Raising the bar for outcomes In addition to a broadened focus on

Raising the bar for outcomes In addition to a broadened focus on physical health, outcomes other than symptomatic improvement have become standard in the field including more systematic and operationalized buy GW788388 approaches to measuring response, remission and recovery,37-40 subjective well-being and quality of life,41,42 cognition43-45 and psychosocial/vocational performance.46-48 These have become end points of increasing importance in routine practice and in clinical trials. However, focusing on such outcomes also requires specific considerations, including

treatment modalities, trial duration, Inhibitors,research,lifescience,medical assessments, end points, etc. Targeting individualized Inhibitors,research,lifescience,medical treatment In addition to raising the bar for outcomes, the ways to measure and predict them have also become topics of increasing interest. Efforts at increasing the predictability of outcomes for individual patients (ie, personalized medicine) have included clinically driven nosological and

phenomenological approaches, but, so far, these have not really succeeded.49 Current approaches that do not yet have consistent clinical applicability Inhibitors,research,lifescience,medical include the use of genetics, neuroimaging, neurocognition, and blood- or tissue-based biomarkers and sets of biomarkers, also called biosignatures.50 Similarly, developments are underway to define biomarkers as surrogate end points in drug development.51 To achieve personalized psychiatric

treatments, specific design considerations are needed. These include Inhibitors,research,lifescience,medical ways of decreasing the heterogeneity- of the study population and the parsing of clinical and biological variables that are relevant for specific mechanisms and treatment effects. In addition, relevant treatment mediators and moderators Inhibitors,research,lifescience,medical can serve as selection criteria and randomization or stratification variables. However, obviously, these approaches will depend on the identification of markers that predict treatment outcome to specific interventions and that are not “just” markers of general illness severity and responsiveness below (although even such general markers could, for example, help to facilitate early identification of patients who should have a trial of clozapine).52,53 One such potentially useful “biomarker” or endophenotype that we will discuss subsequently is the presence or absence of early minimal clinical response, which might be useful to enrich samples for specific studies. Commercialization and globalization of clinical trials Another historical element in any discussion of RCTs is the “commercialization” and “globalization” of research. In the early days of clinical trials in psychopharmacology, there were a relatively small number of largely academic sites which participated in the design and conduct of such investigations.

On the basis of the results it can be

On the basis of the results it can be concluded that the presence of DOTAP leads to significant (P < 0.05) higher research Encapsulation efficiency with DOPC and POPC as main lipid component. LEC liposomes demonstrated the least encapsulation efficiency for DTO, and DOTAP appeared to provide little to no enhancement (Table 3). The role of DOTAP in enhancing the encapsulation efficiency can be explained with electrostatic interactions between DOTAP and DTO at the pH value examined (pH = 7.4). Early experiments with the 60:40 ratio of dipalmitoyl-phosphatidylcholine

(DPPC) to Chol composition provided very low encapsulation efficiency Inhibitors,research,lifescience,medical for encapsulation of DTO (data not shown here). As DTO is a lipophilic sulfur donor, it can be expected that it is localized in the liposomal bilayer, Inhibitors,research,lifescience,medical more or less immersed in it. The saturated bonds of DPPC providing an ordered, relative rigid structure may inhibit the immersion of DTO in the liposomal membrane. Contrarily, POPC and DOPC possessing double bonds and as a consequent of it a less ordered and more fluid membrane structure can promote the encapsulation Inhibitors,research,lifescience,medical of DTO. Thus, instead of DPPC, DOPC, or POPC were used for liposome

preparation and ratios were adjusted to 90:10 lipid to Chol. The results shown in Table 3 indicate that DOPC liposomes containing 3mol% DOTAP provided the highest encapsulation efficiency at 81.7 ± 3.1%. POPC liposomes Inhibitors,research,lifescience,medical with 3% DOTAP were close behind with an encapsulation efficiency of 78.4 ± 2.3%. However, there was no significant difference between encapsulation efficiencies with DOPC and POPC. Table 3 Encapsulation efficiencies for DTO in various liposome compositions with and without DOTAP. DTO concentration was 2.0mM. Total lipid concentration was 10.0mg/mL. The liposome compositions

