0285 Excessive daytime sleepiness with long sleep duration increases myocardial infarction risk

Introduction

Excessive daytime sleepiness (EDS) affects 10-20% of the population and is associated with cardiovascular diseases (CVD) and mortality. However, EDS is heterogeneous, associated with both short and long sleep duration. It is unclear whether each subtype is related to CVD.

Methods

To understand the association of EDS subtypes (stratified by sleep duration) with incident myocardial infarction (MI), we perform multivariable Cox proportional hazards regression on MI using longitudinal medical record data of 471,991 individuals free of CVD at baseline from the UK Biobank. Baseline EDS and sleep duration were assessed by self-reported questionnaires.

Results

After adjusting for multiple social-demographic and behavioral factors, EDS with long sleep (³9 hours) was associated with a 91% increased incidence of MI (HR=1.91, 95% CI 1.34-2.71) compared to healthy sleep pattern (sleeping 6-9 hours without sleepiness), while EDS with normal (6-9 hours) or short sleep (≤6 hours) was not associated with incident MI. Long sleep without sleepiness was associated with a 39% increase in incident MI (HR=1.39, 95% CI 1.14-1.71). The association of EDS with long sleep was not explained by chronotype, insomnia, sleep apnea, depression, hypertension, or type 2 diabetes, but was confounded with self-reported overall health conditions (HR=1.46, 95% CI 1.02-2.08 after adjustment).

Conclusion

Our study suggests the previous association evidence of EDS increasing risk of MI may be primarily driven by its long sleep subtype (high “sleep propensity”), but the underlying mechanisms are unclear. Future work is needed to understand whether there are targetable interventions for this novel sleep phenotype that may improve cardiovascular health.

Support (If Any)

This research has been conducted using the UK Biobank Resource under Application Number 6818. Funding supports: NHLBI R35HL135818 and R01HL153814.

Association of Poor Sleep Burden in Middle Age and Older Adults With Risk for Delirium During Hospitalization

BACKGROUND

Delirium is a distressing neurocognitive disorder recently linked to sleep disturbances. However, the longitudinal relationship between sleep and delirium remains unclear. This study assessed the associations of poor sleep burden, and its trajectory, with delirium risk during hospitalization.

METHODS

About 321 818 participants from the UK Biobank (mean age 58 ± 8 years [SD]; range 37-74 years) reported (2006-2010) sleep traits (sleep duration, excessive daytime sleepiness, insomnia-type complaints, napping, and chronotype-a closely related circadian measure for sleep timing), aggregated into a sleep burden score (0-9). New-onset delirium (n = 4 775) was obtained from hospitalization records during a 12-year median follow-up. About 42 291 (mean age 64 ± 8 years; range 44-83 years) had repeat sleep assessment on average 8 years after their first.

RESULTS

In the baseline cohort, Cox proportional hazards models showed that moderate (aggregate scores = 4-5) and severe (scores = 6-9) poor sleep burden groups were 18% (hazard ratio = 1.18 [95% confidence interval: 1.08-1.28], p < .001) and 57% (1.57 [1.38-1.80], p < .001), more likely to develop delirium, respectively. The latter risk magnitude is equivalent to 2 additional cardiovascular risks. These findings appeared robust when restricted to postoperative delirium and after exclusion of underlying dementia. Higher sleep burden was also associated with delirium in the follow-up cohort. Worsening sleep burden (score increase ≥2 vs no change) further increased the risk for delirium (1.79 [1.23-2.62], p = .002) independent of their baseline sleep score and time lag. The risk was highest in those younger than 65 years at baseline (p for interaction <.001).

CONCLUSION

Poor sleep burden and worsening trajectory were associated with increased risk for delirium; promotion of sleep health may be important for those at higher risk.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

POS1412 IDENTIFYING HIGH-COST DRUGS FOR RARE RHEUMATIC DISEASES IN ROUTINELY COLLECTED NHS DATA. RESULTS FROM A PILOT STUDY OF RITUXIMAB USE IN VASCULITIS USING DATA FROM THE NATIONAL DISEASE REGISTRATION SERVICE AND THE REGISTRATION OF COMPLEX RARE DISEASES-EXEMPLARS IN RHEUMATOLOGY (RECORDER) PROJECT

Background:

Understanding real-world usage of high-cost drugs is crucial to support planning, adoption of innovation and reduce unwarranted variation in treatment. Hospital Episode Statistics (HES) contain diagnoses (coded by ICD-10) and procedures/treatments (coded by OPCS) for all daycase or inpatient care in England. However, OPCS codes are not specific for individual drugs, for example X921 (cytokine inhibitors band 1) includes rituximab (RTX) and 15 other drugs.

