Brain volumes, behavioral inhibition, and anxiety disorders in children: results from the adolescent brain cognitive development study.

BACKGROUND: Magnetic resonance imaging (MRI) studies have identified brain changes associated with anxiety disorders (ADs), but the results remain mixed, particularly at a younger age. One key predictor of ADs is behavioral inhibition (BI), a childhood tendency for high avoidance of novel stimuli. This study aimed to evaluate the relationships between candidate brain regions, BI, and ADs among children using baseline data from the Adolescent Brain Cognitive Development (ABCD) study. METHODS: We analyzed global and regional brain volumes of 9,353 children (9-10 years old) in relation to BI and current ADs, using linear mixed models accounting for family clustering and important demographic and socioeconomic covariates. We further investigated whether and how past anxiety was related to brain volumes. RESULTS: Among included participants, 249 (2.66%) had a current AD. Larger total white matter (Beta = -0.152; 95% CI [-0.281, -0.023]), thalamus (Beta = -0.168; 95% CI [-0.291, -0.044]), and smaller hippocampus volumes (Beta = 0.094; 95% CI [-0.008, 0.196]) were associated with lower BI scores. Amygdala volume was not related to BI. Larger total cortical (OR = 0.751; 95% CI [0.580;0.970]), amygdala (OR = 0.798; 95%CI [0.666;0.956]), and precentral gyrus (OR = 0.802; 95% CI [0.661;0.973]) volumes were associated with lower odds of currently having ADs. Children with past ADs had smaller total white matter and amygdala volumes. CONCLUSIONS: The results show associations between brain volumes and both BI and ADs at an early age. Importantly, results suggest that ADs and BI have different neurobiological correlates and that earlier occurrences of ADs may influence brain structures related to BI and ADs, motivating research that can better delineate the similarities and divergence in the neurobiological underpinnings and building blocks of BI and ADs across their development in early life.

Psychopathology in Children and Adolescents in Lebanon Study (PALS): a national household survey.

INTRODUCTION: Psychiatric disorders are among the leading causes of disability in children and adolescents globally. In Lebanon, a country that has endured a prolonged history of conflict and economic and political uncertainty, mental health surveys in children and adolescents have been limited to specific disorders or specific settings or cities. PALS (Psychopathology in Children and Adolescents in Lebanon Study) is the first study to screen a nationally representative sample of children and adolescents for psychiatric disorders and estimate the national prevalence of children and adolescents at risk of having a psychiatric disorder. METHODS: A nationally representative household sample of 1517 children and adolescents (aged 5 years 0 months to 17 years 11 months) was recruited through a multi-stage stratified proportionate sampling technique between February 2018 and November 2018. Parents and adolescents completed a battery of self-reported scales including the Strengths and Feelings Questionnaire (SDQ), Mood and Feelings Questionnaire (MFQ), Screen for Child Anxiety and Emotional Related Disorders (SCARED), the Peer Relations Questionnaire (PRQ), General Health Questionnaire (GHQ), and Conflict Behavior Questionnaire (CBQ), Child Revised Impact of Events Scale (CRIES), and a demographic/clinical information questionnaire. Logistic regression models were used to examine the correlates of screening positive for psychiatric disorders. RESULTS: About a third of children and adolescents (32.7%, n = 497) screened positive for at least one psychiatric disorder, of whom only 5% (n = 25) reported ever seeking professional mental health help. Academic performance, having a chronic physical illness, higher parental GHQ scores, and involvement in bullying were associated with a higher odds of screening positive for a psychiatric disorder. Higher family income was negatively associated with screening positive for a psychiatric disorder. CONCLUSION: This first national study shows a high prevalence of psychiatric symptoms in Lebanese children and adolescents and an alarming treatment gap. School-based primary prevention programs or screening in primary care settings are key for early detection and management of psychiatric symptoms, and prevention of psychiatric disorders.

Effectiveness of a Preventive Parenting Program Combining Attachment and Behavioral Approaches in an Arab Context: a Cluster-Based Randomized Control Trial.

