Case-finding instruments for depression. Two questions are as good as many

OBJECTIVE

To determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.

DESIGN

The test characteristics of a two-question case-finding instrument that asks about depressed mood and anhedonia were compared with six common case-finding instruments, using the Quick Diagnostic Interview Schedule as a criterion standard for the diagnosis of major depression.

SETTING

Urgent care clinic at the San Francisco Department of Veterans Affairs Medical Center.

PARTICIPANTS

Five hundred thirty-six consecutive adult patients without mania or schizophrenia.

MEASUREMENTS AND MAIN RESULTS

Measurements were two questions from the Primary Care Evaluation of Mental Disorders patient questionnaire, both the long and short forms of the Center for Epidemiologic Studies Depression Scale, both the long and short forms of the Book Depression Inventory, the Symptom-Driven Diagnostic System for Primary Care, the Medical Outcomes Study depression measure, and the Quick Diagnostic Interview Schedule. The prevalence of depression, as determined by the standardized interview, was 18% (97 of 536). Overall, the case-finding instruments had sensitivities of 89% to 96% and specificities of 51% to 72% for diagnosing major depression. A positive response to the two-item instrument had a sensitivity of 96% (95% confidence interval [CI], 90-99%) and a specificity of 57% (95% CI 53-62%). Areas under the receiver operating characteristic curves were similar for all of the instruments, with a range of 0.82 to 0.89.

CONCLUSIONS

The two-question case-finding instrument is a useful measure for detecting depression in primary care. It has similar test characteristics to other case-finding instruments and is less time-consuming.

Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial

CONTEXT

Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown.

OBJECTIVE

To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment.

DESIGN

Randomized controlled trial initiated from June 1996 to March 1997.

SETTING

Forty-six primary care clinics in 6 US managed care organizations.

PARTICIPANTS

Of 27332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.

INTERVENTIONS

Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists.

MAIN OUTCOME MEASURES

Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.

RESULTS

Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P > or = .21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05).

CONCLUSIONS

When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.

Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial

CONTEXT

Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.

OBJECTIVE

To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.

DESIGN

Group-level randomized controlled trial conducted June 1996 to July 1999.

SETTING

Forty-six primary care clinics in 6 community-based managed care organizations.

PARTICIPANTS

One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.

INTERVENTIONS

Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.

MAIN OUTCOME MEASURES

Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.

RESULTS

Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period.

CONCLUSIONS

Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.

Nutritional differences between a gluten-free diet and a diet containing equivalent products with gluten

The gluten-free (GF) products market represents one of the most prosperous markets in the field of food and beverages in the immediate future. Historically, counselling for celiac disease has focused on the absence of gluten in foods, however the nutritional quality of GF foodstuffs is an important aspect to consider. The aim of the present work was to compare the nutritional composition of the 206 GF rendered products most consumed in Spain, against the composition of 289 equivalent foods with gluten, and to make a comparison between the diet including GF products and the same diet with equivalent products with gluten in a 58 adult celiac population. The results of the present collaborative study pointed out differences in calorie, macronutrient, fiber, sodium, salt and cholesterol content between GF rendered and gluten-containing foodstuffs. Thus, calorie and nutrient intake in a GF diet is different when compared to its equivalent diet with gluten. Following a diet based on GF products could suppose a nutritional imbalance for celiac patients as well as for non-celiacs who follow a diet that includes many GF rendered foodstuffs.

Depression in medical outpatients. Underrecognition and misdiagnosis

Depression is a common problem in medical outpatients, yet primary care physicians recognize the disorder in only about half of their depressed patients. We compared physician recognition of depression (defined by chart notation or prescription of antidepressants) with diagnoses generated by the Diagnostic Interview Schedule (DIS) in 265 medical outpatients. Using DIS criteria, diagnoses of major depression in the past year or dysthymia (chronic minor depression) were made in 70 patients. Physicians recognized as depressed only 25 (35.7%) of the 70 DIS-depressed patients. However, 36 patients who were not depressed according to DIS were "recognized" as depressed by physicians. Patients misdiagnosed as depressed by physicians were older, less educated, had more outpatient visits, and were prescribed more medications. Receiver operating characteristic curves of two self-report depression scales suggest that these scales may assist physicians in recognizing depressed outpatients. We conclude that physicians underrecognize and misdiagnose depression in medical outpatients.

