Ultrasound guidance for transfemoral access in coronary procedures: an individual participant-level data metaanalysis from the femoral ultrasound trialist collaboration.

BACKGROUND: Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results. AIMS: We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis. METHODS: We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days. RESULTS: A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009). CONCLUSIONS: In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.

Inaccuracy of brachial blood pressure and its potential impact on treatment and aortic blood pressure estimation.

OBJECTIVE: Although brachial cuff SBP is universally used to guide hypertension management, it can differ significantly from intraarterial SBP. We examine the potential impacts of cuff-to-intraarterial brachial SBP (bSBP) mismatch on hypertension treatment and accuracy towards central SBP. METHODS: In 303 individuals, cuff bSBP (CUFF-bSBP) and central SBP were measured using a Mobil-o-Graph simultaneously to intraarterial bSBP (IA-bSBP) and aortic SBP. According to the difference between CUFF-bSBP and IA-bSBP, we identified three phenotypes: Underestimation (CUFF-bSBP < IA-bSBP by >10 mmHg); No Mismatch (CUFF-bSBP within 10 mmHg of IA-bSBP); Overestimation (CUFF-bSBP > IA-bSBP by >10 mmHg) phenotypes. Risk of overtreatment and undertreatment, and accuracy (ARTERY society criteria: mean difference ≤5 ±â€Š8 mmHg) were determined. A multiple linear regression model was used to assess variables associated with the bSBP difference. RESULTS: Underestimation (n = 142), No Mismatch (n = 136) and Overestimation (n = 25) phenotypes had relatively similar characteristics and CUFF-bSBP (124 ±â€Š17, 122 ±â€Š14, 127 ±â€Š19 mmHg, P = 0.19) but different aortic SBP (133 ±â€Š21, 120 ±â€Š16, 112 ±â€Š18 mmHg, P < 0.001). In the underestimation phenotype, 59% were at risk of undertreatment (14% in No Mismatch), whereas 50% in the Overestimation phenotype were at risk of overtreatment (17% in No Mismatch). CUFF-bSBP accurately estimated aortic SBP only in the No Mismatch Group (mean difference 1.6 ±â€Š8.2 mmHg) whereas central BP never met the accuracy criteria. Male sex, higher height and active smoking were associated with lesser underestimation of bSBP difference. CONCLUSION: The brachial cuff lacks accuracy towards intraarterial BP in a significant proportion of patients, potentially leading to increased risks of BP mismanagement and inaccurate determination of central BP. This illustrates the need to improve the accuracy of cuff-based BP monitors.

Hyperacute multi-organ thromboembolic storm in COVID-19: a case report.

Acute viral pneumonia, hypoxemic respiratory failure and severe inflammatory response are hallmarks of severe coronavirus disease 2019 (COVID-19). The COVID-19-associated inflammatory state may further lead to symptomatic thromboembolic complications despite prophylaxis. We report a 66-year-old female patient with post-mortem diagnosis of COVID-19 who presented progressive livedo racemosa, acute renal failure and myocardial injury, as well as an absence of respiratory symptoms. Transthoracic echocardiography showed severe spontaneous echo contrast in the right cardiac chambers and right-sided cardiac overload presumed to result from pulmonary microvascular thrombosis or embolism. D-dimer levels were increased. The patient developed an acute ischemic stroke and died 2 days following presentation despite therapeutic anticoagulation. Her predominantly thromboembolic presentation supports the concept of coronavirus infection of endothelial cells and hypercoagulability, or COVID-19 endotheliitis. The case we report highlights that COVID-19-associated hyperacute multi-organ thromboembolic storm may precede or present disproportionately to respiratory involvement.

Co-sputtering of gold and copper onto liquids: a route towards the production of porous gold nanoparticles.

