The economic impact of autism in Britain

Little is known about the economic impact of autism. This study estimated the economic consequences of autism in the United Kingdom, based on published evidence and on the reanalysis of data holdings at the Centre for the Economics of Mental Health (CEMH). With an assumed prevalence of 5 per 10,000, the annual societal cost for the UK was estimated to exceed ł1 billion. The lifetime cost for a person with autism exceeded ł2.4 million. The main costs were for living support and day activities. Family costs account for only 2.3 percent of the total cost, but a lack of relevant information limited our ability to estimate these costs. Minor improvements in life outcome for people with autism could substantially reduce costs over the lifetime.

The human dopamine transporter gene: the 5'-flanking region reveals five diallelic polymorphic sites in a Caucasian population sample

The 5'-flanking region of the human dopamine transporter (hDAT) was systematically screened for variants by single strand conformation analysis (SSCA) between -1586 and +97 basepair (bp) relative to the transcription start site. Five diallelic polymorphisms were found, which were shown to be due to single base substitutions: T-67A, G-660C, C-839T, C-1169G, T-1476G. In a population sample of 119 unrelated Caucasians, allele frequencies of the rarer allele were 47% for -67T, 3% for -660C, 45% for -839T, 50% for -1169G, and 8% for -1476G, respectively. Among 15 observed haplotypes, seven haplotypes collected a frequency of about 96% in our sample. T-67A, C-839T, C-1169G, T-1476G were related to potential transcriptional recognition sites. These findings and the occurrence of distinct haplotypes at the hDAT promoter locus in a Caucasian population sample make this region a promising target in the context of linkage and association studies in certain diseases.

Nonreplication of association between mu-opioid-receptor gene (OPRM1) A118G polymorphism and substance dependence

In the present investigation we hypothesized the A118G (Asn40Asp) polymorphism of the mu-opioid receptor gene (OPRM1) as a particular vulnerability factor for heroin and alcohol dependence. Therefore, we tested this hypothesis in two independent large samples by two different methods: a case-control sample (comprising n = 287 heroin and n = 221 alcohol study subjects versus n = 365 nondependent controls) and a family-controlled sample of 111 parent-offspring trios of heroin-dependent study subjects and 75 parent-offspring trios of alcohol-dependent study subjects to avoid stratification artifacts. In both patient samples and by both methods we were unable to corroborate the hypothesis of OPRM1 A118G polymorphism as a particular risk factor for any kind of substance dependence including opioid addiction. In addition, there was no significant association between the endophenotype of the individuals under study (e.g., comorbidity, severity of illness) and a particular genotype of OPRM1.

Association study of the low-activity allele of catechol-O-methyltransferase and alcoholism using a family-based approach

Catechol-O-methyltransferase (COMT) is a major component of the metabolic pathways of neurotransmitters such as dopamine, adrenaline, and noradrenaline. The activity of COMT is known to vary within the population; it exists in common high- and low-activity forms that are determined by a Val --> Met polymorphism at amino acid position 108/158 (in soluble or membrane-bound COMT). Recently, the low-activity allele was reported to contribute to the development of late-onset alcoholism in men. The present study extends this study by utilizing a family-based association approach, and by including individuals with early-onset alcoholism. Although no significant transmission disequilibrium was found in the overall sample of 70 parent/offspring trios (TDT = 1.43, P = 0.23), we observed a preferential transmission of the low-activity allele to patients with an early onset of disease (n = 32, TDT = 4.83, P = 0.028). Our results provide further evidence for an involvement of the COMT low-activity allele in the development of alcoholism and demonstrate the need for further studies in large samples of alcoholic patients.

Costs and characteristics of heavy inpatient service users in outer London

"Heavy users" is a new term often used to describe those who occupy a disproportionate number of psychiatric beds. In this study we identified the heaviest 10% (193) inpatient service users in one London borough over a 6 year period and compared these with a control group of 400 ordinary inpatient users. A weighting index was used to combine frequency of admission with duration. Heavy users were diagnostically and demographically similar to ordinary inpatient service users and only differed by their extensive use of services, about 3 times more than ordinary users in terms of health care costs, during the measured year. Their heavy use mainly depended on occupying hospital beds, and their use of outpatient, day patient and community services was relatively light.

Support for allelic association of a polymorphic site in the promoter region of the serotonin transporter gene with risk for alcohol dependence

OBJECTIVE

An association between the 5-HTTLPR short variant polymorphism in the promoter region of the serotonin transporter gene and risk for alcohol dependence has been reported from case-control studies that are, however, prone to chance findings related to artifacts of population structure. The authors sought additional evidence for this association from a family-based study.

METHOD

Ninety-two alcohol-dependent probands and their parents were tested for nonrandom transmission of alleles from heterozygous parents to affected probands.

RESULTS

Preferential transmission of the short allele was found (65 of 102 transmissions from heterozygous parents).

CONCLUSIONS

The results suggest allelic association between a variant in the promoter region of the serotonin transporter gene and the risk for alcohol dependence. However, it remains to be seen whether the functional properties of this variant are directly responsible for the increased risk to alcohol dependence.

A distinct gene close to the hairless locus on chromosome 8p underlies hereditary Marie Unna type hypotrichosis in a German family

BACKGROUND

Hypotrichosis of the Marie Unna type (HMU) is a rare autosomal dominant disorder characterized by male-pattern hair loss with childhood onset and anomalies of the hair shaft.

