Abstract P3-05-02: Not presented

This abstract was not presented at the conference.

Citation Format: Gruber JJ, Chen J, Geller B, Jager N, Lipchik AM, Snyder MP. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-05-02.

Audit feedback on reading performance of screening mammograms: An international comparison

Objective

Providing feedback to mammography radiologists and facilities may improve interpretive performance. We conducted a web-based survey to investigate how and why such feedback is undertaken and used in mammographic screening programmes.

Methods

The survey was sent to representatives in 30 International Cancer Screening Network member countries where mammographic screening is offered.

Results

Seventeen programmes in 14 countries responded to the survey. Audit feedback was aimed at readers in 14 programmes, and facilities in 12 programmes. Monitoring quality assurance was the most common purpose of audit feedback. Screening volume, recall rate, and rate of screen-detected cancers were typically reported performance measures. Audit reports were commonly provided annually, but more frequently when target guidelines were not reached.

Conclusion

The purpose, target audience, performance measures included, form and frequency of the audit feedback varied amongst mammographic screening programmes. These variations may provide a basis for those developing and improving such programmes.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

Microarray and allergenic activity assessment of milk allergens

BACKGROUND

Cow's milk is one of the most common causes of food allergy affecting approximately 2.5% of infants in the first years of their life. However, only limited information regarding the allergenic activity of individual cow's milk allergens is available.

OBJECTIVE

To analyse the frequency of IgE reactivity and to determine the allergenic activity of individual cow's milk allergens.

METHODS

A nitrocellulose-based microarray, based on purified natural and recombinant cow's milk allergens was used to determine IgE reactivity profiles using sera from 78 cow's milk-sensitized individuals of varying ages. The allergenic activity of the individual allergens was tested using patients' sera for loading rat basophil leukaemia cells (RBL) expressing the α-chain of the human receptor FcεRI.

RESULTS

Using the microarray and the RBL assay, cow's milk allergens were assessed for frequency of IgE recognition and allergenic activity. Moreover, the RBL assay allowed distinguishing individuals without or with mild clinical reactions from those with severe systemic or gastrointestinal symptoms as well as persons who grew out cow's milk allergy from those who did not.

CONCLUSIONS

Component-resolved testing using milk allergen microarrays and RBL assays seems to provide useful additional diagnostic information and may represent a basis for future forms of prophylactic and therapeutic strategies for cow's milk allergy.

Mammographic features and histopathological findings of interval breast cancers

BACKGROUND

Interval cancers are considered a shortcoming in screening mammography due to less favorable prognostic tumor characteristics compared to screening-detected cancers and consequently a lower chance of survival from the disease.

PURPOSE

To describe the mammographic features and prognostic histopathological tumor characteristics of interval breast cancers.

MATERIAL AND METHODS

A total of 231 interval breast cancer cases diagnosed in prevalently screened women aged 50-69 years old were examined. Thirty-five percent of the cases were retrospectively classified as missed cancers, 23% as minimal sign, and 42% as true negative (including occult cancers) in a definitive classification performed by six experienced breast radiologists. The retrospective classification described the mammographic features of the baseline screening mammograms in missed and minimal-sign interval cancers, while histopathological reports were used to describe the tumor characteristics in all the subgroups of interval cancers.

RESULTS

Fifty percent of the missed and minimal-sign interval cancers combined presented poorly defined mass or asymmetric density, and 26% calcifications with or without associated density or mass at baseline screening. Twenty-seven percent of invasive tumors were <15 mm for missed and 47% for true interval cancers (P<0.001). Lymph node involvement was more common in missed (49%) compared with the true cases (33%, P<0.05).

CONCLUSION

Missed interval cancers have less prognostically favorable histopathological tumor characteristics compared with true interval cancers. Improving the radiologist's perception and interpretation by establishing systematic collection of features and implementation of organized reviews may decrease the number of interval cancers in a screening program.

Review of studies of child and adolescent offspring of bipolar parents

OBJECTIVE

The authors reviewed studies of child and adolescent offspring of bipolar (BP) parents. Findings from these studies are critically discussed with respect to methodological issues that can inform future designs.

METHODS

A Medline search was performed to identify studies that examined child and adolescent offspring of BP parents. Publications were excluded if they did not separate offspring of BP parents from offspring of major depressive disorder or schizoaffective parents ("affective offspring") or did not separately analyze data from child- and adolescent-age versus adult offspring.

RESULTS

Seventeen studies fit these review criteria. Rates of mood disorders in child and adolescent offspring of BP parents ranged from 5 to 67% compared with rates in offspring of healthy volunteers of 0-38%. Rates of non-mood disordered psychopathology ranged from 5 to 52% in offspring of BP parents and from 0 to 25% in offspring of healthy volunteers. Rates of mood disorders and of other psychopathology were increased in offspring of BP parents compared with offspring of healthy volunteers in all of the eight studies that included a comparison group of offspring of healthy volunteers.

CONCLUSIONS

Studies suggest that children (< or =21 years) of BP parents are at increased risk for developing mood and other disorders (e.g., disruptive, anxiety). Therefore, additional investigations are clearly warranted. In the context of current research on diagnosis, assessment, longitudinal course and comorbidity of childhood mania, the following suggestions for the design of future studies should be considered: 1) Phenotypic specification of bipolar manifestations (e.g., BP-I, BP-II, BP-NOS) in child/adolescent offspring and in bipolar parents themselves. 2) Control groups that are pediatric-age relevant and thus include attention-deficit hyperactivity disorder. 3) Assessments that include items for prepubertal mania and for onsets and offsets of all occurrences of symptoms and of environmental factors (e.g., life events) in offspring and in parents so that trajectories of overlap and sequence between child and parental mania can be investigated. 4) These detailed onsets and offsets of symptoms are also necessary to investigate prodromal manifestations of mania in the offspring. 5) Unaffected offspring present a unique opportunity to study pre- and postmorbid cognitive and physiological endophenotypes and structural and functional brain abnormalities. Findings from offspring studies will be crucial to inform research on the development of early intervention and prevention strategies.

Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial

OBJECTIVE

To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression.

METHOD

After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores.

RESULTS

Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects.

CONCLUSIONS

Paroxetine is generally well tolerated and effective for major depression in adolescents.

Adult psychosocial outcome of prepubertal major depressive disorder

OBJECTIVE

To compare adult psychosocial functioning (PSF) of subjects with prepubertal major depressive disorder (PMDD) to a normal comparison (NC) group.

METHOD

PSF of subjects with PMDD (n = 72) and of NC subjects (n = 28) was compared after prospective follow-up to adulthood. These 100 subjects were 90.9% of the baseline 110 subjects who participated in the "Nortriptyline in Childhood Depression: Follow-up Study." Research nurses who were blind to group status conducted telephone interviews using the Longitudinal Interval Follow-up Evaluation (LIFE) to obtain PSF data.

RESULTS

At follow-up, the PMDD group was 20.7+/-2.0 and the NC subjects were 20.9+/-2.2 years old. The PMDD subjects were 10.3+/-1.5 years old at baseline. Time between baseline and follow-up was 9.9+/-1.5 years. In the PMDD group, subjects with MDD, bipolar disorder, or substance use disorders during the previous 5 years had significantly worse PSF than NC subjects. These PSF impairments included significantly worse relationships with parents, siblings, and friends; significantly worse functioning in household, school, and work settings; and worse overall quality of life and global social adjustment.

CONCLUSIONS

Although combined treatments for PMDD have little scientific basis, multimodality regimens seem prudent until definitive treatment data become available.

Fingerprint forgery--a survey

The article describes and analyzes the international survey of fingerprint and laboratory personnel about fingerprint forgery, conducted in four countries during the years 1998 through 1999. The awareness and the attitude of the professionals to the problem of fingerprint forgery was tested.

Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections

OBJECTIVE

To investigate the reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections.

METHOD

The 1986 version of the KSADS was modified and expanded to include onset and offset of each symptom for both current and lifetime episodes, expanded prepubertal mania and rapid cycling sections, and categories for attention-deficit/hyperactivity disorder and other DSM-IV diagnoses. To optimize diagnostic research, skip-outs were minimized. Subjects participated in the ongoing "Phenomenology and Course of Pediatric Bipolar Disorder" study. Mothers and children were interviewed separately by research nurses who were blind to diagnostic group status. In addition, ratings of off-site child psychiatrists, made from the narrative documentation given for each WASH-U-KSADS item, were compared with research nurse ratings. This work was performed between 1995 and 2000.

RESULTS

There was 100% interrater reliability, five consecutive times, as both interviewer and observer after 10 to 15 trials. The kappa values of comparisons between research nurse and off-site blind best-estimate ratings of mania and rapid cycling sections were excellent (0.74-1.00). High 6-month stability for mania diagnoses (85.7%) and for individual mania items and validity against parental and teacher reports were previously reported.

CONCLUSIONS

The WASH-U-KSADS mania and rapid cycling sections have acceptable reliability.

Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder

OBJECTIVE

Etiopathogenetic and treatment studies require homogeneous phenotypes. Therefore, effects of gender, puberty, and comorbid attention deficit hyperactivity disorder (ADHD) on DSM-IV mania criteria and other characteristics of a prepubertal and early adolescent bipolar disorder (PEA-BP) phenotype were investigated.

METHOD

Consecutively ascertained PEA-BP (with or without comorbid ADHD) outpatients (n = 93) were blindly assessed by research nurses with comprehensive instruments given to mothers and children separately, consensus conferences, and offsite blind best estimates of both diagnoses and mania items. To fit the study phenotype, subjects needed to have current DSM-IV mania or hypomania with elated mood and/or grandiosity as one criterion and to be definite cases by severity ratings.

RESULTS

Subjects were aged 10.9 +/- 2.6 years, had current episode length of 3.6 +/- 2.5 years, and had early age of onset at 7.3 +/- 3.5 years. No significant differences were found by gender, puberty, or comorbid ADHD on rates of mania criteria (e.g., elation, grandiosity, racing thoughts), mixed mania, psychosis, rapid cycling, suicidality, or comorbid oppositional defiant disorder (ODD), with few exceptions. Subjects with comorbid ADHD were more likely to be younger and male. Pubertal subjects had higher rates of hypersexuality.

CONCLUSIONS

These findings support that the PEA-BP phenotype is homogeneous except for differences (hyperactivity, hypersexuality) that mirror normal development.

Six-month stability and outcome of a prepubertal and early adolescent bipolar disorder phenotype

OBJECTIVE

Six-month follow-up data are provided on a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP). Stabilities were defined as continuous presence of PEA-BP and of individual mania criteria between baseline and 6 months.

METHOD

Baseline and 6-month assessments of consecutively ascertained PEA-BP outpatients (n = 91) included comprehensive instruments given to mothers and children, separately, by research nurses; consensus conferences; and offsite blind best estimates of both diagnoses and mania items. To fit the study phenotype, subjects needed to have current DSM-IV mania or hypomania with elated mood and/or grandiosity as one mania criterion and to be definite cases by severity ratings.

RESULTS

Of the 93 baseline subjects, 91 completed the 6-month assessment, for a retention rate of 97.8%. Baseline age was 10.9 +/- 2.7 years, and age of onset of current episode was 7.3 +/- 3.5 years. At 6 months, 85.7% still had full criteria and severity for mania or hypomania, and only 14.3% had recovered. Six-month stabilities of elated mood and grandiosity were high. Cox modeling and logistic regression did not show any significant effect of multiple covariates (e.g., gender, puberty, psychosis, mixed mania, rapid cycling, or naturalistic treatment).

CONCLUSIONS

These longitudinal stability findings provide validation of a PEA-BP phenotype. Poor outcome was consistent with similarity of PEA-BP baseline characteristics to those of treatment-resistant adult-onset mania.

