Attention-deficit hyperactivity disorder in children born to mothers with infertility: a population-based cohort study

STUDY QUESTION

Is the risk of attention-deficit hyperactivity disorder (ADHD) increased in children born to mothers with infertility, or after receipt of fertility treatment, compared to mothers with unassisted conception?

SUMMARY ANSWER

Infertility itself may be associated with ADHD in the offspring, which is not amplified by the use of fertility treatment.

WHAT IS KNOWN ALREADY

Infertility, and use of fertility treatment, is common. The long-term neurodevelopmental outcome of a child born to a mother with infertility, including the risk of ADHD, remains unclear.

STUDY DESIGN, SIZE, DURATION

This population-based cohort study comprised all singleton and multiple hospital births in Ontario, Canada, 2006–2014. Outcomes were assessed up to June 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Linked administrative datasets were used to capture all hospital births in Ontario, maternal health and pregnancy measures, fertility treatment and child outcomes. Included were all children born at ≥24 weeks gestation between 2006 and 2014, and who were alive at age 4 years. The main exposure was mode of conception, namely (i) unassisted conception (reference group), (ii) infertility without fertility treatment (history of an infertility consultation with a physician within 2 years prior to conception but no fertility treatment), (iii) ovulation induction (OI) or intrauterine insemination (IUI) and (iv) IVF or intracytoplasmic sperm injection (ICSI). The main outcome was a diagnosis of ADHD after age 4 years and assessed up to June 2020. Hazard ratios (HRs) were adjusted for maternal age, income quintile, rurality, immigration status, smoking, obesity, parity, any drug or alcohol use, maternal history of mental illness including ADHD, pre-pregnancy diabetes mellitus or chronic hypertension and infant sex. In addition, we performed pre-planned stratified analyses by mode of delivery (vaginal or caesarean delivery), infant sex, multiplicity (singleton or multiple), timing of birth (term or preterm <37 weeks) and neonatal adverse morbidity (absent or present).

MAIN RESULTS AND THE ROLE OF CHANCE

The study included 925 488 children born to 663 144 mothers, of whom 805 748 (87%) were from an unassisted conception, 94 206 (10.2%) followed infertility but no fertility treatment, 11 777 (1.3%) followed OI/IUI and 13 757 (1.5%) followed IVF/ICSI. Starting at age 4 years, children were followed for a median (interquartile range) of 6 (4–8) years. ADHD occurred among 7.0% of offspring in the unassisted conception group, 7.5% in the infertility without fertility treatment group, 6.8% in the OI/IUI group and 6.3% in the IVF/ICSI group. The incidence rate (per 1000 person-years) of ADHD was 12.0 among children in the unassisted conception group, 12.8 in the infertility without fertility treatment group, 12.9 in the OI/IUI group and 12.2 in the IVF/ICSI group. Relative to the unassisted conception group, the adjusted HR for ADHD was 1.19 (95% CI 1.16–1.22) in the infertility without fertility treatment group, 1.09 (95% CI 1.01–1.17) in the OI/IUI group and 1.12 (95% CI 1.04–1.20) in the IVF/ICSI group. In the stratified analyses, these patterns of risk for ADHD were largely preserved. An exception was seen in the sex-stratified analyses, wherein females had lower absolute rates of ADHD but relatively higher HRs compared with that seen among males.

LIMITATIONS, REASONS FOR CAUTION

Some mothers in the isolated infertility group may have received undocumented OI oral therapy, thereby leading to possible misclassification of their exposure status. Parenting behaviour, schooling and paternal mental health measures were not known, leading to potential residual confounding.

WIDER IMPLICATIONS OF THE FINDINGS

Infertility, even without treatment, is a modest risk factor for the development of ADHD in childhood. The reason underlying this finding warrants further study.

STUDY FUNDING/COMPETING INTEREST(s)

This study was made possible with funding from the Canadian Institutes of Health Research, Grant number PJT 165840. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Observed psychopathology in offspring of parents with major depressive disorder, bipolar disorder and schizophrenia

BACKGROUND

Children of parents with mood and psychotic disorders are at elevated risk for a range of behavioral and emotional problems. However, as the usual reporter of psychopathology in children is the parent, reports of early problems in children of parents with mood and psychotic disorders may be biased by the parents' own experience of mental illness and their mental state.

METHODS

Independent observers rated psychopathology using the Test Observation Form in 378 children and youth between the ages of 4 and 24 (mean = 11.01, s.d. = 4.40) who had a parent with major depressive disorder, bipolar disorder, schizophrenia, or no history of mood and psychotic disorders.

RESULTS

Observed attentional problems were elevated in offspring of parents with major depressive disorder, bipolar disorder and schizophrenia (effect sizes ranging between 0.31 and 0.56). Oppositional behavior and language/thought problems showed variable degrees of elevation (effect sizes 0.17 to 0.57) across the three high-risk groups, with the greatest difficulties observed in offspring of parents with bipolar disorder. Observed anxiety was increased in offspring of parents with major depressive disorder and bipolar disorder (effect sizes 0.19 and 0.25 respectively) but not in offspring of parents with schizophrenia.

CONCLUSIONS

Our results suggest that externalizing problems and cognitive and language difficulties may represent a general manifestation of familial risk for mood and psychotic disorders, while anxiety may be a specific marker of liability for mood disorders. Observer assessment may improve early identification of risk and selection of youth who may benefit from targeted prevention.

Active behaviors and screen time in offspring of parents with major depressive disorder, bipolar disorder and schizophrenia

Activities may be modifiable factors that moderate the risk and resilience in the development of mental health and illness. Youth who spend more time using screens are more likely to have poor mental health. Conversely, time spent engaged in active behaviors (i.e., physical activity, socializing and reading) is associated with better mental health. The choice of activities may be important in offspring of parents with mental illness, who are at increased risk for developing mental disorders. Among 357 youth of the FORBOW (Families Overcoming Risks and Building Opportunities for Well-being) cohort aged 6-21, we examined whether parental diagnosis of mental illness (i.e., major depressive disorder, schizophrenia and bipolar disorder) and current levels of depression influenced the amount of time their offspring spent using screens and engaging in active behaviors. Parental history of mental illness and higher levels of current depression in mothers were associated with less time spent engaged in active behaviors and more time spent using screens. Creating opportunities and incentives for active behaviors may redress the balance between youth with and without a familial history of mental illness.