Prevention of depression with primary care patients: a randomized controlled trial

The prevention of major depression is an important research goal which deserves increased attention. Depressive symptoms and disorders are particularly common in primary care patients and have a negative impact on functioning and well-being comparable with other major chronic medical conditions. The San Francisco Depression Prevention Research project conducted a randomized, controlled, prevention trial to demonstrate the feasibility of implementing such research in a public sector setting serving low-income, predominantly minority individuals: 150 primary care patients free from depression or other major mental disorders were randomized to an experimental cognitive-behavioral intervention or to a control condition. The experimental intervention group reported a significantly greater reduction in depressive levels. Decline in depressive levels was significantly mediated by decline in the frequency of negative conditions. Group differences in the number of new episodes (incidence) of major depression did not reach significance during the 1-year trial. We conclude that depression prevention trials in public sector primary care settings are feasible, and that depressive symptoms can be reduced even in low-income, minority populations. To conduct randomized prevention trials that can test effects on incidence with sufficient statistical power, subgroups at greater imminent risk have to be identified.

Comparative effect of two Mediterranean diets versus a low-fat diet on glycaemic control in individuals with type 2 diabetes

BACKGROUND/OBJECTIVES

Although benefits have been attributed to the Mediterranean diet, its effect on glycaemic control has not been totally elucidated. The aim of this work was to compare the effect of two Mediterranean diets versus a low-fat diet on several parameters and indices related to glycaemic control in type 2 diabetic subjects.

SUBJECTS/METHODS

A multicentric parallel trial was conducted on 191 participants (77 men and 114 women) of the PREDIMED study in order to compare three dietary interventions: two Mediterranean diets supplemented with virgin olive oil (n=67; body mass index (BMI)=29.4±2.9) or mixed nuts (n=74; BMI=30.1±3.1) and a low-fat diet (n=50; BMI=29.8±2.8). There were no drop-outs. Changes in body weight and waist circumference were determined. Insulin resistance was measured by HOMA-IR index, adiponectin/leptin and adiponectin/HOMA-R ratios after 1 year of follow-up.

RESULTS

Increased values of adiponectin/leptin ratio (P=0.043, P=0.001 and P<0.001 for low-fat, olive oil and nut diets, respectively) and adiponectin/HOMA-IR ratio (P=0.061, P=0.027 and P=0.069 for low-fat, olive oil and nut diets, respectively) and decreased values of waist circumference (P=0.003, P=0.001 and P=0.001 for low-fat, olive oil and nut diets, respectively) were observed in the three groups. In both Mediterranean diet groups, but not in the low-fat diet group, this was associated with a significant reduction in body weight (P=0.347, P=0.003 and P=0.021 for low-fat, olive oil and nut diets, respectively).

CONCLUSIONS

Mediterranean diets supplemented with virgin olive oil or nuts reduced total body weight and improved glucose metabolism to the same extent as the usually recommended low-fat diet.

Endorsement of dysfunctional beliefs depends on current mood state

In two studies we tested the hypothesis that endorsement of dysfunctional beliefs depends on current mood state for persons who are vulnerable to depression. The first study showed that reports of dysfunctional beliefs vary with spontaneous diurnal mood fluctuations in 47 depressed psychiatric patients. The effect of mood state was highly significant (p less than .01); dysfunctional thinking increased when mood was worst and decreased when mood was best. The second study conceptually replicated this finding in a population of asymptomatic subjects. As predicted, reports of dysfunctional beliefs varied as a function of mood state in 14 persons who had experienced a depressive episode but not in 27 who had never been depressed. These findings support the cognitive theory of depression, which proposes that dysfunctional beliefs are vulnerability factors for depression but also that reporting of dysfunctional beliefs depends on current mood state.

Unmet mental health needs of women in public-sector gynecologic clinics

OBJECTIVE

We examined the mental health needs of poor young women seen in public-sector gynecologic settings.

STUDY DESIGN

Participants were 205 ethnically diverse women, mean age 29 years, seen by gynecologists at San Francisco General Hospital, all either uninsured or receiving public medical assistance. An interview with an instrument designed to diagnose mood, anxiety, alcohol, and eating disorders in medical patients, the Prime-MD, was used to assess current mental disorders. Any history of sexual or other physical assault was recorded. Receipt of primary care was scored for comprehensiveness.