Inhibitors,research,lifescience,medical including DOTAP were used in further experiments due to the increase in encapsulation efficiency achieved by these films. The effect on encapsulation efficiency by the increase in DTO concentration was evaluated for DOPC and POPC containing liposome compositions with both sets of liposomes containing 3% DOTAP. In order to evaluate the role of DTO concentration on the encapsulation efficiency each set’s films were prepared with DTO concentrations of 10mM, 20mM, and 30mM. The encapsulation efficiency remained high for each Bumetanide liposome formulation containing 3% DOTAP for each applied DTO concentrations of 10mM, 20mM, and 30mM. The encapsulation efficiencies of DTO for POPC samples were 69.7 ± 2.3%, 82.8 ± 7.1%, 79.2 ± 8.1%, while for the DOPC samples DTO encapsulation efficiencies of 74.2 ± 2.0%, 86.2 ± 3.9%, and 89.9 ± 4.2% were determined, for 10mM, 20mM, and 30mM DTO concentrations, respectively. For a given DTO concentration there was no significant difference between the encapsulation efficiency values for DOPC or POPC liposomes (P > 0.05). 3.1.

28-30 In

28-30 In general, most articulations of this model have emphasized

the importance of very early developmental processes, which occurred either prior to birth or shortly afterward. The model assumes that a genetic vulnerability may be present, and that this vulnerability is expressed if a sufficient number of releasing learn more factors converge in the vulnerable individual early in life. Some of these may occur prior to birth, such as viral infections, maternal malnutrition, or exposure to toxins in utero; some may occur shortly after, such as obstetrical complications and birth injuries, Inhibitors,research,lifescience,medical or viral infections. These factors are presumed to injure the developing brain, to express themselves in the type of neuropathology that was described in the 1986 Inhibitors,research,lifescience,medical Benes study and later ones, and to create impairments

in structural or functional connectivity that will be the substrate upon which schizophrenia will develop at a later age. Clinical findings in support of an early developmental abnormality include a variety of premorbid indicators or markers, such as decreased cranial size, motor impairments and neurological Inhibitors,research,lifescience,medical soft signs, and cognitive and social impairments. These findings have been repeatedly replicated in highrisk samples or studies of children who later developed schizophrenia using a variety of ingenious designs.10-18 During the ensuing years, MR studies also continued to add to the evidence in support of the neurodevelopmental hypothesis. Many of the early MR studies examined samples of convenience, such as institutionalized Inhibitors,research,lifescience,medical patients or patients with established chronicity. Determining if brain abnormalities are present in individuals with schizophrenia at the time of onset (“first-episode patients,” FEP) provides a crucial test of Inhibitors,research,lifescience,medical the hypothesis, since any abnormalities noted would have presumably antedated the clinical presentation. Investigators conducting studies of FEP began to study patients at

the time of onset of illness and to find that many types Adenosine triphosphate of brain abnormalities are present early in the illness. These include decreased cerebral size, decreased frontal and temporal lobe size, decreased thalamic size, decreases in GM and WM volume, and increased CSF on the brain surface and in the ventricles.22,31 Does tissue loss continue after onset? Another critical question about the lifetime trajectory of schizophrenia and the related concept of neurodevelopment is whether the brain abnormalities that are present at onset continue to worsen over time. If patients with schizophrenia lose tissue at a greater rate than healthy normals, this could suggest that the disorder also has a neuroprogressive or neurodegenerative component.

This type of thinking is naive It is likely that all of the diff

This type of thinking is naive. It is likely that all of the different executive processes, as well as speed of processing, decline with age and collectively contribute to difficulties in reasoning, memory, and other higher order cognitive functions. Park et al12 examined the joint contributions of speed and working memory to long-term memory function across the life span using structural equation models, and showed that both were important in explaining long-term memory function. This study thus verifies that global mechanisms like speed, as well as Target Selective Inhibitor Library purchase specific mechanisms like working memory, are fundamental in explaining variance in higher-order cognitive function. Inhibitors,research,lifescience,medical In a later

study, Park et al13 reiterated this finding for both visiospatial and verbal working and long-term memory. It is also important to recognize that these mechanisms may not all decline at the same rate within subjects

and that deterioration of different mechanisms might be controlling Inhibitors,research,lifescience,medical similar levels of decline in different individuals. Cognitive aging researchers have devoted relatively little attention to Inhibitors,research,lifescience,medical understanding how the different mechanisms work separately or together in specific individuals to explain declines in cognitive function, and this is an important direction for future research. Other important behavioral issues Three other important issues with respect to behavioral changes in cognitive performance with age relate to rates of change across

