High-Resolution Free-Breathing Automated Quantitative Myocardial Perfusion by Cardiovascular Magnetic Resonance for the Detection of Functionally Significant Coronary Artery Disease

AIMS

Current assessment of myocardial ischaemia from stress perfusion cardiovascular magnetic resonance (SP-CMR) largely relies on visual interpretation. This study investigated the use of high-resolution free-breathing SP-CMR with automated quantitative mapping in the diagnosis of coronary artery disease (CAD). Diagnostic performance was evaluated against invasive coronary angiography (ICA) with fractional flow reserve (FFR) measurement.

METHODS & RESULTS

Seven-hundred and three patients were recruited for SP-CMR using the research sequence at 3 Tesla. Of those receiving ICA within 6 months, 80 patients either had FFR measurement, or identification of a chronic total occlusion (CTO) with inducible perfusion defects seen on SP-CMR. Myocardial blood flow (MBF) maps were automatically generated in-line on the scanner following image acquisition at hyperaemic stress and rest, allowing myocardial perfusion reserve (MPR) calculation. 75 coronary vessels assessed by FFR, and 28 vessels with CTO were evaluated at both segmental and coronary territory level. Coronary territory stress MBF and MPR were reduced in FFR-positive (≤ 0.80) regions (median stress MBF: 1.74 [0.90-2.17] ml/min/g; MPR: 1.67 [1.10-1.89]) compared with FFR-negative regions (stress MBF: 2.50 [2.15-2.95] ml/min/g; MPR 2.35 [2.06-2.54] p < 0.001 for both). Stress MBF ≤ 1.94 ml/min/g and MPR ≤ 1.97 accurately detected FFR-positive CAD on a per-vessel basis (area under the curve: 0.85 and 0.96 respectively; p < 0.001 for both).

CONCLUSIONS

A novel scanner-integrated high-resolution free-breathing SP-CMR sequence with automated in-line perfusion mapping is presented which accurately detects functionally significant CAD.

Human vascular organoids with a mosaic AKT1 mutation recapitulate Proteus syndrome

Vascular malformation, a key clinical phenotype of Proteus syndrome, lacks effective models for pathophysiological study and drug development due to limited patient sample access. To bridge this gap, we built a human vascular organoid model replicating Proteus syndrome's vasculature. Using CRISPR/Cas9 genome editing and gene overexpression, we created induced pluripotent stem cells (iPSCs) embodying the Proteus syndrome-specific AKTE17K point mutation for organoid generation. Our findings revealed that AKT overactivation in these organoids resulted in smaller sizes yet increased vascular connectivity, although with less stable connections. This could be due to the significant vasculogenesis induced by AKT overactivation. This phenomenon likely stems from boosted vasculogenesis triggered by AKT overactivation, leading to increased vascular sprouting. Additionally, a notable increase in dysfunctional PDGFRβ+ mural cells, impaired in matrix secretion, was observed in these AKT-overactivated organoids. The application of AKT inhibitors (ARQ092, AZD5363, or GDC0068) reversed the vascular malformations; the inhibitors' effectiveness was directly linked to reduced connectivity in the organoids. In summary, our study introduces an innovative in vitro model combining organoid technology and gene editing to explore vascular pathophysiology in Proteus syndrome. This model not only simulates Proteus syndrome vasculature but also holds potential for mimicking vasculatures of other genetically driven diseases. It represents an advance in drug development for rare diseases, historically plagued by slow progress.

Abstract OT2-04-04: Multi-institution phase II trial of intraoperative electron beam radiotherapy boost at the time of breast conserving surgery with oncoplastic reconstruction in women with early-stage breast cancer