One-year recovery and relapse rates of children with a prepubertal and early adolescent bipolar disorder phenotype

OBJECTIVE

The study examined 1-year recovery and relapse rates for mania in subjects who met criteria for a prepubertal and early adolescent bipolar disorder phenotype.

METHOD

Outpatients identified by consecutive new-case ascertainment were assessed by means of separate child and parent interviews, consensus conferences, and blind best estimates. The definition of the prepubertal and early adolescent bipolar disorder phenotype was DSM-IV mania with elation and/or grandiosity as one criterion.

RESULTS

Of 93 subjects seen at baseline, 89 were seen at 1 year (95.7% retention). The rate of recovery from mania was 37.1%, and the rate of relapse after recovery was 38.3%. No covariates were significantly associated with recovery or relapse.

CONCLUSIONS

The low recovery and high relapse rates supported the study hypothesis of poor outcomes, which was made on the basis of similarity between the characteristics of the prepubertal and early adolescent bipolar disorder phenotype (long episode duration and high prevalence of mixed mania, psychosis, and rapid cycling) and those of severe bipolar disorder in adults.

Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder

OBJECTIVE

The authors' goal was to conduct an adult follow-up of subjects who had participated in a study of nortriptyline for childhood depression.

METHOD

The study group represented 100 (90. 9%) of the original 110 subjects and included 72 subjects who had a prepubertal diagnosis of major depressive disorder and 28 normal comparison subjects. Subjects were assessed with semistructured research interviews given by research nurses who were blind to the subjects' original diagnoses.

RESULTS

In the original study, the mean age of the children with prepubertal major depressive disorder was 10.3 years (SD=1.5); at adult follow-up the mean age of these subjects was 20.7 years (SD=2.0). At follow-up, significantly more of the subjects who had prepubertal diagnoses of major depressive disorder (N=24 [33.3%]) than normal comparison subjects (none) had bipolar I disorder. Subjects who had prepubertal diagnoses of major depressive disorder also had significantly higher rates of any bipolar disorder than normal subjects (48.6% [N=35] versus 7.1% [N=2]), major depressive disorder (36.1% [N=26] versus 14.3% [N=4]), substance use disorders (30.6% [N=22] versus 10.7% [N=3]), and suicidality (22.2% [N=16] versus 3.6% [N=1]). Parental and grandparental mania predicted bipolar I disorder outcomes.

CONCLUSIONS

High rates of switching to mania have implications for the treatment of depressed children. The authors discuss the reasons for their finding a higher rate of bipolar disorder in this outcome study than was found in the one other adult outcome study of prepubertal major depressive disorder.

Performance of screening mammography among women with and without a first-degree relative with breast cancer

BACKGROUND

Although it is recommended that women with a family history of breast cancer begin screening mammography at a younger age than average-risk women, few studies have evaluated the performance of mammography in this group.

OBJECTIVE

To compare the performance of screening mammography in women with a first-degree family history of breast cancer and women of similar age without such history.

DESIGN

Cross-sectional.

SETTING

Mammography registries in California (n = 1), New Hampshire (n = 1), New Mexico (n = 1), Vermont (n = 1), Washington State n = 2), and Colorado (n = 1).

PARTICIPANTS

389 533 women 30 to 69 years of age who were referred for screening mammography from April 1985 to November 1997.

MEASUREMENTS

Risk factors for breast cancer; results of first screening examination captured for a woman by a registry; and any invasive cancer or ductal carcinoma in situ identified by linkage to a pathology database, the Surveillance, Epidemiology, and End Results program, or a state tumor registry.

RESULTS

The number of cancer cases per 1000 examinations increased with age and was higher in women with a family history of breast cancer than in those without (3.2 vs. 1.6 for ages 30 to 39 years, 4.7 vs. 2.7 for ages 40 to 49 years, 6.6 vs. 4.6 for ages 50 to 59 years, and 9.3 vs. 6.9 for ages 60 to 69 years). The sensitivity of mammography increased significantly with age (P = 0.001 [chi-square test for trend]) in women with a family history and in those without (63.2% [95% CI, 41. 5% to 84.8%] vs. 69.5% [CI, 57.7% to 81.2%] for ages 30 to 39 years, 70.2% [CI, 61.0% to 79.5%] vs. 77.5% [CI, 73.3% to 81.8%] for ages 40 to 49 years, 81.3% [CI, 73.3% to 89.3%] vs. 80.2% [CI, 76.5% to 83.9%] for ages 50 to 59 years, and 83.8% [CI, 76.8% to 90.9%] vs. 87.7% [CI, 84.8% to 90.7%] for ages 60 to 69 years). Sensitivity was similar for each decade of age regardless of family history. The positive predictive value of mammography was higher in women with a family history than in those without (3.7% vs. 2.9%; P = 0.001).

CONCLUSIONS

Cancer detection rates in women who had a first-degree relative with a history of breast cancer were similar to those in women a decade older without such a history. The sensitivity of screening mammography was influenced primarily by age.

Effect of variations in operational definitions on performance estimates for screening mammography

RATIONALE AND OBJECTIVES

The Mammography Quality Standards Act requires practices to measure limited aspects of their performance. The authors conducted this study to calculate the differences in measurements of sensitivity and specificity due only to differences in the definitions used in the analysis. This included definitions for case inclusion.

MATERIALS AND METHODS

Data from the New Mexico Mammography Project for January 1991 to December 1995 on 136,540 women who underwent screening mammography were analyzed. A starting definition was created for each performance measure. The components of the definition were varied, and estimates of sensitivity and specificity for the different definitions were calculated.

RESULTS

Sensitivity was lower and specificity was higher when assessed on the basis of the results of all imaging performed in the screening work-up rather than on the initial screening examination alone. Sensitivity was higher and specificity was lower in women who did not undergo rather than in women who did recently undergo a previous examination. When the definition of a positive examination included cases that were recommended for short-term follow-up, the work-up sensitivity was slightly higher and the work-up specificity was considerably lower. Longer follow-up times for determining the diagnosis of cancer were associated with decreasing sensitivity, particularly when the follow-up period extended beyond 12 months.

