Magnetic resonance imaging of a randomized controlled trial investigating predictors of recovery following psychological treatment in adolescents with moderate to severe unipolar depression: study protocol for Magnetic Resonance - Improving Mood with Psychoanalytic and Cognitive Therapies (MR-IMPACT)

Background Major depressive disorders (MDD) are a debilitating and pervasive group of mental illnesses afflicting many millions of people resulting in the loss of 110 million working days and more than 2,500 suicides per annum. Adolescent MDD patients attending NHS clinics show high rates of recurrence into adult life. A meta-analysis of recent research shows that psychological treatments are not as efficacious as previously thought. Modest treatment outcomes of approximately 65% of cases responding suggest that aetiological and clinical heterogeneity may hamper the better use of existing therapies and discovery of more effective treatments. Information with respect to optimal treatment choice for individuals is lacking, with no validated biomarkers to aid therapeutic decision-making. Methods/Design Magnetic resonance-Improving Mood with Psychoanalytic and Cognitive Therapies, the MR-IMPACT study, plans to identify brain regions implicated in the pathophysiology of depressions and examine whether there are specific behavioural or neural markers predicting remission and/or subsequent relapse in a subsample of depressed adolescents recruited to the IMPACT randomised controlled trial (Registration # ISRCTN83033550). Discussion MR-IMPACT is an investigative biomarker component of the IMPACT pragmatic effectiveness trial. The aim of this investigation is to identify neural markers and regional indicators of the pathophysiology of and treatment response for MDD in adolescents. We anticipate that these data may enable more targeted treatment delivery by identifying those patients who may be optimal candidates for therapeutic response.

Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomised controlled trial

Background Up to 70% of adolescents with moderate to severe unipolar major depression respond to psychological treatment plus Fluoxetine (20-50 mg) with symptom reduction and improved social function reported by 24 weeks after beginning treatment. Around 20% of non responders appear treatment resistant and 30% of responders relapse within 2 years. The specific efficacy of different psychological therapies and the moderators and mediators that influence risk for relapse are unclear. The cost-effectiveness and safety of psychological treatments remain poorly evaluated. Methods/Design Improving Mood with Psychoanalytic and Cognitive Therapies, the IMPACT Study, will determine whether Cognitive Behavioural Therapy or Short Term Psychoanalytic Therapy is superior in reducing relapse compared with Specialist Clinical Care. The study is a multicentre pragmatic effectiveness superiority randomised clinical trial: Cognitive Behavioural Therapy consists of 20 sessions over 30 weeks, Short Term Psychoanalytic Psychotherapy 30 sessions over 30 weeks and Specialist Clinical Care 12 sessions over 20 weeks. We will recruit 540 patients with 180 randomised to each arm. Patients will be reassessed at 6, 12, 36, 52 and 86 weeks. Methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, research assessors independent of treatment team and blind to randomization, analysis by intention to treat, data management using remote data entry, measures of quality assurance, advanced statistical analysis, manualised treatment protocols, checks of adherence and competence of therapists and assessment of cost-effectiveness. We will also determine whether time to recovery and/or relapse are moderated by variations in brain structure and function and selected genetic and hormone biomarkers taken at entry. Discussion The objective of this clinical trial is to determine whether there are specific effects of specialist psychotherapy that reduce relapse in unipolar major depression in adolescents and thereby costs of treatment to society. We also anticipate being able to utilise psychotherapy experience, neuroimaging, genetic and hormone measures to reveal what techniques and their protocols may work best for which patients.

Awareness of number in children with severe and profound learning difficulties: three exploratory case studies

This paper reports on exploratory work investigating how children with severe and profound learning difficulties register an awareness of small quantities and how they might use this information to inform their understanding. It draws on studies of typically developing children and investigates their application to pupils whose response to conventional mathematical tasks are often limited because they lack relevance and interest. The responses of the three pupils to individualized learning contexts mirror the progression suggested in the literature, namely from awareness of number to simple actions using number cues to problem-solving behaviour

Gender, race, and heterogeneous effects of epidemic malaria on human capital and income

This article investigates the impact of exposure to a serious, unusual, and unforeseen malaria epidemic in northeast Brazil in 1938–40 on subsequent human capital attainment and income. Arguing the event was exogenous, the article exploits cohort and regional heterogeneity in exposure to identify effects. Results are consistent with differential mortality rates according to gender and socioeconomic status, such that heterogeneous selection and scarring effects are observed. Analyzing by gender alone, positive (selection) effects are found for men, and mixed (positive and negative) effects for women. Allowing for heterogeneity by race, selection effects persist for men. In contrast, positive (selection) effects are observed for nonwhite women, and negative (scarring) effects for white women. Results contribute to evidence suggesting that exposure to negative environmental shocks affects human capital attainment, while also suggesting it heterogeneously affects cohort composition.