Objectives:

We aimed to validate the accurate identification of patients treated with RTX for ANCA-associated vasculitis (AAV) using HES data.

Methods:

We used data from the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) at Public Health England and their legal permissions (CAG 10-02(d)/2015). We extracted records from HES of all patients treated at two hospitals during financial year 2018/19 who ever had a coded diagnosis of granulomatosis with polyangiitis (GPA, M313), eosinophilic granulomatosis with polyangiitis (EGPA, M301), microscopic polyangiitis (MPA, M317), polyarteritis nodosa (PAN, M300) or arteritis unspecified (I776). Where people had multiple diagnoses of vasculitis, the most specific was considered their diagnosis. Enabled by data sharing agreements, we reviewed hospital records of those patients to validate diagnoses and whether X921 reliably identified RTX. We report the positive predictive value and sensitivity of the coding for X921 and GPA/EGPA/MPA for identifying people with AAV who are treated with RTX.

Results:

At Trust 1 records ever coded with GPA/EGPA/MPA identified 74 people, 69 of whom had AAV confirmed in their medical notes. Among these 74 patients there were 59 episodes coded with X921 procedure codes, of which 56 correctly identified a RTX infusion given for AAV. A total of 64 RTX infusions were given to people with AAV – 3 missed infusions were X921 procedures in patients who had coded diagnoses of PAN or I776 but never GPA/EGPA/MPA and 5 infusions were not coded as X921.

The same analysis at Trust 2 identified 46 people, 44 of whom had AAV confirmed in their medical notes. Among patients identified with AAV there were 17 episodes coded as X921, of which 15 correctly identified a RTX infusion. A total of 23 infusions were given to people with AAV: 4 infusions were X921 procedures in patients who had coded diagnoses of PAN or I776 but never GPA/EGPA/MPA, and 4 infusions were not coded as X921.

Table 1.

Summary of Positive Predictive Values (PPV) applying our algorithm to identify AAV diagnoses and RTX use

Trust 1Trust 2CombinedDiagnosis of AAV and coded as AAV6944113AAV coded7446120Diagnosis of AAV under any code7355128PPV AAV ascertainment (95% CI)93.2% (84.9-97.8)95.7% (85.2-99.5)94.2% (88.4-97.6)Sensitivity of AAV ascertainment (95% CI)94.5% (86.8-98.5)80.0% (67.0-89.6)88.3% (81.4-93.3)RTX given in people coded as AAV561571RTX coded in people coded as AAV591776RTX given for AAV under any diagnostic or procedure code642387PPV RTX ascertainment (95% CI)94.9% (85.9-98.9)88.2% (63.6-98.5)93.4% (85.3-97.8)Sensitivity of RTX ascertainment (95% CI)87.5% (76.8-94.4)65.2% (42.7-83.6)81.6% (71.9-89.1)

Conclusion:

HES data identified patients treated with RTX for AAV with a PPV of 93.4% (85.3-97.8) and sensitivity of 81.6% (71.9-89.1). This demonstrates the utility of national data to identify people receiving RTX for AAV. The RECORDER project, within the National Disease Registration Service plans to conduct real-world studies of the high-cost drug RTX, given for AAV, across the whole of England, and assess whether geography, demographics or socioeconomic factors influence frequency of prescription of this, and potentially other, high-cost drugs in line with the NHS long term plan.

References:

[1]Ward-Platt M, Stevens S, Miller N. I18 The national congenital anomaly and rare disease registration service (NCARDRS): The first year

Acknowledgements:

I have no acknowledgements to declare.

Disclosure of Interests:

Cattleya Godsave: None declared, Mithun Chakravorty: None declared, Megan Rutter: None declared, Peter Lanyon Grant/research support from: P.C.L. is a recipients of a grant from Vifor Pharma. Vifor Pharma had no influence on the design, conduct or interpretation of this study., Jeanette Aston: None declared, Mary Bythell: None declared, Sarah Stevens: None declared, Fiona Pearce Grant/research support from: I have received a research grant from Vifor Pharma

Improving paediatric antimicrobial stewardship in hospital-based settings: why, where and how?