Effective methods for the synthesis of high-purity nanoparticles (NPs) have been extensively studied for a few decades. Among others, cold plasma-based sputtering metals onto a liquid substrate appears to be a very promising technique for the synthesis of high-purity NPs. The process enables the production of very small NPs without using any toxic reagents and complex chemical synthesis routes, and enables the synthesis of alloy NPs which can be the first step towards the formation of porous NPs. In this paper, the synthesis of gold-copper alloy NPs has been performed by co-sputtering gold and copper targets over pentaerythritol ethoxylate. The resulting solutions contain a mixture of gold, copper oxide, and alloy NPs having a radius of few angstroms. The annealing of these NPs, inside the solution, has been performed in order to increase their size and further induce the dealloying of the Au-Cu NPs. The resulting NPs exhibit either a nanoporous structure or are self-organized in an agglomerate of small NPs.

Lamellar nanoporous gold thin films with tunable porosity for ultrasensitive SERS detection in liquid and gas phase.

Lamellar nanoporous gold thin films, constituted of a stack of very thin layers of porous gold, are synthesized by chemical etching from a stack of successively deposited nanolayers of copper and gold. The gold ligament size, the pore size and the distance between lamellas are tunable in the few tens nanometer range by controlling the initial thickness of the layers and the etching time. The SERS activity of these lamellar porous gold films is characterized by their SERS responses after adsorption of probe bipyridine and naphtalenethiol molecules. The SERS signal is investigated as a function of the bipyridine concentration from 10-14 mol L-1 to 10-3 mol L-1. The higher SERS response corresponds to an experimental detection limit down to 10-12 mol L-1. These performance is mainly attributed to the specific nanoporous gold architecture and the larger accessible surface to volume ratio. The lamellar nanoporous gold substrate is explored for sensitive SERS detection of dimethyl methylphosphonate (DMMP), a surrogate molecule of the highly toxic G-series nerve agents. The resultant nanostructure facilitates the diffusion of target molecules through the nanopores and their localization at the enhancing metallic surface leading to the unequivocal Raman signature of DMMP at a concentration of 5 parts per million.

Optimized regimens of combined medications for the treatment of major depressive disorder: a double-blind, randomized-controlled trial.

INTRODUCTION: This study investigated if optimized dose regimens of escitalopram and bupropion combination from treatment initiation can be superior to either drug alone in speed of onset, remission rate, and maintenance of therapeutic efficacy. METHODS: Patients from a single site (N=85) within a larger double-blind 12-week trial (N=245) showed a lower dropout rate (14% vs 40%) and used higher doses; therefore, this cohort was analyzed separately. Uniquely at this single site, after 12 weeks, non-remitters on a single drug received the other one in addition and combination non-remitters underwent a switch of escitalopram for duloxetine for a 6-week period. Escitalopram could be given up to 40 mg/day and bupropion up to 450 mg/day. A 6-month prolongation was then implemented in remitters, maintaining the double-blind design throughout. Remission was defined as ≤7 on the 17-item Hamilton Rating Scale for Depression, as in the initial publication. RESULTS: At week 2, combination treatment was superior in remission rate (5/28) compared with both bupropion (0/26) and escitalopram monotherapies (0/31; P=0.03 and P=0.02, respectively). The week 12 remission rate of combination treatment showed a higher rate (15/28) relative to bupropion monotherapy (7/26; P=0.04), but not statistically different from escitalopram monotherapy (11/31; P=0.13). The 6-week augmentation produced remission in 7/21 monotherapy non-remitters and 0/6 in the switch group (P=0.13). Remission was sustained in 28/31 patients enrolled in the 6-month maintenance. CONCLUSION: These results suggest that combination of escitalopram and bupropion from treatment initiation is superior to either monotherapy in speed of onset. The addition of a second drug in non-remitters can lead to additional remissions, as shown with other combinations of medications. Treatment prolongation using optimized regimens leads to low relapse rates.

Ultrasound guidance versus anatomical landmark approach for femoral artery access in coronary angiography: A randomized controlled trial and a meta-analysis.

