Autism: Is there a folate connection?

Autism is increasing-but why? Birth defect prevention trials were based on the teleological assumption that folic acid could prevent neural tube defects without consideration of long-term effects, some of which could be beneficial, some of which might be harmful. We therefore ask-Is it impossible to look again at these cohorts?

Developing a change model for peer worker interventions in mental health services: a qualitative research study.

AIMS: A range of peer worker roles are being introduced into mental health services internationally. There is some evidence that attests to the benefits of peer workers for the people they support but formal trial evidence in inconclusive, in part because the change model underpinning peer support-based interventions is underdeveloped. Complex intervention evaluation guidance suggests that understandings of how an intervention is associated with change in outcomes should be modelled, theoretically and empirically, before the intervention can be robustly evaluated. This paper aims to model the change mechanisms underlying peer worker interventions. METHODS: In a qualitative, comparative case study of ten peer worker initiatives in statutory and voluntary sector mental health services in England in-depth interviews were carried out with 71 peer workers, service users, staff and managers, exploring their experiences of peer working. Using a Grounded Theory approach we identified core processes within the peer worker role that were productive of change for service users supported by peer workers. RESULTS: Key change mechanisms were: (i) building trusting relationships based on shared lived experience; (ii) role-modelling individual recovery and living well with mental health problems; (iii) engaging service users with mental health services and the community. Mechanisms could be further explained by theoretical literature on role-modelling and relationship in mental health services. We were able to model process and downstream outcomes potentially associated with peer worker interventions. CONCLUSIONS: An empirically and theoretically grounded change model can be articulated that usefully informs the development, evaluation and planning of peer worker interventions.

Daily variations in steady-state plasma concentrations of carbamazepine and its metabolites in epileptic children.

Total plasma carbamazepine, carbamazepine-10,11-epoxide (CBZ-EP) and 10,11-dihydro-10,11-trans-dihydroxy-carbamazepine (CBZ-DIOL) concentrations were measured during a 24h period in 21 patients receiving carbamazepine monotherapy, in equally divided doses, every 12h. Interdose and diurnal variations in plasma concentrations of parent drug and metabolites were assessed. Carbamazepine and both metabolites showed significant differences in mean 4h post-dose plasma concentrations between day and night dosing (p less than 0.001). Significant linear correlations were obtained between carbamazepine dose and plasma concentrations of carbamazepine, CBZ-EP and CBZ-DIOL when sampling times were standardised (p less than 0.01). Comparisons of plasma concentrations of the parent compound with those of its 2 main metabolites revealed significant linear correlations in all cases (p less than 0.01). The effects of daily fluctuations in plasma concentrations of all 3 compounds on their relative concentrations (CBZ-EP:carbamazepine, CBZ-DIOL:carbamazepine and CBZ-DIOL:CBZ-EP) during the 24h period were also determined: the plasma concentration ratios CBZ-EP:carbamazepine and CBZ-DIOL:carbamazepine were significantly related to the dose of carbamazepine at fixed sampling times (p less than 0.05, with 1 exception). The large interdose and diurnal variation in plasma carbamazepine concentrations observed in this study (approximately 40% decrease from peak to trough) has important implications both clinically and in relation to therapeutic drug monitoring.

Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures.

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

Biotransformation of pteroylmonoglutamic acid during absorption: implications of Michaelis-Menten kinetics.

Previously reported work from this laboratory has shown that, in man, the formation of plasma 5-methyltetrahydrofolic acid (5MeTHF) from orally administered pteroylmonoglutamic acid (PGA) obeys Michaelis-Menten kinetics. The regression equation obtained from a plot of the reciprocal amount of 5MeTHF formed (micrograms per litre plasma/min) as a function of reciprocal amount of PGA administered (micrograms/kg body weight) provides a useful means of calculating the improved efficiency of 5MeTHF formation by dividing the total dose of PGA into smaller doses.

The responsiveness of plasma homocysteine to small increases in dietary folic acid: a primary care study.