OBJECTIVES

We aimed to evaluate a number of chromosomal loci as possible candidate regions for HMU.

METHODS

A linkage analysis was performed in a large German family using microsatellite markers spanning candidate regions on chromosomes 8, 12 and 17.

RESULTS

We found that the HMU locus maps to chromosomal region 8p21 in a 13.01-cM interval between markers D8S1145 and D8S1771. This interval harbours the hairless gene (HR). Mutational analysis of HR on the genomic and transcript levels revealed no pathogenic mutation.

CONCLUSIONS

Our findings, together with a recent report of two unrelated families of Dutch and British origin, provide evidence for a hair growth regulatory gene distinct from HR in chromosomal region 8p21.

Differences in stability among the human apolipoprotein E isoforms determined by the amino-terminal domain

Denaturation by guanidine-HCl, urea, or heating was performed on the common isoforms of human apolipoprotein (apo) E (apoE2, apoE3, and apoE4) and their 22-kDa and 10-kDa fragments in order to investigate the effects of the cysteine/arginine interchanges at residues 112 and 158. Previous physical characterization of apoE3 established that apoE contains two domains, the 10-kDa carboxyl-terminal and 22-kDa amino-terminal domains, which unfold independently and exhibit large differences in stability. However, the physical properties of apoE2, apoE3, and apoE4 have not been compared before. Analysis by circular dichroism showed that the different isoforms have identical alpha-helical contents and guanidine-HCl denaturation confirmed that the two domains unfold independently in all three isoforms. However, guanidine-HCl, urea, and thermal denaturation showed differences in stability among the 22-kDa amino-terminal fragments of the apoE isoforms (apoE4 < apoE3 < apoE2). Furthermore, guanidine-HCl denaturation monitored by circular dichroism and fluorescence suggested the presence of a folding intermediate in apoE, most prominently in apoE4. Thus, these studies reveal that the major isoforms of apoE, which are associated with different pathological consequences, exhibit significant differences in stability.

Alternative strategies for stroke care: a prospective randomised controlled trial

BACKGROUND

Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care.

METHODS

A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat.

FINDINGS

152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p<0.001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0.03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p<0.001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0.002). These differences were present at 3 and 6 months after stroke.

INTERPRETATION

Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke.

Aims, outcome measures, study sites and patient sample. EPSILON Study 1. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs

BACKGROUND

Cross-national research into the care of people with severe mental illnesses is hampered by a lack of standardised measures. The European Psychiatric Services: Inputs Linked to Outcome Domains and Needs (EPSILON) Study is a European Union funded project within the BIOMED-2 programme. The project aims to develop standardised instruments to facilitate future cross-national research.

AIMS

To describe the aims, outcome measures, study sites and patient samples of the EPSILON Study.

METHOD, RESULTS, CONCLUSIONS

See companion papers in this supplement.

Mapping of a gene for nonspecific X-linked mental retardation (MRX 75) to Xq24-q26

Nonspecific X-linked mental retardation is a heterogeneous condition consisting of nonsyndromal mental retardation in males. It is caused by mutation in one of several genes on the X chromosome (MRX genes). Here we report on the localization of a presumptive MRX gene to chromosomal region Xq24-q26 in a German family with nonspecific X-linked mental retardation (MRX 75, HUGO Human Gene Nomenclature Committee). Two point linkage analysis with 23 informative markers gave a lod score of 2.53 at theta = 0 for markers DXS425, DXS1254, DXS1114, and HPRT.

Psychiatric patients at greatest risk and in greatest need. Impact of the Supervision Register Policy

BACKGROUND

Mental health provider trusts in England were required in 1994 to establish local Supervision Registers of patients at risk.

AIMS

To identify the factors associated with registration, and obtain clinicians' views on its effectiveness.

METHOD

At a random sample of 14 trusts data were collected from case notes, key workers and responsible medical officers.

RESULTS

A sample of 133 registered patients were more disabled and had more extensive histories of violence and self-harm than 126 comparison patients on the upper tier of the Care Programme Approach (CPA). Those registered were a heterogeneous group. For some there was little evidence of risk. In most cases clinicians did not believe registration had improved care.

CONCLUSIONS

The Supervision Register policy has not resulted in the identification of a well-defined group. Its effectiveness is limited by the lack of operationalized measures of risk.

[Clinical characteristics of patients with tardive dyskinesias]

Although there is a great number of studies on the relationship between tardive dyskinesia and patient characteristics, too often their validity is impaired by the lack of operationalized criteria for the description of patients and signs. Reliable phenotyping is of utmost importance for linking clinical data with data from methods in neurobiology or molecular genetics. 241 patients with the DSM IV diagnosis "schizophrenia" or "schizoaffective disorder" were examined with the instruments SADS-L, OPCRIT, BPRS and PANSS. Motor phenomena were analyzed on 2 separate days within 3 months with the scales TDRS, AIMS, SAS, BAS. Tardive dyskinesia was diagnosed following the research criteria of Schooler and Kane. Lifetime medication with neuroleptics and anticholinergic drugs was assessed quantitatively.