Effect of Osteopathic Manipulative Therapy on Generalized Anxiety Disorder

Context

Traditional management options for generalized anxiety disorder (GAD) have produced low remission rates. As a result, the medical community has turned to complementary and alternative medicine for adjunctive treatment.

Objective

To investigate the efficacy of adjunctive osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) in individuals with GAD.

Methods

This open-label, nonrandomized, black-box study took place at a tertiary care mental health clinic in Toronto, Canada. Adult outpatient participants aged 18 to 65 years with a primary diagnosis of moderate-severe GAD (HAM-A score of ≥20) with or without comorbidities were enrolled in the study between June 2014 and January 2015. Patients who qualified and completed the study received 5 individually tailored OMTh sessions over the course of 8 to 9 weeks. A diagnostic psychiatric assessment (Mini International Neuropsychiatric Interview version 6.0.0) was conducted to confirm diagnoses, along with physician-administered and self-reported measures of anxiety, including the Hamilton Anxiety Scale (HAM-A), the Beck Anxiety Inventory, and the Intolerance for Uncertainty Scale.

Results

Significant reductions in total HAM-A scores after OMTh were observed (P<.0001). Significant reductions in total Intolerance for Uncertainty Scale scores were also observed (P<.0001). Beck Anxiety Inventory scores were not found to change significantly with OMTh. Response (defined as 50% reduction of symptoms) and remission (defined as HAM-A score of ≤7) rates were found to be 62% and 26.9%, respectively.

Conclusion

Osteopathic manipulative therapy may be a valuable adjunct to conventional therapy in patients with GAD, thus warranting further investigation using double-blind procedures.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis {CAPD): A Multi-Centre Randomized Clinical Trial Comparing the Y Connector Disinfectant System to Standard Systems

sixty-one new continuous ambulatory peritoneal dialysis (CAPD) patients were allocated to a Y connector disinfectant (Amuchina, Italy) and 63 to standard systems (Baxter Systems II & III) in a randomized clinical trial addressing peritonitis rates in 8 CAPD programs in 6 Canadian cities. In the Y connector-disinfectant group, 15 patients experienced 21 episodes of peritonitis in 452 patient-months or 1 per 21.53 patient-months. In the standard systems group, 30 patients experienced 47 episodes of peritonitis in 467 patient-months or 1 per 9.93 patient-months ( p = 0.009). The peritonitis risk reduction was 61% (95% confidence limits 27–79%). Exit-site infections occurred in 36% of each group.

Prior to the development of exit -site infection, the monthly risk for peritonitis was 3.12% for the Y connector disinfectant system and 7.37% for the standard system. After an exit -site infection, these probabilities increased to 6.15% and 15.47%, respectively. Skin organisms were responsible for peritonitis in 8/21 (38%) in the Y connector-disinfectant group and 30/47 (64%) in the standard group. There were 75 days hospitalized for peritonitis in the Y connector-disinfectant group compared to 257 days for the standard group. The Y connector disinfectant system decreases the peritonitis rate through its effect on skin organisms. Exit -site infections are a major source of organisms responsible for peritonitis.

Patient Willingness to Consent to Mobile Phone Data Collection for Mental Health Apps: Structured Questionnaire

BACKGROUND

It has become possible to use data from a patient's mobile phone as an adjunct or alternative to the traditional self-report and interview methods of symptom assessment in psychiatry. Mobile data-based assessment is possible because of the large amounts of diverse information available from a modern mobile phone, including geolocation, screen activity, physical motion, and communication activity. This data may offer much more fine-grained insight into mental state than traditional methods, and so we are motivated to pursue research in this direction. However, passive data retrieval could be an unwelcome invasion of privacy, and some may not consent to such observation. It is therefore important to measure patients' willingness to consent to such observation if this approach is to be considered for general use.

OBJECTIVE

The aim of this study was to measure the ownership rates of mobile phones within the patient population, measure the patient population's willingness to have their mobile phone used as an experimental assessment tool for their mental health disorder, and, finally, to determine how likely patients would be to provide consent for each individual source of mobile phone-collectible data across the variety of potential data sources.

METHODS

New patients referred to a tertiary care mood and anxiety disorder clinic from August 2016 to October 2017 completed a survey designed to measure their mobile phone ownership, use, and willingness to install a mental health monitoring app and provide relevant data through the app.

RESULTS

Of the 82 respondents, 70 (85%) reported owning an internet-connected mobile phone. When asked about installing a hypothetical mobile phone app to assess their mental health disorder, 41% (33/80) responded with complete willingness to install with another 43% (34/80) indicating potential willingness to install such an app. Willingness to give permissions for specific types of data varied by data source, with respondents least willing to consent to audio recording and analysis (19% [15/80] willing respondents, 31% [25/80] potentially willing) and most willing to consent to observation of the mobile phone screen being on or off (46% [36/79] willing respondents and 23% [18/79] potentially willing).

CONCLUSIONS

The patients surveyed had a high incidence of ownership of internet-connected mobile phones, which suggests some plausibility for the general approach of mental health state inference through mobile phone data. Patients were also relatively willing to consent to data collection from sources that were less personal but expressed less willingness for the most personal communication and location data.

Low hedonic tone and attention-deficit hyperactivity disorder: risk factors for treatment resistance in depressed adults

BACKGROUND

The burdens imposed by treatment-resistant depression (TRD) necessitate the identification of predictive factors that may improve patient treatment and outcomes. Because depression and attention-deficit hyperactivity disorder (ADHD) are frequently comorbid and share a complex relationship, we hypothesized that ADHD may be a predictive factor for the diagnosis of TRD. This exploratory study aimed to determine the percentage of undetected ADHD in those with TRD and evaluate factors associated with treatment resistance and undetected ADHD in depressed patients.