Background

Antimicrobial resistance (AMR) is being recognized as a priority by healthcare organizations across the world. However, many children are managed on IV antimicrobials in hospital with very little consideration of antimicrobial stewardship issues.

Objectives

A nurse-led paediatric ambulatory outpatient parenteral antimicrobial therapy (OPAT) service, managing children with common infections being ambulated on short courses of IV antimicrobials, was introduced within Southampton Children’s Hospital in January 2018. We evaluated the impact of this service in terms of the quality of antimicrobial prescribing and timing of ambulation in children presenting with common infections.

Methods

All cases managed within the service were reviewed in two separate 2 month time periods: prior to introduction of the service (September–October 2016) and then prospectively after its introduction (September–October 2018).

Results

A total of 96% of IV antibiotic management decisions at 48 h were deemed appropriate in 2018, compared with 75% in 2016. A total of 64% of patients were ambulated on IV antibiotics at some point during their treatment course in 2018, compared with 19% in 2016. However, a significant proportion of antimicrobial decisions made at the point of presentation to hospital remained suboptimal in 2018.

Conclusions

Children are commonly managed with IV antibiotics in hospital. We demonstrate marked improvements in appropriate antimicrobial use through the introduction of a nurse-led ambulatory OPAT service. In addition, such a service can promote a greater proportion of children being ambulated from hospital, freeing up valuable inpatient beds and potentially delivering cost savings that can be used to fund such services.

Male hypogonadism: 14-year prospective outcome in 550 men with type 2 diabetes

INTRODUCTION

Hypogonadism is more prevalent in men with type 2 diabetes (T2DM) (25%-40%) than in men without T2DM. Hypogonadism has been associated with poorer glycaemic outcomes and increased cardiovascular morbidity/mortality. We report a 14-year follow-up study to evaluate the influence of baseline testosterone level on T2DM outcomes.

RESEARCH DESIGN AND METHODS

A total of 550 men with T2DM underwent baseline total testosterone and dihydrotestosterone measurement by tandem mass spectrometry. Mean age of the men was 59.7 ± 12 (mean ± SD) years. Sex hormone-binding globulin (SHBG) was measured and free testosterone estimated. Patients were followed up between 2002 and 2016. Mean follow-up period was 12.2 ± 4 years using the Salford (UK) Integrated Health Records system.

RESULTS

Mean baseline total testosterone was 13.7 ± 5.8 nmol/L, and mean free testosterone was 245.7 ± 88.0 pmol/L. Mean for low total testosterone (<10 nmol/L) was 7.6 ± 2.0 nmol/L (n = 154) and 142 men had a free testosterone <190 pmol/L. During the 14-year duration follow-up, 22% of men experienced a myocardial infarction, 18% experienced a stroke, 11% developed angina, 14% underwent coronary revascularization. About 38% of the men initially recruited died. A lower total testosterone was associated with a higher body mass index (kg/m2) at follow-up: regression coefficient -0.30 (95% CI -0.445 to -0.157), P = 0.0001. The mortality rate was higher in patients with lower total testosterone compared to normal baseline total testosterone (5.0% vs 2.8% per year, P < 0.0001). A similar phenomenon was seen for dihydrotestosterone (4.3% vs 2.9% per year, P = 0.002) for normal vs low dihydrotestosterone) and for lower SHBG. Over the whole follow-up period 36.1% (143/396), men with normal baseline testosterone died vs 55.8% (86/154) of hypogonadal men at baseline. In Cox regression, the age-adjusted hazard ratio (HR) for higher mortality associated with low total testosterone was 1.54 (95% CI: 1.2-2.0, P < 0.002), corresponding to a 3.2 year reduced life expectancy for hypogonadal T2DM men.

CONCLUSION

Low testosterone and dihydrotestosterone levels are associated with higher all-cause mortality in T2DM men. Hypogonadal men with T2DM should be considered as very high risk for cardiovascular events/death.

Metformin in non-diabetic hyperglycaemia: the GLINT feasibility RCT

BACKGROUND

The treatment of people with diabetes with metformin can reduce cardiovascular disease (CVD) and may reduce the risk of cancer. However, it is unknown whether or not metformin can reduce the risk of these outcomes in people with elevated blood glucose levels below the threshold for diabetes [i.e. non-diabetic hyperglycaemia (NDH)].