Interpreting communication of people with profound and severe learning difficulties

The present paper highlights some of the issues involved in interpreting the communication behaviours of people with profound and multiple learning difficulties (PMLDs). Both inference and intention can play an important role in the communication process, and this raises a number of difficulties and dangers where one of the communication partners is not in a position to correct misunderstandings. The present authors discuss the importance of validating communication and pose a number of key questions to ask those who are most significant in the life of a person with PMLDs. A case study is provided that illustrates a number of these issues.

Quinine, mosquitoes and empire: reassembling malaria in British India, 1890-1910

The drug quinine figured as an object of enforced consumption in British India between the late 1890s and the 1910s, when the corresponding diagnostic category malaria itself was redefined as a mosquito-borne fever disease. This article details an overlapping milieu in which quinine, mosquitoes and malaria emerged as intrinsic components of shared and symbiotic histories. It combines insights from new imperial histories, constructivism in the histories of medicine and literature about non-humans in science studies to examine the ways in which histories of insects, drugs, disease and empire interacted and shaped one another. Firstly, it locates the production of historical intimacies between quinine, malaria and mosquitoes within the exigencies and apparatuses of imperial rule. In so doing, it explores the intersections between the worlds of colonial governance, medical knowledge, vernacular markets and pharmaceutical business. Secondly, it outlines ways to narrate characteristics and enabling properties of non-humans (such as quinines and mosquitoes) while retaining a constructivist critique of scientism and empire. Thirdly, it shows how empire itself was reshaped and reinforced while occasioning the proliferation of categories and entities like malaria, quinine and mosquitoes.

Radiographic Findings Among Children Hospitalized With Severe Community-Acquired Pneumonia

Background: Community-acquired pneumonia (CAP) is a leading cause of childhood death. There are few published reports of radiographic findings among children with severe CAP. Objective: To describe chest X-ray (CXR) findings and assess association between these radiographic findings and pneumococcal isolation in children with severe CAP. Methods: A prospective, multicenter, observational study was conducted in 12 centers in Argentina, Brazil, and the Dominican Republic. Children aged 3-59 months, hospitalized with severe pneumonia, were included. On admission, blood and pleural effusion cultures were performed. Streptococcus pneumoniae was identified according to standard procedures in the respective national reference laboratory. Chest X-rays were taken on admission and read before the culture results were reported. Results: Out of 2,536 enrolled patients, 283 (11.2%) had S. pneumoniae isolated, in 181 cases (7.1%) from blood. The follow radiographic patterns were observed: alveolar infiltrate (75.2%), pleural effusion (15.6%), and interstitial infiltrate (9.2%). Overall, pleural effusion was associated with pneumococcal isolation and pneumococcal bacteremia (P < 0.001). Infiltrates were unilateral (78.7%) or bilateral (21.3%), right-sided (76%) or left-sided (24%), in the lower lobe (53.6%) or the upper lobe (46.4%). Multivariate analysis including patients with affection of only one lobe showed that upper lobe affection and pleural effusion were associated with pneumococcal isolation (OR 1.8, 95% CI, 1.3-2.7; OR 11.0, 95% CI, 4.6-26.8, respectively) and with pneumococcal bacteremia (OR 1.7, 95% CI, 1.2-2.6; OR 3.1, 95% CI, 1.2-8.0, respectively). Conclusions: Three-quarters of the patients studied had alveolar infiltrates. Upper lobe compromising and pleural effusion were associated with pneumococcal invasive disease. Pediatr Pulmonol. 2010; 45:1009-1013. (C) 2010 Wiley-Liss, Inc.