OBJECTIVES: The objective was to assess the effect of ultrasound (US)-guidance compared to the anatomical landmark (AL) approach in patients requiring femoral artery (FA) access for coronary angiography/percutaneous coronary interventions (PCI). BACKGROUND: US-guidance has been proposed as a strategy to optimize FA access, potentially leading to decreased vascular complications. METHODS: Patients requiring FA access for coronary angiography/PCI were randomized to the US-guided or AL approaches. The primary endpoint was a composite of immediate procedural vascular outcomes, and access-site outcomes at day one. Results were subsequently pooled in a study-level meta-analysis of randomized trials comparing US-guided FA access to another strategy. RESULTS: A total of 129 patients were randomized (64 US-guided group; 65 AL group). The primary endpoint occurred in 30 patients (47%) with US, and in 39 patients (62%) with AL (P = 0.09). Four additional studies met the inclusion criteria and were included in the meta-analysis (1553 patients). Following data pooling, bleeding events (OR = 0.41; 95%CI 0.20-0.83; P = 0.01), venipunctures (OR = 0.18; 95%CI: 0.11-0.29; P < 0.0001), and multiple puncture attempts (OR = 0.24; 95%CI: 0.19-0.31; P < 0.0001) were significantly improved with US-guidance, but not successful common FA cannulation (OR = 0.84; 95%CI: 0.60-1.17; P = 0.29). CONCLUSION: Our study did not show significant benefits for the use of US to guide arterial femoral access compared to the anatomical landmark approach, but pooled analysis of five randomized trials showed decreased rates of bleeding events and venipunctures, and improved first-pass success. The clinical impact of these findings is uncertain, and do not warrant a systematic use of US-guidance in this clinical setting.

Dealloying of gold-copper alloy nanowires: From hillocks to ring-shaped nanopores.

We report on a novel fabrication approach of metal nanowires with complex surface. Taking advantage of nodular growth triggered by the presence of surface defects created intentionally on the substrate as well as the high tilt angle between the magnetron source axis and the normal to the substrate, metal nanowires containing hillocks emerging out of the surface can be created. The approach is demonstrated for several metals and alloys including gold, copper, silver, gold-copper and gold-silver. We demonstrate that applying an electrochemical dealloying process to the gold-copper alloy nanowire arrays allows for transforming the hillocks into ring-like shaped nanopores. The resulting porous gold nanowires exhibit a very high roughness and high specific surface making of them a promising candidate for the development of SERS-based sensors.

Controlling the Formation of Nanocavities in Kirkendall Nanoobjects through Sequential Thermal Ex Situ Oxidation and In Situ Reduction Reactions.

Controlling the porosity, the shape, and the morphology of Kirkendall hollow nanostructures is the key factor to tune the properties of these tailor-made nanomaterials which allow in turn broadening their applications. It is shown that by applying a continuous oxidation to copper nanowires following a temperature ramp protocol, one can synthesize cuprous oxide nanotubes containing periodic copper nanoparticles. A further oxidation of such nanoobjects allows obtaining cupric oxide nanotubes with a bamboo-like structure. On the other hand, by applying a sequential oxidation and reduction reactions to copper nanowires, one can synthesize hollow nanoobjects with complex shapes and morphologies that cannot be obtained using the Kirkendall effect alone, such as necklace-like cuprous oxide nanotubes, periodic solid copper nanoparticles or hollow cuprous oxide nanospheres interconnected with single crystal cuprous oxide nanorods, and aligned and periodic hollow nanospheres embedded in a cuprous oxide nanotube. The strategy demonstrated in this study opens new avenues for the engineering of hollow nanostructures with potential applications in gas sensing, catalysis, and energy storage.

Planar Arrays of Nanoporous Gold Nanowires: When Electrochemical Dealloying Meets Nanopatterning.

Nanoporous materials are of great interest for various technological applications including sensors based on surface-enhanced Raman scattering, catalysis, and biotechnology. Currently, tremendous efforts are dedicated to the development of porous one-dimensional materials to improve the properties of such class of materials. The main drawback of the synthesis approaches reported so far includes (i) the short length of the porous nanowires, which cannot reach the macroscopic scale, and (ii) the poor organization of the nanostructures obtained by the end of the synthesis process. In this work, we report for the first time on a two-step approach allowing creating highly ordered porous gold nanowire arrays with a length up to a few centimeters. This two-step approach consists of the growth of gold/copper alloy nanowires by magnetron cosputtering on a nanograted silicon substrate, serving as a physical template, followed by a selective dissolution of copper by an electrochemical anodic process in diluted sulfuric acid. We demonstrate that the pore size of the nanowires can be tailored between 6 and 21 nm by tuning the dealloying voltage between 0.2 and 0.4 V and the dealloying time within the range of 150-600 s. We further show that the initial gold content (11 to 26 atom %) and the diameter of the gold/copper alloy nanowires (135 to 250 nm) are two important parameters that must carefully be selected to precisely control the porosity of the material.