CONCLUSION

Variations in the operational definitions for measures of mammographic performance affect these estimates. To facilitate valid comparisons, reports need to be explicit regarding the definitions and methods used.

Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype

OBJECTIVE

To compare psychosocial functioning (PF) in a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) sample to two comparison groups, i.e., attention-deficit/hyperactivity disorder (ADHD) and community controls (CC).

METHOD

There were 93 PEA-BP (with or without comorbid ADHD), 81 ADHD, and 94 CC subjects who were participants in an ongoing study, the Phenomenology and Course of Pediatric Bipolar Disorders. Cases in the PEA-BP and ADHD groups were outpatients obtained by consecutive new case ascertainment, and CC subjects were from a survey conducted by the Research Triangle Institute. To fit the study phenotype, PEA-BP subjects needed to have current DSM-IV mania or hypomania with elation and/or grandiosity as one criterion. Assessments for PF were by experienced research nurses who were blind to group status. Mothers and children were separately interviewed with the Psychosocial Schedule for School Age Children-Revised.

RESULTS

Compared with both ADHD and CC subjects, PEA-BP cases had significantly greater impairment on items that assessed maternal-child warmth, maternal-child and paternal-child tension, and peer relationships.

CONCLUSIONS

Clinicians need to consider PF deficits when planning interventions. In the PEA-BP group, there was a 43% rate of hypersexuality with a <1% rate of sexual abuse, supporting hypersexuality as a manifestation of child mania.

Refractory depression in children and adolescents

Refractory or treatments resistant depression in child and adolescent populations is a difficult construct to operationalize currently. To date, only one of the small number of completed double-blind placebo-controlled treatment investigations have not demonstrated a significant effect of antidepressants in comparison to placebo. However, it has been established that child and adolescent MDD is a serious disorder that appears to have clinical continuity with adult affective disorders and is generally of long duration with high rates of recurrence and eventual progression to mania, substance abuse, or other serious psychopathology. In addition, families of children with affective disorders evidence substantial genetic loading with high rates of affective disorders contributing both genetic vulnerability and potential environmental risk as well. There have been no empirically identified treatments that alter the long-term course of the illness. Thus treatment resistance is a significant issue for this population. This review will focus on controlled treatment trials and will examine the potential relevance of psychosocial impairment, genetic-familial risk, and neuromorphometric brain differences to treatment resistance in children and adolescents with major depression.

Ultradian rapid cycling in prepubertal and early adolescent bipolarity is not in transmission disequilibrium with val/met COMT alleles

BACKGROUND

Prepubertal children and early adolescents with bipolar disorders (PEA-BP) who participate in the ongoing study "Phenomenology and Course of Pediatric Bipolar Disorders" have a high prevalence of ultradian (within 24-hour periods) rapid cycling. Based on a case-control finding reported in bipolar (BP) adults of an association between rapid and ultradian rapid cycling with the low-activity allele of catechol-O-methyltransferase (l-COMT), study of linkage and linkage disequilibrium of l-COMT in the PEA-BP population seemed warranted.

METHODS

Genotypes on a subset of the larger PEA-BP sample, for whom trio blood collection was complete (i. e., probands and both of their biological parents), were used to perform transmission disequilibrium tests (TDTs). Diagnoses were established from a comprehensive battery that included WASH-U-KSADS (Washington University Kiddie Schedule for Affective Disorders and Schizophrenia) given to both mothers and children and from consensus conferences. Probands with PEA-BP (N = 52) were 10.9 +/- 2.8 years old at index episode; had a mean age of BP onset at 8.0 +/- 3.8 years; were severely impaired, with a mean Children's Global Assessment Scale score of 44.5 +/- 8.9; and manifested the cardinal features of BP (84.6% had euphoric mood, 76.9% had grandiosity, and 57.7% had psychosis). Ultradian rapid cycling occurred in 75%. Genotyping of the single nucleotide polymorphism at COMT was performed using automated capillary electrophoresis single-strand conformational polymorphism with detection by laser-induced fluorescence.

RESULTS

Transmission disequilibrium tests were not significant for preferential transmission of l-COMT for the ultradian rapid-cycling subgroup or for the entire PEA-BP sample.

CONCLUSIONS

The lack of linkage disequilibrium between l-COMT and ultradian rapid cycling in the PEA-BP sample compared to reported findings of an association in case-control studies of adults is discussed in terms of age-specific developmentally relevant phenotypes, anticipatory mechanisms, and heterogeneity. Repeat TDT analyses after these PEA-BP probands reach their adult phenotypes will be informative.

Threat mail and forensic science: DNA profiling from items of evidence after treatment with DFO

Two cases of threatening letters with their accompanying envelopes were received to the Division of Forensic Identification unit of the Israel Police. The envelopes, including the stamps, and the letters were initially examined for latent fingerprints by the DFO reagent, known to cause degradation of DNA. Although no latent fingerprints could be visualized on any of the items, the biology laboratory using organic DNA extraction, was successful in defining genetic profiles from all the items employing six STR loci, even after treatment with DFO. In a controlled experiment, a known donor attached a stamp, by licking, to an envelope. This item was treated with DFO and then profiled using STR loci. The results showed that previous DFO treatment on the control stamp before DNA analysis had no negative effects on obtaining the DNA profile of the known donor using STR loci.

The Texas Children's Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVES

To develop consensus guidelines for medication treatment algorithms for childhood major depressive disorder (MDD) based on scientific evidence and clinical opinion when science is lacking. The ultimate goal of this approach is to synthesize research and clinical experience for the practitioner and to increase the uniformity of preferred treatment for childhood MDD. A final goal is to develop an approach that can be tested as to whether it improves clinical outcomes for children and adolescents with MDD.