Concordant Phylogeographies of 2 Malaria Vectors Attest to Common Spatial and Demographic Histories

The phylogeography of South American lineages is a topic of heated debate. Although a single process is unlikely to describe entire ecosystems, related species, which incur similar habitat limitations, can inform the history for a subsection of assemblages. We compared the phylogeographic patterns of the cytochrome oxidase I marker from Anopheles triannulatus (N = 72) and previous results for A. darlingi (N = 126) in a broad portion of their South American distributions. Both species share similar population subdivisions, with aggregations northeast of the Amazon River, in southern coastal Brazil and 2 regions in central Brazil. The average (ST) between these groups was 0.39 for A. triannulatus. Populations northeast of the Amazon and in southeastern Brazil are generally reciprocally monophyletic to the remaining groups. Based on these initial analyses, we constructed the a priori hypothesis that the Amazon and regions of high declivity pose geographic barriers to dispersal in these taxa. Mantel tests confirmed that these areas block gene flow for more than 1000 km for both species. The efficacy of these impediments was tested using landscape genetics, which could not reject our a priori hypothesis but did reject simpler scenarios. Results form summary statistics and phylogenetics suggest that both lineages originated in central Amazonia (south of the Amazon River) during the late Pleistocene (579 000 years ago) and that they followed the same paths of expansion into their contemporary distributions. These results may have implications for other species sharing similar ecological limitations but probably are not applicable as a general paradigm of Neotropical biogeography.

Spatial expansion and population structure of the neotropical malaria vector, Anopheles darlingi (Diptera: Culicidae)

Extensive population structuring is known to occur in Anopheles darlingi, the primary malaria vector of the Neotropics. We analysed the phylogeographic structure of the species using the mitochondrial cytochrome oxidase I marker. Diversity is divided into six main population groups in South America: Colombia, central Amazonia, southern Brazil, south-eastern Brazil, and two groups in north-east Brazil. The ancestral distribution of the taxon is hypothesized to be central Amazonia, and there is evidence of expansion from this region during the late Pleistocene. The expansion was not a homogeneous front, however, with at least four subgroups being formed due to geographic barriers. As the species spread, populations became isolated from each other by the Amazon River and the coastal mountain ranges of south-eastern Brazil and the Andes. Analyses incorporating distances around these barriers suggest that the entire South American range of An. darlingi is at mutation-dispersal-drift equilibrium. Because the species is distributed throughout such a broad area, the limited dispersal across some landscape types promotes differentiation between otherwise proximate populations. Moreover, samples from the An. darlingi holotype location in Rio de Janeiro State are substantially derived from all other populations, implying that there may be additional genetic differences of epidemiological relevance. The results obtained contribute to our understanding of gene flow in this species and allow the formulation of human mosquito health protocols in light of the potential population differences in vector capacity or tolerance to control strategies. (C) 2009 The Linnean Society of London, Biological Journal of the Linnean Society, 2009, 97, 854-866.

Metabolic acidosis in patients with severe sepsis and septic shock: A longitudinal quantitative study

Objective: To describe the composition of metabolic acidosis in patients with severe sepsis and septic shock at intensive care unit admission and throughout the first 5 days of intensive care unit stay. Design: Prospective, observational study. Setting: Twelve-bed intensive care unit. Patients: Sixty patients with either severe sepsis or septic shock. Interventions: None. Measurements and Main Results: Data were collected until 5 days after intensive care unit admission. We studied the contribution of inorganic ion difference, lactate, albumin, phosphate, and strong ion gap to metabolic acidosis. At admission, standard base excess was -6.69 +/- 4.19 mEq/L in survivors vs. -11.63 +/- 4.87 mEq/L in nonsurvivors (p < .05); inorganic ion difference (mainly resulting from hyperchloremia) was responsible for a decrease in standard base excess by 5.64 +/- 4.96 mEq/L in survivors vs. 8.94 +/- 7.06 mEq/L in nonsurvivors (p < .05); strong ion gap was responsible for a decrease in standard base excess by 4.07 +/- 3.57 mEq/L in survivors vs. 4.92 +/- 5.55 mEq/L in nonsurvivors with a nonsignificant probability value; and lactate was responsible for a decrease in standard base excess to 1.34 +/- 2.07 mEq/L in survivors vs. 1.61 +/- 2.25 mEq/L in nonsurvivors with a nonsignificant probability value. Albumin had an important alkalinizing effect in both groups; phosphate had a minimal acid-base effect. Acidosis in survivors was corrected during the study period as a result of a decrease in lactate and strong ion gap levels, whereas nonsurvivors did not correct their metabolic acidosis. In addition to Acute Physiology and Chronic Health Evaluation 11 score and serum creatinine level, inorganic ion difference acidosis magnitude at intensive care unit admission was independently associated with a worse outcome. Conclusions: Patients with severe sepsis and septic shock exhibit a complex metabolic acidosis at intensive care unit admission, caused predominantly by hyperchloremic acidosis, which was more pronounced in nonsurvivors. Acidosis resolution in survivors was attributable to a decrease in strong ion gap and lactate levels. (Crit Care Med 2009; 37:2733-2739)