OBJECTIVE

To assess the feasibility of the Glucose Lowering In Non-diabetic hyperglycaemia Trial (GLINT) and to estimate the key parameters to inform the design of the full trial. These parameters include the recruitment strategy, randomisation, electronic data capture, postal drug distribution, retention, study medication adherence, safety monitoring and remote collection of outcome data.

DESIGN

A multicentre, individually randomised, double-blind, parallel-group, pragmatic, primary prevention trial. Participants were individually randomised on a 1 : 1 basis, blocked within each site.

SETTING

General practices and clinical research facilities in Cambridgeshire, Norfolk and Leicestershire.

PARTICIPANTS

Males and females aged ≥ 40 years with NDH who had a high risk of CVD.

INTERVENTIONS

Prolonged-release metformin (500 mg) (Glucophage® SR, Merck KGaA, Bedfont Cross, Middlesex, UK) or the matched placebo, up to three tablets per day, distributed by post.

MAIN OUTCOME MEASURES

Recruitment rates; adherence to study medication; laboratory results at baseline and 3 and 6 months; reliability and acceptability of study drug delivery; questionnaire return rates; and quality of life.

RESULTS

We sent 5251 invitations, with 511 individuals consenting to participate. Of these, 249 were eligible and were randomised between March and November 2015 (125 to the metformin group and 124 to the placebo group). Participants were followed up for 0.99 years [standard deviation (SD) 0.30 years]. The use of electronic medical records to identify potentially eligible individuals in individual practices was resource intensive. Participants were generally elderly [mean age 70 years (SD 6.7 years)], overweight [mean body mass index 30.1 kg/m2 (SD 4.5 kg/m2)] and male (88%), and the mean modelled 10-year CVD risk was 28.8% (SD 8.5%). Randomisation, postal delivery of the study drug and outcome assessment using registers/medical records were feasible and acceptable to participants. Most participants were able to take three tablets per day, but premature discontinuation of the study drug was common (≈30% of participants by 6 months), although there were no differences between the groups. All randomised participants returned questionnaires at baseline and 67% of participants returned questionnaires by the end of the study. There was no between-group difference in Short Form questionnaire-8 items or EuroQol-5 Dimensions scores. Compared with placebo, metformin was associated with small improvements in the mean glycated haemoglobin level [-0.82 mmol/mol, 95% confidence interval (CI) -1.39 to -0.24 mmol/mol], mean estimated glomerular filtration rate (2.31 ml/minute/1.73 m2, 95% CI -0.2 to 4.81 ml/minute/1.73 m2) and mean low-density lipoprotein cholesterol level (-0.11 mmol/l, 95% CI -0.25 to 0.02 mmol/l) and a reduction in mean plasma vitamin B12 level (-16.4 ng/l, 95% CI -32.9 to -0.01 ng/l). There were 35 serious adverse events (13 in the placebo group, 22 in the metformin group), with none deemed to be treatment related.

LIMITATIONS

Changes to sponsorship reduced the study duration, the limited availability of information in medical records reduced recruitment efficiency and discontinuation of study medication exceeded forecasts.

CONCLUSIONS

A large, pragmatic trial comparing the effects of prolonged-release metformin and placebo on the risk of CVD events is potentially feasible. However, changes to the study design and conduct are recommended to enable an efficient scaling up of the trial. Recommendations include changing the inclusion criteria to recruit people with pre-existing CVD to increase the recruitment and event rates, using large primary/secondary care databases to increase recruitment rates, conducting follow-up remotely to improve efficiency and including a run-in period prior to randomisation to optimise trial adherence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN34875079.

FUNDING

The project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 18. See the NIHR Journals Library website for further project information. Merck KGaA provided metformin and matching placebo.

A new look at the supposed risks of early institutional rearing

The main focus is on the assessment of the effects of early institutional care and compares three longitudinal studies from Romania, Greece and Hong Kong/China. The findings have been strikingly contrasting. The review asks if the risks are dependent on whether or not the institutional rearing is accompanied by gross pervasive deprivation (as it was in Romania) and investigates the methodological issues to explore the causal influence of the outcomes. Evidence is considered on changing institutional practices and the benefits of doing so. Comparison is made between institutions with major deprivation and those without global deprivation. A small number of studies are discussed that look at direct comparisons between institutional and community care. The empirical and conceptual implications of the findings are discussed.