METHOD

A consensus conference was held. Participants included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review and use clinical evidence to recommend specific pharmacological approaches for treatment of MDD in children and adolescents. After a series of presentations of current research evidence and panel discussion, the consensus panel met, agreed on assumptions, and drafted the algorithms. The process initially addressed strategies of treatment and then tactics to implement the strategies.

RESULTS

Consensually agreed-upon algorithms for major depressions (with and without psychosis) and comorbid attention deficit disorders were developed. Treatment strategies emphasized the use of selective serotonin reuptake inhibitors. The algorithm consists of systematic strategies for treatment interventions and recommended tactics for implementation of the strategies, including medication augmentation and medication combinations. Participants recommended prospective evaluation of the algorithms in various public sector settings, and many volunteered as sites for such an evaluation.

CONCLUSIONS

Using scientific and clinical experience, consensus-derived algorithms for children and adolescents with MDD can be developed.

Critical review of tricyclic antidepressant use in children and adolescents

OBJECTIVE

To provide a critical review of the role of tricyclic antidepressant (TCA) medications in children and adolescents.

METHOD

Multiple resources including a Medline search (1966-1998) were used.

RESULTS

There were few double-blind, placebo-controlled studies of TCAs, and even fewer with positive results. Also, potentially serious cardiovascular side effects have been described.

CONCLUSIONS

The future therapeutic role of TCAs for children and adolescents needs to be seriously weighed against lethality of overdose, the unresolved issue of possible sudden unexplained death, and the availability of safer and easier to monitor medications. Ongoing future research on heart rate variability and epidemiology of psychotropic medication-related deaths will address developmental aspects of TCA use.

Serotonin transporter gene (HTTLPR) is not in linkage disequilibrium with prepubertal and early adolescent bipolarity

BACKGROUND

As part of an ongoing, larger study, "Phenomenology and Course of Pediatric Bipolarity", a subset of prepubertal and early adolescent onset bipolar (PEA-BP) probands, on whom trio blood collection was complete, were used to study genetic transmission of the serotonin transporter linked promoter region (HTTLPR) short and long alleles using the transmission disequilibrium test(TDT). The HTTLPR alleles were selected based on postulated serotonergic mechanisms for PEA-BP and on the burgeoning number of HTTLPR allele studies in bipolar (BP) adults.

METHODS

There were 46 complete trios of PEA-BP probands and both biological parents. Probands had a mean age of 11.1 +/- 3.0 years and a mean age of onset of PEA-BP of 8.1 +/- 4.0 years. Comprehensive diagnostic assessments included a semi-structured research interview, the WASH-U-KSADS, administered separately to mothers and to children by blind raters. Probands manifested severe impairment (CGAS 43.9 +/- 8.9), elated mood (84.8%), grandiosity (78.3%), rapid cycling (78.3%) and psychosis (63.0%). The HTTLPR length variant was genotyped using fluorescently labeled primers and automated capillary electrophoresis using laser-induced fluorescence.

RESULTS

The TDT was not significant (TDT chi square = .020, df = 1, p = .89).

CONCLUSIONS

This negative result is consistent with the one negative TDT and two negative linkage studies of HTTLPR alleles in bipolar adults in the literature.

Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling

BACKGROUND

In contrast to differential diagnosis (ddx) of older adolescent and adult bipolarity (BP), which includes schizophrenia and substance use disorders, the main ddx of prepubertal and early adolescent BP is attention-deficit disorder with hyperactivity (ADHD). To address this ddx issue, and to provide prepubertal mania manifestations, interim baseline data are presented from the National Institute of Mental Health (NIMH)-funded study 'Phenomenology and Course of Pediatric Bipolarity'.

METHODS

Data are from the first 60 BP and the first 60 ADHD cases from 270 consecutively ascertained subjects (90 BP, 90 ADHD and 90 community controls). Comprehensive assessments included the Washington University at St. Louis Kiddie and Young Adult-Schedule for Affective Disorders and Schizophrenia--Lifetime and Present Episode Version-DSM-IV (WASH-U-KSADS) blindly administered by nurses to mothers about their offspring and to children/adolescents about themselves. Caseness was established by consensus conferences that included diagnostic and impairment data, teacher and school reports, agency records, videotapes and medical charts.

RESULTS

Mean baseline age of BP cases was 11.0+/-2.7 years and the mean age at onset of BP was 8.1+/-3.5 years. Elated mood, grandiosity, hypersexuality, decreased need for sleep, racing thoughts and all other mania items except hyperenergetic and distractibility were significantly and substantially more frequent among BP than ADHD cases (e.g., elation: 86.7% BP vs. 5.0% ADHD; grandiosity: 85.0% BP vs. 6.7% ADHD). In the BP group, 55.0% had grandiose delusions, 26.7% had suicidality with plan/intent and 83.3% were rapid, ultra-rapid or ultradian cyclers.

LIMITATIONS

Sites for consecutive case ascertainment from the lowest socioeconomic status classes were unavailable due to current health care policies.

CLINICAL RELEVANCE

Prepubertal and early adolescent BP cases differentiate from ADHD by mania-specific criteria and commonly present with ultra-rapid or ultradian cycling.

Lithium for prepubertal depressed children with family history predictors of future bipolarity: a double-blind, placebo-controlled study

BACKGROUND

Because of negative studies of TCAs for prepubertal major depressive disorder (PMDD) and because of the potentially high switch rate of PMDD to prepubertal bipolarity (BP), it was hypothesized that lithium would be efficacious treatment for PMDD in children who also had family history (FH) predictors of future BP.

METHODS

A double-blind, placebo-controlled, and pharmacokinetically dosed study of lithium for PMDD with FH predictors of future BP was performed. Random assignment was stratified by FH of BP-I or mania versus loaded/multigenerational (L/M) FH of MDD without BP-I or mania. Comprehensive assessments were done during a six week outpatient protocol that included weekly serum lithium levels.