OBJECTIVES: To assess the long term effects of small increases in dietary folic acid on the concentration of plasma homocysteine, an independent risk factor for occlusive vascular disease, in a general population. DESIGN: A randomized double-blind placebo-controlled intervention study. SUBJECTS: One hundred and nineteen healthy volunteers, whose intake of fortified or supplemental folic acid was low, were recruited by letter from the patient register of a large inner-city group general practice. METHODS: Volunteers were randomized to receive unfortified cereals, or cereals fortified with 200 microg of folic acid per portion, with or without other vitamins. Blood samples were taken presupplement and at 4, 8 and 24 weeks on treatment and analysed for plasma homocysteine, cysteine and vitamin B12 and serum and red cell folate. Ninety-four subjects completed the study providing blood samples on all four occasions. RESULTS: There were no significant changes in any measured parameter in those eating unfortified cereals. Overall, folic acid fortification of cereals led to significant increases (P < 0.001) in serum folate (66%), and red cell folate (24%), and a decrease in plasma homocysteine (10%; P < 0.001). There were no changes in vitamin B12 or cysteine. The homocysteine decrease persisted until the end of the study and was primarily seen in those who initially had the highest plasma homocysteine or the lowest serum folate. CONCLUSIONS: If homocysteine is found to be a causative risk factor in occlusive vascular disease, food fortification with physiological levels of folic acid should have a significant impact on the prevalence of the disease in the general population.

A rapid HPLC method for monitoring plasma levels of caffeine and theophylline using solid phase extraction columns.

A simple HPLC method for the determination of caffeine and theophylline in plasma is described. Separation of theobromine, paraxanthine, theophylline, beta-hydroxyethyltheophylline and caffeine is obtained using a mobile phase of 1% acetic acid/methanol (83:17, v/v) and a Waters Associates NOVA-PAK C18 column protected by a Guard-PAK precolumn module containing a Guard-PAK CN cartridge. Rapid sample preparation is achieved by solid-phase extraction columns (Bond-Elut C18, 1 mL capacity) which provide excellent recovery values for both drugs. The cost per sample using this approach can be minimised by column regeneration and re-use. Results obtained for theophylline are in good agreement with values determined by other techniques.

New perspectives on folate status: a differential role for the vitamin in cardiovascular disease, birth defects and other conditions.

In recent years, there has been heightened interest in the B vitamin folic acid, initially through its role in reducing neural tube defects, such as spina bifida, and, more recently, through its relationship with homocysteine and consequently the beneficial role it would seem to play in occlusive vascular disease. In addition, its sphere of influence may extend beyond these important conditions to include several cancers, Alzheimer's disease and affective disorders. The beneficial effects of folate in the above conditions can be explained largely within the context of folate-dependent pathways, such as methionine, purine and pyrimidine biosynthesis. However, the precise detail of folate metabolism is extremely complex and difficult to study because folate-dependent one-carbon metabolism is compartmentalised, involves an enormous number of low-abundance, difficult-to-measure, highly labile folyl coenzymes, and is the subject of genetic variability. Here we integrate some of the most recent findings in the field to provide a new perspective on folate status and some of the varied mechanisms by which folate ameliorates disease.

Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey.

OBJECTIVE: To study the time course and prediction of responses to reassurance after gastroscopy showing no serious illness. DESIGN: Selection of consecutive patients were assessed before gastroscopy, immediately after reassurance, and at follow up at 24 hours, 1 week, 1 month, and 1 year. Responses of subgroups of patients identified as high, medium, and low health anxiety by the health anxiety questionnaire were analysed. SETTING: Endoscopy clinic in a general hospital. INTERVENTION: Oral reassurance that there was "nothing seriously wrong." SUBJECTS: One consultant physician and 60 patients aged 18-74 referred for gastroscopy. MAIN OUTCOME MEASURES: Physician's and patients' ratings of the extent of the reassurance and patients' ratings of their anxiety about their health and of their illness belief. RESULTS: There was good agreement between the patients and the physician about whether reassurance had been given. Health anxiety and illness belief decreased markedly after reassurance. Patients with high health anxiety showed a significant resurgence in their worry and illness belief at 24 hours and 1 week, and these levels were maintained at 1 months and 1 year later. Patients with medium levels of health anxiety showed a reduction in worry and illness belief after reassurance, and this was generally maintained during follow up. Patients with low health anxiety maintained low levels of health worry and illness belief throughout the study. Partial correlation analyses showed that the levels of worry and illness belief after reassurance were predicted by the health anxiety questionnaire. This measure also had predictive value beyond that of a measure of general anxiety. CONCLUSIONS: Medical reassurance results in a reduction of worry about health and of illness belief, but this may be very short term. Measurable individual differences in health anxiety can be used to predict the response to reassurance.