Parenting programs aim to help parents and carers enhance their skills and ameliorate infants' and toddlers' wellbeing. In Lebanon and other Arab countries, contextualized group-based parenting programs addressing parents' mental wellbeing, parenting styles, and child development are quite rare. Therefore, a Preventive Parenting Program consisting of 7 sessions has been designed by local experts for the local cultural context. This study aims to assess its effectiveness. Thirty-three sites were identified in Great Beirut: private firms, primary healthcare centers, and child daycares. Sixteen agreed to take part in the study and were randomly assigned to intervention and control arms. From these clusters, 191 mothers of typically developed children younger than three years were recruited to intervention (106) or control (85) groups. The Mental Health Inventory, Caregiver Knowledge about Child Development Inventory, Parent Authority Questionnaire, and a Demographic questionnaire were completed at pre-intervention and post-intervention and 3 months later by both groups of mothers. There were no significant differences between clusters with respect to all scales' scores at baseline as well as the 2 other data collection points. Despite the positive feedback collected from mothers who attended the sessions, no significant effects were detected. The design of the program, the expected outcomes, and the characteristics of the participants may have contributed to the limited results, hence the need for further research.

Building Emotional Resilience in Youth in Lebanon: a School-Based Randomized Controlled Trial of the FRIENDS Intervention.

In Lebanon, approximately one in four adolescents suffers from a psychiatric disorder. Alarmingly, 94% of adolescents with a mental disorder have not sought any treatment. This study assessed the effectiveness of an evidence-based school-based universal mental health intervention (the FRIENDS program) in reducing depression and anxiety symptoms in middle school students in Lebanon. A total of 280 6th graders aged 11-13 years were recruited from 10 schools in Beirut. Schools were matched on size and tuition and randomly assigned to intervention or control groups. The FRIENDS program was translated into Arabic, adapted, and then implemented by trained mental health professionals during 10 classroom sessions over 3 months. We assessed sociodemographic and relevant psychological symptoms by self-report, using the Scale for Childhood Anxiety and Related Disorders (SCARED), Mood and Feelings Questionnaire (MFQ), and Strengths and Difficulties Questionnaire (SDQ), at baseline. We re-administered these scales at 3 months post-intervention. There was a significant time × group interaction for the SDQ emotional score (p = 0.011) and total MFQ score (p = 0.039) indicating significant improvement in depressive and emotional symptoms in the intervention group. Subgroup analysis by gender showed a significant time × group interaction for the total SCARED score (p = 0.025) in females but not in males (p = 0.137), consistent with a reduction of anxiety symptoms in this stratum of the intervention group as compared with the control group. The FRIENDS program was effective in reducing general emotional and depressive symptoms among middle school students in this Lebanese study population. This intervention provides an opportunity for promoting mental health in Lebanese schools and reducing the treatment gap in mental health care.

Impact of Emotions on Test of Variables of Attention(TOVA) Performance in a Pediatric Clinical Population: A Retrospective Study.

BACKGROUND: Continuous Performance Tests, like the Test of Variables of Attention (TOVA), are commonly used to assess attention processes in clinical settings. Although a few previous studies have explored the effects of emotions on the outcome of such tests, the results are scarce and contradictory at times. OBJECTIVE: Through this retrospective study, we  aimed to explore the correlation between performance on the TOVA and parent-reported emotional symptoms in youth. METHODS: We used preexisting datasets of Mood and Feelings Questionnaire, Screen for Child Anxiety Related Disorders, and Vanderbilt Attention-Deficit/Hyperactivity Disorder Diagnostic Rating Scale as well as preexisting results from the TOVA test from 216 patients aged between 8 and 18 years. Pearson's correlation coefficients, as well as linear regression models, were computed to examine the association between depressive and anxiety symptoms and the four indices of TOVA (response time variability, response time, commission errors, and omission errors). Additionally, we used generalized estimating equations to determine whether the reported emotional symptoms affect the TOVA outcome differently as the test progresses. RESULTS: Our results showed no significant effect of the reported emotional symptoms on the TOVA results even when controlling for sex or reported inattention and hyperactivity. CONCLUSION: TOVA results do not seem to be affected by emotional symptoms in youth. This being said, future studies should also explore other factors that can affect the performance on the TOVA, like motor disability, sleepiness, or neurodevelopmental disorders affecting cognitive abilities.