RESULTS

97 out of 233 patients (= 41.6%) displayed persistent tardive dyskinesia. In univariate analysis, significant associations were found between tardive dyskinesia and the following independent variables (higher values means greater risk): Age (p = 0.0001), years from onset of the disorder (p = 0.001), total length of stay in hospital (p = 0.001), PANSS (single scales and sum score) (p = 0.0001), total amount of neuroleptics expressed as CPZ equivalents (p = 0.004). Logistic regression analysis showed that only the variables "age" and "negative symptoms" expressed as score on the PANSS negative subscale showed an association with tardive dyskinesia that could not be explained by covariation with other variables. The same results were found when, instead of the dichotomous variable "tardive dyskinesia yes/no" the associations with the TDRS score were analyzed. Future research should aim to approach the neurobiological correlates of "age" and "negative symptoms" in relationship to tardive dyskinesia.

Susceptibility for alcoholism: DRD4 exon III polymorphism: a case-control and a family-based association approach

Abstract The present investigation explored whether the 7-repeat allele of the exon III polymorphism in the dopamine D4 receptor gene confers to susceptibility of alcoholism. Using a classical case-control approach we first compared DRD4 exon III VNTR frequencies between alcoholics and ethnically matched controls (sample I). Secondly, we applied a family-based association approach in an independent parent-offspring sample of alcoholics (sample II). All patients underwent an inpatient treatment for alcohol detoxification: sample I comprised 218 alcoholics and 197 ethnically matched controls, sample II included 76 alcoholics plus their biological parents. A higher proportion of addicted individuals in sample I revealed the 7-repeat allele compared to the control sample yielding an odds ratio (OR) of 1.43 (individuals homozygous for 7-repeat allele) and an OR of 1.69 (homozygous and heterozygous 7-repeat allele individuals together). However, we failed to detect preferential transmission from parents to offspring of either the 7-repeat allele or the long alleles (5-7 repeats) of the DRD4 exon III VNTR in the family-based association approach (sample II). The impact of the DRD4 exon III polymorphism on susceptibility to addictive behaviour putatively plays only a minor role in our sample of alcohol-dependent patients, since we were not able to replicate our findings by the family-based association approach. However, a larger sample size by the family-based approach would be needed (approximately > 300 parent-offspring trios) to definitely corroborate or reject the findings from our case-control sample.

The "possible triangle" test for extreme discordant sib pairs

For the analysis of quantitative traits in nuclear families, extreme discordant sib pairs proved to be more powerful than unselected sib pairs. Here, we present a test that makes use of selected pairs and, in addition, restricts the parameters of the identical-by-descent distribution analogously to the "possible triangle" for affected sib pairs. In the Problem 2A data, extreme discordant sib pairs are selected. The analysis allowed the detection of most simulated major genes.

Association study of the tryptophan hydroxylase gene and bipolar affective disorder using family-based internal controls

The tryptophan hydroxylase (TPH) gene encodes for the rate-limiting enzyme of the serotonin metabolism and, therefore, has to be considered a major candidate for association studies in affective disorders. Recently, an association between this gene and bipolar affective disorder has been reported in a French population. We sought to replicate this finding in a German sample. Allele frequencies of a biallelic polymorphism (A218C) of the TPH gene were determined in 95 bipolar I patients and their parents. Preferential transmission of alleles from heterozygous parents to bipolar offspring was tested with the "transmission disequilibrium test" (TDT), which eliminates the contribution of population stratification to an association finding. Our sample yielded a power >90% to detect the originally reported effect. Neither allele 218A nor allele 218C were preferentially transmitted from heterozygous parents to bipolar offspring. Our results, therefore, do not support the hypothesis that the TPH gene is involved in the etiology of bipolar disorder.

Linkage and family-based association study of schizophrenia and the synapsin III locus that maps to chromosome 22q13

The human synapsin III gene (synapsin III) is a member of a neuron-specific phosphoprotein gene family involved in short-term neurotransmitter release. We mapped synapsin III to chromosomal region 22q13 (13.1-13.31) by fluorescence in situ hybridization, a region that has been identified as a potential schizophrenia susceptibility locus. The dinucleotide repeat marker D22S280 located in intron 5 of synapsin III was genotyped in a linkage and family-based association study to assess the role of the synapsin III locus in the etiology of schizophrenia. In 12 pedigrees with periodic catatonia comprising 135 individuals, we found exclusion of linkage of marker D22S280 using lod score analysis with autosomal dominant/recessive models as well as affected only LOD score methods with dominant/recessive models. In a family-based association study of 61 unrelated parent-offspring trios with schizophrenia (according to the the Diagnostic and Statistical Manual of Mental Disorders, fourth edition [DSM-IV, American Psychiatric Association, 1994]), we found no association of individual D22S280 alleles to disease. Results of a multiallelic transmission/disequilibrium test (TDT(max) = 3.00; P = 0.55) challenged the possibility that D22S280 alleles appear with DSM-IV schizophrenia more frequently than expected. In addition, no evidence for gender differences or parent-of-origin effects were found. Thus, the synapsin III locus at chromosome 22q13 is not likely to contain a schizophrenia susceptibility gene.

Resonant X-ray diffraction using high-resolution image-plate data

The experimental setup for the collection of synchrotron X-ray powder diffraction data from samples with high absorption (μR> 10) is described. It consists of a combination of a vacuum chamber with an image-plate system. A numerical absorption correction for the applied geometry has been derived and the data were corrected accordingly. Values forf ′(Er) andf ′′(Er) were refined from eight measurements on Er5Re2O12above and below the ErLIIIabsorption edge. Successful refinement of the crystallographic data has verified the high quality of the collected intensities.