The clinical effectiveness and cost-effectiveness of low-intensity psychological interventions for the secondary prevention of relapse after depression: a systematic review.

BACKGROUND: Depression is the most common mental disorder in community settings and a major cause of disability across the world. The objective of treatment is to achieve remission or at least adequate control of depressive symptoms; however, even after successful treatment, the risk of relapse after remission is significant. Although the effectiveness of low-intensity interventions has been extensively evaluated to treat primary symptoms of psychological difficulties, there has been substantially less research examining the use of these interventions as a relapse prevention strategy. OBJECTIVE: To systematically review the clinical effectiveness and cost-effectiveness of low-intensity psychological or psychosocial interventions to prevent relapse or recurrence in patients with depression. As the broader definition of 'low-intensity' psychological intervention is somewhat contested, the review was conducted in two parts: A, a systematic review of all evaluations of 'low-intensity' interventions that were delivered by para-professionals, peer supporters or psychological well-being practitioners as defined by the Improving Access to Psychological Therapies programme; and B, a scoping review of relevant evaluations of interventions involving qualified mental health professionals (e.g. psychiatrists, clinical psychologists, cognitive behavioural therapists) involving < 6 hours of contact per patient. DATA SOURCES: Comprehensive literature searches were developed; electronic databases were searched from inception until September 2010 (including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, EMBASE, The Cochrane Library), internet resources were used to identify guidelines on the treatment of depression, and the bibliographies of relevant reviews, guidelines and included studies were scrutinised. REVIEW METHODS: Two reviewers independently screened titles and abstracts; data were extracted independently by one reviewer using a standardised data extraction form and checked by another. Discrepancies were resolved by consensus, with involvement of a third reviewer when necessary. The inclusion criteria were population - adults or adolescents who had received treatment for depression; intervention - part A, low-intensity interventions, specifically any unsupported psychological/psychosocial interventions or any supported interventions that did not involve highly qualified mental health professionals, and, part B, interventions carried out by qualified mental health professionals that involved < 6 hours of contact per patient; comparator - any, including no treatment, placebo, psychological or pharmacological interventions; outcomes - relapse or recurrence, other outcomes (e.g. social function, quality of life) were recorded where reported; and study design - for clinical effectiveness, randomised, quasi-randomised and non-randomised studies with concurrent control patients. For cost-effectiveness, full economic evaluations that compared two or more treatment options and considered both costs and consequences. No studies met the main part A inclusion criteria. RESULTS: For the clinical effectiveness review, 17 studies (14 completed, three ongoing), reported in 27 publications, met the part B inclusion criteria. These studies were clinically and methodologically diverse, and reported differing degrees of efficacy for the evaluated interventions. One randomised controlled trial (RCT), which evaluated a collaborative care-type programme, was potentially relevant to part A; this study reported no difference between patients receiving the intervention and those receiving usual care in terms of relapse of depression over 12 months. For the cost-effectiveness review, two studies met the criteria for part B. One of these was an economic evaluation of the RCT above, which was potentially relevant to part A. This evaluation found that the intervention may be a cost-effective use of resources when compared with usual care; however, it was unclear how valid these estimates were for the NHS. LIMITATIONS: Although any definition of 'brief' is likely to be somewhat arbitrary, an inclusion threshold of 6 hours contact per patient was used to select brief high-intensity intervention studies. Most excluded studies evaluated clearly resource-intensive interventions, though occasionally, studies were excluded on the basis of having only slightly more than 6 hours contact per patient. CONCLUSIONS: There is inadequate evidence to determine the clinical effectiveness or cost-effectiveness of low-intensity interventions for the prevention of relapse or recurrence of depression. A scoping review of brief high-intensity therapies indicates that some approaches have shown promise in some studies, but findings have not been consistent. Many uncertainties remain and further primary research is required. Careful consideration should be given to the scope of such research; it is important to evaluate the broader patient pathway accounting for the heterogeneous patient groups of interest. Future RCTs conducted in a UK primary care setting should include adult participants in remission or recovery from depression, and evaluate the quality of the intervention and consistency of delivery across practitioners where appropriate. The occurrence of relapse or recurrence should be measured using established methods, and functional outcomes as well as symptoms should be measured; data on quality of life using a generic instrument, such as the European Quality of Life-5 Dimensions (EQ-5D), should be collected. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

The folic acid endophenotype and depression in an elderly population.