A retrospective investigation of the added clinical value of SCT symptoms on neuropsychological assessments in youth with ADHD.

Some researchers believe that Sluggish Cognitive Tempo (SCT) should be its own psychiatric disorder. However, despite the abundance of literature describing its possible symptoms, evidence of its clinical impact on cognitive tests and some clinical comorbidities is still weak. This retrospective study aimed to analyze the added clinical value of exploring SCT symptoms prior to a neuropsychological assessment in a youth population diagnosed with an Attention-Deficit/Hyperactivity Disorder (ADHD). For this purpose, we used linear regressions to examine the association between different test results and SCT, as well as logistic regressions to examine the association between the existence of different diagnoses and SCT in a group of 295 ADHD patients [73 females, 24.7%], aged between 6 and 18 years [Mean (SD): 9.91 (3.12)]. Our results showed that parent-reported SCT symptoms did not help predict neuropsychological test outcomes. In addition, they did not predict Specific Learning Disorder (SLD) or Developmental Coordination Disorder (DCD), nor anxiety and depression when we controlled for age, Vanderbilt inattention and hyperactivity subscales, autism spectrum disorder, and intellectual disability. These results requestion the added-value of screening for SCT in similar clinical neuropsychological settings.

Episode of mixed mood with psychotic features secondary to Binswanger disease: a case report with a literature review.

Neurodegenerative and mood disorders in the geriatric population might exhibit interchangeable cognitive and behavioural symptoms. This overlap in presentation might raise a diagnostic challenge for psychiatrists evaluating elderly patients who are presenting with such symptoms. Additionally, there is limited data published about early psychiatric manifestations of neurodegenerative disorders in the elderly. We report a case of a 71-year-old with a history of refractory depressive disorder and multiple cardiovascular risk factors presenting with verbalisation of suicidal and homicidal intent as well as mixed mood and psychotic symptoms. The patient was diagnosed with Binswanger's disease (BD). We also provide a literature review of challenging early psychiatric presentations of neurocognitive disorders and a summary of similar cases to help facilitate diagnosis of BD cases in future.

Maintenance Electroconvulsive Therapy Is an Essential Medical Treatment for Patients With Catatonia: A COVID-19 Related Experience.

Aim: Describe naturalistic clinical course over 14 weeks in a mixed adolescent and a young-adult patient group diagnosed with developmental delays and catatonia, when the frequency of maintenance electroconvulsive therapy (M-ECT) was reduced secondary to 2020 COVID-19 pandemic restrictions. Methods: Participants were diagnosed with catatonia, and were receiving care in a specialized clinic. They (n = 9), F = 5, and M = 4, ranged in age from 16 to 21 years; ECT frequency was reduced at end of March 2020 due to institutional restrictions. Two parents/caregivers elected to discontinue ECT due to concern for COVID-19 transmission. Majority (n = 8) were developmentally delayed with some degree of intellectual disability (ID). Observable symptoms were rated on a three point scale during virtual visits. Results: All cases experienced clinically significant decline. Worsening of motor symptoms (agitation, aggression, slowness, repetitive self-injury, stereotypies, speech deficits) emerged within the first 3 weeks, persisted over the 14 week observation period and were more frequent than neurovegetative symptoms (appetite, incontinence, sleep). Four participants deteriorated requiring rehospitalization, and 2 among these 4 needed a gastrostomy feeding tube. Conclusion: Moderate and severe symptoms became apparent in all 9 cases during the observation period; medication adjustments were ineffective; resuming M-ECT at each participant's baseline schedule, usually by week 7, resulted in progressive improvement in some cases but the improvement was insufficient to prevent re-hospitalization in 4 cases. In summary, rapid deterioration was noted when M-ECT was acutely reduced in the setting of COVID-19 related restrictions.