Conformational flexibility in the apolipoprotein E amino-terminal domain structure determined from three new crystal forms: implications for lipid binding

An amino-terminal fragment of human apolipoprotein E3 (residues 1-165) has been expressed and crystallized in three different crystal forms under similar crystallization conditions. One crystal form has nearly identical cell dimensions to the previously reported orthorhombic (P2(1)2(1)2(1)) crystal form of the amino-terminal 22 kDa fragment of apolipoprotein E (residues 1-191). A second orthorhombic crystal form (P2(1)2(1)2(1) with cell dimensions differing from the first form) and a trigonal (P3(1)21) crystal form were also characterized. The structures of the first orthorhombic and the trigonal form were determined by seleno-methionine multiwavelength anomalous dispersion, and the structure of the second orthorhombic form was determined by molecular replacement using the structure from the trigonal form as a search model. A combination of modern experimental and computational techniques provided high-quality electron-density maps, which revealed new features of the apolipoprotein E structure, including an unambiguously traced loop connecting helices 2 and 3 in the four-helix bundle and a number of multiconformation side chains. The three crystal forms contain a common intermolecular, antiparallel packing arrangement. The electrostatic complimentarity observed in this antiparallel packing resembles the interaction of apolipoprotein E with the monoclonal antibody 2E8 and the low density lipoprotein receptor. Superposition of the model structures from all three crystal forms reveals flexibility and pronounced kinks in helices near one end of the four-helix bundle. This mobility at one end of the molecule provides new insights into the structural changes in apolipoprotein E that occur with lipid association.

Systematic screening for DNA sequence variation in the coding region of the human dopamine transporter gene (DAT1)

The dopamine transporter (DAT) plays a central role in dopaminergic neurotransmission in the human brain. Genetic association studies have used a variable number of tandem repeat (VNTR) polymorphism in the 3'-flanking region of the dopamine transporter gene (DAT1) to implicate the DAT in the development of various neuropsychiatric disorders. In this study, we have examined the possibility that a mutation exists in the coding region of the DAT1 gene which through linkage disequilibrium accounts for the observed associations. The complete coding region, as well as exon-intron boundaries, was screened in 91 unrelated individuals including 45 patients with bipolar affective disorder and 46 healthy control individuals by the means of single strand conformation analysis. Our findings suggest that the DAT1 gene is highly conserved since we detected only two rare missense substitutions (Ala559Val, Glu602Gly) and three silent mutations (242C/T, 1342A/G, and 1859C/T) in the whole coding region. Five sequence variants were observed in intronic sequences but none affects known splice sites. The lack of frequent variants of possible functional relevance indicates that genetic variation in the coding region of the DAT1 gene is not responsible for the previously observed associations with neuropsychiatric disorders. The two rare missense substitutions were found in single bipolar patients but not in controls. Investigation of the patients' families revealed independent segregation between the Ala559Val variant and affective disorder. The Glu602Gly variant was inherited by the proband from an affected father. It therefore remains possible that Glu602Gly may be a rare cause of bipolar affective disorder.

Dopamine D3 receptor variant and tardive dyskinesia

In the search for genetic factors contributing to tardive dyskinesia, dopamine receptor genes are considered major candidates. The dopamine D3 receptor is of primary interest as dopamine D3 receptor knock-out mice show locomotor hyperactivation resembling extrapyramidal side-effects of neuroleptic treatment. Furthermore, Steen and colleagues (1997) recently reported an association between tardive dyskinesia and a dopamine D3 receptor gene variant. In the present study we tried to replicate this finding. We investigated 157 patients with schizophrenia or schizoaffective disorder receiving long-term neuroleptic medication who never or persistently displayed tardive dyskinesia. As advanced age is a main risk factor for tardive dyskinesia, we also compared older patients with a long duration of schizophrenia not displaying tardive dyskinesia to younger patients with a shorter duration of the illness displaying tardive dyskinesia. However, we found no evidence that the dopamine D3 receptor gene is likely to confer susceptibility to the development of tardive dyskinesia.

Association between an interleukin-6 promoter and 3' flanking region haplotype and reduced Alzheimer's disease risk in a German population

Several studies have demonstrated that interleukin-6 (IL-6) is involved in the pathogenesis of Alzheimer's disease (AD). We previously reported on an association between the C allele of a variable number of tandem repeat polymorphism in the 3' flanking region of IL-6 gene (IL-6vntr) and delayed initial onset and reduced AD risk. A novel G/C polymorphism at position -174 in the IL-6 gene promoter (IL-6prom) has recently been identified and appears to influence the regulation of IL-6 expression. We examined this functional polymorphism in 102 AD patients and two control groups of 191 healthy subjects and 160 depressed patients. There was no evidence for an allelic association between IL-6prom polymorphism and earlier age of onset or risk of AD. However, haplotype analysis showed a strong linkage disequilibrium between IL-6vntr and IL-6prom and demonstrated an interaction between IL-6vntr and IL-6prom which modifies AD risk.