RESULTS

Mean age was 10.7+/-1.2 years; 17 subjects were randomized to active and 13 to placebo; 80% had FH of BP-I or mania (40% of parents had BP-I or mania); and 20% had FH of L/M MDD. Using both intent to treat with last observation carried forward (n = 30) and completer (n = 24) analyses, there were no significant differences on continuous or categorical measures between active and placebo groups. Mean serum lithium level was 0.99+/-0.16 mEq/l. There were no significant differences between mean total daily dose or mean serum lithium levels between responders and non-responders.

LIMITATIONS

Four subjects on active drug were discontinued because of dose-limiting side effects (three were cognitive impairment). Future studies of treatment for PMDD should consider alternative drugs.

CLINICAL RELEVANCE

Lithium was not significantly more efficacious than placebo for PMDD with FH predictors of future BP.

Prepubertal and young adolescent bipolarity versus ADHD: assessment and validity using the WASH-U-KSADS, CBCL and TRF

BACKGROUND

This addendum to 'Prepubertal and early adolescent bipolarity differentiate from ADHD by mania criteria; grandiose delusions; ultra-rapid or ultradian cycling' (in this volume) provides (1) a description of Washington University at St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) with sample sections (hypersexuality, rapid cycling); (2) a comparison of WASH-U-KSADS to KSADS-P/L and KSADS-1986 and (3) a comparison of WASH-U-KSADS to Child Behavior Checklist (CBCL) and Teachers Report Form (TRF) data.

METHODS

Data were from the first 60 bipolar (BP) and first 60 ADHD subjects of 270 consecutively ascertained cases (90 BP, 90 ADHD and 90 community controls) in the NIMH funded 'Phenomenology and Course of Pediatric Bipolarity' study. Comprehensive assessments included the WASH-U-KSADS (administered blindly to mothers and separately to children), CBCL and TRF.

RESULTS

As reported elsewhere in this volume, WASH-U-KSADS data significantly differentiated BP and ADHD groups. Significant differences were also found with the parent-rated CBCL and the teacher-rated TRF, thereby providing cross-modality and cross-informant validation of the WASH-U-KSADS. Because of the close agreement with published CBCL data from another investigator, cross-site validation also occurred.

LIMITATIONS

Venues for consecutive ascertainment from the lowest socioeconomic status classes were unavailable due to current health care policies.

CLINICAL RELEVANCE

CBCL and TRF data separated BP from ADHD groups, largely by non-specific externalizing dimensions (e.g., hyperactivity, aggressivity). Clinically relevant differentiation by categorical mania-specific criteria (e.g., elated mood, grandiosity, racing thoughts) occurred with WASH-U-KSADS data. Both types of data are crucial for genetic and neurobiological studies.

The future of pediatric psychopharmacology

The future of pediatric psychopharmacology will be a collaborative effort among the public, the federal government, the pharmaceutical industry, and clinical scientists. Clinical scientists and the NIH have initiated the process. The federal regulatory guidelines are in place but may need to be amended further to truly facilitate needed research. The pharmaceutical industry is making efforts to study medications in childhood psychiatric disorders. More new drugs are being tested in humans. Many of the new agents offer the promise of more clinical benefit with milder side effects. The future is indeed promising.

Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency

OBJECTIVE

To perform a double-blind, placebo-controlled, random assignment, parallel group, pharmacokinetically dosed study of lithium for adolescents with bipolar disorders (BP) and temporally secondary substance dependency disorders (SDD).

METHOD

Subjects were 16.3 +/- 1.2 years old and were comprehensively assessed during a 6-week outpatient protocol that included random weekly urine collection for drug assays and random and weekly serum collection for lithium levels.

RESULTS

Using both intent-to-treat (N = 25) and completer (n = 21) analyses, there were significant differences on continuous and categorical measures between the active and placebo groups for both psychopathology measures and weekly random urine drug assays. The mean scheduled weekly serum lithium level of active responders was 0.9 mEq/L. Addiction to both alcohol and marijuana was the most frequent category of SDD. Mean age at onset of BP was 9.6 +/- 3.9 years and of SDD was 15.3 +/- 1.3 years. There were multigenerational mood disorders in 96% and multigenerational SDD in 56% of families.

CONCLUSIONS

Lithium treatment of BP with secondary SDD in adolescents was an efficacious treatment for both disorders. These results warrant replication with a long-term maintenance phase. The mean 6-year interval between the onset of BP and onset of SDD strongly argues for earliest recognition of BP.

Child and adolescent bipolar disorder: a review of the past 10 years

OBJECTIVE

To provide a review of the epidemiology, phenomenology, natural course, comorbidity, neurobiology, and treatment of child and adolescent bipolar disorder (BP) for the past 10 years. This review is provided to prepare applicants for recertification by the American Board of Psychiatry and Neurology.

METHOD

Literature from Medline and other searches for the past 10 years, earlier relevant articles, and the authors' experience and ongoing National Institute of Mental Health-funded project "Phenomenology and Course of Pediatric Bipolarity" were used.

RESULTS

Age-specific, developmental (child, adolescent, and adult) DSM-IV criteria manifestations; comorbidity and differential diagnoses; and episode and course features are provided. Included are age-specific examples of childhood grandiosity, hypersexuality, and delusions. Differential diagnoses (e.g., specific language disorders, sexual abuse, conduct disorder [CD], schizophrenia, substance abuse), suicidality, and BP-II are discussed.

CONCLUSION

Available data strongly suggest that prepubertal-onset BP is a nonepisodic, chronic, rapid-cycling, mixed manic state that may be comorbid with attention-deficit hyperactivity disorder (ADHD) and CD or have features of ADHD and/or CD as initial manifestations. Systematic research on pediatric BP is in its infancy and will require ongoing and future studies to provide developmentally relevant diagnostic methods and treatment.

