The cost-effectiveness of an indicated blended care intervention in primary care compared to usual care in patients with moderate persistent somatic symptoms.

INTRODUCTION: Appropriate treatment for people with an increased risk for developing chronic Persistent Somatic Symptoms (PSS) is of great importance at an early stage to improve quality of life and prevent high costs for society. OBJECTIVE: To evaluate the cost-effectiveness of an integrated blended care intervention compared to usual care for QALYs, subjective symptom impact and physical and mental health status in patients with moderate PSS. METHODS: This economic evaluation was conducted alongside a 12-month prospective, multicenter cluster randomized controlled trial in Dutch primary care. 80 participants received the intervention and 80 participants received usual care. Seemingly unrelated regression analyzes were performed to estimate cost and effect differences. Missing data were imputed using multiple imputation. Bootstrapping techniques were used to estimate uncertainty. RESULTS: We found no significant difference in total societal costs. Intervention, primary and secondary healthcare and absenteeism costs were higher for the intervention group. The ICER for QALYs demonstrated the intervention was on average less costly and less effective compared to usual care. For the subjective symptom impact and physical health, the ICER indicated that the intervention group was on average less costly and more effective. For mental health, the intervention was on average more costly and less effective. CONCLUSION: We didn't find an integrated blended primary care intervention to be cost-effective compared to usual care. However, when looking on relevant, but specific outcome measures (subjective symptom impact and physical health) for this population, average costs are found to be lower and the effectiveness found to be higher.

Quality of life in primary care patients with moderate medically unexplained physical symptoms.

PURPOSE: Medically Unexplained Physical Symptoms (MUPS) have a large impact on patient's quality of life. Most studies have been limited to chronic MUPS and thus, little is known about moderate MUPS. Improved knowledge concerning determinants influencing quality of life in moderate MUPS patients can be helpful in managing MUPS. This study is aimed at describing the common characteristics seen in moderate MUPS patients and compare them with characteristics seen in chronic MUPS patients and general population. We also identified determinants of the physical and mental components of quality of life in moderate MUPS patients. METHODS: In a cross-sectional study, moderate MUPS patients (n = 160) were compared with chronic MUPS patients (n = 162) and general population (n = 1742) based on demographic characteristics and patient's quality of life. Multivariable linear regression analyses were performed to identify determinants associated with a patient's quality of life, assessed with the RAND-36. RESULTS: Moderate MUPS patients experienced a better quality of life than chronic MUPS patients, but a worse quality of life as compared to the general population. Determinants associated with the physical and mental components of quality of life explain 49.1% and 62.9% of the variance, respectively. CONCLUSION: Quality of life of patients with MUPS varies with MUPS disease stage. Based on their quality of life scores, moderate MUPS patients would be adequately distinguished from chronic MUPS patients. Half of the variance in the physical component and almost two thirds of the mental component would be explained by a number of MUPS-related symptoms and perceptions.

Exploring the phase diagram of the two-impurity Kondo problem.

A system of two exchange-coupled Kondo impurities in a magnetic field gives rise to a rich phase space hosting a multitude of correlated phenomena. Magnetic atoms on surfaces probed through scanning tunnelling microscopy provide an excellent platform to investigate coupled impurities, but typical high Kondo temperatures prevent field-dependent studies from being performed, rendering large parts of the phase space inaccessible. We present a study of pairs of Co atoms on insulating Cu2N/Cu(100), which each have a Kondo temperature of only 2.6 K. The pairs are designed to have interaction strengths similar to the Kondo temperature. By applying a sufficiently strong magnetic field, we are able to access a new phase in which the two coupled impurities are simultaneously screened. Comparison of differential conductance spectra taken on the atoms to simulated curves, calculated using a third-order transport model, allows us to independently determine the degree of Kondo screening in each phase.

The association between somatization and disability in primary care patients.