RESULTS

The rates of current psychiatric disorders were extremely high; 21.5% had current major depression. The prevalence of anxiety disorders was also elevated among these women. Many had a history of sexual trauma, and 28% had been the victims of unwanted intercourse. Finally, many reported behaviors that pose serious health risks. For example, 32% smoked and 2% used illicit drugs. Fewer than half had access to comprehensive primary medical care.

CONCLUSIONS

Young, poor women who seek care in public-sector gynecologic clinics would benefit from comprehensive medical care addressing their psychosocial needs.

Long-term effectiveness of disseminating quality improvement for depression in primary care

BACKGROUND

This article addresses whether dissemination of short-term quality improvement (QI) interventions for depression to primary care practices improves patients' clinical outcomes and health-related quality of life (HRQOL) over 2 years, relative to usual care (UC).

METHODS

The sample included 1299 patients with current depressive symptoms and 12-month, lifetime, or no depressive disorder from 46 primary care practices in 6 managed care organizations. Clinics were randomized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education, assessment, and treatment planning, plus either nurse care managers for medication follow-up (QI-meds) or access to trained psychotherapists (QI-therapy). Outcomes were assessed every 6 months for 2 years.

RESULTS

For most outcomes, differences between intervention and UC patients were not sustained for the full 2 years. However, QI-therapy reduced overall poor outcomes compared with UC by about 8 percentage points throughout 2 years, and by 10 percentage points compared with QI-meds at 24 months. Both interventions improved patients' clinical and role outcomes, relative to UC, over 12 months (eg, a 10-11 and 6-7 percentage point difference in probable depression at 6 and 12 months, respectively).

CONCLUSIONS

While most outcome improvements were not sustained over the full 2 study years, findings suggest that flexible dissemination of short-term, QI programs in managed primary care can improve patient outcomes well after program termination. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits.

Treating depressed older adults in primary care: narrowing the gap between efficacy and effectiveness

There is a gap between the efficacy of treatments for late-life depression under research conditions and the effectiveness of treatments as they occur in the "real world" of primary care. Considerable evidence supports the efficacy of treatments for late-life depression, but many depressed older adults either are not recognized or do not receive effective treatment for depression in primary care. Older adults face a range of special treatment barriers: knowledge deficits; losses and social isolation; multiple medical problems; and lack of financial resources. More research is needed to understand these barriers and to study the effectiveness of multifaceted, population-based disease management interventions for late-life depression in primary care.

Recruiting and retaining low-income Latinos in psychotherapy research

This article offers suggestions for recruiting and retaining low-income Latinos in treatment studies. Because Latinos underuse traditional mental health services, places such as medical centers or churches with large Latino constituents are suggested as useful alternative sources. To keep Latinos in research protocols, providing culturally sensitive treatments are necessary. Culturally sensitive treatments should incorporate families as part of recruitment efforts, particularly older men in the family. In addition, showing respect is an important aspect of traditional Latino culture that includes using formal titles and taking time to listen carefully. Finally, traditional Latinos tend to like interactions with others that are more warm and personal than is generally part of a research atmosphere.

Intervention for minor depression in primary care patients

This study examines the effectiveness of an intervention for minor depression in primary care patients. One hundred fifty public care medical patients were randomly assigned to either an 8-week cognitive-behavioral course intended to help them use pleasant activities, constructive thinking, and interpersonal relationships to improve mood or a control condition. Assessments were completed at postintervention, 6 months, and 1 year. The results support the effectiveness of the intervention. Persons with minor depression assigned to the intervention experienced reductions in depressive symptomatology, which persisted through the 1-year follow-up. In addition, the intervention lowered the somatic symptomatology that was associated with minor depression. Finally, those with minor depression who received the intervention missed fewer appointments with their primary care provider during the following year than did those with minor depression who received no intervention. The results from this preliminary evaluation suggest that interventions addressing minor depression in medical patients are feasible and are effective in reducing both depressive symptomatology and associated problems.

Demystifying the concept of ethnicity for psychotherapy researchers

At a time when ethnic minority populations are increasing in the United States, few psychotherapy studies are including minorities in their samples. To include ethnic minorities in psychotherapy studies, the complex construct of ethnicity must be carefully measured. In this article, practical advice is offered for conceptualizing, measuring, and interpreting ethnic factors in psychotherapy studies. Also discussed are identifying pathways from ethnicity to psychotherapy outcomes. Pathways that may influence ethnic differences in psychotherapy outcome include cultural factors, minority status, socioeconomic status, acculturation, and immigration experiences.