Increased prevalence and earlier onset of mood disorders among relatives of prepubertal versus adult probands

OBJECTIVE

To compare the familial clustering of affective disorders among first-degree relatives of prepubertal versus adult probands with mood disorders.

METHOD

The Family History-Research Diagnostic Criteria (FH-RDC) assessment instrument was used to obtain data on first-degree relatives of all probands. Logistic regression was used to assess the strength of the age of the proband to predict FH-RDC diagnoses in relatives. Survival analysis was used to examine the age-at-onset distribution of first FH-RDC diagnosis while controlling for year of birth.

RESULTS

The prevalence of major affective disorders was more than two times higher among first-degree relatives of child probands versus those of adult probands even when controlling for birth cohort. Cumulative risk for lifetime major mood disorders in first-degree relatives of child probands was significantly higher than for those of adult probands.

CONCLUSION

These analyses further support that ascertainment of families through affected children identifies pedigrees with a higher proportion of affected relatives than ascertainment through affected adults.

Epidemiology of mutations in superoxide dismutase in amyotrophic lateral sclerosis

We registered 366 families in a study of dominantly inherited amyotrophic lateral sclerosis. Two hundred ninety families were screened for mutations in the gene encoding copper-zinc cytosolic superoxide dismutase (SOD1). Mutations were detected in 68 families. The most common SOD1 mutation is an alanine for valine substitution in codon 4 (50%). We present clinical and genetic data concerning 112 families with 395 affected individuals. The clinical characteristics of patients with familial amyotrophic lateral sclerosis arising from SOD1 mutations are similar to those lacking SOD1 defects. Mean age at onset was earlier (Wilcoxon test, p = 0.004) in the SOD1 group (46.9 years [standard deviation, 12.5] vs 50.5 years [11.5] in the non-SOD1 group). Bulbar onset was associated with a later onset age. The presence of either of two mutations, G37R and L38V, predicted an earlier age at onset. Kaplan-Meier plots demonstrated shorter survival in the SOD1 group compared with the non-SOD1 group at early survival times (Wilcoxon test, p = 0.0007). The presence of one mutation, A4V, correlated with shorter survival. G37R, G41D, and G93C mutations predicted longer survival. This information suggests it will be productive to investigate other genetic determinants in amyotrophic lateral sclerosis and to use epidemiological characteristics of the disease to help discern molecular mechanisms of motor neuron cell death.

Cardiovascular effects of therapeutic doses of tricyclic antidepressants in children and adolescents

OBJECTIVE

Tricyclic antidepressants (TCAs) play an important role in the treatment of pediatric psychiatric disorders. Despite widespread clinical use, concerns about their possible cardiovascular risk have arisen following several published reports of sudden death associated with their use in children. Accordingly, available evidence concerning TCA-associated cardiovascular effects in children and adolescents was surveyed.

METHOD

A systematic literature search from 1967 to 1996 identified relevant pediatric studies that evaluated cardiovascular effects of TCAs.

RESULTS

Twenty-four studies involving 730 children and adolescents given imipramine, amitriptyline, desipramine, or nortriptyline were found. TCA treatment was associated with minor increases in systolic and diastolic blood pressure, in heart rate, and in the electrocardiographic (ECG) conduction parameters, PR, QRS, and QTc. Holter ECG monitoring and exercise testing also revealed minor treatment effects. Some ECG changes related to specific TCAs emerged. Few age-related ECG differences in TCA-treated children, adolescents, or adults were detected. Associations of ECG abnormalities and relatively higher serum TCA levels were found.

CONCLUSION

TCA treatment in children and adolescents, like that in adults, is associated with cardiovascular changes of uncertain, but probably minor, clinical significance. More information is needed on the contribution of other physiological conditions on the cardiovascular system during exposure to TCAs. Guidelines for using TCAs in children and adolescents are presented.

Increased prevalence of alcoholism in relatives of depressed and bipolar children

OBJECTIVE

Previous publications from the "Nortriptyline in Childhood Depression: Follow-up Study" reported increased prevalence rates of mood disorders and alcoholism in the relatives of prepubertal depressed subjects. This article presents data on the association versus independent transmission of alcohol and mood disorders in the families of these subjects.

METHOD

The follow-up study included 6- to 12-year-olds with major depressive disorder (MDD) and matched normal controls. After 2 to 5 years of follow-up, bipolarity developed in 31.7% of the MDD subjects. Family history data for the first- and second-degree relatives and first cousins of the 76 nonadopted MDD subjects and the 31 controls were obtained from the subjects' mothers, using the Family History-Research Diagnostic Criteria.

RESULTS

The prevalence of alcoholism among the relatives of the MDD and bipolar probands was two to three times that reported for control relatives and twice that reported for the relatives of adult MDD and bipolar probands. Mood disorders and maternal alcoholism were independently transmitted while paternal alcoholism increased the risk for mood disorder in offspring.

CONCLUSIONS

The potential psychosocial and genetic effects of familial alcoholism need to be considered for the clinical management and investigation of childhood-onset mood disorders.

Treatment-resistant depression in children and adolescents

Treatment resistance in depressed children and adolescents cannot yet be defined fully because of the paucity of controlled studies that demonstrate efficacy. Therefore, this article addresses several of the age-specific, developmental considerations that may impinge upon treatment response. Areas covered include familial-genetic, psychosocial, and neuroimaging studies in addition to a review of controlled studies to date.

Interethnic psychopharmacologic research in children and adolescents

Interethnic child and adolescent psychopharmacology research is essentially unstudied. Recently there have been reports of interethnic differences in psychopharmacology research on adults. This article addresses the need to focus research on psychopharmacogenetics, pharmacokinetics, pharmacodynamics, and issues of efficacy and effectiveness in child and adolescent populations of different ethnic groups.

Development of a community mammography registry: experience in the breast screening program project

PURPOSE

To assess the formation, implementation, and operation of a community mammography registry, which is a consolidated database for all mammography and breast biopsy reports within a community.