BACKGROUND: Patient encounters for medically unexplained physical symptoms are common in primary health care. Somatization ('experiencing and reporting unexplained somatic symptoms') may indicate concurrent or future disability but this may also partly be caused by psychiatric disorders. The aim of this study was to examine the cross-sectional and longitudinal association between somatization and disability in primary care patients with and without anxiety or depressive disorder. METHODS: Data were obtained from 1545 primary care patients, participating in the longitudinal Netherlands Study of Depression and Anxiety (NESDA). Somatization was assessed using the somatization scale of the Four-Dimensional Symptom Questionnaire (4DSQ). Disability was determined by the WHO Disability Assessment Schedule 2.0 (WHO-DAS II). The relationships between somatization and both the total and subdomain scores of the WHO-DAS II were measured cross-sectionally and longitudinally after one year of follow-up using linear regression analysis. We examined whether anxiety or depressive disorder exerted a modifying effect on the somatization-disability association. RESULTS: Cross-sectionally and longitudinally, somatization was significantly associated with disability. Somatization accounted cross-sectionally for 41.8% of the variance in WHO-DAS disability and, longitudinally, for 31.7% of the variance in disability after one year of follow-up. The unique contribution of somatization to disability decreased to 16.7% cross-sectionally and 15.7% longitudinally, when anxiety and/or depressive disorder was added to the model. CONCLUSION: Somatization contributes to the presence of disability in primary care patients, even when the effects of baseline demographic and health characteristics and anxiety or depressive disorder are taken into account.

Local control of single atom magnetocrystalline anisotropy.

Individual Fe atoms on a Cu(2)N/Cu(100) surface exhibit strong magnetic anisotropy due to the crystal field. We show that we can controllably enhance or reduce this anisotropy by adjusting the relative position of a second nearby Fe atom, with atomic precision, in a low-temperature scanning tunneling microscope. Local inelastic electron tunneling spectroscopy, combined with a qualitative first-principles model, reveal that the change in uniaxial anisotropy is driven by local strain due to the presence of the second Fe atom.

Genetic aspects of sodium channelopathy in small fiber neuropathy.

Small fiber neuropathy (SFN) is a disorder typically dominated by neuropathic pain and autonomic dysfunction, in which the thinly myelinated Aδ-fibers and unmyelinated C-fibers are selectively injured. The diagnosis SFN is based on a reduced intraepidermal nerve fiber density and/or abnormal thermal thresholds in quantitative sensory testing. The etiologies of SFN are diverse, although no apparent cause is frequently seen. Recently, SCN9A-gene variants (single amino acid substitutions) have been found in ∼30% of a cohort of idiopathic SFN patients, producing gain-of-function changes in sodium channel Na(V)1.7, which is preferentially expressed in small diameter peripheral axons. Functional testing showed that these variants altered fast inactivation, slow inactivation or resurgent current and rendered dorsal root ganglion neurons hyperexcitable. In this review, we discuss the role of Na(V)1.7 in pain and highlight the molecular genetics and pathophysiology of SCN9A-gene variants in SFN. With increasing knowledge regarding the underlying pathophysiology in SFN, the development of specific treatment in these patients seems a logical target for future studies.

Nav1.7-related small fiber neuropathy: impaired slow-inactivation and DRG neuron hyperexcitability.

OBJECTIVES: Although small fiber neuropathy (SFN) often occurs without apparent cause, the molecular etiology of idiopathic SFN (I-SFN) has remained enigmatic. Sodium channel Na(v)1.7 is preferentially expressed within dorsal root ganglion (DRG) and sympathetic ganglion neurons and their small-diameter peripheral axons. We recently reported the presence of Na(v)1.7 variants that produce gain-of-function changes in channel properties in 28% of patients with painful I-SFN and demonstrated impaired slow-inactivation in one of these mutations after expression within HEK293 cells. Here we show that the I739V Na(v)1.7 variant in a patient with biopsy-confirmed I-SFN impairs slow-inactivation within DRG neurons and increases their excitability. METHODS: A patient with SFN symptoms including pain, and no identifiable underlying cause, was evaluated by skin biopsy, quantitative sensory testing, nerve conduction studies, screening of genomic DNA for variants in SCN9A, and functional analysis. RESULTS: Voltage-clamp analysis following expression within DRG neurons revealed that the Na(v)1.7/I739V substitution impairs slow-inactivation, depolarizing the midpoint (V(1/2)) by 5.6 mV, and increasing the noninactivating component at 10 mV from 16.5% to 22.2%. Expression of I739V channels within DRG neurons rendered these cells hyperexcitable, reducing current threshold and increasing the frequency of firing evoked by graded suprathreshold stimuli. CONCLUSIONS: These observations provide support, from a patient with biopsy-confirmed SFN, for the suggestion that functional variants of Na(v)1.7 that impair slow-inactivation can produce DRG neuron hyperexcitability that contributes to pain in SFN. Na(v)1.7 channelopathy-associated SFN should be considered in the differential diagnosis of cases of SFN in which no other cause is found.

Predictors of health-related quality of life in patients treated with auto- and allo-SCT for hematological malignancies.