Creating nanoporosity in silver nanocolumns by direct exposure to radio-frequency air plasma.

Nanoporous materials are of great importance for a broad range of applications including catalysis, optical sensors and water filtration. Although several approaches already exist for the creation of nanoporous materials, the race for the development of versatile methods, more suitable for the nanoelectronics industry, is still ongoing. In this communication we report for the first time on the possibility of generating nanoporosity in silver nanocolumns using a dry approach based on the oxidation of silver by direct exposure to a commercially available radio-frequency air plasma. The silver nanocolumns are created by glancing angle deposition using magnetron sputtering of a silver target in pure argon plasma. We show that upon exposure to the rf air plasma, the nanocolumns transform from solid silver into nanoporous silver oxide. We further show that by tuning the plasma pressure and the exposure duration, the oxidation process can be finely adjusted allowing for precisely controlling the morphology and the nanoporosity of the silver oxide nanocolumns. The generation of porosity within the silver nanocolumns is explained according to a cracking-induced oxidation mechanism based on two repeated events occurring alternately during the oxidation process: (i) oxidation of silver upon exposure to the air plasma and (ii) generation of nanocracks and blisters within the oxide layer due to the high internal stress generated within the material during oxidation.

Unusual dealloying effect in gold/copper alloy thin films: the role of defects and column boundaries in the formation of nanoporous gold.

Understanding the dealloying mechanisms of gold-based alloy thin films resulting in the formation of nanoporous gold with a sponge-like structure is essential for the future design and integration of this novel class of material in practical devices. Here we report on the synthesis of nanoporous gold thin films using a free-corrosion approach in nitric acid applied to cosputtered Au-Cu thin films. A relationship is established between the as-grown Au-Cu film characteristics (i.e., composition, morphology, and structure) and the porosity of the sponge-like gold thin films. We further demonstrate that the dealloying approach can be applied to nonhomogenous Au-Cu alloy thin films consisting of periodic and alternate Au-rich/Au-poor nanolayers. In such a case, however, the dealloying process is found to be altered and unusual etching stages arise. Thanks to defects and column boundaries playing the role of channels, the nitric acid is found to quickly penetrate within the films and then laterally (i.e., parallel to the film surface) attacks the nanolayers rather than perpendicularly. As a consequence to this anisotropic etching, the Au-poor layers are etched preferentially and transform into Au pillars holding the Au-rich layers and preventing them against collapsing. A further exposure to nitric acid results in the collapsing of the Au-rich layers accompanied by a transition from a multilayered to a sponge-like structure. A scenario, supported by experimental observations, is further proposed to provide a detailed explanation of the fundamental mechanisms occurring during the dealloying process of films with a multilayered structure.

Examining relations between alpha power as well as anterior cingulate cortex-localized theta activity and response to single or dual antidepressant pharmacotherapies.

Electrocortical indices may be useful in predicting antidepressant response. Greater pretreatment alpha power and high rostral anterior cingulate cortex (rACC) theta activity tend to index a favorable outcome. The predictive utility of alpha power asymmetry has been under-explored. Baseline alpha2 (10.5-13.0 Hz) power/asymmetry, rACC theta2 (6.0-8.0 Hz) activity and early (one week) changes in these measures were assessed in relation to antidepressant response by week 12 to three treatment regimens (escitalopram (ESC) + bupropion (BUP), ESC or BUP) in patients with major depressive disorder (N=51). No treatment differences in response existed at week 12. Overall, treatment responders exhibited high, and non-responders low, frontal baseline alpha2 power. Frontal alpha2 power weakly discriminated responders/non-responders overall while posterior alpha2 power and BA25-localized theta2 activity strongly discriminated ESC responders/non-responders. No associations with alpha2 asymmetry and response emerged. BUP responders exhibited high, and BUP non-responders low, baseline rACC theta2 activity. Greater early decreases in rACC theta2 activity existed in ESC+BUP non-responders versus ESC+BUP responders. BUP responders exhibited greater rACC theta2 activity decreases than ESC responders. These preliminary results indicate that baseline and early changes in alpha2 and rACC theta2 activity associate with response and have implications for tailoring antidepressant treatments.

