to assess improvement and prescription patterns. Logistic regression was used to model the probability of improvement at each visit, and robust standard errors were estimated in order to account for correlation among individuals using Huber's correction for clustered data. The proportion of visits at which ADHD symptoms were rated as improved following initial improvement in manic symptoms was 7.5 times greater than before initial improvement of manic symptoms. The recurrence of manic symptoms following their initial stabilization significantly inhibited ADHD response to medication. Although tricyclic antidepressants (TCAs) significantly increased the probability of ADHD improvement following mood stabilization, there was also a significant association between treatment with TCAs and relapse of manic symptoms. Our results support the hypothesis that mood stabilization is a prerequisite for the successful pharmacologic treatment of ADHD in children with both ADHD and manic symptoms. Although TCAs can be helpful in the management of ADHD children with manic symptoms, these drugs should be used with caution since they can also have a destabilizing effect on manic symptoms.

A pilot controlled clinical trial of ABT-418, a cholinergic agonist, in the treatment of adults with attention deficit hyperactivity disorder

OBJECTIVE

Despite the increasing recognition of attention deficit hyperactivity disorder (ADHD) in adults, there is a paucity of controlled pharmacological trials. Recent reports have suggested the potential usefulness of cholinergic agents for ADHD. To this end, the authors completed a controlled study of ABT-418, a novel cholinergic activating agent, for the treatment of adults with ADHD.

METHOD

This was a double-blind, placebo-controlled, randomized, crossover trial that compared a transdermal patch of ABT-418 (75 mg/day) to placebo in adults who met DSM-IV criteria for ADHD. There were two 3-week treatment periods separated by 1 week of washout.

RESULTS

Of the 32 subjects enrolled in the study (88% were men; mean age = 40 years, SD = 9), 29 completed the study. At the endpoint of each active arm (last observation carried forward), a significantly higher proportion of subjects was considered improved while receiving ABT-418 than while receiving placebo (40% versus 13%). Similarly, at endpoint there was a significantly greater reduction in ADHD symptom checklist scores (28% versus 15%). Symptoms reflective of attention, and subjects with less severe ADHD, responded more robustly to ABT-418. Treatment with ABT-418 was relatively well tolerated; dizziness and nausea were the most frequently reported adverse effects.

CONCLUSIONS

The results of this investigation indicate that ABT-418, a nicotinic analog, may be a potentially useful agent for the treatment of ADHD.

Controlled trial of high doses of pemoline for adults with attention-deficit/hyperactivity disorder

Despite the increasing awareness of attention-deficit/hyperactivity disorder (ADHD) in adults, there are a limited number of controlled pharmacologic studies of this disorder. Because the stimulant medication magnesium pemoline (Cylert, Abbott Laboratories, Abbott Park, IL) has been found effective in treating ADHD in pediatric groups, we tested its efficacy in adults with ADHD using higher daily doses than those previously studied. We conducted a 10-week, double-blind, placebo-controlled, crossover design study of pemoline at a target daily dose of 3 mg/kg per day in 35 adult patients with DSM-III-R and -IV ADHD. We used standardized structured psychiatric instruments for diagnosis. To measure improvement, we used separate assessments of ADHD, depressive, and anxiety symptoms at baseline and at each biweekly visit. ADHD outcome was determined using the ADHD symptom checklist and Clinical Global Impression scales of Severity and Improvement. Of the 35 adults with ADHD who were randomized in the trial, 27 (77%) completed the protocol. Treatment with pemoline in the final week of the 4-week active phase was best tolerated at doses substantially lower than the target dose of 3 mg/kg per day (mean dose, 2.2 mg/kg per day; mean+/-SD, 148+/-95 mg). Pemoline was significantly better at reducing ADHD symptoms compared with placebo (z = 2.4,p < 0.02). Using a predefined 30% reduction in symptoms as an indication of improvement, 50% of pemoline-treated subjects and 17% of subjects in the placebo group were considered positive responders (chi2 = 7.1, p = 0.008). These results indicate that pemoline is moderately effective in the treatment of ADHD in adults. Although robust doses were targeted, most adults preferred more moderate dosing (120-160 mg/day). Given the limited efficacy, tolerability, and concerns of hepatic dysfunction, pemoline should be considered as second-line medication for treating ADHD in adults.