Background: In women amenable to breast conserving therapy, lumpectomy followed by adjuvant whole breast irradiation (WBI) remains the standard of care. Randomized trials demonstrate that addition of a lumpectomy cavity boost significantly reduces the risk of ipsilateral breast tumor recurrences but also increases the risk of breast fibrosis. Contemporary randomized trials define the lumpectomy cavity boost volume as a 1.7 cm isometric expansion on the lumpectomy cavity as delineated on CT. However, identifying the lumpectomy cavity can be challenging, especially in women that receive adjuvant chemotherapy and in cases in which surgical clips are not present. Recently, the use of oncoplastic techniques in breast conserving surgery has increased. These techniques are used to prevent the poor cosmetic results that can occur when a large volume of breast tissue is resected. Women that undergo oncoplastic reconstruction represent especially difficult cases for lumpectomy cavity delineation. Retrospective series have evaluated the use of intraoperative electron radiotherapy (IOERT) as a boost prior to WBI in women receiving lumpectomy without oncoplastic reconstruction. In the largest series of IOERT boost prior to WBI the local control rate of this approach was &gt;99%. Prospective data regarding IOERT boost in women undergoing oncoplastic reconstruction are limited. The advantages of this approach include direct visualization/irradiation of the tumor bed, sparing the skin of irradiation, and reducing the treatment time by ˜1 week. We hypothesize that IOERT boost followed by WBI will result in acceptably low rates of grade 3 fibrosis in women undergoing lumpectomy with oncoplastic reconstruction.

Trial Design: This is a single-arm, prospective study to evaluate the safety, toxicity and efficacy of IOERT boost at the time of breast conserving surgery in women with early-stage breast cancer undergoing oncoplastic reconstruction. Eligible women will receive 1 dose of 8 Gy to the surgical bed after lumpectomy but prior to oncoplastic reconstruction. Women will then receive adjuvant WBI of 40 Gy in 15 fractions or 50 Gy in 25 fractions.

Eligibility: Key criteria include age≥18 yo, clinically node-negative stage I/II, any breast cancer subtype.

Specific Aims: To determine the rate of grade 3 breast fibrosis at 1 year. Additional aims include surgical complication rates, cosmesis, and local regional cancer control.

Statistical Methods: Safety will be evaluated by the rate of surgical complications necessitating hospital readmission or return to the operating room within 30 days of surgery+IOERT. If ≥4 events in the first 10 patients, ≥7 events in the first 20 patients, or ≥9 events in the first 30 patients are seen, the study will be halted. We hypothesize that the grade 3 fibrosis rate in our study will be ≤5%. Assuming an actual rate of 4%, an unacceptable rate of 9%, and a drop-out rate of 10%, the expected sample size is 176.

Sites: Ohio State University, Avera Medical Group, University of North Carolina-Chapel Hill

Patient Accrual: Current accrual is 5/176.

Contact Information: Jose Bazan (jose.bazan2@osumc.edu)

Funding Source: Intraop Medical

Citation Format: Bazan JG, Stephens J, Agnese D, Skoracki R, Arneson K, Reiland J, Gupta G, Gallagher K, McElroy S, Gupta N, White JR. Multi-institution phase II trial of intraoperative electron beam radiotherapy boost at the time of breast conserving surgery with oncoplastic reconstruction in women with early-stage breast cancer [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 OT2-04-04.

Abstract OT2-03-04: Feasibility of assessing radiation response with MRI/CT directed preoperative accelerated partial breast irradiation in the prone position for hormone responsive early stage breast cancer

Background: Accelerated partial breast irradiation (APBI) delivers adjuvant radiation (RT) to the 1-2 cm of the breast at highest risk for recurrence surrounding the lumpectomy (L) cavity over 5-8 days and is an alternative to standard whole breast irradiation for hormone sensitive (HS) stage 1 (T1, N0) breast cancer (BC) based on 2 randomized controlled trials. External beam methods for APBI are common but have notable inherent drawbacks that include: inter-fraction inaccuracy due to patient setup based on anatomy, intra fraction error related to patient or respiratory motion, and inaccurate geometric targeting by relying on L cavity position instead of the tumor position. Postoperative RT has other limitations including delivery in the setting of disrupted blood or lymphatic supply that may be suboptimal for radio sensitivity and it eliminates observation of radiation-induced tumor response. MRI is an established tool for measuring BC extent and response from neoadjuvant systemic therapy. It's hypothesized that MRI directed pre-operative APBI using intensity modulated radiotherapy (IMRT) with image guidance (IGRT) will improve RT delivery, and that MRI features can be identified to correlate with pathologic radiation response.

Trial Design: There are 2 cohorts to this single arm prospective trial. The first cohort is for establishing and verifying patient flow and image fusion between MRI, CT and RT planning. In the second cohort eligible patients will receive preoperative APBI 38.5 Gy in 10 fractions BID with IMRT, IGRT in the prone position using MRI defined targets fused to CT treatment planning.