Severe psychosocial deprivation in early childhood is associated with increased DNA methylation across a region spanning the transcription start site of CYP2E1

Exposure to adverse rearing environments including institutional deprivation and severe childhood abuse is associated with an increased risk for mental and physical health problems across the lifespan. Although the mechanisms mediating these effects are not known, recent work in rodent models suggests that epigenetic processes may be involved. We studied the impact of severe early-life adversity on epigenetic variation in a sample of adolescents adopted from the severely depriving orphanages of the Romanian communist era in the 1980s. We quantified buccal cell DNA methylation at ~400 000 sites across the genome in Romanian adoptees exposed to either extended (6-43 months; n=16) or limited duration (<6 months; n=17) of severe early-life deprivation, in addition to a matched sample of UK adoptees (n=16) not exposed to severe deprivation. Although no probe-wise differences remained significant after controlling for the number of probes tested, we identified an exposure-associated differentially methylated region (DMR) spanning nine sequential CpG sites in the promoter-regulatory region of the cytochrome P450 2E1 gene (CYP2E1) on chromosome 10 (corrected P=2.98 × 10(-5)). Elevated DNA methylation across this region was also associated with deprivation-related clinical markers of impaired social cognition. Our data suggest that environmental insults of sufficient biological impact during early development are associated with long-lasting epigenetic changes, potentially reflecting a biological mechanism linking the effects of early-life adversity to cognitive and neurobiological phenotypes.

Predictors of suicidality across the life span: the Isle of Wight study

BACKGROUND

Data from a representative community sample were used to explore predictors of lifetime suicidality and to examine associations between distal adolescent and more proximal adult risks.

METHOD

Data are from a midlife follow-up of the Isle of Wight study, an epidemiological sample of adolescents assessed in 1968. Ratings of psychiatric symptoms and disorder, relationships and family functioning and adversity were made in adolescence; adult assessments included lifetime psychiatric history and suicidality, neuroticism and retrospective reports of childhood sexual abuse and harsh parenting.

RESULTS

A wide range of measures of childhood psychopathology, adverse experiences and interpersonal difficulties were associated with adult suicidality; associations were particularly strong for adolescent irritability, worry and depression. In multivariate analyses, substantial proportions of these effects could be explained by their association with adult psychopathology and neuroticism, but additional effects remained for adolescent irritability and worry.

CONCLUSIONS

Factors of importance for long-term suicidality risk are evident in adolescence. These include family and experiential adversities as well as psychopathology. In particular, markers of adolescent worry and irritability appeared both potent risks and ones with additional effects beyond associations with adult disorder and adult neuroticism.

Persistence of literacy problems: spelling in adolescence and at mid-life

BACKGROUND

Developmental reading problems show strong persistence across the school years; less is known about poor readers' later progress in literacy skills.

METHOD

Poor (n = 42) and normally developing readers (n = 86) tested in adolescence (ages 14/15 years) in the Isle of Wight epidemiological studies were re-contacted at mid-life (ages 44/45 years). Participants completed a spelling test, and reported on educational qualifications, perceived adult spelling competence, and problems in day-to-day literacy tasks.

RESULTS

Individual differences in spelling were highly persistent across this 30-year follow-up, with correlations between spelling at ages 14 and 44 years of r = .91 (p < .001) for poor readers and r = .89 (p < .001) for normally developing readers. Poor readers' spelling remained markedly impaired at mid-life, with some evidence that they had fallen further behind over the follow-up period. Taking account of adolescent spelling levels, continued exposure to reading and literacy demands in adolescence and early adulthood was independently predictive of adult spelling in both samples; family social background added further to prediction among normally developing readers only.

CONCLUSIONS

By adolescence, individual differences in spelling and its related sub-skills are highly stable. Encouraging young people with reading disabilities to maintain their exposure to reading and writing may be advantageous in the longer term.