Evidence-based care for depression in managed primary care practices

This paper evaluates whether externally designed, evidence-based interventions for improving care for depression can be locally implemented in managed care organizations. The interventions were carried out as part of a randomized trial involving forty-six practices within six diverse, nonacademic managed care plans. Based on evaluation of adherence to the intervention protocol, we determined that local practice leaders are able to implement predesigned interventions for improving depression care. Adherence rates for most key intervention activities were above 70 percent, and many were near 100 percent. Three intervention activities fell short of the goal of 70 percent implementation and should be targets for future improvement.

Differential item functioning in a Spanish translation of the Beck Depression Inventory

Brief and culturally compatible measures of depression are necessary, yet most depression scales are translated without regard for cultural biases. In this study, 292 medical outpatients completed an English or a Spanish-translated and back-translated version of the Beck Depression Inventory (BDI). The BDI items were analyzed for bias between Spanish and English-speaking patients to determine the equivalence of the scale. A Differential Item Function (DIF) using a Mantel Haenszel Approach for Ordered Response Categories was used to analyze how likely subjects in the two ethnic groups were to endorse each response category. The results suggest that regardless of level of depression, Latinos are more likely to endorse items reflecting tearfulness and punishment, and less likely to endorse inability to work. Cultural interpretations and recommendations for use of the BDI are discussed.

Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: a multicenter study

BACKGROUND

Despite medical therapy, 30% of patients with ulcerative colitis (UC) need to undergo surgery. Around 50% of patients with proctocolectomy with ileal pouch-anal anastomosis (IPAA) develop complications of the pouch. Clinical evidence for the use of infliximab (IFX) in refractory pouchitis is limited. The aim of this study was to report efficacy of IFX in these patients.

METHODS

A retrospective, multicenter study was designed. Patients older than 18 years with chronic refractory pouchitis treated with IFX (5 mg/kg) were included. Short-term IFX efficacy was evaluated at week 8 and mid-term efficacy at weeks 26 and 52. Complete response was defined as cessation of diarrhea and urgency and partial response as marked clinical improvement but persisting symptoms. The modified Pouchitis Disease Activity Index (mPDAI) without endoscopy was calculated when available.

RESULTS

Thirty-three consecutive UC patients with chronic refractory pouchitis were included (18 male, mean age 45 years, range 21-67). At week 8, 21% patients achieved complete response and 63% showed partial clinical response. At weeks 26 and 52, 33% and 27% achieved complete response and 33% and 18% showed partial clinical response, respectively. Thirteen patients (39%) withdrew treatment (four for lack of efficacy, four for loss of response and five for adverse events). None of the potential factors analyzed had an influence on response to IFX.

CONCLUSIONS

IFX was effective in the short- and mid-term in patients with chronic refractory pouchitis. However, medication had to be discontinued in a high number of patients.

New insights on the emergence of cholera in Latin America during 1991: the Peruvian experience

After a century of absence, in late January 1991, Vibrio cholerae invaded the Western Hemisphere by way of Peru. Although a number of theories have been proposed, it is still not understood how that invasion took place. We reviewed the clinical records of persons attending hospital emergency departments in the major coastal cities of Peru from September through January of 1989/1990 and 1990/1991. We identified seven adults suffering from severe, watery diarrhea compatible with a clinical diagnosis of cholera during the four months preceding the cholera outbreak, but none during the previous year. The patients were scattered among five coastal cities along a 1,000 km coastline. We postulate that cholera vibrios, autochthonous to the aquatic environment, were present in multiple coastal locations, and resulted from environmental conditions that existed during an El Nino phenomenon. Once introduced into the coastal communities in concentrations large enough for human infection to occur, cholera spread by the well-known means of contaminated water and food.

DSM-III-R disorders in Vietnamese refugees. Prevalence and correlates

This study's purpose was a) to determine the prevalence of DSM-III-R disorders in newly arrived ethnic Vietnamese and ethnic Chinese refugees from Vietnam and b) to determine the correlates of DSM-III-R disorders. A Vietnamese-speaking psychiatrist administered translated sections of the Structured Clinical Interview for DSM-III-R to 201 Vietnamese new arrivals undergoing mandatory health screening. Overall, 18.4% had one or more current disorders: 8.5% had adjustment disorder and 5.5% had major depression. Ethnic Vietnamese, compared with ethnic Chinese, had significantly (p < .05) higher rates of current posttraumatic stress disorder and generalized anxiety disorder. Ethnic differences in psychopathology were largely explained by the fact that ethnic Vietnamese refugees had experienced more traumatic events and separation from family. After adjusting for ethnicity, refugees who reported traumatic events, refugees who were married, and veterans were significantly (p < .05) more likely to have one or more psychiatric disorders.