Investigation of the human serotonin 6 [5-HT6] receptor gene in bipolar affective disorder and schizophrenia

Serotonin (5-hydroxytryptamine, 5-HT) is a neurotransmitter that mediates a wide range of central nervous functions by activating multiple 5-HT receptor subtypes. A possible irregularity of serotonergic neurotransmission has been implicated in a variety of neuropsychiatric diseases. In the present study, we performed a systematic mutation scan of the complete coding region and splice junctions of the 5-HT(6) receptor gene to explore the contribution of this gene to the development of bipolar affective disorder and schizophrenia. Investigating 137 unrelated individuals (including 45 bipolar affective patients, 46 schizophrenic patients, and 46 unrelated controls), we identified six single base substitutions (126G/T, 267C/T, 873+30C/T, 873+128A/C, 1128G/C, 1376T/G). Comparing frequencies between patients and controls, we observed a significant overrepresentation of the 267C allele among bipolar patients (P=0. 023 not corrected for multiple testing). This finding was followed up in an independent sample of 105 bipolar family trios using a family-based association design. Fifty-one transmissions could be examined. In 30 cases allele 267C and in 21 cases allele 267T were transmitted to the affected offspring. Although this result was far from statistical significance (transmission disequilibrium test=1.59, P=0.208), the limited number of possible transmissions may have prevented detection of smaller effects. Our preliminary data suggest that bipolar affective disorder may be associated with variation in the 5-HT(6) gene. It will be important to extend the present analysis to larger samples. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:217-221, 2000.

Same-day transfer of patients to the cardiac telemetry unit after surgery: the Rapid after Bypass Back into Telemetry (RABBIT) program

Early data from this project suggest that the RABBIT program fulfilled the process improvement goals of decreasing costs of cardiac surgery and maintaining high quality. Decreased cost was achieved by decreasing time to extubation and decreasing length of stay in the ICU and the total length of stay in the hospital. The cost savings were achieved without compromising the quality of care, which was assessed by measuring rates of readmission to the ICU and to the hospital and by surveying patients about their level of satisfaction. The success of the RABBIT program can be attributed to several factors. First, members of the cardiac surgery quality improvement team worked well together to solve problems and overcome obstacles, particularly after the pilot program. Second, naming the program helped to motivate staff, physicians, and patients. Outcome data was shared with the staff quarterly, and successes were celebrated. Finally, the use of a facilitator early in the process to establish the process with the surgeons and the staff was invaluable. Opportunities for continued improvement include resolving operational difficulties related to availability of beds and staffing, continuing work with physicians in changing practice patterns, increasing efficiency in scheduling operating rooms, and adjusting the preoperative education provided to patients and their families about the length of stay to expect. Quarterly outcome analysis continues, with reports to the cardiac surgery quality improvement team. The team continues to explore creative solutions to the aforementioned issues, as the goal of having 25% of patients who undergo cardiac surgery be transferred to the CTU on the day of surgery has remained elusive.

Same-day transfer of patients to the cardiac telemetry unit after surgery: the Rapid after Bypass Back into Telemetry (RABBIT) program

Early data from this project suggest that the RABBIT program fulfilled the process improvement goals of decreasing costs of cardiac surgery and maintaining high quality. Decreased cost was achieved by decreasing time to extubation and decreasing length of stay in the ICU and the total length of stay in the hospital. The cost savings were achieved without compromising the quality of care, which was assessed by measuring rates of readmission to the ICU and to the hospital and by surveying patients about their level of satisfaction. The success of the RABBIT program can be attributed to several factors. First, members of the cardiac surgery quality improvement team worked well together to solve problems and overcome obstacles, particularly after the pilot program. Second, naming the program helped to motivate staff, physicians, and patients. Outcome data was shared with the staff quarterly, and successes were celebrated. Finally, the use of a facilitator early in the process to establish the process with the surgeons and the staff was invaluable. Opportunities for continued improvement include resolving operational difficulties related to availability of beds and staffing, continuing work with physicians in changing practice patterns, increasing efficiency in scheduling operating rooms, and adjusting the preoperative education provided to patients and their families about the length of stay to expect. Quarterly outcome analysis continues, with reports to the cardiac surgery quality improvement team. The team continues to explore creative solutions to the aforementioned issues, as the goal of having 25% of patients who undergo cardiac surgery be transferred to the CTU on the day of surgery has remained elusive.

Quality and costs of community-based residential supports, village communities, and residential campuses in the United Kingdom

The costs, nature, and benefits of residential supports were examined for 86 adults with mental retardation living in village communities, 133 adults living in newly built residential campuses, and 281 adults living in dispersed housing schemes (small community-based group homes and supported living). Results indicated that (a) the adjusted comprehensive costs of provision in dispersed housing schemes were 15% higher than in residential campuses and 20% higher than in village communities; (b) dispersed housing schemes and village communities offered a significantly greater quality of care than did residential campuses; and (c) there appeared to be distinct patterns of quality of life benefits associated with dispersed housing schemes and village communities, with both approaches offering a greater quality of life than did residential campuses.

Altered splicing of the ATDC message in ataxia telangiectasia group D cells results in the absence of a functional protein

The ATDC gene was cloned using functional complementation and complements the radiosensitivity of ataxia telangiectasia (AT) group D cells. Although a number of transcripts have been detected, only a 3.0 kb cDNA found in a HeLa cell cDNA library has been cloned. Since AT group D cells express only a 2.4 kb transcript, efforts were made to clone and sequence this transcript. Using a biotinylated oligonucleotide probe, mRNA preparations were enriched in ATDC-related sequences. After this enrichment, 2.4 kb clones were obtained from the resulting library. The 2.4 kb transcript appears to be untranslated, since no protein from this transcript has been detected in AT group D cells, and this transcript is probably non-functional, since a splicing variation has positioned part of intron 1 near the first methionine codon in exon 1, eliminating most of exon 1 and important functional regions from this transcript. This transcript now has a stop codon located 33 bp in front of the first methionine, which would stop translation after the eleventh amino acid. As a result of these changes, the AT group D cell line (AT5BI) expresses no functional ATDC protein.