Gli2 influences proliferation in the developing lung through regulation of cyclin expression

The sonic hedgehog (Shh) signaling pathway is crucial for normal lung development. In the lung, epithelial-produced Shh signals via mesenchymal Gli1-3 transcription factors. Gli-null lung phenotypes suggest that Gli2 is the primary Gli transcription factor transducing Shh-regulated lung growth, although the mechanism has yet to be elucidated. To clarify the role of Gli2 during lung development, we overexpressed gli2 in the lung mesenchyme of mice, to investigate for changes in Shh signaling, and cellular proliferation. The ectopic overexpression of gli2 resulted in increased Shh pathway activation as evident by increased expression of shh, ptc1, ptc2, smo, hhip, and gli1. Interestingly, we also observed increased expression of gli3 transcripts. Using two different mouse models, gli3-null and gli3Delta699 (Gli3 constitutive repressor), it was found that Gli3 activity does not affect the levels of gli2 in the developing lung. Real-time PCR and immunoblotting revealed that there is increased expression of cyclins D1, D2, and E1 associated with increased gli2 levels. Furthermore, the increase and decrease of cyclins (associated with changes in gli2 levels) positively correlated with cellular proliferation, as assessed by phospho-histone H3 immunohistochemistry. To determine if Gli3 has an effect on cyclin expression in the developing lung, we measured the levels of cyclin D1, D2, and E1, in gli3-null and gli3Delta699 mice and compared them to their wild-type counterparts. However, no change in the levels of cyclins D1, D2, or E1 due to altered Gli3 was observed. These findings suggest that Gli2 and not Gli3 is the primary mediator of Shh signaling influencing fetal lung growth through cyclin regulation.

Pathways from science findings to health benefits

There have been numerous exhortations for more 'translational research'. A selective review of historical examples of research leading to health benefits is used to consider the various forms of successful interplay between basic science and clinical applications. This is followed by a consideration of key neuroscience findings that might be relevant for translation, and then by a discussion of the challenges and opportunities in relation to mental disorders. The time-frame for the pathway from science findings to health benefits is usually long, and generally requires an interactive interplay among different scientific strategies. There is a false dichotomy between so-called basic and applied research and translation needs to proceed from the bedside to the laboratory as well as in the opposite direction. There is a key need for bridging research of the hypothesis-testing experimental medicine variety. Health benefits may involve either public health considerations or the treatment of individual patients, or both. There are now some opportunities for direct translational research but there is a much greater need for hypothesis-based bridging studies that occupy a crucial mid-phase in the pathway from science findings to health benefits.

The validity of the family history screen for assessing family history of mental disorders

There is a need to collect psychiatric family history information quickly and economically (e.g., for genome-wide studies and primary care practice). We sought to evaluate the validity of family history reports using a brief screening instrument, the Family History Screen (FHS). We assessed the validity of parents' reports of seven psychiatric disorders in their adult children probands from the Dunedin Study (n = 959, 52% male), using the proband's diagnosis as the criterion outcome. We also investigated whether there were informant characteristics that enhanced accuracy of reporting or were associated with reporting biases. Using reports from multiple informants, we obtained sensitivities ranging from 31.7% (alcohol dependence) to 60.0% (conduct disorder) and specificities ranging from 76.0% (major depressive episode) to 97.1% (suicide attempt). There was little evidence that any informant characteristics enhanced accuracy of reporting. However, three reporting biases were found: the probability of reporting disorder in the proband was greater for informants with versus without a disorder, for female versus male informants, and for younger versus older informants. We conclude that the FHS is as valid as other family history instruments (e.g., the FH-RDC, FISC), and its brief administration time makes it a cost-effective method for collecting family history data. To avoid biasing results, researchers who aim to compare groups in terms of their family history should ensure that the informants reporting on these groups do not differ in terms of age, sex or personal history of disorder.

How should we construct psychiatric family history scores? A comparison of alternative approaches from the Dunedin Family Health History Study

BACKGROUND

There is increased interest in assessing the family history of psychiatric disorders for both genetic research and public health screening. It is unclear how best to combine family history reports into an overall score. We compare the predictive validity of different family history scores.

METHOD

Probands from the Dunedin Study (n=981, 51% male) had their family history assessed for nine different conditions. We computed four family history scores for each disorder: (1) a simple dichotomous categorization of whether or not probands had any disordered first-degree relatives; (2) the observed number of disordered first-degree relatives; (3) the proportion of first-degree relatives who are disordered; and (4) Reed's score, which expressed the observed number of disordered first-degree relatives in terms of the number expected given the age and sex of each relative. We compared the strength of association between each family history score and probands' disorder outcome.

RESULTS

Each score produced significant family history associations for all disorders. The scores that took account of the number of disordered relatives within families (i.e. the observed, proportion, and Reed's scores) produced significantly stronger associations than the dichotomous score for conduct disorder, alcohol dependence and smoking. Taking account of family size (i.e. using the proportion or Reed's score) produced stronger family history associations depending on the prevalence of the disorder among family members.