Electroconvulsive Therapy for the Treatment of Severe Mood Disorders During Adolescence: A Retrospective Chart Review.

Objective: Electroconvulsive therapy (ECT) is a well-recognized treatment of refractory mood disorders in adults. However, relatively little is known about its use for similar conditions in adolescents. Based on a chart review, we describe its use and outcome in a sample of adolescents with severe, refractory mood disorders (unipolar or bipolar disorder) hospitalized in an academic medical center. Methods: The sample was drawn from referrals to an adolescent psychiatry service. After obtaining approval from the ethics board, medical records of 54 adolescents with refractory mood disorder were examined. Participants (males 24, females 30; mean age 15.8 ± 1.5 years) had received their first course of ECT before the age of 18 years during the period 1996-2010. Response to treatment was examined after the initial treatment and during a 1-year follow-up. Results: Following the index course of ECT (mean number of treatments = 13.7 ± 6.3), a 52.8% response rate (defined as a Clinical Global Impressions [CGI] score ≤2) was noted, while 15.1% achieved remission (CGI = 1). The response rate was 82.4% after a 1-year follow-up with a remission rate of 23.5%. The Children's Depression Rating scores declined significantly from pre-ECT to the end of the index course (70.7 ± 16.4 to 52.5 ± 18; p ≤ 0.00). A reduction in suicidal ideation and self-injurious behaviors along with increased school attendance was noted. Cognition, monitored by the Mini-Mental State Examination, did not decline significantly. Minor side effects were limited to the day of the treatment. Prolonged seizures (>2 minutes) were common during ECT (74% of subjects experienced one or more). The only side effect noted at the 1-year follow-up was self-reported memory loss involving events during and around the index treatment course. Conclusions: In this severely impaired sample of adolescents, ECT was found to decrease suicidal behavior, reduce depressive symptoms, and improve overall functioning, as indexed by school attendance at follow-up after 1 year. Prospective studies using large samples are needed to determine its effectiveness and safety in refractory mood disorders in adolescents.

Gross lower gastrointestinal bleeding in patients on anticoagulant and/or antiplatelet therapy: endoscopic findings, management, and clinical outcomes.

OBJECTIVES: Gross gastrointestinal (GI) bleeding is a serious complication of anticoagulant/antiplatelet drug therapy. This study compares the frequencies of colorectal pathologies, endoscopic and resuscitative management measures, and clinical outcomes of patients hospitalized with lower GI bleeding (LGIB) while using anticoagulants/antiplatelets with those of patients not using them. METHODS: A retrospective review of the records of 166 admissions for patients with gross LGIB over 12 years was conducted. The colonoscopic findings, management measures, and clinical outcomes were compared between 2 groups. Group A composed of 100 patients using any antiplatelet/anticoagulant, and group B 66 patients not using any such drugs. Independent t tests and chi were used to test for association between taking antiplatelet/anticoagulant and other variables. RESULTS: Patients in group A were older and had more comorbidities than patients in group B. Severe LGIB occurred in 55.1% and 35.4% in groups A and B, respectively (P=0.01). Severity was not related to old age or the presence of comorbidities. A higher percentage of patients in group A had a hospital stay > or =6 days (44% vs. 27.3%; P<0.03), required blood transfusions (68% vs. 51.5%; P=0.03), and had in-hospital complications (37% vs. 22.7%; P=0.052). The most common source of bleeding was diverticulosis in both groups. Colorectal abnormalities were present in most patients; and in those using warfarin, colon cancer was common. CONCLUSIONS: Use of antiplatelets/anticoagulant drugs is an independent predictor of severe LGIB and is associated with adverse outcomes. Colonoscopy is required in patients who bleed while using such drugs.

Bereavement related and non-bereavement related depressions: a comparative field study.