SUBJECTS AND METHODS

Adults referred (n=160) for psychiatric consultation completed a structured interview (MINI Plus, Mini International Neuropsychiatric Interview Plus) to assess the presence of psychiatric disorders.

RESULTS

TRD was significantly associated with the number of diagnoses (P<0.001), past (P<0.001) and present medications (P<0.001), chronic anhedonia (P=0.013), and suicide ideation (P=0.008). Undetected ADHD was present in 34% of TRD patients. The number of referral diagnoses (P<0.001), failed medications (P=0.002), and past selective serotonin reuptake inhibitor failures (P=0.035) were predictive of undetected ADHD in TRD.

CONCLUSION

Undetected ADHD may be more prevalent among TRD patients than previously thought. In addition, TRD patients are more likely to present with psychiatric comorbidity than non-TRD patients. Screening patients with depression for the presence of ADHD and chronic anhedonia/low hedonic tone may help identify patients with TRD and undetected ADHD and improve treatment outcomes.

Adjunctive Vitamin D in the treatment of non-remitted depression: Lessons from a failed clinical trial

BACKGROUND

Many patients with depression fail to achieve remission after several consecutive treatments. Vitamin D deficiency is prevalent and new research suggests that it may have an impact on mood, primarily through an effect on neurotransmitters. Numerous observational studies suggest a relationship between low levels of vitamin D and increased incidence and severity of mood disorders. A small number of pilot studies have been undertaken but lack rigorous methodology required to draw conclusions about a clinical role for this nutrient in treatment resistant depression.

METHODS

This study was designed as a randomized, double-blind, placebo controlled intervention study administering a weekly (bolus) dose of 28 000IU of Vitamin D3 or placebo to 125 patients with non-remitted depression adjunct to current antidepressant medication. Patients were followed weekly for eight weeks plus a one month follow up. Outcomes measured included depression severity, serum vitamin D levels and safety. Due to slow recruitment during the first season, amendments were made. These included extending the age range to 18-75 and removing the requirement for failing to respond to one pharmacologic antidepressant agent. The protocol was amended to reduce the burden on participants by changing the in-office visits to bi-weekly. Three additional tertiary psychiatric clinics were also added as trial sites.

RESULTS

Over three recruitment period years (fall/winter), a total of 148 participants completed screening, 24 (16.2%) of whom qualified to participate in the study. Use of too many or no psychiatric medications, comorbid exclusionary psychiatric conditions, current use of a vitamin D supplement, and lack of participant compensation were the predominant reasons for ineligibility or unwillingness to participate. 9 participants were successfully enrolled in the study, 7 (77.8%) of whom completed the trial as per the protocol. After the third season, futility was declared based on inability to enroll participants. The sample size of enrolled participants (7/125, 5.6%) lacks power to conduct a full assessment of findings.

DISCUSSION

High accessibility of vitamin D, as well as a growing lack of equipoise in patients and clinicians about the potential ubiquitous benefits of vitamin D for Canadians, not just for mood disorders, resulted in a large proportion of ineligible potential participants. Limited funding provided to studies on natural health products hampered recruitment. The labile and fluctuating nature of non-remitted depression as well as frequent co-morbid conditions creates additional challenges for conducting trials in this population. Future studies assessing vitamin D in depression should consider our experiences in design and conduct of research. Innovations in clinical trial design such as preference trials or accepting patients already using vitamin D but not achieving an optimal target value are potential solutions to some of these challenges.

Intolerance of uncertainty, social anxiety, and generalized anxiety: Differences by diagnosis and symptoms

Research suggests that Intolerance of Uncertainty (IU) is related to the severity of suffering in Generalized Anxiety Disorder (GAD). However, its role in Social Anxiety Disorder (SAD) has not been extensively studied. This study examines IU in a clinical sample of 248 individuals referred to a tertiary care clinic. Few individuals had a diagnosis of pure SAD or pure GAD, but we examined differences of IU scores by diagnostic category. We further examined the relationships between IU scores, social anxiety scores, and worry through a structural equation model. We found that diagnostic category (SAD versus GAD) accounted for little variability in IU scores, but IU scores were strongly related to symptoms of both GAD and SAD. Results highlight that IU is related to both social anxiety and worry; however aspects of IU associated with being unable to act or avoiding uncertainty are more strongly associated with SAD symptoms, whereas aspects of IU more associated with general stress and perceiving uncertainty as unfair are more strongly associated with GAD symptoms. Our results suggest that IU is an important concept for both social anxiety and generalized anxiety, however the relationship between IU and symptoms of these disorders manifests differently.

Abstract A34: BRCA1 and BRCA2 mutation spectrum across 5, 509 high-risk individuals identifies pathogenic variants associated with ethnicity, age of diagnosis, and type of cancer

Hereditary Breast and Ovarian Cancer Sydrome (HBOC) accounts for approximately 5-10% of breast and ovarian cancer cases and germline mutations of the BRCA1 and BRCA2 genes confer substantially increased risk. However, the risk of developing cancer, the type of cancer and the associated age at diagnosis vary depending on the type of mutation carried and the individual's ethnic background and gender. Screening of BRCA1 and BRCA2 mutations was conducted on 5, 512 high-risk individuals with a prior probability of carrying a pathogenic mutation (&gt;10% chance) from the Advanced Molecular Diagnostics Laboratory (AMDL) (Mount Sinai Hospital, Toronto). Information on age, type of cancer diagnosed and age at diagnosis, ethnicity and family history were collected. Cumulative incidence competing risk and Fine-Gray proportional hazard regression analyses were generated to determine factors associated with earlier diagnosis of cancer. Among 5,029 women and 480 men who underwent testing, a total of 845 unique variants were identified of which, 289 (34.2%) are pathogenic. There were 603 female mutation carriers, of these, 303 were affected with breast or ovarian cancer (50%), 16 with another cancer (2.25%) and 284 were unaffected (47.1%). We also identified 20 different ethnic groups presenting with at least 3 unique variants. Six ethnic groups carried at least one variant associated with an earlier diagnosis of cancer and differential breast or ovarian cancer incidence. For instance, among the Ashkenazi Jewish cohort, the c.68_69del variant was associated with significantly earlier age at diagnosis for ovarian cancer incidence (Gray's test = 40.6; Fine-Gray HR = 1.12, 95% CI = 1.05 – 1.31). By screening a diverse cohort of high-risk individuals for BRCA1 and BRCA2 mutations, we identified pathogenic variants associated with an earlier age of diagnosis and differential incidence of breast or ovarian cancer among unique ethnic groups.