CONCLUSIONS

Dichotomous family history scores can be improved upon by considering the number of disordered relatives in a family and the population prevalence of the disorder.

Temperament: concepts, issues and problems

There are marked individual differences in children's temperamental styles-- differences thought to be constitutionally determined in part. The importance of temperamental features is evident in their links with various forms of psychopathology and in their effects on the manner in which other people respond to the child. For these and other reasons it has rightly come to be accepted that greater attention needs to be paid to temperamental issues in consideration of the processes of development, children's responses to stress situations, and the genesis of emotional, behavioural and learning disorders. However, major conceptual, methodological and theoretical problems remain. Problems of measurement are considered in terms of the relativity of measures, whether or not to take social context into account, the functional equivalence of measures at different ages, the circumstances to use in assessing temperament, the choice of measuring instrument and the categorization of temperamental features. The issues involved in the meaning of temperamental differences are discussed with respect to consistency, developmental change, genetic influences, brain damage and mental retardation, sex differences and the mechanisms by which temperamental variables exert their effects.

Psychiatric outcome of localized head injury in children

Previous studies have shown a high prevalence of psychiatric disturbance in children with brain injury. Studies on localized lesions have suggested that injury to the young organism carries a better prognosis for recovery of function than injury at a later age. The present study was designed to investigate these phenomena systematically. A representative sample of children (n = 98) who had been hospitalized for treatment of a compound depressed fracture, associated with a dural tear and visible damage to the underlying cortex, was identified from the records of neurosurgical units throughout the United Kingdom. The children were aged between 3 months and 12 years at the time of injury and between 5 and 15 years at the time of examination. The interval between injury and examination varied but the sample was designed to include only children who had been injured at least two years before examination. The children were examined neurologically and psychometrically, a detailed account of their current psychiatric state was obtained from one or both parents, and their mental state was assessed in a standard psychiatric examination. Preliminary data are presented which relate psychiatric, educational and intellectual status at the time of examination to site and severity of injury, age at injury, and to a number of psychosocial variables.

Heterogeneity among juvenile antisocial behaviours: findings from the Virginia Twin Study of Adolescent Behavioural Development

The examination of heterogeneity in antisocial behaviour was accomplished by applying latent class analytic methods to multivariate categorical data on 389 same-sex male twins, aged 11 to 16 from the Virginia Twin Study of Adolescent Behavioural Development (VTSABD). The data included multiple measures of oppositional and conduct disorder, attention deficit disorder, hyperactivity, impulsivity, reading disability and anxiety from mother, teacher, and child report from both questionnaire and interview (child and adult psychiatric assessment; CAPA). A latent four-class model provided a good fit to the data and yielded four phenotypically and aetiologically distinct latent classes: (1) a non-symptomatic class influenced by both additive genetic and shared environmental factors; (2) a hyperactivity-conduct disturbance class accounted for by both additive and non-additive genetic effects; (3) a 'pure' conduct disturbance class with a very strong shared environmental component; and (4) a multisymptomatic class explained entirely by the additive effect of the genes. Further characterization of these four latent classes by age of the child and parental psychiatric history is also shown.

Childhood experiences and adult psychosocial functioning

Various studies have shown statistically significant associations between adverse experiences in childhood and abnormal psychosocial functioning in early adult life. It should not be assumed that this finding necessarily means an enduring effect of early experience. Part of the explanation is that adverse environments tend to be persistent and, hence, that what is being reflected is simply continuity in risk factors. But even when such continuity is taken into account, substantial associations over time remain. Using data from two long-term longitudinal studies a variety of possible mediating mechanisms are considered and shown to be operative. These include: an immediate effect leading to emotional/behavioural disturbance in childhood that then persists into adult life (this mechanism may be more important than appreciated hitherto, because heterotypic continuity has concealed the strength of the persistence of disturbance); one risk environment increasing the likelihood of occurrence of a second, different risk environment; the establishment of patterns of behaviour that bring about later risk environments; and the development of an increased vulnerability to later risk environments.

