Proteomics to assess myocardial remodelling in human heart failure and explore the effect of medications and comorbidities

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

Background

Myocardial remodelling is a hallmark of heart failure (HF). Our previous proteomics analyses demonstrated a profound effect of beta blockers on cardiac extracellular matrix composition in ischaemic HF patients (1). No comprehensive proteomics characterizations has been performed in non-ischaemic HF patients.

Methods

Mass spectrometry was used to analyze intracellular and extracellular protein extracts from left ventricular samples obtained from patients with ischemic (n=65) and non-ischaemic (n=114) HF after heart transplantation, as well as non-failing controls (n=19). All HF patients had ventricular dilatation and reduced ejection fraction (EF%).

Results

The proteomics comparison across 198 cardiac samples with two tissue extracts revealed hallmarks of HF in both groups of patients compared to controls, including elevated levels of atrial natriuretric peptides and the fibroblast marker vimentin, as well as decreases in creatine kinase M/B, troponin C, and myosin light chain 2 (Figure 1). In comparison to ischaemic HF patients, non-ischaemic HF patients showed elevated levels of proteins involved in proteasome activation, consistent with the notion of increased protein degradation in cardiomyocytes even at the end stage of the disease (2). Despite similar clinical characteristics, myocardial remodelling in response to HF medications and the presence of comorbidities was different between the two HF groups. In ischaemic HF patients the use of β-blockers resulted in reduced proteoglycan deposition. In non-ischaemic patients, few protein changes were associated with medication. Instead, comorbidities such as atrial fibrillation and hypertension were critical determinants of myocardial protein remodelling in these HF patients (Figure 2). Notably, hypertensive HF patients showed a marked reduction in angiotensin converting enzyme 2 (ACE2) compared to normotensive patients, and this was accompanied by a reduction in Cysteine And Glycine Rich Protein 3 (CSRP3), a key player in the organization of cytosolic structures in cardiomyocytes, and the nuclear lamina proteins lamin A/C and B. The inflammation-related galectin 3-binding protein was reduced in hypertensive patients as were the extracellular proteases matrix metalloprotease 2, cathepsin G and chymase 1.

Conclusion

Our study constitutes the largest proteomics analysis of HF to date. We observed distinct protein remodelling processes in ischaemic and non-ischaemic HF patients and discerned the myocardial effects of medications and comorbidities such as hypertension.

Promoting resilience in healthcare workers during the COVID-19 pandemic with a brief online intervention

INTRODUCTION

The psychological wellbeing of healthcare workers has been impacted by the high levels of stress many have experienced during the Coronavirus Disease 2019 (COVID-19) pandemic. This study aimed to examine the feasibility and acceptability of a brief online course focused on introducing evidence-based skills that could increase resilience and decreases emotional distress in healthcare workers during the pandemic.

MATERIALS AND METHODS

Employees of a large healthcare system completed a mental health survey at baseline, and then one month and two months after some employees participated in an online resilience-enhancement course consisting of three 12-19 min videos focused on mindfulness, mentalization, and self-compassion.

RESULTS

A total of 554 participants completed the baseline survey, endorsing moderate to high levels of emotional distress. Of those who completed all three assessments and participated in the course (n = 38), significant improvements in resilience and reductions in emotional distress were found one and two months later, in comparison to those who did not participate in the course (n = 110).

DISCUSSION

These findings suggest that a brief, online intervention can improve the mental health of healthcare workers during a crisis such as the COVID-19 pandemic.

L-methylfolate augmentation of selective serotonin reuptake inhibitors (SSRIS) for major depressive disorder: Results of two randomized, double-blind trials

Introduction

Two randomized, controlled trials of L-methylfolate augmentation of SSRIs for major depressive disorder (MDD) were conducted using a novel study design (sequential parallel comparison design- SPCD).

Objectives/aims

To evaluate the efficacy of L-methylfolate augmentation using the Hamilton Depression Rating Scale.

Methods

In study one (TRD-1), 148 outpatients with SSRI-resistant MDD were enrolled in a 60-day, SPCD study, divided into two 30-day periods (phases 1 and 2). Patients were randomized 2:3:3 to receive L-methylfolate (7.5mg/d in phase 1, 15mg/d in phase 2), placebo in phase 1 followed by L-methylfolate 7.5mg/d in phase 2, or placebo for both phases. Study two (TRD-2) involved 75 patients and was identical in design to TRD-1 except for the dose of L-methylfolate (15mg only).

Results

In the TRD-1 Study, L-methylfolate 7.5 mg/d was not found to be more effective than placebo. In phase 1 of the TRD-2 Study, 37% of patients on L-methylfolate 15mg/d responded and 18% of placebo patients responded, while in phase 2 among placebo non-responders, the response rates were 28% on L-methylfolate 15mg/d and 9.5% on placebo. When phases 1 and 2 were pooled according to the SPCD model, the difference in response rates was statistically significant in favor of L-methylfolate (p = 0.0399). The rates of spontaneously reported AEs and rates of study discontinuation appear r comparable between L-methylfolate and placebo in both studies. Rates of study discontinuation were also comparable

Conclusions

These studies suggest that L-methylfolate 15 mg/d may be a safe and effective augmentation strategy for inadequate response to SSRIs.

Impact of Pediatric Hematopoietic Stem-Cell Transplantation on Craniofacial Growth

OBJECTIVES

To assess the craniofacial skeletal growth in pediatric hematopoietic stem-cell transplantation (HSCT) survivors in comparison with age-sex matched-paired controls.

METHODS

A case-controlled retrospective comparison of the craniofacial growth in 25 HSCT children and 25 matched-paired controls was conducted. Craniofacial growth was quantitatively assessed by linear and angular measurements in panoramic radiographic images using ImageJ¯. Stature growth and body weight were obtained through physical examination. Cancer diagnosis, myeloablative conditioning, and HSCT were retrieved from medical records.

RESULTS

Patients aged 12.2 years (±3.8; 16 male, 9 female). Radiographic images were obtained on an average of 2.43 (±2.0) years after HSCT. The main malignant diagnosis was acute lymphoblastic leukemia (56%), followed by acute myeloid leukemia (36%) and myelodysplastic syndromes (8%). Total body irradiation was associated with chemotherapy at 80%. Mean age at transplantation was 10 (±4.7) years. HSCT survivors showed reduced a vertical growth of the mandibular ramus (p=0.003). This persisted among individuals below 12 years of age (p=0.017). The HSCT group showed delayed dental eruption, though there was no statistically significant difference (p=0.3668). The HSCT group showed stature deficit, increased weight, and body mass index (Z-score stature: -0.28; Z-score weight: 0.38, respectively).

CONCLUSIONS

Pediatric HSCT has decreased vertical craniofacial growth compared to their matched controls. There might be an association between reduced craniofacial vertical growth and reduced estature growth. Further studies to quantitatively investigate the impact of different myeloablative regimens in craniofacial skeletal growth and development.