Eligibility: For cohort 1 it is HS Stage 1 BC that has completed CT in prone position for RT planning. Eligibility for cohort 2 requires: age &gt; 50 yo, clinical stage 1 BC, HS, HER2 negative, intending L, clinically negative axilla verified by ultrasound, able to tolerate the prone position, and MRI with contrast.

Specific aims: To determine the reproducibility of MRI directed preoperative APBI based on meeting 3 criteria: ability to define RT targets by MRI, quality of RT plans and completion of treatment (APBI and surgery). Additional aims include assessing toxicity, cosmetic outcome, local regional cancer control and collection of tissue for correlative studies.

Statistical methods: The optimal two-stage design by Simon is used. Sample size for cohort 2 is based on the first endpoint. 19 eligible patients will be required in the first stage; if 3 or more treatments are scored unacceptable, then early stopping will be recommended. Otherwise, accrual will continue to a total accrual of 30. If &gt; 4 of 30 treatments are scored unacceptable, the technique will be considered not reproducible, and a Phase II study will not be pursued. Under the null hypothesis of an 80% reproducibility rate, this two-stage design has an expected sample size of 24.4.

Patient accrual to cohort 1 has completed the targeted accrual of 3. Patient accrual to Cohort 2 is 5/30.

Contact information: Soyhun Mc Elroy (Sohyun.McElroy@osumc.edu) or Julia White (Julia.White@osumc.edu)

Funding source: Susan G Komen Breast Cancer Foundation Grant # GRT00035216

Citation Format: White J, McElroy S, Sekhon A, Wei L, Bazan J, Yang X, DiCostanzo D, Kuhn K, Gupta N, Knopp M. Feasibility of assessing radiation response with MRI/CT directed preoperative accelerated partial breast irradiation in the prone position for hormone responsive early stage breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-03-04.

Abstract OT2-03-01: Multi-institution phase II trial of intraoperative electron beam radiotherapy boost at the time of breast conserving surgery with oncoplastic reconstruction in women with early-Stage breast cancer

Background: In women amenable to breast conserving therapy, lumpectomy followed by adjuvant whole breast irradiation (WBI) remains the standard of care. Randomized trials have demonstrated that the addition of a lumpectomy cavity boost significantly reduces the risk of ipsilateral breast tumor recurrences but also increases the risk of breast fibrosis. Contemporary randomized trials define the lumpectomy cavity boost volume as a 1.7 cm isometric expansion on the lumpectomy cavity as delineated on CT. However, identifying the lumpectomy cavity can be challenging, especially in women that receive adjuvant chemotherapy and in cases in which surgical clips are not present. Recently, the use of oncoplastic techniques in breast conserving surgery has increased. These techniques are used to prevent the poor cosmetic results that can occur when a large volume of breast tissue is resected. Women that undergo oncoplastic reconstruction represent especially difficult cases for lumpectomy cavity delineation. Retrospective series have evaluated the use of intraoperative electron radiotherapy (IOERT) as a boost prior to WBI in women receiving lumpectomy without oncoplastic reconstruction. In the largest series of IOERT boost prior to WBI the local control rate of this approach was &gt;99%. Prospective data regarding IOERT boost in women undergoing oncoplastic reconstruction are limited. Advantages of this approach include direct visualization/irradiation of the tumor bed, sparing the skin of irradiation, and reducing the treatment time by ˜1 week. We hypothesize that IOERT boost followed by WBI will result in acceptably low rates of grade 3 fibrosis in women undergoing lumpectomy with oncoplastic reconstruction.

Trial Design: This is a single-arm, prospective study to evaluate the safety, toxicity and efficacy of IOERT boost at the time of breast conserving surgery in women with early-stage breast cancer undergoing oncoplastic reconstruction. Eligible women will receive 1 dose of 8 Gy to the surgical bed after lumpectomy but prior to oncoplastic reconstruction. Women will then receive adjuvant WBI of 40 Gy in 15 fractions or 50 Gy in 25 fractions.

Eligibility: Key inclusion criteria include age≥18 yo, clinically node-negative stage I/II, any breast cancer subtype.

Specific Aims: Our primary aim is to determine the rate of grade 3 breast fibrosis at 1 year. Additional aims include surgical complication rates, cosmesis, and local regional cancer control.