Vitamin D receptor allele combinations influence genetic susceptibility to type 1 diabetes in Germans

Vitamin D has been shown to exert manifold immunomodulatory effects. Because type 1 diabetes is regarded to be immune-mediated and vitamin D prevents the development of diabetes in the NOD mouse, we investigated the role of the vitamin D receptor (VDR) gene as a candidate for type 1 diabetes susceptibility. A total of 152 Caucasian families with at least one affected offspring were genotyped for four VDR restriction-site polymorphisms (FokI, BsmI, ApaI, and TaqI). Whereas the BsmI, ApaI, and TaqI polymorphisms are in strong linkage disequilibrium with each other, no significant linkage disequilibrium with the FokI site was observed. Extended transmission disequilibrium testing (ETDT) was used to detect preferential transmission of allelic combinations to affected offspring. We found significant haplotype-wise ETDT results for the BsmI/ApaI/TaqI (chi2 = 18.886, df = 7, P = 0.0086), the BsmI/TaqI (chi2 = 8.373, df = 3, P = 0.0389), and theApaI/TaqI (chi2 = 17.182, df = 3, P = 0.0006) haplotypes. The "At" and "Bt" alleles confer an increased risk, whereas "AT" and "at" are protective. The combination with the strongest susceptibility was the "BAt" haplotype (64% transmitted, P = 0.0106). Analysis of the FokI site does not provide more information on susceptibility (FokI/BsmI/ApaI/TaqI [chi2 = 24.702, df = 15, P = 0.0541]). These findings suggest a linkage of VDR itself or a nearby gene with type 1 diabetes susceptibility in Germans, confirming respective observations previously made in Indian Asians.

A European perspective on social anxiety disorder

Epidemiologic surveys conducted across Europe indicate that the lifetime prevalence of social anxiety disorder in the general population is close to 7%. The disorder in adulthood rarely presents in its 'pure' form and 70-80% of patients have at least one other psychiatric disorder, most commonly depression. Social anxiety disorder is a risk factor for the development of depression and alcohol/substance use or dependence, especially in cases with an early onset (< 15 years). Individuals with social anxiety disorder have significant functional impairment, notably in the areas of initiation and maintenance of social/romantic relationships and educational and work achievement. The economic consequences of social anxiety disorder are considerable, with a high level of diminished work productivity, unemployment and an increased utilisation of medical services amongst sufferers. Effective treatment of social anxiety disorder would improve its course and its health and economic consequences.

Serotonin transporter gene and schizophrenia: evidence for association/linkage disequilibrium in families with affected siblings

The serotonergic (5-HT) system has been implicated in the etiopathogenesis of psychoses. Since the 5-HT transporter plays an important role in regulation of 5-HT transmission, its gene can be considered as a candidate for vulnerability to psychiatric disorders. Two polymorphic sites of the 5-HT transporter gene-5-HTTLPR, a VNTR in the 5' regulatory region, and a VNTR in the second intron-were studied in a sample of 61 families with schizophrenia for transmission disequilibrium. Each family contained at least two siblings affected with schizophrenia or schizoaffective disorder (mainly schizophrenic). One hundred and thirty-nine affected offspring with parental information for genotyping, were available for analysis. No preferential transmission of either short or long alleles of the promoter polymorphism was observed. However, a transmission distortion was detected for alleles of the intronic VNTR polymorphism (chi2TDT max =14.33; P = 0.0002; corrected P value = 0.0003) resulting in more frequent than expected transmission of the 12 repeat allele. This finding adds additional evidence to the idea that the serotonergic system may be involved in development of psychoses. Molecular Psychiatry (2000) 5, 91-95.

DRD4 exon III VNTR polymorphism-susceptibility factor for heroin dependence? Results of a case-control and a family-based association approach

Dopaminergic abnormalities are implicated in the pathogenesis of substance abuse.1 Recently, two reports have been published suggesting an association between opioid dependence and presence of long alleles of the dopamine D4 receptor (DRD4) gene exon III VNTR.2, 3 We have attempted to replicate this finding using a two-tiered strategy employing independent case-control and family-based association samples. Our study was possibly the largest candidate gene association study to date on opioid dependence in a sample of 815 subjects, 396 of whom were patients. We found long alleles of the DRD4 exon III VNTR in similar frequency among 285 heroin addicts and 197 controls. Furthermore, no preferential transmission of long alleles to affected offspring was observed in a sample of 111 patients and their parents. Our results, therefore, do not support the hypothesis that alleles of the DRD4 exon III VNTR are susceptibility factors for opioid dependence in man. Molecular Psychiatry(2000) 5, 101-104.