the life span, spared cognitive processes, and the potential to improve cognitive function. Decline Inhibitors,research,lifescience,medical is continuous across the life span Besides demonstrating that knowledge may increase with age while performance on processing-intensive tasks decreases, Figure 1 also illustrates one poorly understood and little-recognized phenomenon of some importance: both cross-sectional and longitudinal data suggest that decline is relatively continuous across the life span, beginning in young adulthood. We believe that symptoms of cognitive decline that begin occurring in the second decade of life become more noticeable in late adulthood only because they have Inhibitors,research,lifescience,medical accrued to the point where they result in noticeable declines in function.27 As a crude metaphor, consider that an individual Histone demethylase with a million dollars probably would not be very concerned initially about the loss of $2000 per year, but would be much more likely to notice and worry 50 years later when $100 000 in losses had accrued. So it seems to be with cognitive aging. It is also important to consider that losses of executive function and long-term memory in middle-aged adults may not be too apparent to the individual because they are offset by increases in expertise and skill. Little is understood about the interplay among increasing knowledge and declining executive function and memory across the life span. This is a tremendously important issue that we will have more to say about later.

This study showed a benefit of T3 used to augment partial or inco

This study showed a benefit of T3 used to augment partial or incomplete response to TCA monotherapy.34 Stimulants such as amphetamine, methylphenidate, and pemoline, if used judiciously, and taken responsibly, can be effective in achieving a quicker response in patients with resistant, depression. These should be avoided in patients with a history of substance abuse and patients should be informed about the potential, though minimal, risk of developing tolerence.35-37 There has also more recent interest, in exploring modafanil for TRD.38 Evidence indicates that dopamine may have a role in the pathogenesis of depression.39 Dopaminergic agents such as bromocriptine, Inhibitors,research,lifescience,medical pergolidc,

and pramipexole are reported to be useful adjuncts for patients with TRD.40 The serotonin-dopamine receptor antagonism

of atypical antipsychotics has been suggested as a possible mechanism for the antidepressant action of atypical antipsychotics. Recent studies have found that atypical antipsychotics may produce an antidepressant effect in schizophrenia Inhibitors,research,lifescience,medical and may be used either as an adjunctive medication or as an alternative to mood stabilizers in patients with affective disorders.41 Treatment-resistant psychotic depression is shown to be successfully treated with clozapine.42 The addition of risperidone to an SSRI among nonpsychotic depressed patients Inhibitors,research,lifescience,medical led to a rapid response among patients who had not responded to either fluoxetine or paroxetine treatment.43 A combination of olanzapine and fluoxetine showed superior efficacy to either olanzapine or fluoxetine monotherapy in patients with treatment-resistant depressive disorder without psychotic features.44 The presence of psychotic features, Inhibitors,research,lifescience,medical delusional depression, and bipolar depression may be indications

for the use of atypical antipsychotics.7 Other augmentation Inhibitors,research,lifescience,medical strategies include buspirone, pindolol, venlafaxine, mirtazapine, tianeptine, benzodiazepines, and anticonvulsant augmentation of antidepressants.30 Combination strategies This involves the addition to an antidepressant of a compound with a well-established efficacy as a single agent in the treatment of depression.30 Combination strategies include TCAs and SSRIs,TCAs and MAOIs, bupropion and SSRIs, anticonvulsants and antidepressants, and benzodiazepines and antidepressants.5 Adenylyl cyclase However, SSRIs, venlafaxine, or clomipramine should not be combined with MAOIs and the MAOI and TCA combination should be used with caution. Switching strategies Switching involves stopping the antidepressant to which the patient is not HER-2 inhibitor responding and switching to another antidepressant, usually from a different class.45 Switching to an alternative antidepressant from a different class for SSRI nonresponders may be helpful.5 The options for SSRI nonresponders include using bupropion, nefazodone, venlafaxine, tianeptine, and mirtazapine. MAOIs may be used in TCA- or SSRI-resistant patients.


