Socioeconomic deprivation has an adverse effect on outcome after ileostomy closure

Strong association between deprivation and outcome

Efficacy and tolerability of levetiracetam in patients with therapy-resistant epilepsy and learning disabilities

INTRODUCTION

The purpose was to evaluate the effects of levetiracetam (LEV) in routine therapy in learning disabled patients with therapy-resistant epilepsy.

METHODS

In an open observational add-on study design, 46 patients (residents of the Bethel Epilepsy Centre) with severe therapy-resistant epilepsy and different degrees of learning disabilities, who were treated with LEV between its introduction in Autumn 2000 and February 2002, were evaluated retrospectively. Information on monthly seizure frequencies, seizure severity and psychiatric status was extracted from the current patient case records. A 3 months baseline and a 3 months LEV treatment period (after 3 months of titration) were compared. Responders were defined as having a 50% reduction in seizure frequency and being evaluated as good or very good in an ad hoc global clinical efficacy scale. When only one criterion was positive, a careful individual decision was made based on the impact on the patients' daily activities.

RESULTS

The responder rate was 41.3% (34.8 for 50% seizure reduction). It was higher in focal and multifocal epilepsy as compared to symptomatic generalised epilepsy/Lennox Gastaut Syndrome (P<0.05). Antiepileptic response occurred in doses between 500 and 4000 mg/day. Changes in seizure severity were rare. Nine patients experienced positive psychotropic effects (mostly improved vigilance and mood); six of these patients had antiepileptic effects as well. Twelve patients had adverse effects, mostly mild; in three cases, however, more severe effects led to discontinuation.

CONCLUSIONS

LEV is an effective and generally well-tolerated drug for this patient group, especially in focal and multifocal epilepsy.

Impact of country of birth on hospital admission for women of childbearing age in Sweden: a five year follow up study

STUDY OBJECTIVE

This study examines whether morbidity, defined as the first psychiatric hospital admission and the first somatic hospital admission, differs among subgroups of foreign born and second generation (that is, native born with at least one parent born abroad) women compared with Swedish born women (that is, with both parents native born) after adjusting for sociodemographic factors.

DESIGN SETTING

In this follow up study the population consisted of 1 452 944 women, of whom 369 771 have an immigrant background (including second generation immigrants), aged 20-45 years. The population of 31 December 1993 was followed up to 31 December 1998. Differences in risk (hazard ratio) between different groups of immigrant women were estimated, adjusting for age, marital status, number of children, and disposable income.

MAIN RESULTS

All four groups of foreign born women had higher age adjusted risks (HRs varied from 1.44 to 1.67) for a first psychiatric hospital admission than Swedish born women. The risk decreased only marginally when the sociodemographic factors were taken into consideration. Additionally, second generation women also had a higher age adjusted risk (HR = 1.42; CI = 1.37 to 1.48) than Swedish born women. The risk decreased only slightly in the main effect model. However, on analysing country of birth and first somatic hospital admissions, only non-European refugee women showed an increased age adjusted risk (HR = 1.26; CI = 1.24 to 1.29), which remained after adjusting for sociodemographic factors.

CONCLUSIONS

Foreign born and second generation women of childbearing age had a higher risk than Swedish born women for a first psychiatric hospital admission. However, only non-European refugees were at higher risk of somatic hospital admissions.

No association between two polymorphisms at the 5HT2A gene and bipolar affective puerperal psychosis

OBJECTIVE

To examine whether variation at two common polymorphisms, T102C and -1438AG, of the serotonin 2A gene (5HT2A) are involved in the puerperal triggering mechanism of bipolar affective puerperal psychosis.

METHOD

A total of 242 parous women diagnosed with bipolar disorder were genotyped for the two polymorphisms. Of these, 165 women had experienced a manic or psychotic episode, according to DSM-IV criteria, within 6 weeks of childbirth (the puerperal psychosis group). The comparison group comprised of 77 parous women who had not experienced psychiatric disturbance following childbirth.

RESULTS

No significant differences between genotype or allelic frequencies were found between the two groups for either polymorphism.

CONCLUSION

The results indicate that variation at two common polymorphisms of the 5HT2A gene does not appear to play a major role in the development of bipolar affective puerperal psychosis.