Absence of effect of stimulants on the phamacokinetics of desipramine in children

We conducted a retrospective chart review to examine the pharmacokinetic interaction between desipramine and the stimulants methylphenidate and dexedrine using routinely monitored desipramine serum concentrations in children receiving desipramine either alone or with a stimulant. Subjects were 142 children and adolescents (age 6-17 yrs; 113 taking desipramine, 29 taking desipramine-stimulants) in whom 401 dose- and weight-normalized serum concentrations were evaluated (333 desipramine, 68 desipramine-stimulants). Desipramine pharmacokinetic parameters were similar for both groups, including mean weight-corrected dose (3.66+/-1.36 mg/kg, desipramine; 3.66+/-1.09 mg/kg, desipramine-stimulants; p=0.97), weight- and dose-normalized serum concentrations (47.26+/-39.26 [microg/L]/[mg/kg], desipramine, 39.02+/-19.92 [microg/L]/[mg/kg], desipramine-stimulants; p=0.09), and clearance (0.690+/-0.913 [L/kg]/hr, desipramine; 0.613+/-0.514 [L/kg]/hr, desipramine-stimulants; p=0.499). When stratified by age, gender, and type of stimulant, no difference was detected (p>0.05) between groups. Our findings indicate the absence of a clinically significant interaction between desipramine and stimulants.

Erythrocyte and brain methionine adenosyltransferase activities in patients with schizophrenia

The activity of methionine adenosyltransferase (MAT) was investigated in erythrocytes and postmortem brain specimens (cortex gyrus frontalis, hippocampus and thalamus) of patients with schizophrenia treated with neuroleptics. In comparison with the control group, abnormally low values of MAT Vmax and an increased MAT affinity towards methionine (lower Km values) were found in erythrocytes. In the brain, a regionally selective decrease of MAT Km was found in cortex gyrus frontalis but the Vmax values were however, unchanged. In the regions of cortex gyrus frontalis and hippocampus, but not in thalamus, the values of Vmax and Km were inversely correlated with the duration of schizophrenia. In rats treated for 28 days with the typical neuroleptic haloperidol and the atypical clozapine, a significant increase of MAT activity was found in the corpus striatum. There is the possibility that the changes observed in MAT activity in patients with schizophrenia are attributed to the neuroleptic medication.

Desipramine clearance in children and adolescents: absence of effect of development and gender

OBJECTIVE

To examine the influence of development and gender on the pharmacokinetics of desipramine (DMI) in the pediatric population.

METHOD

DMI pharmacokinetic parameters were calculated from 407 routinely drawn, dose- and weight-normalized serum concentrations in 173 youths receiving DMI (90 children, 83 adolescents; 29 were female, 144 were male).

RESULTS

Mean pharmacokinetic parameters for the entire population included dose (3.78 +/- 1.51 mg/kg), weight- and dose-normalized serum concentration (45.41 +/- 47.39 [micrograms/L]/[mg/kg]), and DMI clearance (0.68 +/- 1.51 [L/kg]/hr). No between-group differences for children and adolescents were detected in dose (child, adolescent) (3.73 +/- 1.40 mg/kg, 3.83 +/- 1.68 mg/kg), weight- and dose-normalized serum concentrations (44.52 +/- 39.6 [micrograms/L]/[mg/kg], 46.34 +/- 34.89 [micrograms/L]/[mg/kg]; p = .62), and clearance (0.680 +/- 0.890 [L/kg]/hr, 0.695 +/- 1.05 [L/kg]/hr; p = .103). No between-group gender differences were detected in dose (male, female) (3.83 +/- 1.55 mg, 3.39 +/- 1.84 mg), weight- and dose-normalized serum concentrations (45.15 +/- 37.76 [micrograms/L]/[mg/kg], 47.14 +/- 34.96 [micrograms/L]/mg/kg]; p = .720), and clearance (0.699 +/- 0.89 [L/kg]/hr, 0.606 +/- 0.535 [L/kg]/hr; p = .390).

CONCLUSIONS

These results suggest that age and gender do not significantly influence DMI clearance or dose-normalized serum concentrations in the pediatric population.

The naturalistic course of pharmacologic treatment of children with maniclike symptoms: a systematic chart review

OBJECTIVE

To assess the effectiveness of mood stabilizers in treating maniclike symptoms in children.

METHOD

Subjects were consecutively referred pediatric patients who, at initial intake, satisfied DSM-III-R criteria for mania on a structured diagnostic interview. We systematically reviewed their clinical records to assess (1) the course of maniclike symptoms and (2) all medications prescribed at each follow-up visit. Survival analysis was used to determine the effect of mood stabilizers and other medications on the course of maniclike symptoms.