Presence of a membrane bound pyroglutamyl amino peptidase degrading thyrotropin releasing hormone in rat brain

In the present work we studied the pattern of degradation of [3H-Pro]-TRH by soluble and membrane fractions from rat brain. Demonstration of the membrane bound or soluble nature of the activities was obtained by comparing their distribution to that of lactate dehydrogenase and by looking at the effect of NaCl washes on the membrane fractions. We observed that the pyroglutamyl amino peptidase activity detected in brain homogenates is a result of two different enzymes. One of them is a soluble enzyme previously characterized, that needs DTT and EDTA for its expression, is inhibited by SH-blocking agents such as iodoacetamide and utilizes p-glu-beta-naphtylamide as a substrate. The other one, a membrane enzyme, is inhibited by chelating agents such as EDTA and DTT, is not affected by iodoacetamide and does not degrade p-glu-beta-naphtylamide. The later presents some specificity towards TRH as shown by competition experiments with TRH analogs. We were able to corroborate that the post proline cleaving enzyme acting on TRH is a soluble enzyme. In membranes we demonstrated also the presence of a post-proline dipeptidyl aminopeptidase. The membrane bound pyroglutamidase activity is a potential new source of L-his-L-pro-diketopiperazine in brain. The presence of a TRH degrading enzyme in membrane fractions is of particular importance in searching an inactivation mechanism of this peptide once it is released into the synaptic cleft.

Protein arginine methyltransferase 5 promotes cholesterol biosynthesis-mediated Th17 responses and autoimmunity

Protein arginine methyltransferase 5 (PRMT5) catalyzes symmetric dimethylation (SDM) of arginine, a posttranslational modification involved in oncogenesis and embryonic development. However, the role and mechanisms by which PRMT5 modulates Th cell polarization and autoimmune disease have not yet been elucidated. Here, we found that PRMT5 promoted SREBP1 SDM and the induction of cholesterol biosynthetic pathway enzymes that produce retinoid-related orphan receptor (ROR) agonists that activate RORγt. Specific loss of PRMT5 in the CD4+ Th cell compartment suppressed Th17 differentiation and protected mice from developing experimental autoimmune encephalomyelitis (EAE). We also found that PRMT5 controlled thymic and peripheral homeostasis in the CD4+ Th cell life cycle and invariant NK (iNK) T cell development and CD8+ T cell maintenance. This work demonstrates that PRMT5 expression in recently activated T cells is necessary for the cholesterol biosynthesis metabolic gene expression program that generates RORγt agonistic activity and promotes Th17 differentiation and EAE. These results point to Th PRMT5 and its downstream cholesterol biosynthesis pathway as promising therapeutic targets in Th17-mediated diseases.

Exhaled nitric oxide during exercise in primary pulmonary hypertension and pulmonary fibrosis

STUDY OBJECTIVES

Nitric oxide (NO), a potent vasodilator, is present in the exhaled air of humans. We wished to quantify NO production in patients with abnormalities of the pulmonary circulation.

PARTICIPANTS

Nine patients with primary pulmonary hypertension (PPH), six with pulmonary fibrosis (PF), and 20 normal volunteers were studied.

INTERVENTIONS

All subjects were studied at rest and during continuous incremental (ramp) cycle ergometry exercise. All patients with PPH and nine matched normal volunteers also performed constant exercise at equal absolute work rates.

MEASUREMENTS AND RESULTS

The concentration of NO was measured continuously in mixed expired air, and the rate of NO production (VNO) calculated. Peak exercise capacity was markedly impaired in both patient groups. VNO was similar at rest in the PPH patients (142 +/- 84 nL/min) and the normal subjects (117 +/- 45 nL/min), but lower in the PF patients (66 +/- 13 nL/min; p < 0.05; analysis of variance with Bonferonni correction). While VNO in normal subjects more than doubled by peak exercise to 268 +/- 85 nL/min, there was no significant rise with exercise in either patient group (PPH, 155 +/- 81 nL/min; PF, 91 +/- 67 nL/min). Constant work rate exercise induced a significant rise in VNO in the normal subjects (rest, 101 +/- 68 nL/min; exercise, 147 +/- 87 nL/min; p < 0.001) but no significant change in the PPH patients (rest, 127 +/- 111 nL/min; exercise, 68 +/- 65 nL/min).