Citation Format: Andrew H. Girgis, Marina Wang, Alexa Fine Kathleen-Rose ZakoorSam Khalouei, George Charames, Jordan Lerner-Ellis. BRCA1 and BRCA2 mutation spectrum across 5, 509 high-risk individuals identifies pathogenic variants associated with ethnicity, age of diagnosis, and type of cancer. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research; Oct 17-20, 2015; Bellevue, WA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(2_Suppl):Abstract nr A34.

Genetic testing for BRCA1 and BRCA2 in the Province of Ontario

In 2001, genetic testing for BRCA1 and BRCA2 was introduced in Ontario, for women at high-risk of breast or ovarian cancer. To date over 30,000 individuals have been tested throughout Ontario. Testing was offered to all Ontario residents who were eligible under any of 13 criteria. We report the results of tests conducted at Mount Sinai Hospital from 2007 to 2014. A total of 4726 individuals were tested, 764 (16.2%) were found to carry a pathogenic variant (mutation). Among 3684 women and men who underwent testing without a known familial BRCA mutation, 331 (9.0%) were found to carry a mutation. Among 1042 women and men tested for a known family mutation, 433 (41.6%) were positive. There were 603 female mutation carriers, of these, 303 were affected with breast or ovarian cancer (50%) and 16 with another cancer (2.3%). Of 284 unaffected female carriers, 242 (85%) were tested for a known family mutation and 42 (15%) were the first person in the family to be tested. By placing greater emphasis on recruiting unaffected female relatives of known mutation carriers for testing, greater than one-half of newly identified carriers will be unaffected.

Specific systemic lupus erythematosus disease manifestations in the six months prior to conception are associated with similar disease manifestations during pregnancy

Past studies have focused on aggregate lupus disease activity during pregnancy and have produced conflicting results. Our study evaluated lupus activity based on involvement of five specific organ systems during the six months prior to conception and during pregnancy. We assessed 147 pregnancies among 113 women followed at Brigham and Women's Lupus Center, 1990-2013. Organ-specific activity included hematologic disorder, nephritis, skin disease, arthritis, and serositis. We hypothesized that the presence of organ-specific activity six months prior to conception would increase the risk for that same type of activity during pregnancy. Our study population was 68% white; 100% had a positive ANA and 30% had a history of nephritis. Among women with organ-specific lupus activity during the six months before conception, the crude odds for the same type of activity during pregnancy was 7.7- to 32.5-fold higher compared to women without that type of activity immediately before conception. An adjusted logistic regression model also indicated significantly higher odds of organ-specific activity during pregnancy if that type of activity were present six months before conception. Approaching lupus based on specific organ systems may be a useful way for women and their physicians to consider the potential risk for disease activity during pregnancy.

Development of SLE among "potential SLE" patients seen in consultation: long-term follow-up

OBJECTIVE

To identify factors associated with development of systemic lupus erythematosus (SLE) among patients evaluated at a tertiary care Lupus Center for potential SLE.

METHODS

We identified patients first seen at the Brigham and Women's Hospital Lupus Center between 1 January 1992 and 31 December 2012 and thought to have potential SLE by a board-certified rheumatologist. All had 1-3 SLE ACR criteria at initial visit and > 2 follow-up visits ≥ 3 months apart. We reviewed medical records through 15 May 2013 for: SLE signs and symptoms, autoimmune serologies, prescriptions and diagnoses by board-certified rheumatologists. Bivariable analyses and multivariable logistic regression models were used to identify independent predictors of developing SLE.

RESULTS

Two hundred and sixty four patients met inclusion criteria. At initial visit, mean age was 39.2 (SD 12.4) years, 94% were female and 67% white. Mean number of SLE ACR criteria was 2.7 (SD 1.0) and 88% were antinuclear antibody (ANA) positive at initial consultation. Mean follow-up time was 6.3 (SD 4.3) years and 67% were prescribed hydroxychloroquine in follow-up. At most recent visit, 56 (21%) had been diagnosed with SLE; 47 (18%) were thought not to have SLE and 161 (61%) were still considered to have potential SLE. In multivariable regression models, oral ulcers (OR 2.40, 95% CI 1.03-5.58), anti-dsDNA (OR 2.59, 95% CI 1.25-5.35) and baseline proteinuria or cellular casts (OR 16.20, 95% CI 1.63-161.02) were independent predictors of developing SLE. The most common other final diagnoses included fibromyalgia, Sjögren's syndrome, mixed connective tissue disease and cutaneous lupus.

CONCLUSION

Among patients with potential SLE at initial consultation, 21% were diagnosed with definite SLE within 6.3 years. Oral ulcers, anti-dsDNA and proteinuria or cellular casts were independent predictors of developing definite SLE. A better means of accurately identifying those who will develop SLE among those presenting with potential disease is necessary.

[Anthropological approach to current parental perceptions of children's seizures]

Pediatric seizures are a common symptom, especially when associated with fever. This phenomenon is still shocking and traumatic for parents. The study analyzed current parental perceptions of seizures in order to improve the quality of management, care, and explanations provided to families at our emergency unit.

METHODS

Using an anthropological approach, we analyzed 28 interviews of 37 parents whose child was admitted to our pediatric emergency unit between November 2007 and August 2008 due to a first seizure.

RESULTS

The parental experience of the crisis was marked by upsetting memories of a "scary"-looking body and the perception of imminent death. Parental interpretations of the pathophysiology of the event were often wrong; very few mentioned the possibility of its cerebral origin, leading to inappropriate rescue attempts (e.g., giving CPR). The meaning attributed by parents to the word "seizure" and "epilepsy" usually referred to an exact clinical description of the phenomenon, but many admitted being unfamiliar with the term or at least its origin. Many studies have found the expectation of imminent death as well as inappropriate behaviors. This is the first study to consider interpretations expressed by parents around the convulsive phenomenon and to confirm a low level of knowledge of the symptom. Some historical interpretations persisted (e.g., the influence of excessive mood, anger, menstruation, demonic possession).