RESULTS

Of the 59 subjects meeting criteria for mania, 44 (75%) exhibited evidence of maniclike symptoms during follow-up. The occurrence of manic symptoms significantly predicted the subsequent prescription of mood stabilizers (rate ratio = 2.9, 95% confidence interval [CI] = 1.6 to 5.5), and use of mood stabilizers predicted decreases in manic symptoms (rate ratio = 4.9, 95% CI = 1.2 to 20.8). However, improvement was slow and associated with a substantial risk for relapse.

CONCLUSION

Mood stabilizers were frequently used in children with maniclike symptoms, and their use was associated with significant improvement of maniclike symptoms, whereas use of antidepressant, antipsychotic, and stimulant medications was not.

Calcium responses in fibroblasts from asymptomatic members of Alzheimer's disease families

We have previously identified alterations of K+ channel function, IP3-mediated calcium release, and Cp20 (a memory-associated GTP binding protein) in fibroblasts from Alzheimer's disease (AD) patients vs controls. Some of these alterations can be integrated into an index that distinguishes AD patients from controls with both high specificity and high sensitivity. We report here that alterations in IP3-mediated calcium responses are present in a large proportion of AD family members (i.e., individuals at high risk) before clinical symptoms of Alzheimer's disease are present. This was not the case if such members later "escaped" AD symptoms. This preclinical calcium signal correlate of later AD does not reflect, however, the presence of the PS1 familial AD gene.

Defensive ink pigment processing and secretion in Aplysia californica: concentration and storage of phycoerythrobilin in the ink gland

The marine snail Aplysia californica obtains its defensive ink exclusively from a diet of red seaweed. It stores the pigment (phycoerythrobilin, the red algal photosynthetic pigment, r-phycoerythrin, minus its protein) in muscular ink-release vesicles within the ink gland. Snails fed a diet of green seaweed or romaine lettuce do not secrete ink and their ink-release vesicles are largely devoid of ink. Successive activation of individual ink-release vesicles by ink motor neurons causes them to secrete approximately 55 % of their remaining ink (similar to the percentage of ink reserves released from the intact gland). The peripheral activation of vesicles appears to be cholinergic: 70 % of isolated vesicles were induced to squeeze ink from their valved end by solutions of acetylcholine at concentrations of 0.5 mmol l-1 or below. Ultrastructural analysis commonly found three cell types in the ink gland. The RER cells, the most numerous, were characterized by an extensive rough endoplasmic reticulum with greatly distended cisternae. This cell type is probably the site for synthesis of the high molecular mass protein of secreted ink. The granulate cells, less common than RER cells, had nuclear and cell areas significantly larger than those of RER cells. In addition, granulate cells of red-algal-fed snails had 4-14 vacuoles that contained electron-dense material with staining characteristics similar to that of ink in mature ink-release vesicles. The granulate cell's plasma membrane was regularly modified into grated areas, which both localized and expanded the surface area for coated vesicle formation and provided a sieve structure that prevented large particles in the hemolymph either from being taken up by, or from occluding, the coated vesicles. Electron-dense particles within coated vesicles were similar in size to those in granulate vacuoles but larger (on average by approximately 1 nm) than those that make up the ink. In green-seaweed-fed snails, granulate cells and their vacuoles were present but the vacuoles were empty. The third cell type, the vesicle cell, expands markedly, with its nucleus enlarging concurrent with cell growth until it is on average 50 times larger in cross-sectional area than the nuclei of either RER or granulate cells; the cytoplasm eventually becomes filled with ink, which obscures the mitochondria, vacuoles and nucleus. Continued cell expansion ceases with the appearance of an encircling layer of muscle and 1-3 layers of cells of unknown origin, thereby becoming the ink-release vesicle itself. The absorption spectra of the soluble contents of mature ink-release vesicles from snails fed red algae had peaks characteristic of the red algal pigment r-phycoerythrin or/and phycoerythrobilin. Immunogold localization of r-phycoerythrin showed no statistical difference in the amount of label within the ink-release vesicles, RER or granulate cell types. Furthermore, there was no localization of phycoerythrin immunoreactivity within the various cellular compartments of either the RER or granulate cells (nucleus, endoplasmic reticulum, mitochondria, vacuoles). Immunogold labeling in the ink gland ranged from 11 to 16 % of that for the digestive vacuoles of the rhodoplast digestive cells lining the tubules of the digestive gland. Our observations suggest (a) that the main form of the ink pigment in the gland is phycoerythrobilin or/and a non-antigenic form of phycoerythrin, and (b) that separation of the bilin from phycoerythrin (or its modification so that it is no longer antigenic) occurs before it reaches the ink gland, probably within the vacuoles of the rhodoplast digestive cells of the digestive gland. We propose the following model. The ink pigment, phycoerythrobilin, is cleaved from its protein in rhodoplast digestive vacuoles in the digestive gland. (ABSTRACT TRUNCATED)