This suggestion of a general psychomotor effect li


This suggestion of a general psychomotor effect links interestingly to findings reported by Schifferstein and colleagues [Schifferstein et al. 2011] who reported enhanced dancing activity for all odorants tested compared with controls, irrespective of purported properties. It may be parsimonious to suggest that the perception of smells produces a global psychomotor enhancement, but the evidence does suggest somewhat greater specificity. For example, Moss and colleagues report a slowing of response speed during exposure to ylang ylang, something not Inhibitors,research,lifescience,medical associated with peppermint in the same study, indicating differential effects of the two aromas [Moss et al. 2008]. An alternative possibility regarding the finding of improved reaction time on all three tasks might be that 1,8-cineole Inhibitors,research,lifescience,medical affects speed as a consequence of increased subjective alertness of participants. However, correlations performed here between 1,8-cineole and the subjective mood reports suggest otherwise, with no strong evidence present that change in subjective ratings of alertness bore any relationship to plasma 1,8-cineole

levels. Only contentedness possessed a significant relationship with 1,8-cineole levels, and interestingly to some of the cognitive performance Inhibitors,research,lifescience,medical outcomes, leading to the intriguing proposal that positive mood can improve performance whereas aroused mood cannot. Previously, Moss and colleagues suggested that the impact of aromas on task performance was independent of subjective feelings [Moss et al. 2003]. Others [e.g. Warm et al. 1991; Itai et al. 2000] have Inhibitors,research,lifescience,medical also argued for the independence of effects of aromas on cognition and mood, proposing avenues of influence which are not related to psychological beliefs and expectations. Such proposals sit

well with the pharmacological mechanisms described above. Whether the effects on mood found here and elsewhere are a consequence Inhibitors,research,lifescience,medical of interactions of compounds with the monoaminergic system is an intriguing possibility worthy of further investigation. The relationship between the Bond-Lader mood scales used here, and those of another widely used scale in environmental Nature Medicine research, the Pleasure, Arousal, Dominance (PAD) scale has yet to be established. The PAD scale [Mehrabian and Russell, 1974] was developed at the same time as Bond and Lader were working on their scale, and has been described as ‘the premier measure in the area of environmental psychology for assessing the impact of the environment on people’ [Machleit and Eroglu, 2000, p. 102]. Given the considerable value of the two scales for assessing mood CFTR inhibitor states it is perhaps surprising that they have not previously been explored in tandem.

Indeed, when the LC caffeine group was compared with the control

Indeed, when the LC caffeine group was compared with the control group (Figure 1), increases in perfusion occurred bilaterally in the inferior frontal gyrus-anterior insular cortex (predominantly on the right side) and in the uncus, on the left side in the internal parietal cortex, on the right side in the lingual gyrus and cerebellum. In the HC group compared with the control group, perfusion increases were located bilaterally in hypothalamus.

When both caffeine groups were pooled and compared with the whole Inhibitors,research,lifescience,medical control group, significant perfusion increases occurred bilaterally in the inferior frontal gyrus-anterior insula, hypothalamus, right cerebellum, and left uncus (Figure 1). Figure 1 Caffeine-induced perfusion changes superimposed on transaxial slices of a standard MRI surface : left column : Low consumption (LC) group (n=8) vs control group (n=8); middle column : High consumption (HC) group (n=6) vs control group (n=6); right column … Discussion The main findings of this study were the lack of significant differences Inhibitors,research,lifescience,medical in perfusion between

caffeine-exposed subjects and controls, Inhibitors,research,lifescience,medical whether they were HC or LC, the lack of effects of the methylxanthine on the areas of reinforcing and reward and only very discrete changes in perfusion in areas mediating mainly anxiety, attention and vigilance, and cardiovascular function. The vasoconstrictive properties of caffeine in the brain have been known for a long time, and caffeine Inhibitors,research,lifescience,medical has been shown to decrease cerebral blood flow in humans.19-23 Previous studies used the 133Xe-xenon inhalation technique,22 positron emission tomography,19 inversion recovery perfusion MR technique [20] and blood oxygenation level-dependent (BOLD) signal intensity changes in functional MRI (fMRI).22,23 Recent papers studied the effects of caffeine on cerebral circulation since caffeine ingestion Inhibitors,research,lifescience,medical might be a source of errors in functional brain imaging experiments.20,21,23 The present study showed a 6% to 8% statistically nonsignificant caffeine-induced decrease