OBJECTIVES: Folate status and/or genes have been linked to depression in a number of studies. This may be via a direct action (or actions) on neuronal membranes or indirect effects through the metabolism of methyl groups involved in neurotransmitter synthesis. This study examines folate and related thiol metabolism that might underpin either phenomenon. DESIGN: Cohort study describing the relationship between several genetic and nutritional aspects of folic acid homeostasis and depression assessed by the HADS psychometric index in an elderly cohort. SETTING: New South Wales (Australia) retirement village. PARTICIPANTS: 118 elderly participants (age 65-90 years). RESULTS: Stepwise multiple regression was used to determine the best statistical model to predict depression; C677T-MTHFR (p=0.0103) was found to be positively associated with depression, while the thiol dipeptide Cys-Gly was negatively associated (p=0.0403). The statistical models used accounted for the major folate related indices (genetic and biochemical) that are most often evaluated in the context of health and disease. When only genetic data were examined for interactions, C677T-MTHFR was found to be negatively associated with the HADS Depression Index Score (p=0.0191). CONCLUSION: The potential influence of Cys-Gly on this phenotype is novel, and of considerable interest given that it has been linked to altered spontaneous activity and sedation in an animal model. Cys-Gly is a recognised ligand at the N-methyl-D-aspartatic acid (NMDA) subclass of glutamate receptor, a system associated with depression. In addition, the C677T-MTHFR association adds further support to existing findings underscoring the potential role of folate in depression.

Fetal folate C677T methylenetetrahydrofolate reductase gene polymorphism and low birth weight.

The aim of this study was to determine if fetal C677T methylenetetrahydrofolate reductase (MTHFR) genotype contributes to low birth weight. The study group consisted of 243 term babies with a birth weight<10th centile for gestational age, with subgroup analyses for those <1st centile. The control group consisted of 132 term babies with a birth weight 3.3-3.8 kg. Odds ratio analyses with 95% confidence intervals (CI) were calculated for carriage of the t allele and overall genotype frequencies. There was no significant difference in carriage of the t allele between study and control groups, odds ratio (OR) 0.79 (95% CI, 0.57-1.09). No differences were observed for frequencies of heterozygote and recessive homozygote genotypes for the two populations. In the subgroup analyses, no statistical differences were observed in the t allele frequency, frequency of the heterozygote or homozygote genotype. Trends were seen and the study suggests that fetal C677T MTHFR genotype may be a factor contributing to birth weight. The potential may exist to influence clinical outcome by maternal folate supplementation.

Folic acid: nutritional biochemistry, molecular biology, and role in disease processes.

This paper reviews the chemistry, metabolism, and molecular biology of folic acid, with a particular emphasis on how it is, or may be, involved in many disease processes. Folic acid prevents neural tube defects like spina bifida, while its ability to lower homocysteine suggests it might have a positive influence on cardiovascular disease. A role for this B vitamin in maintaining good health may, in fact, extend beyond these clinical conditions to encompass other birth defects, several types of cancer, dementia, affective disorders, Down's syndrome, and serious conditions affecting pregnancy outcome. The effect of folate in these conditions can be explained largely within the context of folate-dependent pathways leading to methionine and nucleotide biosynthesis, and genetic variability resulting from a number of common polymorphisms of folate-dependent enzymes involved in the homocysteine remethylation cycle. Allelic variants of folate genes that have a high frequency in the population, and that may play a role in disease formation include 677C --> T-MTHFR, 1298A --> C-MTHFR, 2756A --> G-MetSyn, and 66A --> G-MSR. Future work will probably uncover further polymorphisms of folate metabolism, and lead to a wider understanding of the interaction between this essential nutrient and the many genes which underpin its enzymatic utilization in a plethora of critical biosynthetic reactions, and which, under adverse nutritional conditions, may promote disease.

Improved high-performance liquid chromatographic procedure for the determination of chlormethiazole levels following solid-phase extraction from plasma.

An improved high-performance liquid chromatographic method for the determination of chlormethiazole levels in plasma is described. The drug is extracted from plasma using commercially available reversed-phase extraction columns; recovery values obtained using Sep-Pak C18 and Bond Elut C1, C2, C4, C6, C8, C18 columns are compared. Separation was achieved by reversed-phase chromatography, using a mobile phase consisting of 0.025 M sodium acetate buffer, pH 4.5-acetonitrile (67:33) at a flow-rate of 1.6 ml/min in conjunction with a 15-cm Jones Chromatography Apex ODS column. The analytical column was protected by a Waters Assoc. Guard-Pak module containing a Guard-Pak CN insert. Using ultraviolet detection at 254 nm chlormethiazole levels in the region of 50 ng/ml can be measured with only 500 microliter of plasma.