Effectiveness and tolerability of tomoxetine in adults with attention deficit hyperactivity disorder

OBJECTIVE

The authors assessed the experimental noradrenergic compound tomoxetine as an alternative treatment for adult attention deficit hyperactivity disorder (ADHD).

METHOD

They conducted a double-blind, placebo-controlled, crossover study of tomoxetine in 22 adults with well-characterized ADHD.

RESULTS

Treatment with tomoxetine at an average oral dose of 76 mg/day was well tolerated. Drug-specific improvement in ADHD symptom was highly significant overall and sufficiently robust to be detectable in a parallel-groups comparison restricted to the first 3 weeks of the protocol. Eleven of 21 patients showed improvement after receiving tomoxetine, compared with only two of 21 patients who improved after receiving placebo. Significant tomoxetine-associated improvement was noted on neuropsychological measures of inhibitory capacity from Stroop tests.

CONCLUSIONS

This preliminary study showed that tomoxetine was effective in treating adult ADHD and was well tolerated. These promising results provide support for further studies of tomoxetine over an extended period of treatment.

Six-week, double-blind, placebo-controlled study of desipramine for adult attention deficit hyperactivity disorder

OBJECTIVE

Despite the increasing awareness of attention deficit hyperactivity disorder (ADHD) in adults, there are a limited number of controlled pharmacologic studies of this disorder; most of the trials have focused on the psychostimulants. Because the tricyclic anti-depressant desipramine has been found to be effective in treating ADHD in pediatric groups, the authors tested its efficacy in adults with ADHD.

METHOD

The authors conducted a randomized, 6-week, placebo-controlled, parallel-design study of desipramine at a target daily dose of 200 mg in 41 adult patients with DSM-III-R ADHD. They used standardized structured psychiatric instruments for diagnosis and, as the dependent variables (outcome), used separate assessments of ADHD, depressive, and anxiety symptoms at baseline and at each biweekly visit.

RESULTS

There were highly significant differences in the reduction of ADHD symptoms between adults receiving desipramine and placebo. Within the desipramine-treated group, there were clinically and statistically significant differences between baseline and the week 6 end point for 1) reduction of 12 of 14 symptoms of ADHD and 2) decreases in the broad categories of hyperactivity, impulsivity, and inattentiveness. In contrast, placebo-treated patients showed no differences between baseline and end point for any of the ADHD symptoms assessed. According to strict, predefined criteria for response, 68% of desipramine-treated subjects and no subjects in the placebo group were considered positive responders. Response to desipramine was independent of dose, level of impairment, gender, or lifetime psychiatric comorbidity with anxiety or depressive disorders.

CONCLUSIONS

These results, similar to findings in children and adolescents with ADHD, indicate that desipramine is effective in the treatment of ADHD in adults.

Decreased cytochrome-c oxidase activity and lack of age-related accumulation of mitochondrial DNA deletions in the brains of schizophrenics

Defects in mitochondrial energy production have been implicated in several neurodegenerative disorders, such as Parkinson disease and amyotrophic lateral sclerosis. To study the contribution of mitochondrial defects to Alzheimer disease and schizophrenia, cytochrome-c oxidase (COX) activity and levels of the mtDNA4977 deletion in postmortem brain tissue specimens of patients were compared with those of asymptomatic age-matched controls. No difference in COX activity was observed between Alzheimer patients and controls in any of five brain regions investigated. In contrast, schizophrenic patients had a 63% reduction of the COX activity in the nucleus caudatus (P < 0.0001) and a 43% reduction in the cortex gyrus frontalis (P < 0.05) as compared to controls. The average levels of the mtDNA4977 deletion did not differ significantly between Alzheimer patients and controls, and the deletion followed similar modes of accumulation with age in the two groups. In contrast, no age-related accumulation of mtDNA deletions was found in schizophrenic patients. The reduction in COX activity in schizophrenic patients did not correlate with changes in the total amount of mtDNA or levels of the mtDNA4977 deletion. The lack of age-related accumulation of the mtDNA4977 deletion and reduction in COX activity suggest that a mitochondrial dysfunction may be involved in the pathogenesis of schizophrenia.