Mandibular radiomorphometric assessment of bone mineral density in survivors of pediatric hematopoietic stem-cell transplantation

OBJECTIVE

Hematopoietic stem-cell transplantation (HSCT) childhood survivors of hematologic malignancies are prone to develop late osteopenia and osteoporosis. The purpose of this retrospective study was to quantitatively and qualitatively assess bone mineral density (BMD) in HSCT childhood survivors and to compare the effectiveness of both qualitative and quantitative assessment methods.

METHODS

DESIGN BMD assessment using panoramic radiographs of childhood HSCT survivors aged 3.69-18.88 years using two radiomorphometric indexes. Case-control double-blinded comparison of panoramic radiographic images from childhood HSCT survivors and age- and sex-matched healthy controls. Quantitative assessment was performed by measuring the cortical bone width bilaterally at the mental foramen level. Qualitative assessment was performed using the mandibular cortical index bilaterally on all panoramic images.

RESULTS

Radiographs were taken 6.59-83.95 months after bone marrow transplantation [median±SD=25.92±24.9 months]. Fifty-two panoramic radiographic images were analyzed: 21 from HSCT survivors and 31 from healthy controls aged 3.69-25.1 years [mean±SD=11.89±5.28 years]. The mandibular cortical bone width was 17% smaller in childhood HSCT survivors than in healthy controls (case group: 2.420, control group: 3.307; p=0.00617). Qualitative analysis revealed an increased frequency of severe mandibular cortical erosion in childhood HSCT survivors, although no significant difference was observed (case group: 1.540, control group: 1.490; p=0.32). The interobserver agreement was 85% (Kappa index).

CONCLUSIONS

HSCT childhood survivors exhibit quantitative and qualitative mandibular bone impairments. Further studies are needed to establish an association between mandibular cortical bone impairment and osteoporosis.

Review of a three-year study on the dental care of onco-hematological pediatric patients

The aim of this study was to provide an updated review of dental procedures undertaken at the dental unit of the Onco-hematology service of the Instituto da Criança at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (ICr/HC-FMUSP). We retrospectively reviewed 565 of 1902 medical and dental records of patients diagnosed with onco-hematological diseases who were seen in a 3-year study (January 2015 to December 2017). We assessed data regarding population characteristics, onco-hematological diagnosis and dental procedures performed. Of the selected medical records, preventive dentistry was the most common procedure undertaken in this population, followed by oral maxillofacial surgeries, restorative dentistry and oral mucositis treatment. The most prevalent malignant diagnosis was acute lymphocytic leukemia, and the most prevalent nonmalignant diagnosis was sickle-cell anemia. Preventive dental procedures represent most of the dental procedures undertaken in hospitalized onco-hematological pediatric patients.

Comparative analysis of different prophylatic methods on primary teeth enamel roughness

Objective: The purpose of this study was to perform an experimental quantitative comparison of primary teeth enamel alterations under three commonly prophylaxis surface polishing treatments. Material and Methods: 36 healthy primary teeth naturally exfoliated were selected and randomly separated in three groups. Group I was treated with a rotary instrument set at a low speed, rubber cup and a mixture of water and pumice; group II with a rotary instrument set at a low speed, rubber cup and prophylaxis paste Herjos-F (Vigodent S/A Indústria e Comércio, Rio de Janeiro, Brazil); and group III with sodium bicarbonate spray Profi II Ceramic (Dabi Atlante Indústrias Médico Odontológicas Ltda, Ribeirão Preto, Brazil). All procedures were performed by the same operator for ten seconds, and samples were rinsed and stored in distilled water. Pre-and post-treatment surface evaluation was completed using a surface profilometer Mitutoyo SJ400. Results: The results of this study were statistically analyzed with the GraphPad PRISM (version 6, 2010). The pumice and water led to significantly rougher surfaces than other groups in Tukey’s test (Group I: 1.22 Ra; Group II 0.38 Ra; Group III: 1.01 Ra). Pre-and post-treatment comparison revealed significantly rougher enamel surface with pumice. Conclusion: Based on this study, it can be concluded that there was an increased enamel surface roughness when teeth were treated with pumice and water in comparison to bicarbonate spray and prophylaxis paste.KeywordsDental enamel; Dental prophylaxis; Jet abrasive system; Enamel roughness; Primary teeth.

Salience network coupling is linked to both tobacco smoking and symptoms of attention deficit hyperactivity disorder (ADHD)

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) symptoms, even those below diagnostic threshold, enhance the likelihood of nicotine dependence, suggesting a neurobiological link between disorders. Of particular interest is the salience network (SN), which mediates attention to salient internal/external stimuli to guide behavior and is anchored by the dorsal anterior cingulate cortex (dACC) and bilateral anterior insula (AI). Disrupted interactions between the SN and the default mode (DMN) and central executive networks (CEN) have been noted in both ADHD and nicotine dependence. Further, enhanced intra-SN coupling between the dACC-AI influences aspects of nicotine dependence such as reactivity to smoking cues.

METHODS

To identify links between SN functional connectivity and ADHD symptoms in nicotine dependence, we compared 21 nicotine dependent individuals with 17 non-smokers on ADHD symptoms as measured by the ADHD self-report scale (ASRS) and resting state intra and inter-SN functional connectivity.

RESULTS

Relative to healthy controls, nicotine dependent individuals had significantly higher ASRS scores and greater dACC-AI coupling. No group differences were noted on inter-SN network coupling. A significant association was found between ASRS and dACC-AI coupling both in the entire cohort and specifically when evaluating nicotine dependent individuals alone.

CONCLUSIONS

The greater ASRS scores in nicotine dependent individuals is in line with existent literature and the stronger dACC-AI coupling in smokers further supports the role of this network in nicotine dependence. The significant association between dACC-AI coupling and ASRS suggests that intra-SN coupling strength may impact neurocognitive functioning associated with both ADHD symptoms and nicotine dependence.

Revisiting the role of the insula and smoking cue-reactivity in relapse: A replication and extension of neuroimaging findings

INTRODUCTION

The ability to direct smoking cessation treatment based on neuroscientific findings holds incredible promise. However, there is a strong need for consistency across studies to confirm neurobiological targets. While our prior work implicated enhanced insula reactivity to smoking cues in tobacco smoking relapse vulnerability, this finding has not been confirmed.

METHOD

Using functional magnetic resonance imaging (fMRI), we evaluated the pre-cessation brain reactivity to smoking vs. neutral cues in nicotine dependent smokers who were and were not able to maintain subsequent abstinence.

RESULTS

Of the 23 (7 women) individuals assessed, 13 relapsed and there were no demographic differences between those who did and did not relapse. However, smokers who relapsed showed enhanced reactivity to smoking cues in the right insula and dorsal striatum, showing significant overlap between our current and prior work despite methodological differences, including the fact that our previous work only included women.