Identifying factors that predict health-related quality of life (QOL) following hematopoietic SCT, is important in estimating patients' abilities to adjust to the consequences of their disease and treatment. As the studies that have been published on this subject are scattered, the present study aimed to systematically review prognostic factors for health-related QOL after auto- and allo-SCT in hematological malignancies. A systematic, computerized search in Medline, EMBASE, PsycINFO and the Cochrane Library was conducted from 2002 to June 2010. The methodological quality of the studies was assessed using an adaptation of Hayden's criteria list. Qualitative data synthesis was performed to determine the strength of the scientific evidence. In all, 35 studies fulfilled the selection criteria. Strong-moderate evidence was found for GVHD, conditioning regimen, being female, younger age, receiving less social support and pre-transplant psychological distress as predictors of various aspects of health-related QOL following hematopoietic SCT. The results of this review may help transplant teams in selecting patients at risk for experiencing a diminished health-related QOL following hematopoietic SCT. Follow-up treatment can be provided in order to promote QOL.

Expression of p53 as predictor for the development of esophageal cancer in achalasia patients.

Patients with longstanding achalasia have an increased risk of developing esophageal cancer. Surveillance is hampered by chronic stasis. We investigated whether aberrant expressions of tumor suppressor gene p53 and proliferation marker ki67 are early predictors for progression to malignancy. In 399 achalasia patients, 4% died of esophageal cancer despite surveillance. We performed a cohort study, using surveillance biopsies from 18 patients (11 carcinoma, one high-grade dysplasia [HGD], and six low-grade dysplasia [LGD]) and 10 controls (achalasia patients without cancer or dysplasia development). One hundred sixty-four biopsies were re-evaluated and studied for p53 and ki67 expression using immunohistochemistry. Eighty-two percent of patients with cancer/HGD showed p53 overexpression in surveillance biopsies at a mean of 6 (1-11) years prior to cancer development. In 67% of patients with LGD and only in 10% of the controls p53 overexpression was present. The proportion of samples with p53 overexpression increased with increasing grades of dysplasia. We found no difference for ki67 overexpression. p53 overexpression may identify achalasia patients at increased risk of developing esophageal carcinoma. Further study is needed to determine if patients with p53 overexpression would benefit from intensive surveillance to detect esophageal neoplasia at a potential curable stage.

Increased opioid release in specific brain areas in animals exposed to prenatal morphine and emotional stress later in life.

Prenatal morphine treatment and emotional stress both have been shown to increase sensitivity to reward-related behaviors. It has been postulated that this increased sensitivity to rewarding stimuli may be the result of an enhanced release of endogenous opioids. In the present study, in vivo autoradiography was employed to investigate the endogenous opioid release in specific brain areas in rats. Pregnant animals were exposed to morphine or saline from day 8 of gestation till birth. Development of pups was monitored and play behavior was tested on postnatal day 21. Adult rats were exposed to repeated emotional stress or control treatment for five consecutive days and tested in a small open field 5 days later. [(3)H]-Diprenorphine was injected following this test to investigate endogenous opioid release. Prenatal morphine treatment increased play behavior and endogenous opioid release in a number of cortical and subcortical brain areas after being subjected to an open field challenge later in life. Emotional stress exposure increased locomotor activity in the open field irrespective of the type of prenatal treatment and increased endogenous opioid release in some specific brain areas. It is suggested that the increased release of endogenous opioids in the substantia nigra, the piriform cortex and the septum observed after both types of treatments is related to the increased sensitivity to reward.

Myoclonus-dystonia: clinical and genetic evaluation of a large cohort.

BACKGROUND: Myoclonus-dystonia (M-D) is an autosomal dominant inherited movement disorder. Various mutations within the epsilon-sarcoglycan (SGCE) gene have been associated with M-D, but mutations are detected in only about 30% of patients. The lack of stringent clinical inclusion criteria and limitations of mutation screens by direct sequencing might explain this observation. METHODS: Eighty-six M-D index patients from the Dutch national referral centre for M-D underwent neurological examination and were classified according to previously published criteria into definite, probable and possible M-D. Sequence analysis of the SGCE gene and screening for copy number variations were performed. In addition, screening was carried out for the 3 bp deletion in exon 5 of the DYT1 gene. RESULTS: Based on clinical examination, 24 definite, 23 probable and 39 possible M-D patients were detected. Thirteen of the 86 M-D index patients carried a SGCE mutation: seven nonsense mutations, two splice site mutations, three missense mutations (two within one patient) and one multiexonic deletion. In the definite M-D group, 50% carried an SGCE mutation and one single patient in the probable group (4%). One possible M-D patient showed a 4 bp deletion in the DYT1 gene (c.934_937delAGAG). CONCLUSIONS: Mutation carriers were mainly identified in the definite M-D group. However, in half of definite M-D cases, no mutation could be identified. Copy-number variations did not play a major role in the large cohort.