Pharmacotherapy of adult attention deficit/hyperactivity disorder: a review

Adult attention deficit/hyperactivity disorder (ADHD) is an increasingly recognized disorder with associated psychiatric comorbidity and impairment. Although pharmacotherapy serves an important role in treating ADHD and other concurrent psychiatric disorders in children and adolescents, the use of pharmacotherapeutics for adults with ADHD remains less established. In this report, the effectiveness and dosing parameters of the various agents investigated for adult ADHD are reviewed. A systematic review of the available literature identified 7 studies (N = 193 subjects) of psychostimulants and 10 studies of nonstimulant medications (N = 167 subjects) including antidepressants, antihypertensives, and amino acids for the treatment of ADHD in adults. The majority of double-blind investigations were with the psychostimulants, with the nonstimulant agents, generally antidepressants, studied under open conditions. There was considerable variability in diagnostic criteria, dosing parameters, and response rates between the various studies. Under controlled conditions, the aggregate literature shows that the stimulants had a clinically and statistically significant effect on reducing ADHD symptoms. Open studies on the nonserotonergic antidepressants (tricyclics, bupropion, and monoamine oxidase inhibitors) also show a moderate anti-ADHD effect. The literature appears to support the use of robust doses of both stimulants and antidepressants for ADHD in adults. Further controlled studies applying stringent diagnostic criteria and outcome methodology are necessary to define the range of pharmacotherapeutic options for adults with ADHD.

Document imaging: long-term solution or stop-gap measure?

Just what exactly does a "paperless office" mean? To some healthcare professionals, it means just that-no use of paper documents whatsoever. But to others, "paperless" more or less means using paper documents to reach a higher level of electronic recording, in other words-document imaging. We asked four industry insiders to discuss their views and opinions on the use of document imaging in healthcare. Their comments follow.

Mitochondrial enzyme deficiencies in Down's syndrome

Defects in cytochrome oxidase (CO; complex 4) have recently been demonstrated in blood platelets and in brain tissue from patients with Alzheimer's disease (AD) with possible etiological implications. Because of pathogenetic similarities with AD, we have measured the activities of several mitochondrially localised enzymes in the blood platelets of individuals afflicted with trisomy-21 (Down's syndrome). The activities of monoamine oxidase, cytochrome oxidase, isocitrate dehydrogenase, and glutamate dehydrogenase were assayed in washed platelets from sixty caucasian, male and female control individuals (ages 18-60) and ten, young Down's Syndrome patients (ages 9-21). Significant reductions in the activities of monoamine oxidase, cytochrome oxidase, and isocitrate dehydrogenase were found. In all cases the average activities in Down's syndrome individuals were approximately two-thirds those of controls (DS/Controls = 0.68, 0.67, 0.64 respectively). The activity of the fourth enzyme studied, glutamate dehydrogenase, was found to be similar to controls. Results suggest that these reductions are a consequence of a generalised mitochondrial disturbance which may lie behind some pathogenetic aspect(s) of the disease.

An in situ study of beta-glucosidase activity in normal and Gaucher fibroblasts with fluorogenic probes

Beta-glucosidase activity was evaluated in situ by means of fluorogenic probes in normal human fibroblasts and fibroblasts from homozygous carriers of the Gaucher trait. Probe internalization, targeting to lysosomes and post-cleavage probe retention were the primary concerns. Internalization and targeting were attempted by in situ photosensitized labilization of lysosomal membranes, lysosomotropic detergents and the use of low density lipid (LDL) or the receptor ligand apolipoprotein E (ApoE). Post-cleavage increase of fluorescence with fluoresceinyl (bis) beta-glucopyranoside was appreciably above the rather large pre-cleavage emission. In cells incubated overnight with nonylumbelliferyl-beta-glucoside (UG9) in the presence of bovine serum albumin and in the absence of ApoE, the probe was dealt with as a cytotoxic agent, accumulating in a paranuclear cap, most likely comprising elements of the endoplasmic reticulum (ER) and Golgi apparatus. Targeting of UG9 to lysosomes occurred within 1 to 3 h of preincubation in the presence of ApoE. There was some evidence of specificity, as Gaucher fibroblasts exhibited weaker cleavage of UG9 (by 50 per cent or more) compared to normal fibroblasts, but in the Gaucher cells there was some residual beta-glucosidase activity. Cleavage of UG9 was nearly totally suppressed in Gaucher cells treated with the beta-glucosidase inhibitor, conduritol B epoxide, for 24 h to 7 days. Suppression in the control fibroblasts was evident but to a lesser degree. The in situ method of fluorogenic assay established for beta-glucosidase deficiency, is in principle applicable to enzyme deficiencies in other lysosomal storage diseases, or to evaluate enhanced enzyme activity following gene therapy.