CONCLUSION

Understanding and integrating these parental interpretations seems essential to improving care for families who first experience this symptom. This study motivated the implementation of a special educational workshop on seizures in 2010.

Waldenström's macroglobulinemia in monozygotic twins

This paper reports a unique familial occurrence of Waldenström's macroglobulinemia (WM) in monozygotic twins. The determination of twin monozygosity has been performed by electrophoretic and immunological typing of genetic systems (erythrocyte blood groups, leucocyte antigens and serum protein polymorphism). The two monoclonal IgM differ one from the other by their light chain type and their idiotypic determinants. Although a genetic predisposition to WM exists in these twins, the gene recombination leading to idiotypic specificity and light chain assortment occurs independently of the monoclonal malignant involvement.

Alveolar macrophage activation and an emphysema-like phenotype in adiponectin-deficient mice

Adiponectin is an adipocyte-derived collectin that acts on a wide range of tissues including liver, brain, heart, and vascular endothelium. To date, little is known about the actions of adiponectin in the lung. Herein, we demonstrate that adiponectin is present in lung lining fluid and that adiponectin deficiency leads to increases in proinflammatory mediators and an emphysema-like phenotype in the mouse lung. Alveolar macrophages from adiponectin-deficient mice spontaneously display increased production of tumor necrosis factor-alpha (TNF-alpha) and matrix metalloproteinase (MMP-12) activity. Consistent with these observations, we found that pretreatment of alveolar macrophages with adiponectin leads to TNF-alpha and MMP-12 suppression. Together, our findings show that adiponectin leads to macrophage suppression in the lung and suggest that adiponectin-deficient states may contribute to the pathogenesis of inflammatory lung conditions such as emphysema.

Long-term potentiation in the rat dentate gyrus is associated with enhanced Arc/Arg3.1 protein expression in spines, dendrites and glia

Electron microscopic immunocytochemical methods were used to determine the localization, subcellular distribution and expression of activity-regulated cytoskeletal protein (Arc/Arg3.1) in dentate gyrus after unilateral induction of long-term potentiation (LTP) in the perforant pathway of anaesthetized rats. At 2 h post-induction, immunoreaction product was visible in the dentate gyrus in both the granule cell and molecular layers. Arc expression was higher in the potentiated than the unstimulated contralateral hemisphere. Single-section electron microscopy analysis in unstimulated tissue and in tissue prepared 2 and 4 h after LTP induction showed Arc immunoreactivity (Arc-IR) in dendrites, dendritic spines and glia. Arc-IR was associated with synaptic and non-synaptic plasma membrane apposed to axon terminals and with cytoplasmic organelles, including the cytoskeleton. Arc-IR was also present in neuronal perikarya and there was occasional labelling of nuclei and axons. At 2 h post-LTP induction, there were significant increases in Arc-IR within the granule cell and molecular layers of the dentate gyrus and particularly within the middle molecular layer relative to the inner and outer molecular layers. This increase in Arc expression 2 h after LTP induction was blocked by the N-methyl-D-aspartate receptor antagonist (RS)-3-2-carboxypiperazin-4-yl-propyl-1-phosphonic acid. In animals killed 4 h after LTP induction, Arc expression had declined and differences between the potentiated and unpotentiated hemispheres were no longer significant. Our data provide ultrastructural evidence for a transient LTP-associated increase in the expression of Arc protein in the middle molecular layer of the dentate gyrus, with preferential targeting to dendrites, dendritic spines and glia.

Derivation of lung epithelium from bone marrow cells

Recent studies demonstrate the capacity of BM-derived cells to engraft as differentiated cells of a variety of organs, including lung. In this paper, we review the current state-of-the-art in this area. We also summarize our work demonstrating that cultured adherent marrow cells can serve as progenitors of lung alveolar epithelium.

Extracellular Ca2+ depletion contributes to fast activity-dependent modulation of synaptic transmission in the brain

Synaptic activation is associated with rapid changes in intracellular Ca(2+), while the extracellular Ca(2+) level is generally assumed to be constant. Here, using a novel optical method to measure changes in extracellular Ca(2+) at high spatial and temporal resolution, we find that brief trains of synaptic transmission in hippocampal area CA1 induce transient depletion of extracellular Ca(2+). We show that this depletion, which depends on postsynaptic NMDA receptor activation, decreases the Ca(2+) available to enter individual presynaptic boutons of CA3 pyramidal cells. This in turn reduces the probability of consecutive synaptic releases at CA3-CA1 synapses and therefore contributes to short-term paired-pulse depression of minimal responses. This activity-dependent depletion of extracellular Ca(2+) represents a novel form of fast retrograde synaptic signaling that can modulate glutamatergic information transfer in the brain.

Canadian survey of clinical status at dialysis initiation 1998-1999: a multicenter prospective survey

AIMS

The current growth in end-stage kidney disease populations has led to increased efforts to understand the impact of status at dialysis initiation on long-term outcomes. Our main objective was to improve the understanding of current Canadian nephrology practice between October 1998 and December 1999.

METHODS

Fifteen nephrology centers in 7 provinces participated in a prospective data collection survey. The main outcome of interest was the clinical status at dialysis initiation determined by: residual kidney function, preparedness for chronic dialysis as measured by presence or absence of permanent peritoneal or hemodialysis access, hemoglobin and serum albumin. Uremic symptoms at dialysis initiation were also recorded, however, in some cases these symptom data were obtained retrospectively.

RESULTS

Data on 251 patients during 1-month periods were collected. Patients commenced dialysis at mean calculated creatinine clearance levels of approximately 10 ml/min, with an average of 3 symptoms. 35% of patients starting dialysis had been known to nephrologists for less than 3 months. These patients are more likely to commence without permanent access and with lower hemoglobin and albumin levels. Even of those known to nephrologists, only 66% had permanent access in place.