Methylfolate modulates potassium evoked neuro-secretion: evidence for a role at the pteridine cofactor level of tyrosine 3-hydroxylase.

We have previously shown that 5-methyltetrahydrofolate influences neuro-secretion. The present study more precisely characterises the processes involved and considers one probable site of action. Focusing on the tyrosine-noradrenalin axis in cerebellum we showed 5-methyltetrahydrofolate causes a significant reduction in the apparent K+ evoked secretion of noradrenalin to only 12.9% of control release. Evidence supports the idea that this could actually be due to increased synthesis leading to; depletion of reserves, possibly through leakage, exocytotic inhibition via activation of presynaptic receptors or end product inhibition by noradrenalin at the pteridine cofactor level of tyrosine hydroxylase: a) concomitant decreased measurement of perfusate and intracellular tyrosine with released noradrenalin following 5-methyltetrahydrofolate treatment supports the idea of increased transmitter turn over; b) kinetic studies indicate that at saturating concentrations of tyrosine and in the presence of an inhibitor of L-DOPA decarboxylase, 5-methyltetrahydrofolate partially duplicates the rate limiting behaviour of a synthetic pteridine cofactor--DL,2-amino-4-hydroxy-6,7,dimethyltetrahydropteridine. We debate whether, in vivo, CSF 5-methyltetrahydrofolate might interact at the tetrahydrobiopterin cofactor level of tyrosine hydroxylase and other aromatic amino-acid hydroxylases.

A rapid and specific HPLC-electrochemical method for the determination of endogenous 5-methyltetrahydrofolic acid in plasma using solid phase sample preparation with internal standardization.

A rapid and specific HPLC-electrochemical method for determining endogenous 5-methyltetrahydrofolic acid (5MeTHF) in plasma is described. Quantitative solid phase extraction of 5MeTHF and internal standard, beta-hydroxyethyltheophylline, was carried out using proprietary phenyl bonded-silica columns (Bond Elut Phenyl cartridges, 1.0 mL capacity). Chromatographic separation was achieved using a mobile phase consisting of 15% (v/v) methanol in 0.05 M KH2PO4, pH 3.5 at a flow rate of 2.0 mL/min in conjunction with a Waters Assoc. radially compressed Nova-Pak phenyl column (10 cm x 8 mm, 4 microns bonded silica). The internal standard was measured by UV detection at 254 nm. A Bioanalytical Systems Inc. LC-17 glassy carbon oxidative flow cell with a potential held at +0.35 V vs Ag/AgCl using the LC-4A amperometric controller allowed levels of 1-2 ng/mL 5MeTHF to be measured in 500 microL of plasma. Daily appraisal of the ratio produced by authentic materials clearly demonstrated that quantitation using dual detection was not subject to problems of differential response. Inter-day variation of the differential detector response is cited. Comparison of the Lactobacillus casei bioassay with HPLC demonstrates good agreement between methods but at the same time highlights the drawback of using such non-specific methods to measure samples where more than one folylmonoglutamate may be present. Antoxidant free storage for three months at -70 degrees C in darkness resulted in no deterioration of 5MeTHF. A comparison of the means and range of values for plasma folate obtained using HPLC, L. casei bioassay and the radiometric binding assay is reported.

Modulation of potassium evoked secretory function in rat cerebellar slices measured by real time monitoring: evidence of a possible role for methylfolate in cerebral tissue.

The real time dynamics of K+ evoked neurosecretion in cerebellar slices has been monitored electrochemically. In the presence of 5-methyltetrahydrofolate a statistically significant diminution in secretory response occurs. Agonists to probe the pharmacological basis for this indicate it is not due to voltage sensitive Ca2+ channel blockade, nor does it show any similarity of effect with kainate, whose receptor is a putative binding site for 5-methyltetrahydrofolate. The method is fully validated, although no account is taken of individual molecular species. High performance liquid chromatography combined with off line microbiological assay could only detect 5-methyltetrahydrofolate in cerebrospinal fluid. We therefore discuss our findings in relation to possible cerebral roles for cerebrospinal fluid 5-methyltetrahydrofolate in the context of both membrane and transmitter related interactions.