CONCLUSION

The current work supports our prior results and builds on the concept that the insula and dorsal striatum work in concert to maintain nicotine dependence. Specifically, dorsal striatal-mediated habitual responding may be triggered both by the external drug-associated cues, and the insula-mediated internal states that provide additional context motivating drug use. This replicated finding also mirrors preclinical work that finds the same individualized distinction, as only some rodents attribute incentive salience to drug cues and are more likely to reinstate drug seeking after extinction. To effectively treat addiction, these individual characteristics and their underlying neurobiological foundations must be considered.

A Phase 1B, randomized, double blind, placebo controlled, multiple-dose escalation study of NSI-189 phosphate, a neurogenic compound, in depressed patients

We wanted to examine tolerability and efficacy of NSI-189, a benzylpiperizine-aminiopyridine neurogenic compound for treating major depressive disorder (MDD). This was a Phase 1B, double blind, randomized, placebo controlled, multiple-dose study with three cohorts. The first cohort received 40 mg q.d. (n=6) or placebo (n=2), the second cohort 40 mg b.i.d. (n=6) or placebo (n=2), and the third cohort 40 mg t.i.d. (n=6) or placebo (n=2). Twenty-four patients with MDD were recruited, with the diagnosis and severity confirmed through remote interviews. Eligible patients received NSI-189 or placebo for 28 days in an inpatient setting with assessments for safety, pharmacokinetics (PK) and efficacy. Outpatient follow-up visits were conducted until day 84 (±3). NSI-189 was relatively well tolerated at all doses, with no serious adverse effects. NSI-189 area under the curve increased in a dose-related and nearly proportional manner across the three cohorts, with a half-life of 17.4-20.5 h. The exploratory efficacy measurements, including Symptoms Of Depression Questionnaire (SDQ), Montgomery-Asberg Depression Scale (MADRS), Clinical Global Impressions-Improvement (CGI-I), and The Massachusetts General Hospital (MGH) Cognitive and Physical Functioning Questionnaire (CPFQ) showed a promising reduction in depressive and cognitive symptoms across all measures for NSI-189, with significant improvement in the SDQ and CPFQ, and a medium to large effect size for all measures. These improvements persisted during the follow-up phase. In summary, NSI-189 shows potential as a treatment for MDD in an early phase study. The main limitation of this preliminary study was the small sample size of each cohort.

Tooth abnormalities in pediatric patients submitted to antineoplastic treatment for central nervous system neoplasms

Objective: The aim of this study was to evaluate the frequency of tooth abnormalities in pediatric patients treated for central nervous system neoplasms. Material and methods: This cross-sectional study assessed thirty-one patients, median age 14.2 years (range 5 - 25), who were off therapy for at least one year, comparatively with a control group of thirty-one healthy patients matched for age with the study group. Tooth abnormalities were evaluated by panoramic radiographs. Results: There was no statistical significant evidence that patients of the study group (age range 5 - 25 years) have more frequency of tooth abnormalities comparatively with controls.   However, in children who were diagnosed before 5 years of age, microdontia was the most common abnormality with statistically significant difference (P=0.037). Root shortening grade III was observed in patients over 10 years of age at the time of radiographic examination, also with statistical significance (P=0.046). Conclusions: Tooth abnormalities frequency in patients treated for central nervous system neoplasms is directly related to the age of diagnosis and stage of odontogenesis. Microdontia and reduced root surface areas, the most common abnormalities observed, can lead to future oral health impairment due to malocclusion and less periodontal support. It is important to give parents and patients early orientation about maintenance of good oral hygiene and proper treatment by orthodontics or dentofacial orthopedics.

Long-term dental follow-up in hematological stem cells transplantation children

Objective: The aim of this paper is to update the current published content about the craniofacial long-term development disturbances of childhood hematopoietic stem-cell transplantation (HSCT) and the preparative regimens for the onco-hematological malignancies treatments. Material and Methods: Two authors independently reviewed the published articles about long-term effects of childhood HSCT that fitted in to predetermined inclusion/exclusion criteria: clear definition of exposure or intervention, standard outcomes measurement and appropriate statistical analysis. Results: Twelve papers matched all the previous established eligibility criteria and were included in this review. The children’s age at HSCT were related to a higher risk of dental development disturbances, such as agenesis, dental hypoplasia, root stunting, crown-root proportion alterations, and microdontia. Craniofacial vertical growth was impaired in the irradiated patients without antero-posterior or latero-lateral impairment. Temporomandibular joint dysfunction was found to be more prevalent in the patients who was diagnosed with graft-versus-host disease. Conclusion: The late effects of craniofacial development disturbances leads to several aesthetic and functional impairment, periodontal bone resorption with consequent impairment of chewing ability, and risk of early tooth loss often associated with life’s quality impairment. Further investigations should be performed to provide accurate information for patients, parents and health care professionals. Keywords: Dental development. Craniofacial growth. Bone marrow transplantation. Hematopoietic stem-cell transplantation. Chemotherapy. Radiotherapy.

Effects of thermomechanical and thermocycling on the shear bond strength of brackets to bovine enamel bonded with conventional and self-etching adhesive systems

Several adhesive systems have been developed in the last decade. The aim of the current study was to evaluate the shear bond strength of orthodontic brackets bonded with conventional primers or self-etching primers, artificially aged by means of thermocycling and thermomechanical procedures.90 bovine incisors were used in the investigation. The roots were sectioned in the amelo-cementary junction. All samples were randomly divided in 2 groups ( n= 45), according to the primer used for bracket bonding. XT Group–hydrophobic conventional primer (Transbond XT, 3M unitek, Monrovia, Calif); SEP Group –self-etching primer (Transbond Plus SEP, 3 M Unitek, Monrovia, Calif). All specimens were bonded with XT Transbond resin adhesive (3 M Unitek, Monrovia, Calif). A Universal Testing Machine EMIC DL2000 (EMIC Equip. Sist. Ensaio Ltda., São José dos Pinhais, PR, Brazil) was used for the collection of the values of SBS resistance. The results of the current study were: (Prompt L-Pop 1.72±0.13 MPa; Clearfil SE Bond 1.75±0.19 MPa; FL Bond 1.71±0.22 MPa; One-Up Bond 1.77±0.14 MPa; XT Control 10.5±0.86 MPa). In conclusion: the number of cycles in thermal and thermo mechanical cycling did not influence shear bond strength values for any of the primers tested;SEP Transbond Plus showed the greatest values for bond strength of orthodontic brackets.

Is S-Adenosyl Methionine (SAMe) for Depression Only Effective in Males? A Re-Analysis of Data from a Randomized Clinical Trial

OBJECTIVE

The aim of this study was to examine whether gender differences may have affected treatment response to S-adenosyl methionine (SAMe) in a recent failed randomized clinical trial (RCT) for adults with major depressive disorder.

METHODS

Data from a 2-site, 12-week, double-blind RCT (n=189) assessing the efficacy of SAMe vs. placebo and a comparator selective serotonin reuptake inhibitor (escitalopram) were subjected to post-hoc analyses to evaluate effects of patient gender on treatment response.