Pediatric writer's cramp in myoclonus-dystonia: maternal imprinting hides positive family history.

Myoclonus-dystonia (M-D) is an autosomal dominantly inherited movement disorder with myoclonic jerks and dystonic contractions most frequently due to a mutation in the epsilon-sarcoglycan (SGCE, DYT11) gene. We describe two unrelated children with M-D (DYT11) who presented with writer's cramp. Due to maternal imprinting the family history appeared initially negative for M-D. In children with writer's cramp screening of the SGCE gene should be considered, even with a negative family history.

Recovery of posterior communicating artery aneurysm-induced oculomotor palsy after coiling.

BACKGROUND AND PURPOSE: Recovery of oculomotor (cranial nerve [CN] III) palsy after surgery of posterior communicating artery (PcomA) aneurysms has been well documented, but recovery after coiling is poorly understood. In this study, we report the recovery after coiling of PcomA aneurysm-induced CN III palsy in 21 patients at follow-up of 1 to 7 years. MATERIALS AND METHODS: Of 135 patients with a PcomA aneurysm treated with coils between January 1997 and December 2003, there were 21 patients with initial CN III dysfunction who were selected and reevaluated. There were 2 men and 19 women with a mean age of 54.9 years. In 17 patients, CN III palsy was associated with subarachnoid hemorrhage (SAH). Timing of treatment after onset of symptoms was 1 to 3 days in 5 patients, 4 to 14 days in 13, and more than 14 days in 3. Mean size of the aneurysm was 9 mm. Initial CN III palsy was complete in 15 patients and partial in 6. Mean follow-up after coiling was 3.7 years (range, 1-7 years). RESULTS: Of 15 patients with initial complete CN III palsy, recovery was complete in 3 and partial in 10. In 2 patients, complete CN III palsy was unchanged. Of 6 patients with initial partial CN III palsy, recovery was complete in 5 and partial in 1. Initial partial CN III palsy was the only predictor of complete recovery at follow-up. CONCLUSION: PcomA aneurysm-induced CN III palsy improves or cures after coiling in most patients. Complete recovery is more likely with initial partial dysfunction of the nerve.

Distal myoclonus and late onset in a large Dutch family with myoclonus-dystonia.

We report a large myoclonus-dystonia (M-D) pedigree with a two-base pair deletion in Exon 5 of the epsilon-sarcoglycan gene. Three individuals had onset after age 40 years. Distal myoclonus of the arms was present in all 20 symptomatic mutation carriers. These findings expand the known phenotype of M-D and require revision of the current diagnostic criteria. Five of 14 asymptomatic mutation carriers who inherited the mutation from their mother showed minimal axial dystonia, arguing against a maternal imprinting mechanism.

Increased limbic phosphorylated extracellular-regulated kinase 1 and 2 expression after chronic stress is reduced by cyclic 17beta-estradiol administration.

Chronic stress induced neuronal changes that may have consequences for subsequent stress responses. For example, chronic stress in rats rearranges dendritic branching patterns and disturbs the phosphorylation of extracellular-regulated kinase 1 and 2 (ERK) 1/2 throughout the limbic system. Stress-induced psychopathology occurs more often in women, however, most of studies have been done in male rats. Therefore, we studied the effect of stress in female rats. Other studies show that estradiol can modulate neuronal plasticity and might protect against stress-induced aberrations. To investigate the role of estradiol in stress responses we manipulated the hormone levels. Ovariectomized rats were cyclically treated with vehicle or with 17beta-estradiol-benzoate (1x in 4 days, 10 microg/250 g, s.c.) and subjected to either acute (3 days) or chronic (22 days) stress. In ovariectomized rats, the number of c-Fos positive cells in the infralimbic and prelimbic cortex of the prefrontal cortex and in the medial and basolateral amygdala was increased after acute stress. Moreover, acute stress reduced the number of phosphorylated ERK1/2 positive neurons in the prefrontal cortex of ovariectomized rats. Chronic stress, on the other hand, abolished normal patterns of c-Fos immunoreactivity in the prefrontal cortex and amygdala and increased the prefrontocortical phosphorylation of ERK1/2 in ovariectomized rats. Cyclic estradiol treatment preserved the neuronal reactivity in the infralimbic cortex after chronic stress and prevented sustained accumulation of phosphorylated ERK1/2. Therefore, cyclic estradiol administration apparently preserves the integrity of signal transduction cascades in limbic structures, which may protect against the harmful consequences of recurrent stress.