Complex segregation analysis of families ascertained through Gilles de la Tourette syndrome

Although family and twin studies suggest that genetic factors are involved in the etiology of Tourette syndrome and other related tic disorders, further evidence is needed to demonstrate that the familial transmission is consistent with known genetic factors. We performed a complex segregation analysis that allowed for a variable age of onset of Gilles de la Tourette, other tic disorders and obsessive compulsive phenotype information on 108 extended families, each ascertained through one Tourette proband by using regressive models that are able to incorporate additional explanatory variables and major gene effects. A special version of the S.A.G.E. program, REGTLhunt, was used to explore the likelihood surface of all examined models. Results indicated that the pattern of Tourette and other related tic disorders in our data sample is not consistent with Mendelian inheritance even after modelling explanatory variables such as obsessive compulsive symptomatology.

Genetic analysis of a complex disease in the presence of an environmental risk factor

The role of a gene in a disease may be hidden by the presence of another risk factor such as an environmental factor. In that case, stratifying the data according to this factor strengthens power to detect linkage or association. We followed this strategy on the simulated data provided by GAW11. The transmission/disequilibrium test (TDT) and the maximum likelihood score (MLS) were performed on the first replicate of 100 sib pairs from the population in which the disease risk was significantly influenced by an environmental factor (E1). However, only the TDT was powerful enough to detect one of the four loci involved in the genetic determination of the disease. The MLS showed no evidence for linkage after taking into account the fact that multiple tests were performed. Even when stratifying the sample according to the presence of E1, no additional loci could be detected. Given the simulated models, 100 sib pairs are too low a sample size for a systematic screening of the genome, which in this case was an analysis of 300 markers.

Costs and disability among stroke patients

BACKGROUND

The high costs of health and social care support for stroke survivors, and the development of new service arrangements, have concentrated growing attention on economic issues. However, there are few data on costs and their association with levels of disability.

METHODS

Secondary analyses of data from the OPCS (Office of Population Censuses and Surveys) Surveys of Disability conducted in the mid-1980s were used to examine service utilization and costs for more than 1000 people who have had a stroke. Costs were estimated for all health and social care services. Regression analyses examined the cost-disability association in the context of other covariates for people living in private households.

RESULTS

Disability problems were common among stroke survivors, particularly in relation to locomotion, self-care and holding. Among people living alone, the major contributors to costs were in-patient care (Pound Sterling 27 per week) and home help (Pound Sterling 30 per week). Among people living with others, in-patient hospital care was also a major cost (Pound Sterling 28 per week). Other services costing more than Pound Sterling 5 per week were general practitioner consultations, hospital out-patient care and day centre attendances. Resource use patterns varied considerably. Costs were associated with severity of disability, time since stroke and whether the person was living alone. Looking at the overall balance of care, a greater proportion of stroke survivors with severe disability were resident in communal establishments.

CONCLUSION

The analyses provide a baseline from which more recent local studies and evaluations can be compared. Key issues for economic studies of stroke are the inclusion of a broad range of services, a reasonable duration of follow-up and consideration of the impact of the substitution of informal for formal services.

The EPSILON study of schizophrenia in five European countries. Design and methodology for standardising outcome measures and comparing patterns of care and service costs

BACKGROUND

There is a lack of cross-national research on care for people with schizophrenia.

AIMS

To produce standardised European versions of five instruments in key areas of mental health service research in five languages, and to compare data from five European countries regarding patients with schizophrenia and mental health care provision and costs.

METHOD

Five centres, in Amsterdam, Copenhagen, London, Santander and Verona, participated. Instruments assessing needs, service use, informal career involvement, quality of life, and service satisfaction were subjected to a conversion procedure including translation, back-translation, focus group discussion and reliability assessment. Patients of local mental health services with a Schedules for Clinical Assessment in Neuropsychiatry diagnosis of schizophrenia were interviewed.

RESULTS

Service provision varied between sites; 404 patients were studied. Instrument reliability was found to be good.

CONCLUSIONS

The instruments developed were reliable across the range of countries, and will facilitate future comparative health service research.

hSKCa3: no association of the polymorphic CAG repeat with bipolar affective disorder and schizophrenia

hSKCa3 is a neuronal small conductance calcium-activated potassium channel, which contains a polyglutamine tract, encoded by a polymorphic CAG repeat in the gene. Since an association between longer alleles of this CAG repeat and bipolar disorder or schizophrenia has been reported, we genotyped the polymorphic CAG repeat in 91 German family trios of patients with bipolar disorder I and used the transmission disequilibrium test (TDT) to test for association. Applying a dichotomized model (< or = 19 or > 19 CAG triplets), we found no evidence for an association of longer alleles with bipolar disorder (TDT = 0.75, P = 0.386). Regarding the whole range of alleles, there was no preference in transmitting the larger of the two observed alleles from parents to the affected offspring. In parallel we performed an independent case-control study on German patients with bipolar disorder and schizophrenia. Again we did not detect an overrepresentation of longer CAG repeats in patients. Thus, our data do not support the hypothesis that longer CAG repeats in the hSkCa3 gene contribute to the susceptibility for bipolar disorder and schizophrenia.