RESULTS

When assessing the efficacy outcomes within each gender separately, SAMe was superior to placebo among males (n=51), but not among females (n=62). Males showed a significant reduction of depression severity from baseline to study endpoint on the 17-item Hamilton Depression Rating Scale (4.3 point difference; p=0.034; d=0.95), while females did not show significant change. This finding emerged despite equivalence on baseline measures of depression severity between the gender groups.

CONCLUSION

RESULTS of this secondary data analysis suggest that gender might impact the antidepressant efficacy of SAMe, with greater therapeutic effect found in males. The underlying mechanism is still relatively unknown. Further work is needed to replicate this observation in independent samples.Clinicaltrials.gov identifier: NCT00101452.

The effects of co-morbidity in defining major depression subtypes associated with long-term course and severity

BACKGROUND

Although variation in the long-term course of major depressive disorder (MDD) is not strongly predicted by existing symptom subtype distinctions, recent research suggests that prediction can be improved by using machine learning methods. However, it is not known whether these distinctions can be refined by added information about co-morbid conditions. The current report presents results on this question.

METHOD

Data came from 8261 respondents with lifetime DSM-IV MDD in the World Health Organization (WHO) World Mental Health (WMH) Surveys. Outcomes included four retrospectively reported measures of persistence/severity of course (years in episode; years in chronic episodes; hospitalization for MDD; disability due to MDD). Machine learning methods (regression tree analysis; lasso, ridge and elastic net penalized regression) followed by k-means cluster analysis were used to augment previously detected subtypes with information about prior co-morbidity to predict these outcomes.

RESULTS

Predicted values were strongly correlated across outcomes. Cluster analysis of predicted values found three clusters with consistently high, intermediate or low values. The high-risk cluster (32.4% of cases) accounted for 56.6-72.9% of high persistence, high chronicity, hospitalization and disability. This high-risk cluster had both higher sensitivity and likelihood ratio positive (LR+; relative proportions of cases in the high-risk cluster versus other clusters having the adverse outcomes) than in a parallel analysis that excluded measures of co-morbidity as predictors.

CONCLUSIONS

Although the results using the retrospective data reported here suggest that useful MDD subtyping distinctions can be made with machine learning and clustering across multiple indicators of illness persistence/severity, replication with prospective data is needed to confirm this preliminary conclusion.

Comparison of disinfection protocol of irreversible hydrocolloid (alginate) impressions through plastic and metallic trays

Introduction: Many studies have evaluated the disinfection of irreversible hydrocolloid impressions through different disinfecting agents. However, impression trays can be source of cross-infection requiring disinfection. This study aimed to determine which would be the most suitable tray (metallic or plastic), available in dental market, and the ideal time to achieve disinfection by using 1% sodium hypochlorite poured into the alginate impression. Material and methods: Thirty dental impressions from the patients aged from 7-12 years and treated in the Discipline of Orthodontics of the institution were divided into two groups according to the impression tray type: 15 impressions through plastic tray (Morelli) and 15 impressions through metallic tray (Tecnodent). The material collection was performed before and after the application of 1% sodium hypochlorite for 3, 5 and 10 minutes. After the incubation period of 48 hours at 37ºC, the microorganism colonies were counted on the plates presenting from 30 to 300 colonies to determine the colony-forming unit (CFU) per mL. CFU/mL results were transformed into logarithm and submitted to statistical analysis by applying ANOVA and Tukey test (p ? 0.05). Results: Greater CFU percentage reduction occurred in alginate after three minutes, in both tray types. Concerning to tray types, it could be observed that the plastic tray showed 100% of reduction after 5 minutes while the metallic tray exhibited 81.49% of reduction after 3 minutes. Conclusion: 1 – The plastic tray showed the most effective disinfection after 5 minutes, with 100% of CFU reduction; 2 – The most effective time of disinfection with 1% sodium hypochlorite poured into the impression was 5 minutes, for both tray types.

Dental anomalies in children submitted to antineoplastic therapy

Cancer is the third most frequent cause of death in children in Brazil. Early diagnosis and medical advances have significantly improved treatment outcomes, which has resulted in higher survival rates and the management of late side effects has become increasingly important in caring for these patients. Dental abnormalities are commonly observed as late effects of antineoplastic therapy in the oral cavity. The incidence and severity of the dental abnormalities depend on the child's age at diagnosis and the type of chemotherapeutic agent used, as well as the irradiation dose and area. The treatment duration and aggressivity should also be considered. Disturbances in dental development are characterized by changes in shape, number and root development. Enamel anomalies, such as discoloration, opacities and hypoplasia are also observed in these patients. When severe, these abnormalities can cause functional and esthetic sequelae that have an impact on the children's and adolescents' quality of life. General dentists and pediatric dentists should understand these dental abnormalities and how to identify them aiming for early diagnosis and appropriate treatment.

Proposed DSM-5 mixed features are associated with greater likelihood of remission in out-patients with major depressive disorder

BACKGROUND

Draft DSM-5 criteria for a mixed major depressive episode have been proposed, but their predictive validity has not yet been established. We hypothesized that such symptoms would be associated with poorer antidepressant treatment outcomes.

METHOD

We examined outcomes among individuals with major depressive disorder participating in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, an effectiveness study conducted at primary and specialty care centers in the USA. Mixed features were derived from the six self-report items of the mania subscale of the Psychiatric Diagnosis Screening Questionnaire. Primary analyses examined the association between the presence of at least two of these in the 6 months before study entry, and remission across up to four sequential treatment trials, as well as adverse outcomes.

RESULTS

Of the 2397 subjects with a major depressive episode of at least 6 months' duration, 449 (18.7%) reported at least two mixed symptoms. The presence of such symptoms was associated with a greater likelihood of remission across up to four sequential treatments, which persisted after adjustment for potential confounding clinical and demographic variables (adjusted hazard ratio 1.16, 95% confidence interval 1.03-1.28). Two individual items, expansive mood and cheerfulness, were strongly associated with a greater likelihood of remission.

CONCLUSIONS

Proposed DSM-5 mixed state features were associated with a greater rather than a lesser likelihood of remission. While unexpected, this result suggests the potential utility of further investigation of depressive mixed states in major depression.