Combination antidepressant therapy for major depressive disorder: speed and probability of remission.

INTRODUCTION: Only about a third of patients with an episode of major depressive disorder remit with a given treatment and few remissions occur within the first weeks of treatment. This study tested whether combining escitalopram and bupropion as initial treatment would result in quicker remission and a higher remission rate than monotherapy with either drug. METHOD: Two hundred forty-five outpatients aged 18-65 having non-psychotic, non-bipolar major depression were randomly assigned to double-blind treatment with bupropion or escitalopram or the combination dosed to a maximum of bupropion 450 mg/d and/or escitalopram 40 mg/d for 12 weeks. A Montgomery-Asberg Depression Rating Scale score of 22 was required for randomization, while a Hamilton Rating Scale for Depression score ≤ 7 defined remission. We hypothesized that bupropion plus escitalopram would outperform both monotherapies in both earlier onset of remission and higher rate of remission. RESULTS: Primary analyses did not demonstrate that dual therapy outperformed both monotherapies in either timing of remission or remission rate. All three treatments were well tolerated. DISCUSSION: These results do not support initial use of bupropion plus escitalopram to speed or enhance antidepressant response. CLINICAL TRIALS REGISTRATION: NCT00519428.

Electron beam nanosculpting of Kirkendall oxide nanochannels.

The nanomanipulation of metal nanoparticles inside oxide nanotubes, synthesized by means of the Kirkendall effect, is demonstrated. In this strategy, a focused electron beam, extracted from a transmission electron microscope source, is used to site-selectively heat the oxide material in order to generate and steer a metal ion diffusion flux inside the nanochannels. The metal ion flux generated inside the tube is a consequence of the reduction of the oxide phase occurring upon exposure to the e-beam. We further show that the directional migration of the metal ions inside the nanotubes can be achieved by locally tuning the chemistry and the morphology of the channel at the nanoscale. This allows sculpting organized metal nanoparticles inside the nanotubes with various sizes, shapes, and periodicities. This nanomanipulation technique is very promising since it enables creating unique nanostructures that, at present, cannot be produced by an alternative classical synthesis route.

Auditory P3 in antidepressant pharmacotherapy treatment responders, non-responders and controls.

Event-related potentials (ERPs), derived from electroencephalographic (EEG) recordings, can index electrocortical activity related to cognitive operations. The fronto-central P3a ERP is involved in involuntary processing of novel auditory information, whereas the parietal P3b indexes controlled attention processing. The amplitude of the auditory P3b has been found to be decreased in major depressive disorder (MDD). However, few studies have examined the relations between the P3b, the related P3a, and antidepressant treatment response. We tested 53 unmedicated individuals (25 females) with MDD, as well as 43 non-depressed controls (23 females) on the novelty oddball task, wherein infrequent deviant (target) and frequent standard (non-target) tones were presented, along with infrequent novel (non-target/distractor) sounds. The P3a and P3b ERPs were assessed to novel and target sounds, respectively, as were their accompanying behavioral performance measures. Depression ratings and the antidepressant response status were assessed following 12 weeks of pharmacotherapy with three different regimens. Antidepressant treatment non-responders had smaller baseline P3a/b amplitudes than responders and healthy controls. Baseline P3b amplitude also weakly predicted the extent of depression rating changes by week 12. Females exhibited larger P3a/b amplitudes than males. With respect to task performance, controls had more target hits than treatment non-responders. ERP measures correlated with clinical changes in males and with behavioral measures in females. These results suggest that greater (or control-like) baseline P3a/b amplitudes are associated with a positive antidepressant response, and that gender differences characterize the P3 and, by extension, basic attentive processes.