CONCLUSIONS

Patients commencing dialysis in Canada appear to be doing so in relative concordance with published guidelines with respect to timing of initiation. Despite an increased awareness of kidney disease, a substantial number of patients continues to commence dialysis without previous care by a nephrologist. Of those who are seen by nephrologists, clinical and laboratory parameters are suboptimal according to current guidelines. This survey serves as an important baseline for future comparisons after the implementation of educational strategies for referring physicians and nephrologists.

Perineuronal nets in the rhesus monkey and human basal forebrain including basal ganglia

Perineuronal nets of extracellular matrix have been shown to characterize the microenvironment of individual neurons and the chemoarchitecture of brain regions such as basal forebrain nuclei. Previous work has also demonstrated that neurons in the human cerebral cortex ensheathed by perineuronal nets rarely undergo cytoskeletal changes in Alzheimer's disease, suggesting a neuroprotective effect of extracellular matrix components. It is not known, however, whether or not perineuronal nets are absent in the microenvironment of the cholinergic basal forebrain neurons that are involved early in the cascade of neurodegeneration in humans. Therefore, the present study was undertaken to examine the distribution patterns of perineuronal nets in the basal forebrain of the higher primates, rhesus monkey and human. Cytochemical staining was performed with the lectin Wisteria floribunda agglutinin and a polyclonal antibody to core proteins of chondroitin sulfate proteoglycans in the perfusion-fixed tissue of rhesus monkeys. In human brains, perineuronal nets were only stained with the immunoreaction for chondroitin sulfate proteoglycans. The results showed similar characteristics in distribution patterns of perineuronal nets in the medial septum, the diagonal band of Broca, the basal nucleus of Meynert (Ch1-Ch4), the lateral septum, the caudate-putamen, and the globus pallidus in both species. Double-labelling revealed that the vast majority of cholinergic neurons, labelled either with antibodies to choline acetyltransferase or the low-affinity neurotrophin receptor p75(NTR), were not ensheathed by perineuronal nets. A small subpopulation of net-associated neurons in close proximity to or intermingled with cholinergic neurons of the Ch1-Ch4 cell groups was found to be immunoreactive for parvalbumin. In the caudate-putamen, a large number of the parvalbumin-positive neurons were surrounded by perineuronal nets, whereas in the external and internal segments of the globus pallidus the coincidence of both markers was nearly complete. The study demonstrates that perineuronal nets of extracellular matrix are associated with different types of non-cholinergic neurons in the primate basal forebrain. The absence of nets around cholinergic basal forebrain neurons may be related to their slow modulatory activity but may also contribute to their susceptibility to degeneration in Alzheimer's disease.

Bone marrow-derived cells as progenitors of lung alveolar epithelium

We assessed the capacity of plastic-adherent cultured bone marrow cells to serve as precursors of differentiated parenchymal cells of the lung. By intravenously delivering lacZ-labeled cells into wild-type recipient mice after bleomycin-induced lung injury, we detected marrow-derived cells engrafted in recipient lung parenchyma as cells with the morphological and molecular phenotype of type I pneumocytes of the alveolar epithelium. At no time after marrow cell injection, did we detect any engraftment as type II pneumocytes. In addition, we found that cultured and fresh aspirates of bone marrow cells can express the type I pneumocyte markers, T1α and aquaporin-5. These observations challenge the current belief that adult alveolar type I epithelial cells invariably arise from local precursor cells and raise the possibility of using injected marrow-derived cells for therapy of lung diseases characterized by extensive alveolar damage.

[The nursing infant at the intersection of different bodies of knowledge]

The effects of baby children's feeding on their mortality is known. It is thus interesting to know the cultural context in which bottle-feeding was adopted. In the 1930s, many women in the Eastern Pyrenees abandoned breast-feeding on the advice of their doctor because, they said, they had bad milk that "poisoned" their baby. This idea, widely spread in France at the time, took place within a set of traditional images of maternal milk and its spoiling which referred to ancient and complex beliefs concerning feminine physiology and blood disorders. These ideas were shared by women as well as by doctors until a relatively recent date.

Ultrastructural distribution of the alpha7 nicotinic acetylcholine receptor subunit in rat hippocampus

Acetylcholine (ACh) is an important neurotransmitter in the mammalian brain; it is implicated in arousal, learning, and other cognitive functions. Recent studies indicate that nicotinic receptors contribute to these cholinergic effects, in addition to the established role of muscarinic receptors. In the hippocampus, where cholinergic involvement in learning and memory is particularly well documented, alpha7 nicotinic acetylcholine receptor subunits (alpha7 nAChRs) are highly expressed, but their precise ultrastructural localization has not been determined. Here, we describe the results of immunogold labeling of serial ultrathin sections through stratum radiatum of area CA1 in the rat. Using both anti-alpha7 nAChR immunolabeling and alpha-bungarotoxin binding, we find that alpha7 nAChRs are present at nearly all synapses in CA1 stratum radiatum, with immunolabeling present at both presynaptic and postsynaptic elements. Morphological considerations and double immunolabeling indicate that GABAergic as well as glutamatergic synapses bear alpha7 nAChRs, at densities approaching those observed for glutamate receptors in CA1 stratum radiatum. Postsynaptically, alpha7 nAChRs often are distributed at dendritic spines in a perisynaptic annulus. In the postsynaptic cytoplasm, immunolabeling is associated with spine apparatus and other membranous structures, suggesting that alpha7 nAChRs may undergo dynamic regulation, with insertion into the synapse and subsequent internalization. The widespread and substantial expression of alpha7 nAChRs at synapses in the hippocampus is consistent with an important role in mediating and/or modulating synaptic transmission, plasticity, and neurodegeneration.

The outbreak of West Nile virus infection in the New York City area in 1999

BACKGROUND

In late August 1999, an unusual cluster of cases of meningoencephalitis associated with muscle weakness was reported to the New York City Department of Health. The initial epidemiologic and environmental investigations suggested an arboviral cause.