Prevalence of dental anomalies in children analyzed by orthopantomography

Objective: To determine the prevalence of dentalanomalies in patients aged from 4-12 years-oldthrough radiographic examination. Materialand Methods: 523 panoramic radiographs andfile records were selected and analyzed by 3calibrated examiners. The material was selectedfrom the Orthodontic and Pediatric Dentistry filesof Child Clinics of the Science and TechnologyInstitute of Sao Jose dos Campos of the Sao PauloState University, including only those with highquality and contrast. Data were submitted tostatistical analysis. Results: The tabulated datawere statistically analyzed by Mann Whitneytest and Fisher’s exact test. There was a higherincidence of abnormalities in females (56.72%).It was found 7 cases (1.34%) of supernumeraryteeth, 47 cases (8.99%) of anodontia, 45 cases(8.60%) of impacted teeth, 28 cases (5.35%) ofdilacerated teeth, and 7 cases (1.34%) of ankyloseddeciduous teeth. Conclusion: According to thesample studied, dental anomalies were presentin 25.62% of the children. Considering thenumber of supernumerary, ankylosed, impactedand dilacerated teeth, there were no statisticaldifferences between genders. There was statisticaldifference between genders regarding to thenumber of anodontia, with higher predominancein females.KeywordsDental anomalies; Children; Deciduous teeth; Panoramic radiograph.

Psychosocial stressors and the prognosis of major depression: a test of Axis IV

BACKGROUND

Axis IV is for reporting 'psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorders'. No studies have examined the prognostic value of Axis IV in DSM-IV.

METHOD

We analyzed data from 2497 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with major depressive episode (MDE). We hypothesized that psychosocial stressors predict a poor prognosis of MDE. Secondarily, we hypothesized that psychosocial stressors predict a poor prognosis of anxiety and substance use disorders. Stressors were defined according to DSM-IV's taxonomy, and empirically using latent class analysis (LCA).

RESULTS

Primary support group problems, occupational problems and childhood adversity increased the risks of depressive episodes and suicidal ideation by 20-30%. Associations of the empirically derived classes of stressors with depression were larger in magnitude. Economic stressors conferred a 1.5-fold increase in risk for a depressive episode [95% confidence interval (CI) 1.2-1.9]; financial and interpersonal instability conferred a 1.3-fold increased risk of recurrent depression (95% CI 1.1-1.6). These two classes of stressors also predicted the recurrence of anxiety and substance use disorders. Stressors were not related to suicidal ideation independent from depression severity.

CONCLUSIONS

Psychosocial and environmental problems are associated with the prognosis of MDE and other Axis I disorders. Although DSM-IV's taxonomy of stressors stands to be improved, these results provide empirical support for the prognostic value of Axis IV. Future work is needed to determine the reliability of Axis IV assessments in clinical practice, and the usefulness of this information to improving the clinical course of mental disorders.

In vitro evaluation of the microhardness of bovine enamel exposed to acid solutions after bleaching

Acid erosion is a superficial loss of enamel caused by chemical processes that do not involve bacteria. Intrinsic and extrinsic factors, such as the presence of acid substances in the oral cavity, may cause a pH reduction, thus potentially increasing acid erosion. The aim of this study was to evaluate the microhardness of bleached and unbleached bovine enamel after immersion in a soda beverage, artificial powder juice and hydrochloric acid. The results obtained for the variables of exposure time, acid solution and substrate condition (bleached or unbleached enamel) were statistically analyzed by the ANOVA and Tukey tests. It was concluded that a decrease in microhardness renders dental structures more susceptible to erosion and mineral loss, and that teeth left unbleached show higher values of microhardness compared to bleached teeth.

Is prior course of illness relevant to acute or longer-term outcomes in depressed out-patients? A STAR*D report

BACKGROUND

Major depressive disorder (MDD) is commonly chronic and/or recurrent. We aimed to determine whether a chronic and/or recurrent course of MDD is associated with acute and longer-term MDD treatment outcomes.

METHOD

This cohort study recruited out-patients aged 18-75 years with non-psychotic MDD from 18 primary and 23 psychiatric care clinics across the USA. Participants were grouped as: chronic (index episode >2 years) and recurrent (n = 398); chronic non-recurrent (n=257); non-chronic recurrent (n=1614); and non-chronic non-recurrent (n = 387). Acute treatment was up to 14 weeks of citalopram (≤ 60 mg/day) with up to 12 months of follow-up treatment. The primary outcomes for this report were remission [16-item Quick Inventory of Depressive Symptomatology - Self-Rated (QIDS-SR(16)) ≤ 5] or response (≥ 50% reduction from baseline in QIDS-SR(16)) and time to first relapse [first QIDS-SR16 by Interactive Voice Response (IVR) ≥ 11].

RESULTS

Most participants (85%) had a chronic and/or recurrent course; 15% had both. Chronic index episode was associated with greater sociodemographic disadvantage. Recurrent course was associated with earlier age of onset and greater family histories of depression and substance abuse. Remission rates were lowest and slowest for those with chronic index episodes. For participants in remission entering follow-up, relapse was most likely for the chronic and recurrent group, and least likely for the non-chronic, non-recurrent group. For participants not in remission when entering follow-up, prior course was unrelated to relapse.

CONCLUSIONS

Recurrent MDD is the norm for out-patients, of whom 15% also have a chronic index episode. Chronic and recurrent course of MDD may be useful in predicting acute and long-term MDD treatment outcomes.

Outcomes on the pharmacopsychometric triangle in bupropion-SR vs. buspirone augmentation of citalopram in the STAR*D trial

OBJECTIVE

To compare within the framework of a novel pharmacopsychometric triangle, augmentation treatment with bupropion vs. buspirone in the acute therapy of major depression in the STAR*D study. The triangle provides a composite view in three domains of antidepressive activity, side effects, and quality of life.

METHOD

Within the pharmacopsychometric triangle, the short six-item subscales of the Hamilton Depression Scale (HAM-D(17)) and of the Inventory of Depressive Symptomatology (IDS-C(30)), referred to as HAM-D(6) and IDS-C(6), were focussed on pure antidepressive effect. Side-effects (tolerable vs. intolerable) and quality of life were measured using patient-administered questionnaires. A modified intention to treat sample was used.

RESULTS

Within the pharmacopsychometric triangle, bupropion-SR (sustained release) was superior to buspirone when augmented to the current citalopram treatment. Thus, in the domain of pure antidepressive effect, bupropion-SR was superior (P = 0.05) on the HAM-D(6), IDS-C(6), and IDS-C(30), but not on the HAM-D(17). In the domain of side effects, the total scores on the Patient Rated Inventory of Side Effects (PRISE) were reduced significantly more by bupropion-SR than by buspirone (P = 0.03). In the domain of quality of life, the total scores on the Quality of Life Enjoyment and Satisfaction Questionnaire (QLES-Q) showed a trend (P = 0.10) from baseline to endpoint of a superiority for bupropion-SR compared with buspirone.

CONCLUSION

In all domains of the pharmacopsychometric triangle, bupropion-SR was superior to buspirone as augmentation therapy in depressed outpatients not responding to citalopram.

Using electronic medical records to enable large-scale studies in psychiatry: treatment resistant depression as a model

BACKGROUND

Electronic medical records (EMR) provide a unique opportunity for efficient, large-scale clinical investigation in psychiatry. However, such studies will require development of tools to define treatment outcome.

