Confirmatory test of two factors and four subtypes of bipolar disorder based on lifetime psychiatric co-morbidity

BACKGROUND

The first aim was to use confirmatory factor analysis (CFA) to test a hypothesis that two factors (internalizing and externalizing) account for lifetime co-morbid DSM-IV diagnoses among adults with bipolar I (BPI) disorder. The second aim was to use confirmatory latent class analysis (CLCA) to test the hypothesis that four clinical subtypes are detectible: pure BPI; BPI plus internalizing disorders only; BPI plus externalizing disorders only; and BPI plus internalizing and externalizing disorders.

METHOD

A cohort of 699 multiplex BPI families was studied, ascertained and assessed (1998-2003) by the National Institute of Mental Health Genetics Initiative Bipolar Consortium: 1156 with BPI disorder (504 adult probands; 594 first-degree relatives; and 58 more distant relatives) and 563 first-degree relatives without BPI. Best-estimate consensus DSM-IV diagnoses were based on structured interviews, family history and medical records. MPLUS software was used for CFA and CLCA.

RESULTS

The two-factor CFA model fit the data very well, and could not be improved by adding or removing paths. The four-class CLCA model fit better than exploratory LCA models or post-hoc-modified CLCA models. The two factors and four classes were associated with distinctive clinical course and severity variables, adjusted for proband gender. Co-morbidity, especially more than one internalizing and/or externalizing disorder, was associated with a more severe and complicated course of illness. The four classes demonstrated significant familial aggregation, adjusted for gender and age of relatives.

CONCLUSIONS

The BPI two-factor and four-cluster hypotheses demonstrated substantial confirmatory support. These models may be useful for subtyping BPI disorders, predicting course of illness and refining the phenotype in genetic studies.

Health-promoting behaviors among adults with type 2 diabetes: findings from the Health and Retirement Study

BACKGROUND

Type 2 diabetes has an enormous impact on the health care system and individuals. Dietary habits, exercise, weight management, and smoking status are critical to management and prevention of complications. This study describes the prevalence of these behaviors and their change over time in a national sample of adults with type 2 diabetes. The relationships between behavior change and sociodemographic and health status measures are explored.

METHODS

Data are from the first and third longitudinal waves of the Health and Retirement Study. Surveys were conducted face-to-face or via telephone in 1992 and 1996.

RESULTS

The sample consisted of 733 persons with type 2 diabetes, ages 50-62. The most common behaviors were being on a special diet (79.6%), and not smoking (76.6%). Sixty-six percent were engaged in some physical activity, and 58.4% were trying to lose weight. Reports of being on a special diet, trying to lose weight, and exercising all diminished over time.

CONCLUSIONS

The prevalence of these behaviors is disappointing. Worse, they declined over the 4-year period. A better understanding of factors contributing to a person's decision to begin or discontinue health-promoting behaviors is needed to plan effective supportive or preemptive interventions.

Symptoms in hospitalized patients: outcome and satisfaction with care

PURPOSE

Physical symptoms are responsible for substantial morbidity in outpatients. We assessed symptoms in patients admitted to a hospital to determine their frequency, persistence at discharge, and the relation between symptom outcome and satisfaction with care.

METHODS

During a 12-month period, 2,126 hospitalized medical patients completed a study interview within 2 hours of admission. More than half (n = 1,168) of the patients were re-interviewed within 24 hours of discharge. We ascertained the presence and severity of 11 physical symptoms, as well as activities of daily living, mobility, mood, self-rated health, physiologic severity of illness, satisfaction with care, and length of stay.

RESULTS

Symptoms were common at the time of hospital admission, particularly fatigue (80% of patients), dyspnea (60%), cough (51%), dizziness (51%), headache (47%), chest pain (46%), and nausea or vomiting (43%). Individual symptoms failed to resolve by hospital discharge approximately 25% to 50% of the time. The three most prominent predictors of persistence of symptoms were shorter length of stay, severity of the symptom on admission, and total symptom count. Patient satisfaction with care was associated with total symptom severity score at discharge and the degree of symptomatic improvement that had occurred during hospitalization.

CONCLUSION

Because symptoms are common at discharge and associated with decreased satisfaction with care, asking about them would be a reasonable way to enhance patient-oriented care.

Panhandle polymerase chain reaction amplifies MLL genomic translocation breakpoint involving unknown partner gene

We used a new approach called panhandle polymerase chain reaction (PCR) to clone an MLL genomic translocation breakpoint in a case of acute lymphoblastic leukemia of infancy in which karyotype analysis was technically unsuccessful and did not show the translocation partner. Panhandle PCR amplified known MLL sequence 5' of the breakpoint and 3' sequence from the unknown partner gene from a DNA template with an intrastrand loop schematically shaped like a pan with a handle. The 7-kb panhandle PCR product contained the translocation breakpoint in MLL intron 8. The partner DNA included unique nonrepetitive sequences, Alu and mammalian apparent LTR-retrotransposon (MaLR) repetitive sequences, and a region of homology to expressed sequence tags. MaLR sequences have not been found before near leukemia-associated translocation breakpoints. The nonrepetitive sequences were not homologous to known partner genes of MLL. Screening of somatic cell hybrid and radiation hybrid lines by PCR and fluorescence in situ hybridization analysis of normal metaphase chromosomes mapped the partner DNA to chromosome band 4q21. Reverse transcriptase-PCR identified an MLL-AF-4 chimeric mRNA, indicating that panhandle PCR identified a fusion of MLL with a previously uncharacterized AF-4 intronic sequence. Panhandle PCR facilitates cloning translocation breakpoints and identifying unknown partner genes.

Ablepharon macrostomia syndrome with associated cutis laxa: possible localization to 18q

The ablepharon-macrostomia (AMS) and Barber-Say syndromes (BSS) are rare disorders characterized by absence of the eyelids or ectropion, macrostomia, ambiguous genitalia, abnormal ears, rudimentary nipples, and dry, redundant skin. Patients with Barber-Say syndrome also have hypertrichosis. We present a patient with a phenotype similar to AMS who has a complex rearrangement of chromosome 18, involving both an inversion and interstitial deletion. Our patient lacks the typical features of the 18q deletion syndrome. We review AMS and BSS as compared with our patient, and recognize cutis laxa as a feature shared by all. We propose that the gene(s) for this phenotype may lie on chromosome 18 in the region of the deletion or inversion breakpoints.

Ocular albinism in a male with del (6)(q13-q15): candidate region for autosomal recessive ocular albinism?

We describe a boy with an interstitial deletion of 6(q13-q15) and include "coarse" facial features, upslanting palpebral fissures, thin vermilion border of the upper lip, elongated philtrum, developmental delay, and profound hypotonia. The child's eye findings, pedigree, paucity of maternal ocular changes, and lack of melanin macroglobules in the skin suggest that this individual's phenotype is clinically similar to that of autosomal recessive ocular albinism. Though it is possible that this deletion and his ophthalmic disorder are coincidental, we postulate that the ocular albinism may be due to hemizygosity for a paternally derived ocular albinism gene located on chromosome 6 in the region q13-q15. This patient's deletion is secondary to a recombination of a maternal intrachromosomal inverted insertion of this region. Of the 7 reported 6q1 deletions, this is the only case that is due to a familial chromosome rearrangement.