METHODS

Active surveillance was implemented to identify patients hospitalized with viral encephalitis and meningitis. Cerebrospinal fluid, serum, and tissue specimens from patients with suspected cases underwent serologic and viral testing for evidence of arboviral infection.

RESULTS

Outbreak surveillance identified 59 patients who were hospitalized with West Nile virus infection in the New York City area during August and September of 1999. The median age of these patients was 71 years (range, 5 to 95). The overall attack rate of clinical West Nile virus infection was at least 6.5 cases per million population, and it increased sharply with age. Most of the patients (63 percent) had clinical signs of encephalitis; seven patients died (12 percent). Muscle weakness was documented in 27 percent of the patients and flaccid paralysis in 10 percent; in all of the latter, nerve conduction studies indicated an axonal polyneuropathy in 14 percent. An age of 75 years or older was an independent risk factor for death (relative risk adjusted for the presence or absence of diabetes mellitus, 8.5; 95 percent confidence interval, 1.2 to 59.1), as was the presence of diabetes mellitus (age-adjusted relative risk, 5.1; 95 percent confidence interval, 1.5 to 17.3).

CONCLUSIONS

This outbreak of West Nile meningoencephalitis in the New York City metropolitan area represents the first time this virus has been detected in the Western Hemisphere. Given the subsequent rapid spread of the virus, physicians along the eastern seaboard of the United States should consider West Nile virus infection in the differential diagnosis of encephalitis and viral meningitis during the summer months, especially in older patients and in those with muscle weakness.

Postsynaptic calcium transients evoked by activation of individual hippocampal mossy fiber synapses

Control of Ca(2+) within dendritic spines is critical for excitatory synaptic function and plasticity, but little is known about Ca(2+) dynamics at thorny excrescences, the complex spines on hippocampal CA3 pyramidal cells contacted by mossy fiber terminals of dentate granule cell axons. We have monitored subthreshold stimulus-dependent postsynaptic Ca(2+) transients in optically and ultrastructurally characterized complex spines and find that such spines can act as discrete units of Ca(2+) response. In contrast to the more common "simple" spines, synaptically evoked Ca(2+) transients at complex spines have only a small NMDA receptor-dependent component and do not involve release of calcium from internal stores. Instead, they result mainly from AMPA receptor-gated Ca(2+) influx through voltage-activated calcium channels on the spine; these channels provide graded amplification of the response of thorny excrescences to individual mossy fiber synaptic events.

Health care systems: the emperor has no clothes

Stand-alone hospitals are becoming something of a rarity on the American landscape. While hospital boards have repeatedly voted to form systems in the last 10 to 20 years, they have been just as likely to neglect to identify specific, measurable benefits that a merger would bring to their institution. An even if they did, they frequently discontinued evaluating whether system formation brought the hoped-for benefits, thereby justifying ongoing system participation. It is an incumbent fiduciary obligation to continually ask the question: Does continued participation make sense; that is, are we appropriately exercising stewardship over the hospitals' or system's assets by participating in this system? In a sense, boards are in danger of becoming like the emperor in the children's fairy tale, believing they have done the right thing without taking a hard look at today's reality.

A requirement for the immediate early gene Zif268 in the expression of late LTP and long-term memories

The induction of long-term potentiation (LTP) in the dentate gyrus of the hippocampus is associated with a rapid and robust transcription of the immediate early gene Zif268. We used a mutant mouse with a targeted disruption of Zif268 to ask whether this gene, which encodes a zinc finger transcription factor, is required for the maintenance of late LTP and for the expression of long-term memory. We show that whereas mutant mice exhibit early LTP in the dentate gyrus, late LTP is absent when measured 24 and 48 hours after tetanus in the freely moving animal. In both spatial and non-spatial learning tasks, short-term memory remained intact, whereas performance was impaired in tests requiring long-term memory. Thus, Zif268 is essential for the transition from short- to long-term synaptic plasticity and for the expression of long-term memories.

Patients on chronic peritoneal dialysis for ten years or more in North America

Thirty-six patients on peritoneal dialysis (PD) for more than ten years in six North American centers were analyzed retrospectively. In the six centers, the percentage of patients surviving for more than ten years varied between 0.8% and 7.3%. The study group included 27 females and 9 males aged 38.6 +/- 14.2 years [mean +/- standard deviation (SD)] at the start of treatment. Of the 36 patients, 28 were Caucasian. The most common cause of end-stage renal disease (ESRD), present in 12 patients, was chronic glomerulonephritis. Only 4 patients had diabetes. At the beginning of the study, 19 patients had hypertension (the most common comorbid condition); 11 had no comorbid conditions at the start. Creatinine clearance at the start was 4.12 +/- 3.5 mL per minute, and the mean duration to anuria was 51 +/- 25 months. Mean initial body weight was 55 +/- 9 kg, and mean body surface area was 1.5 +/- 0.2 m2. Serum albumin levels showed an increase from 33.8 +/- 3.6 g/L at the start of the study to 38.2 +/- 3.9 g/L at the end. Hospitalization rate was low at 0.5 +/- 0.3 admissions per patient-year, and duration of hospitalization was 4.8 +/- 3.7 days per patient-year. Peritonitis was the most common cause of hospitalization. The mean peritonitis rate was 1 episode every 52 +/- 48 patient-months. There were 36 catheter changes in 18 patients; 16 patients had a single PD catheter throughout the period of study. Autonomous hyperparathyroidism was the most common long-term complication. At the end of the study period, 11 patients were still on PD, 9 had died, 5 had been transferred to hemodialysis (HD), 1 was alive with a functioning allograft, and 1 was lost to follow-up. We conclude that patients who survive longer than ten years on PD are most likely to be young Caucasian females, small in body size, who are non diabetic, with few comorbid conditions. These long-term survivors have few hospitalizations, and their peritonitis rate is low. In this group of patients, severe autonomous hyperparathyroidism is the most common long-term complication.