Highly ordered hollow oxide nanostructures: the Kirkendall effect at the nanoscale.

Highly ordered ultra-long oxide nanotubes are fabricated by a simple two-step strategy involving the growth of copper nanowires on nanopatterned template substrates by magnetron sputtering, followed by thermal annealing in air. The formation of such tubular nanostructures is explained according to the nanoscale Kirkendall effect. The concept of this new fabrication route is also extendable to create periodic zero-dimensional hollow nanostructures.

Response prediction to antidepressants using scalp and source-localized loudness dependence of auditory evoked potential (LDAEP) slopes.

The loudness-dependence of the auditory evoked potential (LDAEP) slope may be inversely related to serotonin (5-HT) neurotransmission. Thus, steep LDAEPs tend to predict a positive response to selective serotonin reuptake inhibitor (SSRI) antidepressants, which augment 5-HT. However, LDAEPs also predict outcome to antidepressants indirectly altering 5-HT (e.g. bupropion). Hence, the LDAEP's predicative specificity and sensitivity to antidepressant response/outcome remains elusive. Scalp N1, P2 and N1/P2 LDAEP slopes and standardized low resolution brain electromagnetic tomography (sLORETA)-localized N1 and P2 LDAEP slopes were assessed in depressed individuals (N=51) at baseline, 1 and 12 weeks post-treatment with one of three antidepressant regimens [escitalopram (ESC)+bupropion (BUP), ESC or BUP]. Clinical response was greatest with ESC+BUP at week 1. Treatment responders had steep N1 sLORETA-LDAEP baseline slopes while non-responders had shallow ones. P2 sLORETA-LDAEP slope increases at 1 week existed in responders; decreases were noted in non-responders. Exploratory analyses indicated that more BUP and ESC responders versus non-responders had steep baseline N1 sLORETA-LDAEP slopes. Additionally, slight decreases in scalp P2 LDAEP by week 1 existed for ESC treatment, while slope increases existed with ESC+BUP treatment. Only baseline N1 sLORETA-LDAEP discriminated treatment responders/non-responders. This work confirms that certain LDAEP measures are associated with treatment outcome and appear to be differentially modulated with varying antidepressant drug regimens, though this should be confirmed using larger samples.

Highly ordered ultralong magnetic nanowires wrapped in stacked graphene layers.

We report on the synthesis and magnetic characterization of ultralong (1 cm) arrays of highly ordered coaxial nanowires with nickel cores and graphene stacking shells (also known as metal-filled carbon nanotubes). Carbon-containing nickel nanowires are first grown on a nanograted surface by magnetron sputtering. Then, a post-annealing treatment favors the metal-catalyzed crystallization of carbon into stacked graphene layers rolled around the nickel cores. The observed uniaxial magnetic anisotropy field oriented along the nanowire axis is an indication that the shape anisotropy dominates the dipolar coupling between the wires. We further show that the thermal treatment induces a decrease in the coercivity of the nanowire arrays. This reflects an enhancement of the quality of the nickel nanowires after annealing attributed to a decrease of the roughness of the nickel surface and to a reduction of the defect density. This new type of graphene-ferromagnetic-metal nanowire appears to be an interesting building block for spintronic applications.

Familial paraphilia: a pilot study with the construction of genograms.

Biological factors are likely predisposing and modulating elements in sexually deviant behavior. The observation that paraphilic behavior tends to cluster in some families is intriguing and potentially raises questions as to whether shared genetic factors may play a role in the transmission of paraphilia. This pilot study introduces five families in which we found presence of paraphilia over generations. We constructed genograms on the basis of a standardized family history. Results document the aggregation of sexual deviations within the sample of families and support a clinical/phenomenological heterogeneity of sexual deviation. The concept of paraphilia in relation to phenotypic expressions and the likelihood of a spectrum of related disorders must be clarified before conclusions can be reached as to family aggregation of paraphilia based on biological factors.