METHOD

Natural language processing (NLP) was applied to classify notes from 127 504 patients with a billing diagnosis of major depressive disorder, drawn from out-patient psychiatry practices affiliated with multiple, large New England hospitals. Classifications were compared with results using billing data (ICD-9 codes) alone and to a clinical gold standard based on chart review by a panel of senior clinicians. These cross-sectional classifications were then used to define longitudinal treatment outcomes, which were compared with a clinician-rated gold standard.

RESULTS

Models incorporating NLP were superior to those relying on billing data alone for classifying current mood state (area under receiver operating characteristic curve of 0.85-0.88 v. 0.54-0.55). When these cross-sectional visits were integrated to define longitudinal outcomes and incorporate treatment data, 15% of the cohort remitted with a single antidepressant treatment, while 13% were identified as failing to remit despite at least two antidepressant trials. Non-remitting patients were more likely to be non-Caucasian (p<0.001).

CONCLUSIONS

The application of bioinformatics tools such as NLP should enable accurate and efficient determination of longitudinal outcomes, enabling existing EMR data to be applied to clinical research, including biomarker investigations. Continued development will be required to better address moderators of outcome such as adherence and co-morbidity.

Evaluation of bond strength of self-adhesive cements to dentin with or without application of adhesive systems

PURPOSE

To evaluate the bond strength of indirect restorations to dentin using self-adhesive cements with and without the application of adhesive systems.

MATERIAL AND METHODS

Seventy-two bovine incisors were used, in which the buccal surfaces were ground down to expose an area of dentin measuring a minimum of 4 x 4 mm. The indirect resin composite Resilab was used to make 72 blocks, which were cemented onto the dentin surface of the teeth and divided into 4 groups (n = 18): group 1: self-adhesive resin cement BiFix SE, applied according to manufacturer's recommendations; group 2: self-adhesive resin cement RelyX Unicem, used according to manufacturer's recommendations; group 3: etch-and-rinse Solobond M adhesive system + BiFix SE; group 4: etch-and-rinse Single Bond 2 adhesive system + RelyX Unicem. The specimens were sectioned into sticks and subjected to microtensile testing in a universal testing machine (EMIC DL- 200 MF). Data were subjected to one-way ANOVA and Tukey's test (α = 5%).

RESULTS

The mean values (± standard deviation) obtained for the groups were: group 1: 15.28 (± 8.17)a, group 2: 14.60 (± 5.21)a, group 3: 39.20 (± 9.98)c, group 4: 27.59 (± 6.57)b. Different letters indicate significant differences (ANOVA; p = 0.0000).

CONCLUSION

The application of adhesive systems before self-adhesive cements significantly increased the bond strength to dentin. In group 2, RelyX Unicem associated with the adhesive system Single Bond 2 showed significantly lower mean tensile bond strengths than group 3 (BiFix SE associated with the etch-and-rinse Solobond M adhesive system).

Factor structure and dimensionality of the two depression scales in STAR*D using level 1 datasets

BACKGROUND

The factor structure and dimensionality of the HAM-D(17) and the IDS-C(30) are as yet uncertain, because psychometric analyses of these scales have been performed without a clear separation between factor structure profile and dimensionality (total scores being a sufficient statistic).

METHODS

The first treatment step (Level 1) in the STAR*D study provided a dataset of 4041 outpatients with DSM-IV nonpsychotic major depression. The HAM-D(17) and IDS-C(30) were evaluated by principal component analysis (PCA) without rotation. Mokken analysis tested the unidimensionality of the IDS-C(6), which corresponds to the unidimensional HAM-D(6.)

RESULTS

For both the HAM-D(17) and IDS-C(30), PCA identified a bi-directional factor contrasting the depressive symptoms versus the neurovegetative symptoms. The HAM-D(6) and the corresponding IDS-C(6) symptoms all emerged in the depression factor. Both the HAM-D(6) and IDS-C(6) were found to be unidimensional scales, i.e., their total scores are each a sufficient statistic for the measurement of depressive states.

LIMITATIONS

STAR*D used only one medication in Level 1.

CONCLUSIONS

The unidimensional HAM-D(6) and IDS-C(6) should be used when evaluating the pure clinical effect of antidepressive treatment, whereas the multidimensional HAM-D(17) and IDS-C(30) should be considered when selecting antidepressant treatment.

Using magnetic resonance phase-contrast velocity mapping for diagnosing pelvic congestion syndrome

Objective

To evaluate phase-contrast velocity mapping (PCVM) as a diagnostic tool for pelvic congestion syndrome and comparing this approach with direct venography.

Method

We prospectively include nine women with clinical suspicion of pelvic congestion syndrome during a six-month period. All patients underwent a magnetic resonance phase-contrast scan before a direct venography. We considered a case of pelvic congestion syndrome when the PCVM showed a retrograde or slow (less than 5 cm/second) flow in any gonadal vein. This criterion was compared with the standard diagnostic criterion observed from a direct venography.

Results

Using direct venography we found 14 abnormal veins and all of them were correctly identified by the PCVM. The other four veins were found to be normal by the direct venography. However, two of them (the same patient) were abnormal in the PCVM, even though this patient had the classical symptoms of pelvic congestion syndrome.

Conclusion

PCVM is a useful tool for diagnosing pelvic contrast syndrome and can avoid invasive procedures such as direct venography.

Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis

BACKGROUND

Prevention of relapse and recurrence represents an important task in the successful treatment of major depressive disorder (MDD). The aim of this meta-analysis was to examine the efficacy of the sequential integration of psychotherapy and pharmacotherapy in reducing the risk of relapse and recurrence in MDD.

METHOD

Keyword searches were conducted in Medline, EMBASE, PsycINFO and the Cochrane Library from inception of each database to December 2008. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD were considered for inclusion in the meta-analysis.

RESULTS

Eight high-quality studies with 442 patients in a sequential treatment arm and 433 in a control treatment arm were included. The pooled risk ratio (RR) for relapse/recurrence was 0.797 [95% confidence interval (CI) 0.659-0.964] according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence for the sequential administration of treatments compared with control conditions. Performing subgroup analyses, we found a trend favoring psychotherapy during continuation of antidepressant drugs compared to antidepressants or treatment as usual (RR 0.842, 95% CI 0.674-1.051). Patients randomized to psychotherapy while antidepressants were discontinued were significantly less likely to experience relapse/recurrence compared to controls (RR 0.650, 95% CI 0.463-0.912).

CONCLUSIONS

We found evidence that the sequential integration of psychotherapy and pharmacotherapy is a viable strategy for preventing relapse and recurrence in MDD. In addition, our findings suggest that discontinuation of antidepressant drugs may be feasible when psychotherapy is provided.