in perfusion. Several other studies reported caffeine-induced cerebral blood flow decreases ranging from 3.4% to 18%19,20,22,24,25 but not consistently in all subjects.22 Nature Reviews Molecular Cell Biology The reasons for the discrepancies may have various origins. First, the hemodynamic response measured by different techniques (cerebral blood flow, BOLD contrast, or perfusion changes) is not directly comparable. Second, in most if not all studies, the same dose of caffeine was given to the subjects independently of body weight. Conversely, in the present study, the dose of caffeine ingested was adjusted to body weight, ie, 3 mg/kg. The third factor differing amongst the studies is the period of abstinence from caffeine. The latter was Natural Product Library purchase similar to the one applied here, ie, about 12 h in several studies,19,23 very short, 2 to 3 hours in other studies,22,24 or much longer, ie, 30 hours.

29% (68 57%-100%) Table 1

29% (68.57%-100%). Table 1 Patient Characteristics. Table 2 Inter-rater agreement. Kappa values for specific items were as follows: no agreement (k = 0) for item 2, fair agreement (k = 0.21 to 0.40) for item 1, and moderate agreement (k = 0.41 to 0.60) for items 5, 10, 12, and 13. There was substantial agreement (k = 0.61 to 0.80) for items 4, 7, 9, and 11, and high agreement (k = 0.81 to 1.00) for items Inhibitors,research,lifescience,medical 3, 6, 8, 14, and 15. Discussion The Perme ICU Mobility Score was conceived as an ICU-specific tool to measure mobility status of patients with limited independent activities that often present during a critical illness. It is indicative of functional

performance, and particularly the patient’s walking capability, in the ICU at a specific moment in time. Preliminary data suggest that the validity of this tool is supported by expert concurrence, its overall reliability is high, and its clinical use

is acceptable. Kasotakis et al.28 recently reported the use of the RAAS inhibitor Surgical ICU Optimal Mobility Score (SOMS), a simple numeric scale that describes Inhibitors,research,lifescience,medical mobilization capacity of patients and an algorithm developed to select the optimal activity level. The results demonstrated it to be a reliable and valid tool to predict both mortality and ICU/hospital length of stay in surgical critically Inhibitors,research,lifescience,medical ill patients without preexisting impairment of mobility status. Its main use, however, is as an algorithm to advance activity rather than a tool to Inhibitors,research,lifescience,medical measure mobility status, as the Perme

ICU Mobility Score was designed to do. In a retrospective study, Montagnani et al. reported that all 18 items of the FIM could be used as a functional status outcome measure in a small group of patients with a tracheostomy and difficulty weaning from mechanical ventilation.29 While the FIM is possibly suitable Inhibitors,research,lifescience,medical for stable patients in a weaning unit, it has limited validity and usefulness in patients with unstable critical illness or during periods of complex monitoring in the ICU. The FIM has a strong focus on activities of daily living (ADL), which are not commonly performed or expected in the ICU. The Functional Status Score for the Intensive Care Unit (FSS-ICU) included 3 of the 18 FIM items: grooming, bathing, and ambulation. Four other functional tasks relevant to the ICU setting were also included: rolling, transfer from supine to sit, sitting at the edge of bed, and transfer from sit to stand.13 This mix of ADL and ICU activities may lead to low scores Sitaxentan that are not specific to ICU clinician expectations of functional performance. In contrast, all 15 activities in the Perme ICU Mobility Score are feasible for patients in the ICU. Activities such as wheelchair mobility and ADL were not included in the Perme ICU Mobility Score because an expert panel determined that wheelchair mobility activities and independent or assisted self-care activities are not routinely performed in the ICU.

Abbreviations EmCP: Emergency care practitioner; ECP: Extended ca

Abbreviations EmCP: Emergency care practitioner; ECP: Extended care paramedic; SA: South Australia; NSW: New South Wales; WA: Western Australia; SJA-WA: St John Ambulance Western Australia. Competing interests JF receives partial salary support from St John Ambulance Western Australia (SJA-WA); IJ is Clinical Services Director at SJA-WA;