Statistical Methods: Safety will be evaluated by the rate of surgical complications necessitating hospital readmission or return to the operating room within 30 days of surgery+IOERT. If ≥4 events in the first 10 patients, ≥7 events in the first 20 patients, or ≥9 events in the first 30 patients are seen, the study will be halted. We hypothesize that the grade 3 fibrosis rate in our study will be ≤5%. Assuming an actual rate of 4%, an unacceptable rate of 9%, and a drop-out rate of 10%, the expected sample size is 176.

Patient Accrual: Current accrual is 0 of 176.

Contact Information: Soyhum McElroy (soyhun.mcelroy@osumc.edu) or Jose Bazan (jose.bazan2@osumc.edu)

Funding Source: Intraop Medical

Citation Format: Bazan JG, Stephens J, Terando A, Skoracki R, McElroy S, Sexton J, Gupta N, White J. Multi-institution phase II trial of intraoperative electron beam radiotherapy boost at the time of breast conserving surgery with oncoplastic reconstruction in women with early-Stage breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-03-01.

Abstract OT2-03-02: Feasibility of assessing radiation response with MRI/CT directed preoperative accelerated partial breast irradiation in the prone position for hormone sensitive early stage breast cancer

Background: Accelerated partial breast irradiation (APBI) delivers adjuvant radiation (RT) to the 1-2 cm of the breast at highest risk for recurrence surrounding the lumpectomy (L) cavity over 5-8 days and is an alternative to standard whole breast irradiation for hormone sensitive (HS) stage 1 (T1, N0) breast cancer (BC) based on 2 randomized controlled trials. External beam methods for APBI are common but have notable inherent drawbacks that include: inter-fraction inaccuracy due to patient setup based on anatomy, intra fraction error related to patient or respiratory motion, and inaccurate geometric targeting by relying on L cavity position instead of the tumor position. Postoperative RT has other limitations including delivery in the setting of disrupted blood or lymphatic supply that may be suboptimal for radio sensitivity and it eliminates observation of radiation-induced tumor response. MRI is an established tool for measuring BC extent and response from neoadjuvant systemic therapy. It's hypothesized that MRI directed pre-operative APBI using intensity modulated radiotherapy (IMRT) with image guidance (IGRT) will improve RT delivery, and that MRI features can be identified to correlate with pathologic radiation response.

Trial Design: There are 2 cohorts to this single arm prospective trial. The first cohort is for establishing and verifying patient flow and image fusion between MRI, CT and RT planning. In the second cohort eligible patients will receive preoperative APBI 38.5 Gy in 10 fractions BID with IMRT, IGRT in the prone position using MRI defined targets fused to CT treatment planning.

Eligibility: For cohort 1 it is HS Stage 1 BC that has completed CT in prone position for RT planning. Eligibility for cohort 2 requires: age &gt; 60 yo, clinical stage 1 BC, HS, HER2 negative, intending L, clinically negative axilla verified by ultrasound, able to tolerate the prone position, and MRI with contrast.

Specific aims: To determine the reproducibility of MRI directed preoperative APBI based on meeting 3 criteria: ability to define RT targets by MRI, quality of RT plans and completion of treatment (APBI and surgery). Additional aims include assessing toxicity, cosmetic outcome, local regional cancer control and collection of tissue for correlative studies.

Statistical methods: The optimal two-stage design by Simon is used. Sample size for cohort 2 is based on the first endpoint. 19 eligible patients will be required in the first stage; if 3 or more treatments are scored unacceptable, then early stopping will be recommended. Otherwise, accrual will continue to a total accrual of 30. If &gt; 4 of 30 treatments are scored unacceptable, the technique will be considered not reproducible, and a Phase II study will not be pursued. Under the null hypothesis of an 80% reproducibility rate, this two-stage design has an expected sample size of 24.4.

Patient accrual to cohort 1 is 2 and targeted accrual is 3. Patient accrual to Cohort 2 is 0 and targeted accrual is 30.

Contact information: Soyhun Mc Elroy ( Sohyun.McElroy@osumc.edu) or Julia White (Julia.White@osumc.edu)

Funding source: Susan G Komen Breast Cancer Foundation Grant # GRT00035216.

Citation Format: White J, McElroy S, Seykon A, Wei L, Bazan J, Yang X, DiCostanzo D, Gupta N, Knopp M. Feasibility of assessing radiation response with MRI/CT directed preoperative accelerated partial breast irradiation in the prone position for hormone sensitive early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-03-02.