Micromorfologia do esmalte de dentes decíduos condicionados pelo ácido maleico a 10% ou fosfórico a 35%

O objetivo deste estudo in vitro foi de avaliar ao microscópio eletrônico de varredura, a micromorfologia do esmalte de dentes decíduos após o condicionamento com ácido fosfórico a 35% e maleico a 10%, com tempos de 7, 15, 30 e 45s, sobre a superfície vestibular de molares decíduos. Foram selecionados 32 molares decíduos, clinicamente hígidos, esfoliados naturalmente ou extraídos por indicações clínicas, armazenados em solução salina e timol a 0,1% à temperatura ambiente. As amostras sofreram limpeza coronária com pasta de pedra-pomes e água em baixa velocidade e foram divididas aleatoriamente em oito grupos experimentais, com quatro dentes em cada grupo. As amostras dos grupos 1 a 4 receberam ácido fosfórico a 35%, nos tempos de 7, 15, 30 e 45s. As amostras dos grupos 5 a 8 receberam ácido maleico a 10%, nos tempos de 7, 15, 30 e 45s. Após, todos os espécimes foram lavados com spray de ar/água durante 30s. Foram desidratados, montados em bases metálicas, cobertos com ouro e examinados em um microscópio eletrônico de varredura (Jeol, JSM-6100). A análise das fotomicrografias revelou que as amostras dos grupos 1, 2 e 3 apresentaram predominância do padrão tipo I, enquanto nos grupos 4 e 8 observou-se uma predominância do padrão tipo II. Já nos grupos 5, 6 e 7 não houve formação de nítidos padrões de condicionamento. Em todos os grupos, quanto maior o tempo de aplicação do agente condicionador, os variados padrões de condicionamento mostram-se mais evidentes.

Avaliação dimensional de arcos dentários decíduos utilizando os gabaritos de Long

Um dos principais objetivos da Odontopediatria moderna é a prevenção e a manutenção da saúde dos pacientes infantis, que apresentam contínuo crescimento e desenvolvimento. Qualquer desvio da normalidade da arcada dentária poderá acarretar problemas, quando não detectados e tratados precocemente. Long, em 1999, desenvolveu gabaritos da forma dos arcos decíduos do tipo I e II de Baume, através da computação eletrônica, para análise morfológica da dentadura decídua, por sobreposição em modelos de gesso. Este estudo testou estes gabaritos desenvolvidos por Long em 30 pares de modelos de gesso com de pacientes da clínica de odontopediatria da Faculdade de Odontologia da UNESP-SJC, com dentadura decídua completa. Alguns destes pacientes tinham maloclusão, outros oclusão normal. Foi, então, analisado o posicionamento vestíbulo-lingual de cada um dos dentes das arcadas superior e inferior. Observou-se que 60% dos dentes analisados na maxila estavam vestibularizados em relação à posição ideal, enquanto que na mandíbula, 50% dos dentes tinham um bom posicionamento. Desta forma, concluiu-se que, os gabaritos são de simples aplicação clínica, inclusive para o clínico geral, podendo ser muito útil na determinação precoce de problemas na dentadura decídua.

Condicionamento ácido em diferentes regiões do esmalte de molares decíduos

O objetivo deste estudo in vitro foi de avaliar ao microscópio eletrônico de varredura, a micromorfologia do esmalte de dentes decíduos após condicionamento com ácido fosfórico a 35%, com tempos de aplicação de 15, 30 ou 45 segundos, sobre a superfície vestibular ou oclusal de molares decíduos. Foram selecionados 24 molares decíduos, clinicamente hígidos, esfoliados naturalmente, que foram armazenados em solução fisiológica à temperatura ambiente. As amostras sofreram limpeza coronária com pasta de pedra pomes e água em baixa velocidade e foram divididas aleatoriamente em 6 grupos experimentais, com 4 dentes em cada grupo. As amostras dos grupos 1 a 3 receberam condicionamento ácido na superfície vestibular e as amostras dos grupos 4 a 6 na superfície oclusal. Nos G1 e G4, o condicionamento foi realizado durante 15 segundos, nos G2 e G5 durante 30 s e nos G3 e G6 durante 45 s. Após, todos os espécimes foram lavados com spray de ar- água durante 15 s. Foram desidratados, montados em bases metálicas, cobertos com ouro e examinados em um microscópio eletrônico de varredura ( Jeol, JSM – 6100). A análise das fotomicrografias revelou que as amostras dos grupos 1, 2 , 5 e 6 apresentaram predominância do padrão tipo I, enquanto nos grupos 3 e 4 observou-se uma predominância do padrão tipo II. Em todos os grupos, quanto maior o tempo de aplicação do agente condicionador, os variados padrões de condicionamento mostram-se mais evidentes.

Observações ao microscópio eletrônico de varredura, do esmalte aprismático, em fissuras de molares decíduos erupcionados

O objetivo deste estudo in vitro foi de avaliar ao microscópio eletrônico de varredura, a estrutura, freqüência, distribuição e espessura do esmalte aprismático nas regiões superior, média, inferior e fundo da fissura de molares decíduos erupcionados. Foram utilizados 12 segundos molares decíduos inferiores hígidos, que foram fraturados no sentido vestíbulolingual, para análise ao microscópio eletrônico de varredura. Os resultados obtidos, demonstraram que estruturalmente o esmalte aprismático caracterizou-se por apresentar cristais de hidroxiapatita paralelos entre si e perpendiculares à superfície externa do dente. A camada aprismática foi observada em toda extensão da fissura. Observou-se diferença estatisticamente significante, quando a medida da camada aprismática da região do fundo da fissura foi comparada com as regiões superior, média e inferior. Nas demais regiões, quando comparadas entre si, não encontrou-se diferenças estatisticamente significantes.

Efeitos do ácido fosfórico nas concentrações de 10% ou 32% sobre a superfície do esmalte dental: estudo ao microscópio eletrônico de varredura

O objetivo deste estudo in vitro foi de avaliar os efeitos de duas diferentes concentrações de ácido fosfórico e tempos de condicionamento, na morfologia do esmalte dentário de prémolares humanos hígidos. A superfície vestibular de 18 prémolares extraídos de pacientes jovens, foi submetida a ação do ácido fosfórico nas concentrações de 10% ou 32% por 15, 30 ou 60 segundos. Os resultados obtidos ao microscópio eletrônico de varredura demonstraram a formação de uma superfície de esmalte rugosa, com padrões variáveis de condicionamento, independentemente do tempo de aplicação e das concentrações utilizadas.

Indicators of pretreatment suicidal ideation in adults with major depressive disorder

OBJECTIVE

In order to evaluate the presence of treatment emergent suicidal ideation (SI), it becomes necessary to identify those patients with SI at the onset of treatment. The purpose of this report is to identify sociodemographic and clinical features that are associated with SI in major depressive disorder (MDD) patients prior to treatment with a selective serotonin reuptake inhibitor.

METHOD

This multisite study enrolled 265 out-patients with non-psychotic MDD. Sociodemographic and clinical features of participants with and without SI were compared post hoc.

RESULTS

Social phobia, bulimia nervosa, number of past depressive episodes, and race were independently associated with SI by one or more SI measure.