BACKGROUND AND METHOD: In the otherwise a-theoretical diagnostic manual, the DSM-III and IV bereavement exclusion for the diagnosis of major depression (MDD) stands out as the sole exception to the rule. No other life event excludes the diagnosis of any other axis I disorder. Since this diagnostic convention has important diagnostic and treatment implications, it is important to evaluate the validity of this exception. By comparing multiple features of bereavement related to non-bereavement related MDD, this prospective community study critically evaluates the validity of the bereavement exclusion. RESULTS: The prevalence of conditional criteria was common in the total sample (N=685) and did not differ between bereaved and non-bereaved groups. The global 'symptom profile' of depressed individuals was similar in both groups. 'Duration' was found to be longer in the bereaved group. Among all conditional criteria required by DSM-IV to accept bereavement-related episodes under the category of MDD, only 'marked dysfunction' predicted treatment. Neither the 'four conditional symptoms' nor the 'duration' criterion predicted marked dysfunction. The 'risk for recurrence' was similar whether the first episode was bereavement related or not. LIMITATIONS: 'Psychotic symptoms' were not assessed, and 'marked dysfunction' was not assessed on a continuous scale. The number of DSM-IV excluded episodes was too small to allow for generalization. CONCLUSION: Our results suggest that the conditional criteria do not seem to serve the purpose of the originators of the bereavement exclusion criteria. The 'conditional symptoms' and the 'duration' criterion seem not to be markers of severity. We propose that the descriptive and etiologically neutral approach the DSM presumes in reaching a diagnosis should be applied in the case of MDD until more convincing data point to the contrary.

Behavioral modeling to guide adherence to fluid control in hemodialysis patients.

OBJECTIVE: This study used the health belief model (HBM) and the transtheoretical model (TTM) to assess hemodialysis (HD) patients' readiness to comply with recommended fluid intake as it relates to their perceptions of therapy and disease. DESIGN: This was a multicenter, cross-sectional study. SETTING: The setting involved 3 hospital-based HD centers in Lebanon. PATIENTS: Patients included 172 consenting HD patients who had been on HD for at least 3 months and were mentally stable. INTERVENTION: Placement of patients into TTM stages was based on their readiness to comply with recommended fluid intake, as confirmed by 4-week interdialytic weight-gain measures, and taking into account their perceptions toward therapy (using HBM constructs). MAIN OUTCOME MEASURES: Mean scores of HBM constructs for each patient were placed in one of the TTM stages of readiness to change. RESULTS: This study included 54.1% males, the average age was 57.8 +/- 14.0 (SD) years, and average number of years on dialysis was 4.6 +/- 4.9. Regarding stages, 18.5% of participants were placed in precontemplation, 40.0% in contemplation, 38.1% in preparation, and 3.4% were in the action/maintenance stages. The HBM constructs were significantly associated with TTM (P < .01). Perceptions of benefits (P = .04) and self-efficacy (P < .01) were significantly associated with TTM. CONCLUSION: Compliance is a multifaceted topic, essential for the survival and quality of life of HD patients. A better understanding of patients' beliefs and level of self-efficacy is a fundamental key to enhancing patients' compliance to therapy and achieving the required behavioral modifications.

Prevention of depression in at-risk adolescents: a randomized controlled trial.