More pernicious course of bipolar disorder in the United States than in many European countries: implications for policy and treatment

BACKGROUND

There is some controversy but growing evidence that childhood onset bipolar disorder may be more prevalent and run a more difficult course in the United States than some European countries.

METHODS

We update and synthesize course of illness data from more than 960 outpatients with bipolar disorder (average age 40) from 4 sites in the U.S. and 3 sites in Netherlands and Germany. After giving informed consent, patients reported on parental history, childhood and lifetime stressors, comorbidities, and illness characteristics.

RESULTS

Almost all aspects of bipolar disorder were more adverse in patients from the US compared with Europe, including a significantly higher prevalence of: bipolar disorder in one parent and a mood disorder in both parents; childhood verbal, physical, or sexual abuse; stressors in the year prior to illness onset and the last episode; childhood onsets of bipolar illness; delay to first treatment; anxiety disorder, substance abuse, and medical comorbidity; mood episodes and rapid cycling; and nonresponse to prospective naturalistic treatment.

LIMITATIONS

Selection bias in the recruit of patients cannot be ruled out, but convergent data in the literature suggest that this does not account for the findings. Potential mechanisms for the early onset and more adverse course in the U.S. have not been adequately delineated and require further investigation.

CONCLUSIONS

The data suggest the need for earlier and more effective long-term treatment intervention in an attempt to ameliorate this adverse course and its associated heavy burden of psychiatric and medical morbidity.

Increased parental history of bipolar disorder in the United States: association with early age of onset

OBJECTIVE

Early-onset bipolar (BP) disorder and other poor prognosis characteristics are more prevalent in patients from the United States than from the Netherlands and Germany (abbreviated as Europe). We explored the impact of parental loading for affective illness on onset and other characteristics of BP disorder.

METHOD

Parental history for unipolar (UP) and bipolar (BP) depression and course of illness characteristics were obtained from self-report in adults (average age 42) with BP disorder. Illness characteristics were examined by χ2 and multinomial logistic regression in relationship to the degree of parental loading: i) both parents negative; ii) one UP disorder; iii) one with BP disorder; and iv) both affected.

RESULTS

After controlling for many poor prognosis factors, compared with those from Europe, patients from the United States had more iii) one parent with BP disorder and iv) both parents affected. An early age of onset of BP disorder was independently associated with this increased parental loading for affective disorder.

CONCLUSION

Parental history of BP disorder and both parents with a mood disorder were more common in the United States than Europe and were associated with an early onset of bipolar disorder and other poor prognosis characteristics. These findings deserve replication and exploration of the potential mechanisms involved and their therapeutic implications.

Normal cerebral, renal and abdominal regional oxygen saturations using near-infrared spectroscopy in preterm infants

OBJECTIVE

The aim of this study is to characterize baseline regional oxygen saturations (rSO(2)) in stable preterm infants during the first weeks of life.

STUDY DESIGN

Cerebral, renal and abdominal rSO(2) were continuously monitored from the time of birth to 21 days in twelve preterm infants of 29-34 weeks gestation. Regional saturations were evaluated for trends over time, variability and differences between gestational ages (GAs) and reported pediatric values.

RESULT

Both cerebral (66-83%) and renal (64-87%) rSO(2) baselines were within the range of reported neonatal values but consistently decreased over the first weeks of life (P<0.01). The baseline abdominal rSO(2) was 32-66% and increased with GA (P=0.05). The rSO(2) variability was lowest for cerebral measurements and highest at the abdomen. Abdominal rSO(2) variability decreased over time (P≤0.05).

CONCLUSION

Daily baseline rSO(2) in preterm infants changes over the first weeks of life, especially at the abdomen. Evolution in baseline rSO2 over time may indicate regional developmental maturation of physiological oxygen balance.

Tranylcypromine vs. lamotrigine in the treatment of refractory bipolar depression: a failed but clinically useful study

OBJECTIVE

To compare the efficacy and tolerability of tranylcypromine vs. lamotrigine in bipolar depression not responding to conventional antidepressants.

METHOD

Bipolar depressed patients received open randomized treatment with tranylcypromine or lamotrigine as add-on to a mood stabilizer during 10 weeks. In a second treatment phase, non-responding patients could receive the opposite drug. Outcome criteria were response (measured with CGI-BP and IDS-C), switch into mania, and completion of the study.