CONCLUSION

Concurrent social phobia and bulimia nervosa may be potential risk factors for SI in patients with non-psychotic MDD. Additionally, patients with more than one past depressive episode may also be at increased risk of SI.

Dental approach in the pediatric oncology patient: characteristics of the population treated at the dentistry unit in a pediatric oncology brazilian teaching hospital

OBJECTIVES

The objective of this paper was to characterize the population seen at the dentistry unit of the hematology-oncology service of the Oncology-Hematology Service, Instituto da Criança at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. Oral problems resulting from cancer therapy increase the risk of infection, length of hospital stay, treatment cost and negative impact on the course and prognosis of the disease.

METHOD

Of the 367 medical records of cancer patients seen from November 2007 until December 2008: 186 with a cancer diagnosis and complete clinical data were selected, while 20 with a cancer diagnosis and incomplete records were excluded; 161 medical records with only hematological diagnosis were also excluded. The following characteristics were assessed: ethnicity, gender, age, diagnosis and characteristics of the neoplasm, cancer therapy status and performed dental procedures.

RESULTS

Review of 1,236 visits indicated that 54% (n=100) of the patients had blood cancers, 46% (n=86) had solid tumors and 63% were undergoing anticancer therapy. The proportion of males (52.7%) in the study population was slightly greater. The most common cancer was acute lymphocytic leukemia (32.2%). Cancer occurred more often among those patients aged 5 to 9 years. The most common dental procedures were restorative treatment, preventive treatment and removal of infectious foci.

CONCLUSION

The characteristics of the studied population were similar to those of the general Brazilian and global populations, especially regarding gender and diagnosis distributions. The aim of implementation of the dentistry unit was to maintain good oral health and patients' quality of life, which is critical to provide oral care and prevent future oral problems.

Painful physical symptoms and treatment outcome in major depressive disorder: a STAR*D (Sequenced Treatment Alternatives to Relieve Depression) report

BACKGROUND

Painful physical symptoms (PPS) are both common and reduce the likelihood of remission in major depressive disorder (MDD), based upon results of clinical trials in selected populations. Whether PPS significantly contribute to poorer treatment outcome overall in primary or specialty psychiatric care settings remains unclear.

METHOD

Out-patients (n=2876) with MDD were treated in the first step of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial with citalopram up to 60 mg/day for up to 14 weeks. Presence of painful symptoms, as well as severity of depression, physical illness, and demographic and treatment factors were examined. Time to and overall rates of remission were analysed in relation to the presence of PPS.

RESULTS

Of the participants, 80% complained of PPS. These patients, both in primary and specialty psychiatric settings, had significantly lower remission rates and took longer to remit. Increasing severity of PPS was associated with greater physical illness burden, lower socio-economic status, absence of private insurance and being female, African-American or Hispanic. After adjustment for these factors, patients with PPS no longer had significantly poorer treatment outcomes.

CONCLUSIONS

Presence and severity of PPS is an indicator of MDD that may have poorer treatment outcome with an initial selective serotonin reuptake inhibitor. These poorer treatment outcomes are multifactorial, however, and are not explained by the presence and severity of pain per se.

Residual symptoms after remission of major depressive disorder with citalopram and risk of relapse: a STAR*D report

BACKGROUND

Many patients with major depressive disorder (MDD) who experience full symptomatic remission after antidepressant treatment still have residual depressive symptoms. We describe the types and frequency of residual depressive symptoms and their relationship to subsequent depressive relapse after treatment with citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.

METHOD

Participants in primary (n=18) and psychiatric (n=23) practice settings were openly treated with citalopram using measurement-based care for up to 14 weeks and follow-up for up to 1 year. We assessed 943 (32.8% of 2876) participants who met criteria for remission to determine the proportions with individual residual symptoms and any of the nine DSM-IV criterion symptom domains to define a major depressive episode. At each visit, the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR16) and the self-report Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale were used to assessed depressive symptoms and side-effects respectively.

RESULTS

More than 90% of remitters had at least one residual depressive symptom (median=3). The most common were weight increase (71.3%) and mid-nocturnal insomnia (54.9%). The most common residual symptom domains were sleep disturbance (71.7%) and appetite/weight disturbance (35.9%). Those who remitted before 6 weeks had fewer residual symptoms at study exit than did later remitters. Residual sleep disturbance did not predict relapse during follow-up. Having a greater number of residual symptom domains was associated with a higher probability of relapse.

CONCLUSIONS

Patients with remission of MDD after treatment with citalopram continue to experience selected residual depressive symptoms, which increase the risk of relapse.

BDNF, relative preference, and reward circuitry responses to emotional communication

Brain derived neurotrophic factor (BDNF) regulates neural development and synaptic transmission. We have tested the hypothesis that functional variation in the BDNF gene (Val66Met polymorphism, rs6265) affects brain reward circuitry encoding human judgment and decision-making regarding relative preference. We quantified relative preference among faces with emotional expressions (angry, fearful, sad, neutral, and happy) by a keypress procedure performed offline to measure effort traded for viewing time. Keypress-based relative preferences across the ensemble of faces were mirrored significantly by fMRI signal in the orbitofrontal cortex, amygdala, and hippocampus when passively viewing these faces. For these three brain regions, there was also a statistically significant group difference by BDNF genotype in the fMRI responses to the emotional expressions. In comparison with Val/Met heterozygotes, Val/Val individuals preferentially sought exposure to positive emotions (e.g., happy faces) and had stronger regional fMRI activation to aversive stimuli (e.g., angry, fearful, and sad faces). BDNF genotype accounted for approximately 30% of the variance in fMRI signal that mirrors keypress responses to these stimuli. This study demonstrates that functional allelic variation in BDNF modulates human brain circuits processing reward/aversion information and relative preference transactions.

A validation analysis of two self-reported HAM-D6 versions

OBJECTIVE

The six items of the clinician-administrated Hamilton Depression Scale (HAM-D(6)) cover the core items of depressive states reflecting the antidepressive effect of medication. In this study, the two self-reported versions of the HAM-D(6) have been psychometrically validated to ensure the unidimensionality of this administration form in patients with mild-to-moderate depression.

METHOD

The item response theory analysis of Mokken was used to test the unidimensionality of both the Interactive Voice Recording System (IVRS) version of the HAM-D(6) and a paper-and-pencil self-reported version (S-HAM-D(6)). Patients with typical major depression and with seasonal affective disorder were included.

RESULTS

The Mokken analysis showed that the two self-reported versions of the HAM-D(6) obtained coefficients of homogeneity above 0.40, similar to the clinician-rated HAM-D(6) and thus implying unidimensionality. By contrast, the full HAM-D(17) versions (self-reported as well as clinician-rated) obtained coefficients of homogeneity below 0.40, implying that the HAM-D(17) is a multidimensional scale.

CONCLUSION

The analysis show that both the IVRS version and the S-HAM-D(6) version are unidimensional self-rating scales for the measurement of depressive states.