Effect of chemical stabilizers of hypoxia-inducible factors on early lung development

Low oxygen stimulates pulmonary vascular development and airway branching and involves hypoxia-inducible factor (HIF). HIF is stable and initiates expression of angiogenic factors under hypoxia, whereas normoxia triggers hydroxylation of the HIF-1α subunit by prolyl hydroxylases (PHDs) and subsequent degradation. Herein, we investigated whether chemical stabilization of HIF-1α under normoxic (20% O2) conditions would stimulate vascular growth and branching morphogenesis in early lung explants. Tie2-LacZ (endothelial LacZ marker) mice were used for visualization of the vasculature. Embryonic day 11.5 (E11.5) lung buds were dissected and cultured in 20% O2 in the absence or presence of cobalt chloride (CoCl2, a hypoxia mimetic), dimethyloxalylglycine (DMOG; a nonspecific inhibitor of PHDs), or desferrioxamine (DFO; an iron chelator). Vascularization was assessed by X-gal staining, and terminal buds were counted. The fine vascular network surrounding the developing lung buds seen in control explants disappeared in CoCl2- and DFO-treated explants. Also, epithelial branching was reduced in the explants treated with CoCl2 and DFO. In contrast, DMOG inhibited branching but stimulated vascularization. Both DFO and DMOG increased nuclear HIF-1α protein levels, whereas CoCl2 had no effect. Since HIF-1α induces VEGF expression, the effect of SU-5416, a potent VEGF receptor (VEGFR) blocker, on early lung development was also investigated. Inhibition of VEGFR2 signaling in explants maintained under hypoxic (2% O2) conditions completely abolished vascularization and slightly decreased epithelial branching. Taken together, the data suggest that DMOG stabilization of HIF-1α during early development leads to a hypervascular lung and that airway branching proceeds without the vasculature, albeit at a slower rate.

Hypoxia-inducible factors in the first trimester human lung

Lung development takes place in a relatively low-oxygen environment, which is beneficial for lung organogenesis, including vascular development. Hypoxia-inducible factor (HIF)-1 plays an important role in mediating oxygen-regulated events. HIF-1 is stable and initiates gene transcription under hypoxia, whereas in normoxia, interaction with the von Hippel-Lindau (VHL) tumor suppressor protein leads to rapid degradation of the HIF-1alpha subunit. Interaction with VHL requires hydroxylation of HIF-1alpha proline residues by prolyl hydroxylases (PHDs). We investigated the expression of the various components regulating HIF-1alpha stability in first trimester (8-14 weeks) human lungs. Spatial expression was assessed by immunohistochemistry and temporal expression by quantitative PCR. Immunoreactivity for PHD1, PHD3, and seven in absentia homolog (SIAH)1 was noted in the pulmonary epithelium. PHD2 was not expressed in the airway epithelium, but in the lung parenchyma. HIF-1alpha and vascular endothelial growth factor (VEGF) immunoreactivity were primarily detected in the branching epithelium. HIF-2alpha and ARNT proteins localized to the developing epithelium as well as mesenchymal, most likely vascular, structures in the parenchyma. VEGF receptor 2 (VEGFR2) was found in the subepithelium as well as in vascular structures of the mesenchyme. All components of the VEC complex (VHL, NEDD8, and Cullin2) were found in the epithelium. Quantitative PCR analysis demonstrated that VEGF, VEGFR1, HIF-1alpha, HIF-2alpha, ARNT, PHD1, PHD2, PHD3, and SIAH1 gene expression was constant during early pulmonary organogenesis. Cumulatively, the data suggest that the lung develops in a low-oxygen environment that allows for proper vascular development through HIF-regulated pathways.

Making sense of informant disagreement for overanxious disorder

A community sample of 2798 8-17-year-old twins and their parents completed a personal interview about the child's current psychiatric history on two occasions separated by an average of 18 months. Parents also completed a personal interview about their own lifetime psychiatric history at entry to the study. Results indicate that informant agreement for overanxious disorder (OAD) was no better than chance, and most cases of OAD were based on only one informant's ratings. Disagreement about level of OAD symptoms or presence of another disorder (mostly phobias or depression) accounted for most cases of informant disagreement: 60% of cases based only on child interview, 67% of cases based only on maternal interview, and 100% of cases based only on paternal interview. OAD diagnosed only by maternal interview was also distinguished by an association with maternal alcoholism and increasingly discrepant parental reports of marital difficulties. Given the substantial overlap in case assignments for DSM-III-R OAD and DSM-IV GAD, these findings may identify sources of informant disagreement that generalize to juvenile GAD.