Phenotype-genotype correlation in Dutch patients with myoclonus-dystonia.

The epsilon-sarcoglycan (SGCE) gene is an important cause of myoclonus-dystonia (M-D), although the majority of cases with an M-D phenotype test negative. Seven of 31 patients with the M-D phenotype carried a mutation in the SGCE gene. Positive family history and truncal myoclonus were independent prognostic factors. Early disease onset, onset with both myoclonus and dystonia, and axial dystonia were detected significantly more often in the mutation carriers.

Chronic cocaine injections attenuate behavioral response of kappa-opioid receptors to U-50,488H agonist.

Chronic injections of cocaine (20 mg/kg daily for 10 days) increase activity and decrease anxiety in male C57Bl/6j mice in comparison with animals chronically injected with normal saline. U-50,488H (kappa-opioid receptor agonist; 2.5 mg/kg) produced an anxiolytic effect in animals preinjected with normal saline and had no effect in animals chronically injected with cocaine. Presumably, chronic activation of dopaminergic systems caused by cocaine injections is paralleled by desensitization of kappa-opioid receptor system.

Pair-housing of male and female rats during chronic stress exposure results in gender-specific behavioral responses.

UNLABELLED: Social support has a positive influence on the course of a depression and social housing of rats could provide an animal model for studying the neurobiological mechanisms of social support. Male and female rats were subjected to chronic footshock stress for 3 weeks and pair-housing of rats was used to mimic social support. Rats were isolated or housed with a partner of the opposite sex. A plastic tube was placed in each cage and subsequently used as a 'safe' area in an open field test. Time spent in the tube was used as a measurement of anxiety levels. Chronic stress increased adrenal weights in all groups, except for isolated females who showed adrenal hypertrophy in control conditions. In isolated males, chronic stress resulted in an increase in the time the animals spent in the tube. While stress did not affect this parameter in socially housed males, males with a stressed partner showed a similar response as isolated stressed males. Even though adrenal weights showed that isolated females were more affected by stress, after chronic stress exposure, they spent less time in the tube than socially housed females. Socially housed stressed females spent less time in the 'safe' tube compared to control counterparts, indicating that stress has a gender-specific behavioral effect. IN CONCLUSION: pair-housing had a stress-reducing effect on behavior in males. Isolation of females was stressful by itself. Pair housing of females was not able to prevent stress-induced behavioral changes completely, but appeared to reduce the effects of chronic stress.

Constitutive UCP3 overexpression at physiological levels increases mouse skeletal muscle capacity for fatty acid transport and oxidation.

Uncoupling protein 3 (UCP3) expression is directly correlated to fatty acid oxidation in skeletal muscle. UCP3 has been hypothesized to facilitate high rates of fatty acid oxidation, but evidence thus far is lacking. Our aim was to investigate the effects of UCP3 overexpression and ablation on fatty acid uptake and metabolism in muscle of mice having congenic backgrounds. In mice constitutively expressing the UCP3 protein (human form) at levels just over twofold higher than normal (230% of wild-type levels), indirect calorimetry demonstrated no differences in total energy expenditure (VO2), but a shift toward increased fat oxidation compared with wild-type (WT) mice. Metabolic efficiency (gram weight gain/kcal ingested) was similar between Ucp3 overexpressors, WT and Ucp3 (-/-) mice. In muscle of Ucp3-tg mice, plasma membrane fatty acid binding protein (FABPpm) content was increased compared with WT mice. Although hormone-sensitive lipase activity was unchanged across the genotypes, there were increases in carnitine palmitoyltransferase I, beta-hydroxyacylCoA dehydrogenase, and citrate synthase activities and decreases in intramuscular triacylglycerol in muscle of Ucp3-tg mice. There were no differences in muscle mitochondrial content. High-energy phosphates and total muscle carnitine and CoA were also greater in Ucp3-tg compared with WT mice. Taken together, the findings demonstrate an increased capacity for fat oxidation in the absence of significant increases in thermogenesis in Ucp3-tg mice. Findings from Ucp3 (-/-) mice revealed few differences compared with WT mice, consistent with the possibility of compensatory mechanisms. In conjunction with our observed increases in CoA and carnitine in muscle of Ucp3 overexpressors, the findings support the hypothesized role for Ucp3 in facilitating fatty acid oxidation in muscle.