CONCLUSIONS

We conclude that the low resting VNO in PF may be due to loss of normal functional pulmonary capillary bed. The increase in VNO seen in normal subjects may be associated with dilatation and recruitment of the pulmonary capillary bed during exercise, and failure to increase VNO during exercise in disease states may reflect an inability to recruit the capillary bed.

Gingival enlargement induced by drugs

Gingival enlargement, an abnormal growth of the periodontal tissue, is mainly associated with dental plaque-related inflammation and drug therapy. Its true incidence in the general population is unknown. Gingival enlargement produces aesthetic changes, pain, gingival bleeding and periodontal disorders. Although gingival overgrowth has been traditionally recognised as an adverse effect of phenytoin therapy, it has recently been reported in association with the use of cyclosporin and calcium antagonists. These 3 classes of drugs produce important changes in fibroblast function, which induce an increase in the extracellular matrix of the gingival connective tissue. In the majority of those patients for whom dosage reduction, or drug discontinuation or substitution is not possible, and for whom prophylactic measures have failed, surgical excision of gingival tissue remains the only treatment of choice.

Premature placental aging in term small-for-gestational-age and growth-restricted fetuses

OBJECTIVE

To perform a comprehensive assessment of the placental aging process in small term fetuses classified as being small-for-gestational age (SGA) or having fetal growth restriction (FGR) through analysis of senescence and apoptosis markers.

METHODS

This was a prospective nested case-control study of singleton pregnancies delivered at term, including 21 control pregnancies with normally grown fetuses and 36 with a small fetus classified as SGA (birth weight between the 3^rd and 9^th percentiles and normal fetoplacental Doppler; n = 18) or FGR (birth weight < 3^rd percentile and/or abnormal cerebroplacental ratio and/or uterine artery Doppler; n = 18). Telomerase activity, telomere length (quantified by comparing the amount of amplification product for the telomere sequence (T) to that of a single copy of the gene 36B4 (S)) and RNA expression of senescence (Sirtuins 1, 3 and 6) and apoptosis (p53, p21, BAX and Caspases 3 and 9) markers (analyzed using the 2^-ΔΔCt method) were determined in placental samples collected at birth and compared between the three groups.

RESULTS

Compared to pregnancies with a normally grown fetus, both SGA and FGR pregnancies presented signs of accelerated placental aging, including lower telomerase activity (mean ± SD, 12.8 ± 6.6% in controls vs 7.98 ± 4.2% in SGA vs 7.79 ± 4.6% in FGR; P = 0.008), shorter telomeres (mean ± SD T/S ratio, 1.20 ± 0.6 in controls vs 1.08 ± 0.9 in SGA vs 0.66 ± 0.5 in FGR; P = 0.047) and reduced Sirtuin-1 RNA expression (mean ± SD 2^-ΔΔCt , 1.55 ± 0.8 in controls vs 0.91 ± 0.8 in SGA vs 0.63 ± 0.5 in FGR; P = 0.001) together with increased p53 RNA expression (median (interquartile range) 2^-ΔΔCt , 1.07 (0.3-3.3) in controls vs 5.39 (0.6-15) in SGA vs 3.75 (0.9-7.8) in FGR; P = 0.040). FGR cases presented signs of apoptosis, with increased Caspase-3 RNA levels (median (interquartile range) 2^-ΔΔCt , 0.94 (0.7-1.7) in controls vs 3.98 (0.9-31) in FGR; P = 0.031) and Caspase-9 RNA levels (median (interquartile range) 2^-ΔΔCt , 1.21 (0.6-4.0) in controls vs 3.87 (1.5-9.0) in FGR; P = 0.037) compared with controls. In addition, Sirtuin-1 RNA expression, telomerase activity, telomere length and Caspase-3 activity showed significant linear trends across groups as severity of the condition increased.

CONCLUSIONS

Accelerated placental aging was observed in both clinical forms of late-onset fetal smallness (SGA and FGR), supporting a common pathophysiology and challenging the concept of SGA fetuses being constitutionally small. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.