TA is Chief Executive Officer at SJA-WA; GA receives sitting fees for both the SJA-WA and Silver Chain Medical Policy Committees; DM is a member of the Inhibitors,research,lifescience,medical Australasian College of Emergency Medicine (ACEM) Council and Chair of the ED overcrowding sub-committee; IR receives sitting fees and is a Board member of SJA-WA. All other author(s) declare that they have no competing interests. Authors’ contributions JF drafted the manuscript Inhibitors,research,lifescience,medical and all other authors provided critical review of the manuscript. HT collated and incorporated the feedback from all authors. All authors (except HT, IR & MB) were principal or associate investigators on the original funding application from the Inhibitors,research,lifescience,medical WA Department of GSK343 cell line Health – with IJ as the Chief Investigator. All authors read and approved the final manuscript. Pre-publication history The pre-publication

history for this paper can be accessed here: http://www.biomedcentral.com/1471-227X/13/13/prepub Acknowledgements We would also like to acknowledge and thank Ms Amanda Holman Inhibitors,research,lifescience,medical (Health Economist) for her advice regarding the Economic Evaluation and Dr Geoff McDonnell, Director Adaptive Care Systems,

New South Wales, for advice regarding systems modelling. We would also like to acknowledge and thank Mr Brian Stafford, who is the consumer representative on the Study Management Committee. Funding This study is funded by a Western Australian Department of Health ‘Targeted Research’ grant.
The patients of Group I were triaged by the responsible nurse Inhibitors,research,lifescience,medical to outpatient service or rescue room of ED. And they were diagnosed by initial doctors according to personal judgment and experience. While patients of Group II were all enrolled in rescue room and were diagnosed and rescued according to the acute chest pain screening flow-process diagram (Figure ​(Figure1).1). The diseases associated with fatal chest pain include acute myocardial infarction, unstable angina, pulmonary embolism, aortic dissection, pneumothorax and cardiac tamponade. Misdiagnosis includes error diagnosis, delay diagnosis (beyond two hours) and Journal of Clinical Oncology missed diagnosis[2]. The definite time to diagnosis means time from patient’s visiting to getting definite diagnosis. Figure 1 Screening of acute chest pain in emergency department Statistics processing SPSS 13.0 software was used for data management and analysis. Measurement data was described as . Difference inter-group was compared with t-test. Count data was analysed with nonparametric tests, P<0.05 was considered to have statistic difference.

For a century the disorder was considered to be untreatable Only

For a century the disorder was considered to be untreatable. Only 40 years ago the patients’ “natural” age at death was 15 years. In those days the physicians left most of their

patients untreated in large sickrooms until they died, usually from a lung infection. Only a few researchers wanted to investigate the click here etiology of the disease or to develop a therapy for it, because such engagements seemed to be without promise of success. Today we know that the affected gene product constitutes such a small amount of protein in the muscle cells that it was unlikely to be detected by conventional biochemical techniques. Since the cause of DMD was unknown the physicians Inhibitors,research,lifescience,medical tried Inhibitors,research,lifescience,medical on the

off-chance a great number of drugs that had been effective with other diseases (1, p. 214): none of them worked out! When in 1986 Lou Kunkel (2) isolated the so-called Duchenne gene and one year later Eric Hoffman (3) described its product, dystrophin, not only did all researchers and physicians, but also all patients and their parents believe that this would quickly open the Inhibitors,research,lifescience,medical way to a causal therapy. Today, a quarter century later, the end of this journey may be – more or less distinctly – in sight: availability of the much anticipated gene therapy. But even today we cannot predict when we will have completed this journey. The kind of gene therapy that is currently believed to have the greatest

chances of success, namely “exon skipping” (4), will be applicable to about 80% of patients. But at present it is being developed and clinically Inhibitors,research,lifescience,medical tested in a phase- III trial for only those 13.0% who need the skipping of their exon 51 of the extremely large gene. For all the others, many more so-called “personal Inhibitors,research,lifescience,medical therapies” and other more conventional forms of treatment will have to be developed (regularly updated status report [5]). Obviously there are still many obstacles on this route and nobody knows when they will be removed. The parents, who see the strength of their children’s muscles wane every day, are desperate. Bumetanide Some of them accuse the physicians of this failure; others try to find themselves sources to accelerate research into gene therapy. But is the situation indeed so hopeless for the Duchenne families? Let us briefly look at their general situation: how has it changed in the time span since the discovery of the dystrophin gene? There are many positive factors in support of genetic counseling. At least in the developed countries the often quoted figure for the incidence of DMD of 1 in 3500 male births is not true anymore. An effective figure is not available, but there is no doubt that the incidence has decreased in conjunction with progress in prenatal diagnostics (6).