RESULTS

Only 20 of 70 planned patients were randomized, due to problems with recruitment, and 19 patients received any medication. During the first treatment phase 5/8 patients (62.5%) responded to tranylcypromine without switch into mania, compared with 4/11 patients (36.4%) on lamotrigine with two switches (statistically not significant). Over both treatment phases, 8/10 patients (80%) receiving tranylcypromine completed the study vs. 5/13 (38.5%) on lamotrigine (likelihood 0.02).

CONCLUSION

There still appears to be a role for tranylcypromine in the treatment of refractory bipolar depression. Larger controlled studies are demanded.

Mood switch in bipolar depression: comparison of adjunctive venlafaxine, bupropion and sertraline

BACKGROUND

Few studies have examined the relative risks of switching into hypomania or mania associated with second-generation antidepressant drugs in bipolar depression.

AIMS

To examine the relative acute effects of bupropion, sertraline and venlafaxine as adjuncts to mood stabilisers.

METHOD

In a 10-week trial, participants receiving out-patient treatment for bipolar disorder (stratified for rapid cycling) were randomly treated with a flexible dose of one of the antidepressants, or their respective matching placebos, as adjuncts to mood stabilisers.

RESULTS

A total of 174 adults with bipolar disorder I, II or not otherwise specified, currently in the depressed phase, were included. All three antidepressants were associated with a similar range of acute response (49-53%) and remission (34-41%). There was a significantly increased risk of switches into hypomania or mania in participants treated with venlafaxine compared with bupropion or sertraline.

CONCLUSIONS

More caution appears indicated in the use of venlafaxine rather than bupropion or sertraline in the adjunctive treatment of bipolar depression, especially if there is a prior history of rapid cycling.

Segmental linkage disequilibrium within the dopamine transporter gene

The dopamine transporter gene (DAT) has been implicated in a variety of disorders, including bipolar disorder, attention-deficit hyperactivity disorder, cocaine-induced paranoia, Tourette's syndrome, and Parkinson's disease. As no clear functional polymorphism has been identified to date, studies rely on linkage disequilibrium (LD) to assess the possible genetic contribution of DAT to the various disorders. A better understanding of the complex structure of LD across the gene is thus critical for an accurate interpretation of the results of such studies, and may facilitate the mapping of the actual functional variants. In the process of characterizing the extent of variation within the DAT gene, we have identified a number of single nucleotide polymorphisms (SNPs) suitable for LD studies, 14 of which have been analyzed, along with a 3' repeat polymorphism, in a sample of 120 parent-proband triads. Calculations of pairwise LD between the SNPs in the parental haplotypes revealed a high degree of LD (P < 0.00001) in the 5' (distal promoter through intron 6) and 3' (exon 9 through exon 15) regions of DAT. This segmental LD pattern is maintained over approximately 27 kb and 20 kb in these two regions, respectively, with very little significant LD between them, possibly due to the presence of a recombination hotspot located near the middle of the gene. These analyses of the DAT gene thus reveal a complex structure resulting from both recombination and mutation, knowledge of which may be invaluable to the design of future studies.

Evidence for linkage disequilibrium between the dopamine transporter and bipolar disorder

A role for the dopamine transporter (DAT) in bipolar disorder is implicated by several lines of pharmacological evidence, as well as suggestive evidence of linkage at this locus, which we have reported previously. In an attempt to identify functional mutations within DAT contributing a susceptibility to bipolar disorder, we have screened the entire coding region, as well as significant portions of the adjacent non-coding sequence. Though we have not found a definitive functional mutation, we have identified a number of single nucleotide polymorphisms (SNPs) that span the gene from the distal promoter through exon 15. Of the 39 SNPs that are suitable for linkage disequilibrium (LD) studies, 14 have been analyzed by allele-specific PCR in a sample of 50 parent-proband triads with bipolar disorder. A haplotyped marker comprised of five SNPs, spanning the region between exon 9 and exon 15, was constructed for each individual, and transmission/disequilibrium test (TDT) analysis revealed this haplotype to be in linkage disequilibrium with bipolar disorder (allele-wise TDT p = 0.001, genotype-wise TDT p = 0.0004). These data replicate our previous finding of linkage to markers within and near DAT in a largely different family set, and provide further evidence for a role of DAT in bipolar disorder. Published 2001 Wiley-Liss. Inc.