Molecular genetic approaches to puerperal psychosis

Puerperal psychosis, an episode of mania or psychosis precipitated by childbirth follows approximately one in 1000 deliveries. The evidence of clinical, outcome and genetic studies supports the hypothesis that the majority of puerperal psychotic episodes are manifestations of an affective disorder diathesis with a puerperal trigger. Furthermore the available evidence supports the hypothesis that genes are involved in susceptibility to both diathesis and trigger. For complex genetic disorders such as affective illness there are marked benefits in focussing on a homogeneous subtype which allows a subset of hypotheses to be tested. Molecular genetic studies of puerperal psychosis provide an excellent example of this strategy, allowing a hierarchy of hypotheses concerning the involvement of neurosteroid pathways in pathophysiology to be tested. Puerperal psychosis results in considerable suffering to a woman and her family. Elucidating the pathophysiological basis of this disorder will lead to better prevention and treatment and, it is anticipated, inform research on affective disorders more generally.

Molecular genetic studies of bipolar disorder and puerperal psychosis at two polymorphisms in the estrogen receptor alpha gene (ESR 1)

A number of lines of evidence point to the possible involvement of estrogen pathways in the pathophysiology of bipolar disorder in general and puerperal psychosis in particular. There is strong evidence from clinical, follow-up, and genetic studies to support the hypothesis that most cases of puerperal psychosis are manifestations of an affective disorder diathesis with a puerperal trigger and that genes influence susceptibility to both diathesis and trigger. The nature of the trigger is unknown but in view of the abrupt onset at a time of major physiological change it is widely believed that biological, probably hormonal, mechanisms are of paramount importance, with estrogen receiving the most attention to date. We have undertaken a case control association study of bipolar disorder and puerperal psychosis at two known polymorphisms within the estrogen receptor alpha gene (ESR 1) in a sample of 219 unrelated bipolar probands and 219 controls. We could exclude these polymorphisms from an important contribution to susceptibility to bipolar disorder with a high level of confidence. We found no support for the hypothesis that they contribute specific susceptibility to the puerperal trigger, but due to the small numbers of puerperal probands (n = 26) no firm conclusions can be drawn regarding their involvement in puerperal psychosis. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:850-853, 2000.

Molecular genetic studies of bipolar disorder and puerperal psychosis at two polymorphisms in the estrogen receptor alpha gene (ESR 1)

A number of lines of evidence point to the possible involvement of estrogen pathways in the pathophysiology of bipolar disorder in general and puerperal psychosis in particular. There is strong evidence from clinical, follow-up, and genetic studies to support the hypothesis that most cases of puerperal psychosis are manifestations of an affective disorder diathesis with a puerperal trigger and that genes influence susceptibility to both diathesis and trigger. The nature of the trigger is unknown but in view of the abrupt onset at a time of major physiological change it is widely believed that biological, probably hormonal, mechanisms are of paramount importance, with estrogen receiving the most attention to date. We have undertaken a case control association study of bipolar disorder and puerperal psychosis at two known polymorphisms within the estrogen receptor alpha gene (ESR 1) in a sample of 219 unrelated bipolar probands and 219 controls. We could exclude these polymorphisms from an important contribution to susceptibility to bipolar disorder with a high level of confidence. We found no support for the hypothesis that they contribute specific susceptibility to the puerperal trigger, but due to the small numbers of puerperal probands (n = 26) no firm conclusions can be drawn regarding their involvement in puerperal psychosis. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:850-853, 2000.

Tumour necrosis factor alpha and bipolar affective puerperal psychosis

The macrophage theory of depression proposes that an excessive secretion of monocyte/macrophage cytokines causes symptoms of depression. It has been suggested that changes in immune function that accompany pregnancy and childbirth could contribute to the affective symptoms suffered by many puerperal women. Tumour necrosis factor alpha (TNFalpha) is a pro-inflammatory cytokine that has been implicated in inflammatory infections and immune diseases. Production of TNFalpha has been shown to be regulated by oestrogen, which suggests it as a potential candidate for susceptibility to post-partum mood disorders. Several polymorphisms have been identified in the TNFalpha gene. The -308 promoter polymorphism has been associated with elevated production of TNFalpha and has been found to influence the neurological outcome of various infections. In a case-control association study, we have examined the frequency of this polymorphism in groups of parous DSM-IV Bipolar females with (N = 116) and without (N = 56) puerperal psychosis, and a female non-psychiatric comparison group (N = 72). We provided no support for the hypothesis that this polymorphism influences susceptibility to bipolar disorder, or acts as a trigger for puerperal psychosis. However, variation at other polymorphisms within TNFalpha or in other oestrogen-regulated genes involved in immune function remain interesting candidates for study in post-partum mood disorders.