MATERIALS AND METHODS

A registry was created in Lee County, Fla. Mammography interpretation data were provided by 13 facilities and 38 radiologists organized in several private practice groups.

RESULTS

The registry contains data on 87,926 mammograms and 3,234 breast biopsies performed between June 1991 and May 1994. The registry calculates individual and group mammography interpretation accuracy measures, such as sensitivity, specificity, positive predictive value, false-positive and false-negative rates, and clinical outcome measures such as sizes and stages of malignant lesions detected.

CONCLUSION

The registry allows community radiologists and mammography practices to compare their outcomes with those of their local peers and to published data and encourages focused interventions for quality improvement based on objective experience.

Complex and rapid-cycling in bipolar children and adolescents: a preliminary study

26 subjects aged 7-18 years were studied. Diagnoses of bipolar disorders were established using the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present Episode Version-1986 modified for DSM-III-R criteria and for rating the number and duration of manic and hypomanic episodes. Complex cycling patterns were observed. These included numerous brief episodes suggesting continuous rapid-cycling in 80.8% of cases. Mean age of onset was early (8.5 +/- 4.4 years). Psychotic phenomena, suicidality, hyperactivity and 'mixed mania' were highly prevalent. Data in this report provide support for complex and rapid-cycling patterns in childhood onset bipolar disorder.

Preliminary study of magnetic resonance imaging characteristics in 8- to 16-year-olds with mania

OBJECTIVE

To examine magnetic resonance imaging (MRI) characteristics in children and adolescents with mania according to DSM-III-R criteria.

METHOD

A convenience sample of consecutively referred 8- to 16-year-old manic (n = 10) and normal (n = 5) subjects were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode Version, the Children's Global Assessment Scale, and the Family History-Research Diagnostic Criteria. MRI scans were obtained from unsedated subjects using a 1.5 T MR scanner to acquire T1-weighted coronal and sagittal images and T2-weighted axial images. Images were assessed by blind clinical interpretation, ratings of T2-weighted deep white matter hyperintensities and petalia, and computer-assisted volumetric analysis of ventricular and cerebral volumes.

RESULTS

Eight of 10 manic subjects and all 5 controls completed the scans. Scans of 4 manic subjects and 1 control subject showed ventricular or white matter abnormalities by clinical interpretation. Significant findings were positive correlations between increasing age and both right and left ventricular volumes. Two of the 8 manic subjects and no controls had confluent subcortical hyperintensities.

CONCLUSIONS

MRI brain scanning was feasible in 8- to 16-year-olds. Preliminary findings from clinical interpretations and structured ratings suggest structural differences between young manic and normal subjects. Investigations of larger samples are needed to better characterize the differences.

Rate and predictors of prepubertal bipolarity during follow-up of 6- to 12-year-old depressed children

OBJECTIVE

To investigate the rate and predictors of onset of DSM-III bipolar I and bipolar II disorders among 6- to 12-year-old prepubertal subjects with DSM-III major depressive disorder (MDD) who were followed for a 2- to 5-year period.

METHODS

This was a prospective, blindly rated study of 79 children with MDD and 31 normal control children matched for age, gender, and socioeconomic status. Subjects and a second informant were assessed at 4-month intervals using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present Episode Version-1986 modified to include 4-month interval ratings and to include DSM-III diagnoses. Family history (FH) was assessed using the FH-Research Diagnostic Criteria obtained from the mother about the subject's first- and second-degree relatives.

RESULTS

Bipolarity developed in 31.7% (N = 25) of the children with MDD at a mean age of 11.2 +/- 2.0 years and 80% were prepubertal. Loaded FH and multigenerational FH were significantly associated with bipolar I. Neither prior nor current use of tricyclic antidepressants nor atypical depressive features were predictive.

CONCLUSIONS

These findings strongly support the need to educate families of children with prepubertal-onset MDD about the possibility of the emergence of manic and hypomanic symptoms to encourage early recognition and appropriate treatment.

Genetic studies of affective disorders: should we be starting with childhood onset probands?

OBJECTIVE

The objective of this study is to test whether the presence of childhood onset affective disorder identifies families with increased incidence and severity of affective disorders.

METHOD

Family history information was collected on the first and second degree relatives and first cousins age > or = 15 years of 22 children with bipolar affective disorder, 54 children with major depressive disorder, and 31 psychiatrically normal children.

RESULTS

Compared with the relatives of normal children, relatives identified through children with bipolar affective disorder or major depressive disorder had elevated rates of affective disorders and increased severity of affective disorders as judged by earlier age of onset and increased suicide attempts. Segregation analyses could reject purely environmental transmission of illness.

CONCLUSION

Ascertaining families through childhood onset affective disorder probands identifies extended pedigrees with high incidence and severity of affective disorders. These families may be more appropriate for genetic analyses than are families of adult probands.

Another sudden death in a child treated with desipramine

The sudden death of three children receiving the tricyclic antidepressant medication desipramine for behavioral disorders was reported in 1990. We now provide new information about these children and describe a fourth case. Because desipramine is a useful medication for many children, these deaths pose clinical dilemmas for physicians and families. The cardiac long QT syndrome has been proposed as a mechanism for these sudden deaths. Considerable uncertainty remains about the basis of the apparent association between the use of desipramine and the sudden deaths.

Charged residues render pro-OmpA potential dependent for initiation of membrane translocation

We have examined the effects of positively and negatively charged residues on the translocation of outer membrane protein A precursor (pro-OmpA) across the bacterial inner membrane. Pro-OmpA does not translocate across the membrane when 2 positively charged residues are inserted immediately after the leader peptide, whereas it does insert when 2 neutral or negatively charged residues are introduced. Using a cell-free translocation system, we show that the membrane potential stimulated the rate of initial insertion of pro-OmpA with negatively charged residues, inhibited pro-OmpA with positively charged residues, and had no effect on neutral pro-OmpA. Thus, acidic residues render pro-OmpA potential-dependent for loop formation, which then initiates the translocation process.