Refined diagnostic criteria for the bipolar disorders: phase two of the AREDOC project.

OBJECTIVE: As limitations exist across DSM criteria sets for defining and differentiating the bipolar disorders generally and their component bipolar I (BP-1) and bipolar II (BP-II) sub-types, we sought to generate empirically based criteria. METHOD: We formed an international Task Force (TF) comprising members with bipolar disorder expertise, and who recruited 74 patients with a TF-diagnosed bipolar I and 104 with a bipolar II condition (with patients responding to definitional queries and symptom questionnaires), while 33 unipolar depressed patients recruited by the first author also completed the symptom questionnaire. A factor analysis sought to determine granular hypo/manic constructs. RESULTS: The bipolar disorder subjects strongly affirmed a new general definition of a bipolar disorder (capturing both manic and hypomanic episodes). While DSM-5 requires impaired functioning, we established that a high percentage of individuals with a BP-I or a BP-II disorder reported improved functioning and therefore modified this criterion. Analyses identified syptoms with differential high rates in individuals with bipolar disorder and its sub-types (and thus not simply capturing happiness), while a factor analysis generated seven symptom constructs both linked with and differing from DSM-5 bipolar symptom criteria. CONCLUSION: This second-stage report details a new set of criteria for differentiating the bipolar disorders from unipolar depressive conditions, while arguing for BP-I and BP-II disorders being differentiated principally by the respective presence or absence of psychotic features. Future studies will evaluate whether further modifications are required and examine for differential treatment benefits for those with a BP-I versus a BP-II condition.

Differentiating clinical and non-clinical depression: a heuristic study offering a template for extension studies.

OBJECTIVE: To differentiate clinical and non-clinical depression via a set of symptoms. METHODS: A sample of 140 patients attending a clinical service for those with mood disorders together with 40 subjects denying ever experiencing a clinical episode of depression were compared, with participants completing a questionnaire capturing many symptoms of depression as well as illness correlates. RESULTS: A latent class analysis of symptom data identified two classes and with class assignment corresponding strongly with initial clinical vs. non-clinical assignment. Univariate analyses identified the extent to which individual symptoms contributed to differentiation. Study data suggested DSM criteria that would benefit from re-writing or of reassignment. Two models for classifying clinical depression were generated. The first involved individuals feeling hopeless and also being suicidal or at risk of self-harm. The second involved a symptom set corresponding to DSM-5 criteria but with only five making significant independent contributions to diagnostic differentiation. CONCLUSION: The study is heuristic in offering a strategy for more precisely differentiating clinical and non-clinical depression in more representative samples, so allowing resolution of key features, and determining whether a monothetic or polythetic diagnostic symptom criterion model is optimal.

The pain course: a randomised controlled trial comparing a remote-delivered chronic pain management program when provided in online and workbook formats.

This study compared a remote-delivered pain management program, the Pain Course, when delivered in online and workbook formats. Participants (n = 178) were randomised into 2 groups: (1) an Internet Group (n = 84) who were provided with secure accounts to the program in an online format; or (2) a Workbook Group (n = 94) who were mailed workbook versions of the program. The content of both programs was identical and comprised 5 core lessons, which participants were encouraged to work through over an 8-week period, according to a prescribed timetable. All participants were provided with weekly contact with a clinical psychologist through email and telephone throughout the program. The overall findings suggest that the workbook format was no less effective or acceptable than the validated online format. Significant improvements (avg. improvement; Internet Group vs Workbook Group) in levels of disability (PDI: 16% vs 24%; RMDQ: 12% vs 15%), anxiety (GAD-7: 36% vs 26%), and depression (PHQ-9: 36% vs 36%) were observed in both groups immediately posttreatment. Further improvements were observed in disability levels to 3-month follow-up, and improvements across the other primary outcomes were maintained until 12-month follow-up. High treatment completion rates and levels of satisfaction were reported in both groups, and both groups required a similarly small amount of clinician contact per participant (M = 74.85 minutes; SD = 41.03). These results highlight the public health potential of remote-delivered pain management programs, delivered in either workbook or online formats, as methods of increasing access to pain management.

Glycolysis gene expression analysis and selective metabolic advantage in the clinical progression of colorectal cancer.