Variation at the serotonin transporter gene influences susceptibility to bipolar affective puerperal psychosis

Up to half of parous females with bipolar disorder (manic depression) develop an episode of severe psychiatric disturbance, usually called puerperal psychosis, within a few days of giving birth. We report significant evidence (p<0.003) that variation at the serotonin transporter gene exerts a substantial (odds ratio=4) and important (population attributable fraction=69%) influence on susceptibility to such episodes.

A study of barriers to the engagement of significant others in adult addiction treatment

Using the focus group methodology, this study identified personal and structural barriers to the engagement of significant others in an outpatient addictions treatment program. Twenty-eight significant others (family members, other kin, and friends) associated with 21 patients participated in one of three focus group sessions. The cut-and-paste technique was used to analyze the narrative data. Improving communication and reconnecting patients with a supportive community were forms of support identified. Patients' willingness to accept support and therapists' invitation to involve significant others in the treatment were identified as necessary precursors to their initial involvement. Providing educational and therapeutic support to significant others were endorsed as important elements in maintaining their involvement. Offering a diversity of therapeutic services beyond standard office hours, providing home visits and child care were viewed as facilitators for their involvement. It became apparent that support providers tended to resent having their own needs ignored. Feelings of isolation, fatalism, loneliness, ignorance, and fear were expressed by significant others. Theoretical and practical implications of the findings are discussed.

Intracellular forms of human NOTCH1 functionally activate essential Epstein-Barr virus major latent promoters in the Burkitt's lymphoma BJAB cell line but repress these promoters in Jurkat cells

We have demonstrated that intracellular forms of NOTCH1 transactivate two major Epstein-Barr virus (EBV) latent promoters, the LMP1 and Cp1 promoters in an EBV-negative B-cell line, BJAB. Truncated intracellular NOTCH1 associated with the nuclear membrane (DeltaE) transactivates the LMP1 promoter fivefold; however, the intranucleus localized form of NOTCH1 (ICN) transactivates this promoter approximately twofold in chloroamphenicol acetyltransferase (CAT) reporter assays in BJAB cells. Additionally, DeltaE activated the major Cp1 promoter 12-fold, whereas the ICN form of NOTCH1 activates at only about half that level when compared to that of DeltaE membrane-bound NOTCH1. This result differs from previously observed data, where intracellular NOTCH1 bound to the nuclear membrane, DeltaE, and nucleus-localized NOTCH1, ICN, all had similar levels of activation in 293 cells. This suggests distinct transcriptional activities in different cell types. Moreover, in Jurkat cells, a T-cell line, intranucleus localized NOTCH1 molecules demonstrated a repressive activity against the two EBV major latent promoters. Only DeltaE activated the Cp1 and LMP1 promoters at a level slightly above background, whereas intranucleus localized NOTCH1 ICN, or the form of NOTCH1 lacking the ankyrin repeats, DeltaE(TAR), surprisingly resulted in the repression of these promoters in Jurkat cells. Similarly, another truncated form of NOTCH1, referred to as ICNW, which contains the tryptophan residue W(1767) within one of the RBP-Jkappa interacting domains, repressed the LMP1 promoter approximately twofold. Further analysis of the truncated NOTCH1 molecules on the LMP1 promoter element, lacking the two RBP-Jkappa binding sites, suggests that repression in Jurkat cells may be affected by the presence of the two RBP-Jkappa binding sites. These studies indicate that intracellular NOTCH1 can activate the EBV major latent promoters in BJAB cells. However, in Jurkat cells, intracellular truncated forms of NOTCH1 lacking the RBP-Jkappa binding sites repress these EBV latent promoters. Only the membrane-bound form of NOTCH1, DeltaE, activated the EBV major latent promoters in Jurkat cells, albeit at a lower level than that seen in BJAB cells. Our data suggest that EBNA2 and truncated intracellular nuclear localized forms of NOTCH1 may be functionally similar in their interactions with RBP-Jkappa; however, these molecules may have distinctly different transcriptional partners in BJAB and Jurkat cells. Moreover, these truncated NOTCH1 molecules may not represent the normal processed forms of NOTCH1 in cells and may exhibit dominant negative phenotypes in the absence of the required posttranslational modifications. Further investigations are necessary to determine the similarity and differences occurring with intracellular NOTCH1 in other B- and T-cell lines.