CONTEXT: Adolescent offspring of depressed parents are at markedly increased risk of developing depressive disorders. Although some smaller targeted prevention trials have found that depression risk can be reduced, these results have yet to be replicated and extended to large-scale, at-risk populations in different settings. OBJECTIVE: To determine the effects of a group cognitive behavioral (CB) prevention program compared with usual care in preventing the onset of depression. DESIGN, SETTING, AND PARTICIPANTS: A multicenter randomized controlled trial conducted in 4 US cities in which 316 adolescent (aged 13-17 years) offspring of parents with current or prior depressive disorders were recruited from August 2003 through February 2006. Adolescents had a past history of depression, current elevated but subdiagnostic depressive symptoms, or both. Assessments were conducted at baseline, after the 8-week intervention, and after the 6-month continuation phase. INTERVENTION: Adolescents were randomly assigned to the CB prevention program consisting of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions or assigned to receive usual care alone. MAIN OUTCOME MEASURE: Rate and hazard ratio (HR) of a probable or definite depressive episode (ie, depressive symptom rating score of > or = 4) for at least 2 weeks as diagnosed by clinical interviewers. RESULTS: Through the postcontinuation session follow-up, the rate and HR of incident depressive episodes were lower for those in the CB prevention program than for those in usual care (21.4% vs 32.7%; HR, 0.63; 95% confidence interval [CI], 0.40-0.98). Adolescents in the CB prevention program also showed significantly greater improvement in self-reported depressive symptoms than those in usual care (coefficient, -1.1; z = -2.2; P = .03). Current parental depression at baseline moderated intervention effects (HR, 5.98; 95% CI, 2.29-15.58; P = .001). Among adolescents whose parents were not depressed at baseline, the CB prevention program was more effective in preventing onset of depression than usual care (11.7% vs 40.5%; HR, 0.24; 95% CI, 0.11-0.50), whereas for adolescents with a currently depressed parent, the CB prevention program was not more effective than usual care in preventing incident depression (31.2% vs 24.3%; HR, 1.43; 95% CI, 0.76-2.67). CONCLUSION: The CB prevention program had a significant prevention effect through the 9-month follow-up period based on both clinical diagnoses and self-reported depressive symptoms, but this effect was not evident for adolescents with a currently depressed parent. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00073671.

The Role of Epigenetics in Addiction: Clinical Overview and Recent Updates.

Addiction is an international public health problem. It is a polygenic disorder best understood by accounting for the interplay between genetic and environmental factors. A recent way of perceiving this interaction is through epigenetics, which help grasp the neurobiological changes that occur in addiction and explain its relapsing-remitting nature. It is now known that every cell has a different way of expressing its phenotype, despite a universal DNA sequence. This is particularly true in the central nervous system where environmental factors influence this expression. Three major epigenetic processes have been found to participate in the perpetuation of addiction by changing the state of the chromatin and the degree of gene transcription: histone acetylation and methylation, DNA methylation, and noncoding RNAs. In the animal model literature, substantial evidence exists about the role of these epigenetic changes in the different phases of substance use disorders. This book chapter is a non-systematic literature review of the recent publications tackling the topic of epigenetics in addiction. Even though this evidence remains scarce and relatively poorly systematized, it is a promising foundation for future research of molecules that target specific brain regions and their functions to address core behavioral changes seen in addiction.

Salivary melatonin onset in youth at familial risk for bipolar disorder.

Melatonin secretion and polysomnography (PSG) were compared among a group of healthy adolescents who were at high familial risk for bipolar disorder (HR) and a second group at low familial risk (LR). Adolescent participants (n = 12) were a mean age 14 ± 2.3 years and included 8 females and 4 males. Saliva samples were collected under standardized condition light (red light) and following a 200 lux light exposure over two consecutive nights in a sleep laboratory. Red Light Melatonin onset (RLMO) was defined as saliva melatonin level exceeding the mean of the first 3 readings plus 2 standard deviations. Polysomnography was also completed during each night. HR youth, relative to LR, experienced a significantly earlier melatonin onset following 200 lux light exposure. Polysomnography revealed that LR youth, relative to HR, spent significantly more time in combined stages 3 and 4 (deep sleep) following red light exposure. Additionally, regardless of the group status (HR or LR), there was no significant difference in Red Light Melatonin Onset recorded at home or in the laboratory, implying its feasibility and reliability.