Carboxyl-terminal domain of human apolipoprotein E: expression, purification, and crystallization

Thioredoxin fusion expression vectors for two carboxyl-terminal fragments of human apolipoprotein (apo) E (residues 223-272 and 223-299) were generated from an apoE cDNA with the objective of obtaining structural information on this functionally important region of apoE by X-ray crystallography. A thrombin cleavage recognition site was positioned at the fusion junction to release the apoE fragments from the fusion protein. The fusion proteins were expressed in Escherichia coli, isolated from cell lysates by nickel-affinity column chromatography, and cleaved with thrombin. After gel filtration and ion exchange chromatography, yields of each fragment were approximately 14 mg/L. Both fragments bind to the phospholipid dimyristoylphosphatidylcholine in a manner similar to that of the 216-299 fragment of apoE isolated from plasma, which represents the major lipid-binding region of the protein. Orthorhombic crystals of the apoE 223-272 fragment that diffracted to 1.8 A were obtained in a mixture of 0.1 M imidazole (pH 6.0) and 0.4 M NaOAc (pH 7.0-7.5), containing 30% glycerol. The space group is C222 with cell dimensions of a = 35.17 A, b = 38.95 A, and c = 133.27 A.

Extraction of rutin from buckwheat (Fagopyrum esculentumMoench) seeds and determination by capillary electrophoresis

The content of the flavonoid rutin was determined in different milling fractions of buckwheat seeds and in buckwheat stems, leaves, and flowers. The extraction was performed by using a solvent containing 60% of ethanol and 5% of ammonia in water. The extracts were analyzed by capillary electrophoresis (running buffer of 50 mM borate (pH 9.3), 100 mM sodium dodecyl sulfate; determination at 380 nm). In bran fractions the concentration of rutin was 131-476 ppm, and in flour fractions 19-168 ppm. On average, about 300, 1000, and 46000 ppm of rutin were found in leaves, stems, and flowers, respectively. The results indicate that buckwheat could be an important nutritional source of flavonoids, especially in countries with a low mean daily flavonoid intake.

Human delta-opioid receptor gene and susceptibility to heroin and alcohol dependence

In the present study, we tested the hypothesis that addictive behavior may be influenced by genetic variation in the human delta-opioid receptor gene. We investigated the contribution of a silent T to C change in the coding region to the development of heroin and alcohol dependence using large case-control and family-based association samples. Presence of the C allele was previously reported to significantly increase the risk for heroin dependence. In the present study, however, we did not find statistically significant differences between patients and controls nor did we find preferential transmission of the C allele from parents to affected offspring. Our results, therefore, do not support an association between genetic variation of the delta-opioid receptor and addictive behavior in man.

Evaluating mental health policy in England. Care Programme Approach and supervision registers

BACKGROUND

The Care Programme Approach (CPA) and supervision register policies in England are intended to prioritize patients to receive specialist mental health care.

AIMS

To describe and evaluate the practical application of the policies.

METHOD

A questionnaire survey of key informants in mental health provider trusts and an analysis of aggregated data collected by health authorities using the Mental Illness Needs Index as a measure of population need.

RESULTS

On average, 1175 per 100,000 total population are subject to the CPA (95% CI = 1055-1309) and 8.6 per 100,000 (95% CI = 7.5-9.9) are on supervision registers. Wide local variations in the number of people subject to the CPA and supervision registers are not explained by variations in population need.

CONCLUSIONS

Prioritization to receive specialist mental health services is carried out inconsistently, and inequitable use of resources may result.

Engineered Bacillus lentus subtilisins having altered flexibility

The three-dimensional structures of engineered variants of Bacillus lentus subtilisin having increased enzymatic activity, K27R/N87S/V104Y/N123S/T274A (RSYSA) and N76D/N87S/S103A/V104I (DSAI), were determined by X-ray crystallography. In addition to identifying changes in atomic position we report a method that identifies protein segments having altered flexibility. The method utilizes a statistical analysis of variance to delineate main-chain temperature factors that represent significant departures from the overall variance between equivalent regions seen throughout the structure. This method reveals changes in main-chain mobility in both variants. Residues 125-127 have increased mobility in the RSYSA variant while residues 100-104 have decreased mobility in the DSAI variant. These segments are located at the substrate-binding site and changes in their mobility are believed to relate to the observed changes in proteolytic activity. The effect of altered crystal lattice contacts on segment flexibility becomes apparent when identical variants, determined in two crystal forms, are compared with the native enzyme.

Functional PAX-6 gene-linked polymorphic region: potential association with paranoid schizophrenia

BACKGROUND

Early differentiation of the nervous system and adult CNS neuroplasticity is modulated by PAX-6. We have shown previously that a highly polymorphic, functional AC/AG repeat in the 5' regulatory region of the gene showed significantly increased promoter activity, if containing > or = 29 repeats, and that the heterozygous genotype (< or = 28/> or = 29) revealed increased mRNA PAX-6 levels in human brain tissue compared to the homozygous short variant.

METHODS

In a case-control study of 655 unrelated individuals, allele frequencies and genotype distributions of the functional PAX-6 promoter polymorphism were investigated comprising patients with DSM-IV schizophrenia, patients with affective disorders, and population controls.

RESULTS

No allelic or genotypic association of the PAX-6 promoter polymorphism to affective disorder or to schizophrenia as one disease entity was observed. After subtyping schizophrenia into paranoid and nonparanoid forms, potential evidence was found for a genotypic association of the high-activity variant with the paranoid subtype of schizophrenia (p = .02). The estimated odds ratio was 1.7 (95% CI .98 to 2.95) for those heterozygous and 1.4 (95% CI .82 to 2.42) for those heterozygous or homozygous for the high-activity variant compared to the homozygous low-activity variant.

CONCLUSIONS

Our finding indicates that early developmental genes may be involved in the etiopathogenesis of schizophrenia subtypes via variable transcriptional regulation in the developing and adult human brain.