Perceptions of care and services by the clients and families: a personal experience

This study was initiated in response to a provincial mental health policy emphasizing the primacy of the person and the hospital's decision to adopt total quality management. The objective of the project was to learn more about how clients and families viewed the care and services received during a psychiatric admission. Their perceptions were elicited through seven focus groups including multiple admission (3) clients and families of single and multiple admission clients (2 each). Group sessions were tape-recorded, transcribed and analysed for themes. Three major themes were identified: quantity and quality of care, individuality and partnership. Both positive and negative comments were made within each of these themes, but two major areas for improvement were continuity of care and the environment. The findings are being used to change practices within the Department of Psychiatry.

Patterns of drug use among nonmetropolitan and rural adults

This article examines illegal drug use among adults living in nonmetropolitan and rural areas of the United States using data from the National Household Survey on Drug Abuse. Subjects were classified into three categories by residence: nonmetropolitan-urban, metropolitan-rural, and nonmetropolitan-rural. Respondents indicate about 10% of adults were current users of marijuana or other illegal drugs. Discriminant analysis was used to examine differences among groups of individuals classified as current users, past users, and nonusers. For both marijuana and other illegal drugs, the variables that accounted most for group differences were age, marital, status, employment status, occupation, and income. Only minor differences in drug use were exhibited across the three residential categories. It is recommended that future research on the rural and nonmetropolitan adult population incorporate both structural level measures of socioeconomic and demographic characteristics of localities, and individual level measures of peer influence, work stress, family factors, and psychosocial characteristics.

Physiotherapy in knee osteoarthrosis: effect on pain and walking

Patients with knee osteoarthrosis are often referred for physiotherapy and many different types of treatment are given. The value of many of these treatments has been questioned. This study was intended to evaluate the effect of commonly used physiotherapy treatments in a training programme on patients with medial knee osteoarthrosis, scheduled for surgery. The results from this study also provide useful data for further evaluation of different physiotherapy treatments to this patient group. Thirty-four patients were randomised to physiotherapy three times a week for 5 weeks and the other 34 received no treatment. The training programme is described in detail. The patients were evaluated by clinical examination, step test, gait analysis and isokinetic measurements of thigh muscle strength before and after treatment. The patients in the treatment group experienced a feeling of overall improvement in the knee and the ability to descend steps improved when compared to the control group. There were no significant differences in gait, range of motion or isokinetic measurements of muscle strength between the groups. We conclude that physiotherapy as given here made our patients feel better and their ability to descend stairs improved. These improvements are beneficial to the patients and support the positive effects of exercises and activity. Whilst the objective improvements were small, suggesting that this treatment may not be justified, patients in the treatment group believed that they were improved.

Prevalence of human T-cell lymphotropic virus type 1 (HTLV-1) and HTLV-2 infection among Spanish drug users measured by HTLV-1 assay and HTLV-1 and -2 assay. HTLV-1 and HTLV-2 Spanish Study Group

The prevalence of human T-cell lymphotropic virus type 1 (HTLV-1) and HTLV-2 infection in 1992 and 1993 was determined by testing 2,152 specimens from injection drug users living in 11 geographic areas in Spain. Results obtained by an authentic HTLV-1 and -2 test were compared with those obtained by an HTLV-1 assay. HTLV infection was identified in 7 of 11 regions, with an overall prevalence of 2.5% (range, 0.4 to 11.5%). Fourty-four (81%) of 54 subjects were infected with HTLV-2; the viral strains in the remaining 10 subjects could not be serologically typed. Underestimation of HTLV infection because of the low sensitivities of HTLV-1 enzyme immunoassays for HTLV-2 antibody was relatively low (< 20%). Therefore, previous epidemiologic findings generated with HTLV-1 enzyme immunoassays appear to be reasonably accurate. Our results suggest that the rate of HTLV infection may have been increasing recently among Spanish drug users.