Production of lactate even in the presence of sufficient levels of oxygen (aerobic glycolysis) seems the prevalent energy metabolism pathway in cancer cells. The analysis of altered expression of effectors causing redirection of glucose metabolism would help to characterize this phenomenon with possible therapeutic implications. We analyzed mRNA expression of the key enzymes involved in aerobic glycolysis in normal mucosa (NM), primary tumor (PT) and liver metastasis (LM) of colorectal cancer (CRC) patients (pts) who underwent primary tumor surgery and liver metastasectomy. Tissues of 48 CRC pts were analyzed by RT-qPCR for mRNA expression of the following genes: hexokinase-1 (HK-1) and 2 (HK-2), embryonic pyruvate kinase (PKM-2), lactate dehydrogenase-A (LDH-A), glucose transporter-1 (GLUT-1), voltage-dependent anion-selective channel protein-1 (VDAC-1). Differences in the expression of the candidate genes between tissues and associations with clinical/pathologic features were studied. GLUT-1, LDH-A, HK-1, PKM-2 and VDAC-1 mRNA expression levels were significantly higher in PT/LM tissues compared with NM. There was a trend for higher expression of these genes in LM compared with PT tissues, but differences were statistically significant for LDH-A expression only. RAS mutation-positive disease was associated with high GLUT-1 mRNA expression levels only. Right-sided colon tumors showed significantly higher GLUT-1, PKM-2 and LDH-A mRNA expression levels. High glycolytic profile was significantly associated with poor prognosis in 20 metastatic, RAS-mutated pts treated with first-line chemotherapy plus Bevacizumab. Altered expression of effectors associated with upregulated glucose uptake and aerobic glycolysis occurs in CRC tissues. Additional analyses are warranted for addressing the role of these changes in anti-angiogenic resistance and for developing novel therapeutics.

The Pain Course: exploring predictors of clinical response to an Internet-delivered pain management program.

There is significant interest in the potential of Internet-delivered pain management programs for adults with chronic pain. Understanding the characteristics of people who do and do not benefit from Internet-delivered programs will help to guide their safe and effective use. Using a large sample from a previous randomised controlled trial of an established Internet-delivered pain management program, the Pain Course, this study (n = 463) examined whether several demographic, clinical, psychological, and treatment-related variables could be used to predict clinical response in levels of disability, depression, anxiety, or average pain. Multiple univariate and multivariate stepwise logistic regressions were used to identify unique predictors of clinical improvement, which, consistent with recommendations, was defined as a ≥30% reduction in symptoms or difficulties from baseline. Several unique predictors of clinical improvement were found. However, no particularly decisive or dominant predictors emerged that were common across time points or across the outcome domains. Reflecting this, the identified predictors explained only 18.1%, 13.7%, 7.6%, and 9.5% of the variance in the likelihood of making a clinical improvement in disability, depression, anxiety, and average pain levels, respectively. The current findings suggest that a broad range of patients may benefit from emerging Internet-delivered pain management programs and that it may not be possible to predict who will or will not benefit on the basis of patients' demographic, clinical, and psychological characteristics.

Clinical benchmarking enabled by the digital health record.

Office-based physicians are often ill equipped to report aggregate information about their patients and practice of medicine, since their practices have relied upon paper records for the management of clinical information. Physicians who do not have access to large-scale information technology support can now benefit from low-cost clinical documentation and reporting tools. We developed a hosted clinical data mart for users of a web-enabled charting tool, targeting the solo or small group practice. The system uses secure Java Server Pages with a dashboard-like menu to provide point-and-click access to simple reports such as case mix, medications, utilization, productivity, and patient demographics in its first release. The system automatically normalizes user-entered clinical terms to enhance the quality of structured data. Individual providers benefit from rapid patient identification for disease management, quality of care self-assessments, drug recalls, and compliance with clinical guidelines. The system provides knowledge integration by linking to trusted sources of online medical information in context. Information derived from the clinical record is clinically more accurate than billing data. Provider self-assessment and benchmarking empowers physicians, who may resent "being profiled" by external entities. In contrast to large-scale data warehouse projects, the current system delivers immediate value to individual physicians who choose an electronic clinical documentation tool.

Association between changes in adrenal secretion and cerebral morphometric correlates in normal aging and senile dementia.

The circadian organization of adrenal secretion was studied in 23 healthy elderly subjects, 23 elderly demented patients and 10 healthy young subjects, in order to investigate the relationships between the hypothalamic-pituitary-adrenal axis and some cerebral morphometric parameters. The cerebral morphometric analysis was performed in some subjects of the three groups by MRI. A significant increase in cortisol levels during evening and nighttime was found in both groups of the aged subjects. In elderly subjects, particularly if demented, the mean serum dehydroepiandrosterone sulfate (DHEAs) levels throughout the 24-hour cycle were significantly lower than in young controls. A significant reduction of the hippocampal and temporal volume and an enlargement of the lateral ventricles were found in aged subjects, these changes being significantly related to subjects' age. Moreover, the hippocampal volume was positively correlated with the circadian mesor of DHEAs (i.e., the circadian rhythm adjusted mean) and with the cortisol nocturnal increase. Our data may suggest the existence of a link between the selective impairment of cortisol secretion and DHEAs levels, and the progression of hippocampal degeneration.

Glycine causes increased excitability and neurotoxicity by activation of NMDA receptors in the hippocampus.