Multicenter double-blind comparison of sertraline and desipramine for concurrent obsessive-compulsive and major depressive disorders

BACKGROUND

Serotonin reuptake inhibitors (SRIs) have demonstrated consistent efficacy in the treatment of obsessive-compulsive disorder (OCD), while agents that are primarily norepinephrine reuptake inhibitors have not. Comparable efficacy has been demonstrated for SRI and non-SRI antidepressants in uncomplicated major depressive disorder (MDD). This multicenter trial is the first comparison of an SRI (sertraline) and a non-SRI antidepressant (desipramine) in the treatment of OCD with concurrent MDD.

METHODS

One hundred sixty-six patients diagnosed using structured clinical interviews and recruited from 16 treatment sites were randomly assigned to double-blind treatment with either sertraline (up to 200 mg/d) or desipramine (up to 300 mg/d) over 12 weeks. Measures of severity of OCD and MDD symptoms, as well as adverse effects of the medications, were monitored over the course of the treatment period.

RESULTS

Patients assigned to sertraline responded significantly better at end point on measures of OCD and MDD symptoms compared with patients assigned to desipramine. Sertraline was also associated with a significantly greater number of patients who achieved a "robust" improvement in OCD symptoms (> or =40% reduction) compared with desipramine. More patients receiving desipramine than sertraline discontinued treatment because of adverse events.

CONCLUSIONS

The SRI sertraline was more effective in reducing MDD and OCD symptoms than the primarily norepinephrine reuptake inhibitor desipramine for patients with concurrent OCD and MDD.

The relationship between substance use disorders, impulse control disorders, and pathological aggression

The authors examine the relationship between substance use disorders, impulse control disorders (ICDs), and pathological aggression. Phenomenologic evidence, neurobiologic evidence, and comorbidity data, as well as evidence from the pharmacotherapy of aggression and impulse control and substance use disorders, suggest links between substance use, impulsivity, and pathologic aggression. There also is evidence suggesting that dysfunction in common neurotransmitter systems, particularly the serotonin and GABAergic systems, may be involved in both disorders. Serotonergic agents have been explored in the treatment of ICDs, pathological aggression, and substance use disorders. Mood-stabilizing anticonvulsant have GABAergic activity, have received preliminary exploration in the treatment of ICDs and aggression in a number of psychiatric disorders. There is also evidence that these agents may be useful in subgroups of individuals with substance use disorders.

A 2-year study of sertraline in the treatment of obsessive-compulsive disorder

The present study investigated the tolerability, safety profile, and anti-obsessional efficacy of sertraline, a selective serotonin reuptake inhibitor, during long-term treatment of patients with obsessive-compulsive disorder (OCD). Fifty-nine OCD patients who had completed a 1 year double-blind, fixed dose study comparing sertraline and placebo subsequently entered a 1-year open extension. Among the 51 patients who had been treated with sertraline during the double-blind phase, the mean total duration of sertraline treatment was 690 days. Only treatment responders who completed the 52-week double-blind treatment phase were permitted to enter the open extension. The higher rate (p < 0.02) of sertraline patients (51 out of 241) than of placebo patients (eight out of 84), who responded to treatment and entered the open-label phase is therefore consistent with the greater mean improvement observed in the sertraline group during double-blind treatment. Placebo responders differed from sertraline responders in that they were less impaired at baseline of the double-blind study [Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) of 18.5 versus 23.4] and they exhibited less improvement during double-blind treatment (-6.1 versus -11.4). In the open-label phase all patients received sertraline at a starting dose of 50 mg once a day, titrated in 50 mg increments to a maximum dose of 200 mg according to clinical response. At end-point the mean Y-BOCS score for all patients decreased by a further 3.6 points. Patients previously treated with placebo showed greater improvement after being switched to sertraline than those who received continued sertraline treatment. Patients who completed the study and received 2 full years of sertraline treatment (n = 38) exhibited a mean improvement of 15.6 points using the Y-BOCS. Sertraline was well tolerated during both the double-blind phase and the open extension, and the incidence of adverse experiences was generally reduced during the second year of treatment. Three patients discontinued open treatment because of adverse experiences. Long-term sertraline treatment did not appear to be associated with the emergence, increased incidence, or increased severity of adverse experiences or clinically significant abnormalities in laboratory tests, vital signs, or the electrocardiogram. The study supports the long-term safety and tolerability of sertraline over a 2-year treatment course and the sustained efficacy of sertraline in patients with OCD.