Factor V HR2 haplotype: a risk factor for venous thromboembolism in individuals with absence of Factor V Leiden.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), occurs secondary to a number of hereditary and acquired disorders of hemostasis. A recently recognized polymorphism in Factor V (FV) gene H1299R (also named HR2) has been reported to be a possible risk factor for the development of VTE. The aim of this study is to evaluate the role of HR2 polymorphism in VTE in a group of Lebanese patients. Seventy-three VTE patients and 125 healthy subjects were examined for HR2. The average ages for the patients and controls were 45.0+/-19.1 years and 35.4+/-18.6 years, respectively. Sixty patients (82.2%) had DVT, eight patients (11%) had PE, and five patients (6.8%) had both. There was significant association between FV Leiden and VTE (p<0.001). HR2 haplotype had a prevalence of 16.4% in patients. VTE patients with normal FV were 2.7 times more likely to have the HR2 haplotype as compared to controls with normal FV (p=0.036, 95% CI=1.04-7.06). We conclude that the FV HR2 haplotype significantly affects the risk of VTE in subjects with normal FV. This finding entails that screening for the HR2 haplotype should be done in VTE patients with normal FV Leiden results.

Prognostic factors in patients with advanced cholangiocarcinoma: role of surgery, chemotherapy and body mass index.

AIM: To study the factors that may affect survival of cholangiocarcinoma in Lebanon. METHODS: A retrospective review of the medical records of 55 patients diagnosed with cholangio-carcinoma at the American University of Beirut between 1990 and 2005 was conducted. Univariate and multivariate analyses were performed to determine the impact of surgery, chemotherapy, body mass index, bilirubin level and other factors on survival. RESULTS: The median survival of all patients was 8.57 mo (0.03-105.2). Univariate analysis showed that low bilirubin level (< 10 mg/dL), radical surgery and chemotherapy administration were significantly associated with better survival (P = 0.012, 0.038 and 0.038, respectively). In subgroup analysis on patients who had no surgery, chemotherapy administration prolonged median survival significantly (17.0 mo vs 3.5 mo, P = 0.001). Multivariate analysis identified only low bilirubin level < 10 mg/dL and chemotherapy administration as independent predictors associated with better survival (P < 0.05). CONCLUSION: Our data show that palliative and postoperative chemotherapy as well as a bilirubin level < 10 mg/dL are independent predictors of a significant increase in survival in patients with cholangiocarcinoma.

Killer cell immunoglobulin-like receptor (KIR) genotypes in patients with recurrent tonsillitis.

AIMS: This study represents the first report on the distribution of killer cell immunoglobulin-like receptor (KIR) genotype among recurrent tonsillitis patients. We recruited 34 Lebanese pediatric patients diagnosed with recurrent tonsillitis and had their DNA typed using sequence-specific primer technique for the presence of 16 KIR loci. RESULTS: We observed that 25 different KIR genotypes were present similar to the general control population with the same KIR gene content. There was no statistically significant difference in the distribution of the activating and inhibitory KIR genes between the two categories. Like in the general control population, we noted a predominance of the AB genotype; however, the KIR genotypic distribution among the tonsillitis patients was much more heterogeneous with even new genotypes not reported in the control group. CONCLUSIONS: Although the sample size is small, this first study observes an interesting heterogeneous KIR gene profile in recurrent tonsillitis that warrants larger and further research in the area for the true biological and clinical significance of this observation.

Thalidomide and thrombosis. A meta-analysis.

With the increase in the number of reports and trials on the use of thalidomide as a part of the treatment of different medical conditions, particularly multiple myeloma (MM), it was observed that this drug might be associated with an increase in the risk of venous thromboembolic (VTE) events. It was the objective of this study to assess this risk, to check whether it might be affected by the concomitant administration of other medications, specifically dexamethasone, and to study the effect of anticoagulation and anti-platelet medications. A literature search for articles describing the use of thalidomide and the resultant VTE events was performed, and 50 articles were reviewed. A sample consisting of 3,322 patients resembling the above-mentioned studies was designed, and multivariate logistic regression was conducted. While thalidomide, dexamethasone and their combination were found to significantly increase the risk of VTE events among MM patients by 2.6, 2.8 and eight times, respectively, "adequate" anticoagulation significantly reduced the risk. In conclusion, patients receiving thalidomide should be carefully monitored for thromboembolic events, and those receiving concomitantly dexamethasone or other chemotherapy should be followed even more closely. Administering prophylactic doses of low-molecular-weight heparin or warfarin with therapeutic International Normalized Ratio reduces the risk of thromboembolic events among MM patients.