A gene for cleidocranial dysplasia maps to the short arm of chromosome 6

Cleidocranial dysplasia (CCD) is an autosomal dominant generalized bone dysplasia characterized by mild-to-moderate short stature, clavicular aplasia or hypoplasia, supernumerary and ectopic teeth, delayed eruption of secondary teeth, a characteristic craniofacial appearance, and a variety of other skeletal anomalies. We have performed linkage studies in five families with CCD, with 24 affected and 20 unaffected individuals, using microsatellite markers spanning two candidate regions on chromosomes 8q and 6. The strongest support for linkage was with chromosome 6p microsatellite marker D6S282 with a two-point lod score of 4.84 (theta = .03). Furthermore, the multipoint lod score was 5.70 in the interval between D6S282 and D6S291. These data show that the gene for autosomal dominant CCD is located within a 19-cM interval on the short arm of chromosome 6, between D6S282 and D6S291.

Mutations in the X-linked E1 alpha subunit of pyruvate dehydrogenase: exon skipping, insertion of duplicate sequence, and missense mutations leading to the deficiency of the pyruvate dehydrogenase complex

Human pyruvate dehydrogenase (PDH)-complex deficiency is an inborn error of metabolism that is extremely heterogeneous in its presentation and clinical course. In a study of 14 patients (7 females and 7 males), we have found a mutation in the coding region of the E1 alpha gene in all 14 patients. Two female patients had the same 7-bp deletion at nt 927; another female patient had a 3-bp deletion at nt 931. Another female patient was found to have a deletion of exon 6 in her cDNA. Two other female patients were found to have insertions, one of 13 bp at nt 981 and one of 46 bp at nucleotide 1078. Two male patients were found to have a 4-bp insertion at nucleotide 1163. The remaining six patients all had missense mutations. A male patient and a female patient both had an A1133G mutation. The other missense mutations were C214T, C615A, and C787G (two patients). Five of these mutations are novel mutations, five have been previously reported in other patients, and two were published observations in other patients in an E1 alpha-mutation summary. In the four cases where parent DNA was available, only one mother was found to be a carrier of the same mutation as her child.

Reducing the complexity of the transforming Epstein-Barr virus genome to 64 kilobase pairs

Transformation-competent, replication-defective Epstein-Barr virus (EBV) recombinants which are deleted for 18 kbp of DNA encoding the largest EBNA intron and for 58 kbp of DNA between the EBNA1 and LMP1 genes were constructed. These recombinants were made by transfecting three overlapping cosmid-cloned EBV DNA fragments into cells infected with a lytic replication-competent but transformation-defective EBV (P3HR-1 strain) and were identified by clonal transformation of primary B lymphocytes into lymphoblastoid cell lines. One-third of the lymphoblastoid cell lines were infected with recombinants which had both deletions and carried the EBNA2 and EBNA3 genes from the transfected EBV DNA and therefore are composed mostly or entirely from the transfected EBV DNA fragments. The deleted DNA is absent from cells infected with most of these recombinants, as demonstrated by Southern blot and sensitive PCR analyses for eight different sites within the deleted regions. Cell growth and EBNA, LMP, and BZLF1 gene expression in lymphoblastoid cell lines infected with these recombinants are similar to those in cells infected with wild-type EBV recombinants. Together with previous data, these experiments reduce the complexity of the EBV DNA necessary for transformation of primary B lymphocytes to 64 kbp. The approach should be useful for molecular genetic analyses of transforming EBV genes or for the insertion of heterologous fragments into transforming EBV genomes.

Isolated glycerol kinase deficiency in a neonate

Glycerol kinase deficiency occurs either as a relatively benign isolated enzyme deficiency, or as part of a syndrome resulting from a microdeletion in the p21 region of the X chromosome associated with congenital adrenal hypoplasia and/or Duchenne muscular dystrophy. Developmental delay is a consistent feature of the microdeletion syndrome but not of the isolated enzyme defect. We report a case of isolated glycerol kinase deficiency in a neonate presenting with hypotonia, apnea, mild developmental delay, and glyceroluria, without evidence of adrenal insufficiency or myopathy. A mild communicating hydrocephalus was noted on magnetic resonance imaging brain scan. It is important, therefore, to exclude glyceroluria in infants being investigated for apnea and hypotonia.