Glycine is an inhibitory neurotransmitter in the spinal cord and also acts as a permissive cofactor required for activation of the N-methyl-D-aspartate (NMDA) receptor. We have found that high concentrations of glycine (10 mM) cause marked hyperexcitability and neurotoxicity in organotypic hippocampal slice cultures. The hyperexcitability, measured using intracellular recording in CA1 pyramidal neurons was completely blocked by the NMDA receptor antagonist MK-801 (10 microM), but not by the AMPA receptor antagonist DNQX (100 microM). The neurotoxicity caused by glycine occurred in all regions of hippocampal cultures but was most marked in area CA1. There was significant CA1 neuronal damage in cultures exposed to 10 mM glycine for 30 min or longer (P < 0.01) or those exposed to 4 mM glycine for 24 h compared to control cultures (P < 0.01). The NMDA antagonists MK-801 (10 microM) and APV (100 microM) significantly reduced glycine-induced neuronal damage in all hippocampal subfields (P < 0.01). The AMPA antagonists CNQX, DNQX, and NBQX (100 microM) had no effect on glycine-induced neuronal damage. High concentrations of glycine therefore appear to enhance the excitability of hippocampal slices in an NMDA receptor-dependent manner. The neurotoxic actions of glycine are also blocked by NMDA receptor antagonists.

Reinnervation of stratum lucidum by hippocampal mossy fibers is developmentally regulated.

Mossy fibers from dentate gyrus granule cells establish synapses on CA3 pyramidal neurons during the first 3 postnatal weeks in the rat. Mossy fiber synapses are primarily restricted to the stratum lucidum. When examined by Timm stain after 10-14 days in vitro, cultured hippocampal slices from postnatal day 4 rat pups show a similar mossy fiber termination pattern in stratum lucidum. Thus, axon guidance cues used by mossy fibers in vivo appear to be preserved in these cultured slices. Three experimental manipulations were performed on hippocampal slice cultures to examine whether the axon guidance cues used by mossy fibers are developmentally regulated. First, mossy fibers were transected on the day of culture or day 7 in vitro. Mossy fibers transected on either day were able to reestablish their synaptic pattern in stratum lucidum of CA3. Second, dentates and hippocampi of same age or different age were co-cultured. Same age co-cultures (P4 dentates to P4 hippocampi or P11 dentates to P11 hippocampi) showed good mossy fiber reinnervation of stratum lucidum, as did different age co-cultures from P4 dentates to P11 hippocampi. However, P11 dentates to P4 hippocampi co-cultures showed little mossy fiber reinnervation of stratum lucidum. Third, new P4 or P11 dentates were co-cultured onto hippocampal slices in which mossy fibers had been allowed to degenerate. New mossy fibers reinnervated these hippocampi, but did not reestablish their normal synaptic pattern in stratum lucidum. These three experimental manipulations suggest that mossy fiber axon guidance mechanisms are developmentally regulated, and that existing mossy fibers play a role in directing mossy fiber reinnervation of stratum lucidum.

Differential effects of zinc on hyperpolarizing and depolarizing GABAA synaptic potentials in hippocampal slice cultures.

We have examined the changes in GABAA-mediated synaptic potentials recorded from CA3 pyramidal neurons in hippocampal slice cultures following application of zinc (Zn2+). Unlike 4-AP, Zn2+ did not enhance fast hyperpolarizing potentials but primarily enhanced depolarizing GABAA potentials. Zn2+ did not alter the postsynaptic response of pyramidal neurons to pressure applied GABA, consistent with previous reports that Zn2+ enhances the release of GABA from presynaptic terminals. To examine the role of local circuitry in the production of Zn2+ responses, we recorded from cultures maintained for 7-10 days following removal of the dentate and hilus to allow complete degeneration of the mossy fibers (DGX cultures). Zn2+ produced giant depolarizing potentials (GDPs) in DGX cultures that were identical to those in intact cultures. In contrast, the 4-AP response was dramatically altered in DGX cultures. In DGX cultures, Zn2+ co-applied with 4-AP appeared to inhibit the production of fast hyperpolarizing GABAA synaptic potentials produced by 4-AP alone. This inhibition of fast hyperpolarizing potentials suggests that Zn2+ may reduce the release of GABA onto pyramidal cell somata. These observations suggest that Zn2+ enhances GABA release from local circuit neurons that synapse onto pyramidal cell dendrites, and inhibits GABA release onto pyramidal cell somata.

Activity of spinal trigeminal pars oralis and adjacent reticular formation units during differential conditioning of the rabbit nictitating membrane response.

Spinal trigeminal nucleus pars oralis (SpoV) is anatomically linked to brain circuitry thought to subserve unconditioned and conditioned nictitating membrane responses in rabbit. Single-unit recording from SpoV and adjacent reticular formation obtained during conditioning from awake, behaving animals revealed modulation of unit firing related to CS, US, and CR occurrence. SpoV participates directly in the unconditioned response and probably relays US information to other brain areas subserving conditioning. The presence of CR-related activity suggests that SpoV may participate in the CR motor output pathway, and may also provide CR-related information to cerebellum. Sensory convergence and CR-related activity in reticular formation mark this structure as a candidate locus of primary neuronal plasticity in this example of conditioning.