Lessons from the West Nile viral encephalitis outbreak in New York City, 1999: implications for bioterrorism preparedness

The involvement and expertise of infectious disease physicians, microbiologists, and public health practitioners are essential to the early detection and management of epidemics--both those that are naturally occurring, such as the 1999 outbreak of West Nile virus (WN virus) in New York City, and those that might follow covert acts of bioterrorism. The experience with the WN virus outbreak offers practical lessons in outbreak detection, laboratory diagnosis, investigation, and response that might usefully influence planning for future infectious disease outbreaks. Many of the strategies used to detect and respond to the WN virus outbreak resemble those that would be required to confront other serious infectious disease threats, such as pandemic influenza or bioterrorism. We provide an overview of the critical elements needed to manage a large-scale, fast-moving infectious disease outbreak, and we suggest ways that the existing public health capacity might be strengthened to ensure an effective response to both natural and intentional disease outbreaks.

Calcium stores in hippocampal synaptic boutons mediate short-term plasticity, store-operated Ca2+ entry, and spontaneous transmitter release

Evoked transmitter release depends upon calcium influx into synaptic boutons, but mechanisms regulating bouton calcium levels and spontaneous transmitter release are obscure. To understand these processes better, we monitored calcium transients in axons and presynaptic terminals of pyramidal neurons in hippocampal slice cultures. Action potentials reliably evoke calcium transients in axons and boutons. Calcium-induced calcium release (CICR) from internal stores contributes to the transients in boutons and to paired-pulse facilitation of EPSPs. Store depletion activates store-operated calcium channels, influencing the frequency of spontaneous transmitter release. Boutons display spontaneous Ca2+ transients; blocking CICR reduces the frequency of these transients and of spontaneous miniature synaptic events. Thus, spontaneous transmitter release is largely calcium mediated, driven by Ca2+ release from internal stores. Bouton store release is important for short-term synaptic plasticity and may also contribute to long-term plasticity.

Analysis of microbiological trends in peritoneal dialysis-related peritonitis from 1991 to 1998

The microbial cause of peritoneal dialysis-related peritonitis is an important determinant of clinical outcome and the basis of widely used treatment guidelines. Five hundred forty-six cases of peritonitis in 374 patients from 1991 to 1998 were analyzed. The rate of peritonitis declined significantly from 1.37 episodes/patient-year in 1991 to 0.55 episode/patient-year in 1998 (P = 0.02). The rate of Gram-positive peritonitis decreased significantly from 0.75 to 0.28 episode/patient-year during the same period (P = 0.02). Conversely, the occurrence of Gram-negative peritonitis remained constant at approximately 0.16 episode/patient-year (P = 0.28). Staphylococcus epidermidis and Staphylococcus aureus were the most common causes of peritonitis, isolated in 27.8% and 19.3% of the culture-positive cases, respectively. A distinct decrease in peritonitis caused by S epidermidis was observed, with 0.40 episode/patient-year in 1991 compared with 0.11 to 0.20 episode/patient-year during subsequent years. The rate of infections caused by S aureus decreased significantly over time from a high of 0.21 episode/patient-year in 1992 to a low of 0.04 episode/patient-year in 1998 (P = 0.01). Pseudomonas aeruginosa, Escherichia coli, and KLEBSIELLA: species were the most common causes of Gram-negative peritonitis, identified in 7.1%, 6.8%, and 5.2% of culture-positive cases, respectively. The most dramatic increase in antibiotic resistance was seen among S epidermidis. From 1991 and 1992 to 1997 and 1998, resistance to ciprofloxacin increased from 5.4% to 47.8% (P = 0.003), and resistance to methicillin increased from 18.9% to 73.9% (P = 0.03). Our study showed significant trends in the causative pathogens of peritoneal dialysis-related peritonitis and dramatic increases in antibiotic resistance. These data support further study and warrant reevaluation of current treatment practices.

Marked variation in peritoneal insulin absorption in peritoneal dialysis

OBJECTIVE

To assess both peritoneal insulin absorption and adsorption of insulin to the plastic delivery system, and to assess whether variation in peritoneal absorption is related to transport status.

DESIGN

Eight insulin-dependent diabetic patients on continuous ambulatory peritoneal dialysis were studied. Insulin was added to the dialysate. The amount adsorbed by the bag tubing was determined; peritoneal absorption was measured by complete spent dialysate collection.

RESULTS

Only 14% +/- 5% of added insulin was adsorbed onto the dialysate delivery system. Marked variation in peritoneal absorption occurred (38% +/- 14%, range 17%-66%). Variations in membrane transport status did not account for variation in absorption.

CONCLUSION

Marked variation in peritoneal absorption of insulin occurs, accounting for some of the variation in intraperitoneal insulin requirements. This is not related to membrane transport status.

Age-dependent pre- and postsynaptic distribution of AMPA receptors at synapses in CA3 stratum radiatum of hippocampal slice cultures compared with intact brain

Organotypic slice cultures of rat hippocampus are widely used as experimental preparations for the study of synaptic plasticity, but their degree of correspondence with intact brain is not fully known. Here, using postembedding immunogold labelling, we describe the ultrastructural distribution of AMPA-type glutamate receptors (GluR1-4) in CA3 stratum radiatum of organotypic hippocampal slice cultures at 10 days to 11 weeks in vitro and compare the labelling with intact brain of corresponding age. In both types of preparation, the 11-week-old samples contained the highest proportion of AMPA receptor-like immunoreactive synapses. The incidence of labelled synapses, however, was higher in vivo (49%) than in vitro (24%). The intensity of labelling (number of gold particles per labelled synapse) also increased with age and was also higher in vivo than in vitro. In both organotypic cultures and intact brain, labelling was frequently found at presynaptic sites, often attached to vesicular structures. The specificity of these findings was supported both by light microscopic immunolabelling of GluR2/3 subunits and by electron microscopic double labelling of different epitopes of the GluR2 subunit. The vesicular localization of AMPA receptors was supported by Western blot analysis of subcellular fractions. Morphological evidence of presynaptic excitatory innervation of glutamatergic neurons supports a functional role for presynaptically located AMPA receptors. Our results therefore suggest that AMPA receptors occur in both pre- and postsynaptic profiles and that the distribution of AMPA receptors in cultured brain slices is fundamentally similar to intact brain, but that synaptic maturation may be retarded in vitro.