Bioregulatory mechanisms at the level of cell organelle interactions: microspectrofluorometric in situ studies

The spatiotemporal analysis of bioregulatory mechanisms at the level of intracellular multienzyme complexes and organelle interactions is made possible by the availability of endogenous and exogenous fluorescence probes, the development of microspectrofluorometers allowing one- and two-dimensional scans of intracellular fluorescence reactions, and the use of micromanipulatory techniques enabling the rapid alteration of metabolic states. Absorbed photons are not only a tool for quantitative evaluation of metabolic processes, they can also trigger alterations of cell membranes and functions as mediated by photosensitizer drugs. In the hierarchy of intracellular organization different levels of complexity are accessible to study, such as the regulation of multienzyme complexes and the interaction of organelle complexes. Typical applications of these methods are the investigation of drug effects (e.g., on melanoma cells), metabolic and structural alterations (e.g., in cystic fibrosis and Gaucher fibroblasts), organelle interactions in cells treated with toxic agents. The implications are relevant to biotechnology for better control of metabolite production and processing, design and testing of new drugs, understanding of drug resistance and better targeting of drugs or probes to selected intracellular sites. In addition, such in vitro methods can contribute to the provision of an alternative to "whole animal experiments" as already achieved in human and mouse fibroblasts, hepatocytes, hepatoma, Swiss 3T3 cells and other cells in culture, especially with regards to an analysis of the action of xenobiotics and drugs in cell physiology and pathology, fluorescence recovery after photobleaching, study of cytoskeleton dynamics and multiparameter probing of organelle activity during in vitro wound repair.

Mental health in Dutch adolescents: self-reported competencies and problems for ages 11-18

Beside parents and teachers, adolescents themselvess may be valuable informants about their own psychological functioning. The present study, which provides prevalence data on behavioral/emotional problems and competencies reported by adolescents aged 11-18 from the general population, was preceded by two studies providing such data for parent and teacher reported problems. The instrument used in the present study is the Youth Self Report (YSR) developed by Achenbach and Edelbrock to obtain adolescents' self-reports on their problems and competencies in a standardized way. YSRs completed by 52 adolescents on two occasions with a time-interval of 3-4 weeks revealed test-retest reliability expressed as intraclass correlation coefficients of 0.87 for total problem scores and 0.69 for total competence scores. The YSR was completed by 941 adolescents aged 11-18 from the general population. For each of the 103 problem items and 17 competence items, the prevalence rates were presented graphically for both genders in two-year age-groups. To identify differences related to sex, age and socio-economic status (SES), ANCOVAs were performed on the scores for each problem and competence item as well as on total problem and total competence scores. Whereas the level of problem scores was the same across the 11-18 years age-span, girls obtained higher total problem scores with increasing age. Younger girls scored lower and older girls scored somewhat higher than boys. Implications of these findings with respect to sex differences in referral rates for children and adults are discussed. The increase with increasing age in self-reports of problems concerning inner feelings and thoughts may reflect the adolescent's change in cognitive, socio-emotional and physical functioning. We could not demonstrate significant SES differences in problem scores. Comparisons of problem scores obtained for referred and nonreferred adolescents revealed a correct classification rate of 73.6%, which seems satisfactory given the fact that parents rather than the adolescent usually initiate referrals. Comparisons of problem item scores in ANCOVAs of referred and nonreferred samples revealed significant referral status effects for 68 of the 103 problem items, with referred adolescents scoring higher than nonreferred adolescents. The largest effect of referral status was found for the item "Nervous". The third largest effect was obtained for the item "Unhappy, sad, depressed", which also showed strong discrimination between parent scores for referred and nonreferred samples. Competence scores showed much weaker discrimination between referred and nonreferred groups.