Predictors of early stable symptomatic remission after an exacerbation of schizophrenia: the significance of symptoms, neuropsychological performance and cognitive biases

Neuropsychological deficits and severity of initial psychopathology have been repeatedly associated with poor symptomatic outcomes in schizophrenia. The role of higher-order cognitive biases on symptomatic outcomes of the disorder has not yet been investigated. The present study aimed to assess the contribution of cognitive biases, psychopathology and neuropsychological deficits on the probability of achieving early symptomatic remission after a psychotic episode in patients with schizophrenia. Participants were 79 patients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder undergoing an acute psychotic episode, and 25 healthy controls. According to psychopathology assessments, patients were split into those who had achieved remission after an average follow-up interval of 7 months, and those who had not (NR). Patients who achieved remission exhibited higher premorbid IQ and better performance on the TMT-B, as well as lower baseline positive, disorganized and distress symptoms than NR patients. TMT-B performance and positive symptoms at baseline were the best predictors of remission. Cognitive biases and negative symptoms were not associated with later remission. The findings highlight the significance of initial symptom severity for at least short-term symptomatic outcomes and, thus, the importance of adequate symptomatic treatment and prevention of psychotic outbreaks in patients.

Neurocognitive impairments and quality of life in unemployed patients with remitted major depressive disorder

Quality of life (QOL) has been reported to be impaired in patients with major depressive disorder (MDD), even after remission according to symptom rating scales. Although a relationship between QOL and neurocognitive dysfunction has been reported during depressive episodes, little is known about this relationship in remitted MDD patients. The aim of the present study was to investigate the relationship between QOL and neurocognitive dysfunction in patients with remitted MDD while controlling for confounding factors. Forty-three remitted MDD patients were assessed with neuropsychological tests and QOL, which was measured by a short-form 36-item health survey. The neurocognitive performances of the patients were compared with those of 43 healthy controls. We next evaluated the relationships between neurocognitive impairments, clinical factors, and QOL. Remitted MDD patients had poorer neurocognitive performances than healthy controls for psychomotor speed, attention, and verbal memory. Residual depressive symptoms were strongly associated with QOL. Delayed verbal recall was associated with general health perceptions, which are part of the QOL assessment, even after the effects of the residual depressive symptoms were considered. The results may indicate that clinicians should try to detect neurocognitive dysfunctions that may interfere with QOL using neurocognitive assessments in their daily practice.

When knowing what to do is not sufficient to make good decisions: deficient use of explicit understanding in remitted patients with histories of suicidal acts

Disadvantageous decision-making has been reported in patients who had attempted suicide and may represent a cognitive risk factor for suicide. Making decisions necessitates both implicit/associative and explicit/analytic processes. Here, we explored explicit mechanisms, and hypothesized that suicide attempters fail to use explicit understanding to make favorable choices. The Iowa Gambling Task (IGT) was used to assess decision-making in 151 non-depressed patients with a history of mood disorder and suicidal act, 81 non-depressed patients with a history of mood disorders but no suicidal act, and 144 healthy individuals. After performing the task, we assessed the explicit understanding of the participants of the contingencies in the task, i.e. which options yielded higher gain or loss. Correct explicit understanding was reported less often in suicide attempters and affective controls than in healthy controls (45.7% and 42.0% vs. 66.0%). Moreover, understanding was associated with better performance in healthy and affective controls, but not in suicide attempters, with no between-group difference among those who did not reach understanding. Patients with histories of suicide attempt, therefore, show a disconnection between what they "know" and what they "do", possibly reflecting underlying impairments in implicit associative processes. These cognitive alterations should be addressed in preventative interventions targeting suicide.

What is the best treatment strategy for early RA?

Treatment of early rheumatoid arthritis has to be started very early, when the diagnosis is made, preferentially before 6 months of symptoms. Combination therapy with conventional disease-modifying anti-rheumatic drugs (DMARDs) with low-dose, oral glucocorticoids in the induction phase from the start gives the best results. The patient should be monitored systematically, at start between 1 and 3 months, and the patient should have access to additional visits if a flare or arthritis or adverse event occurs. The treatment should aim to remission (no tender and swollen joints, no signs of inflammatory activity), which can be reached by 60-80% of the patients. Intra-articular glucocorticoid injections as part of the treatment strategy increase the suppression of arthritis and retard joint destruction. Biological drugs are reserved for patients who have consistent active disease and who do not respond to conventional combinations.

Cognitive deficits in geriatric depression: clinical correlates and implications for current and future treatment

The purpose of this article is to identify the cognitive deficits commonly associated with geriatric depression and describe their clinical significance. The complex relationship between geriatric depression and dementia is summarized and possible shared mechanisms discussed. Evidence regarding whether the cognitive deficits in depression may be mitigated with medication or with computerized cognitive remediation is presented.

The beneficial effects of combining pharmacological and psychosocial treatment on remission and functional outcome in outpatients with schizophrenia

OBJECTIVE

The effects of pharmacological and psychosocial treatment on remission and the functional outcome in outpatients with schizophrenia were evaluated. Remission was assessed according to the criteria proposed by the Remission in Schizophrenia Working group and psychosocial functioning according to the Global Assessment of Functioning with a score > 60. Functional outcome was the result of these two variables.

METHOD

One hundred fifty two patients were randomized to receive either, antipsychotic treatment as usual (TAU) or social skills training and family psychoeducation in addition to TAU. A final sample of 119 patients: n = 68 in the social skills training group, and n = 51 in the TAU group completed the study protocol. Patients were assessed at baseline and at 6-month follow-up.

RESULTS

At the end of the study, 80% of the patients fulfilled the criteria for symptomatic remission: 62 patients (91.2%) in the social skills training group in contrast to 34 patients (66.7%) in the TAU group. Functional improvement criteria were accomplished by 41 patients (34.5%) at the endpoint of the study. Forty of these patients (58.8%) belonged to social skills training and one patient to customary treatment (χ(2) = 41.7, df 1, p < 0.001) and when criteria for symptomatic remission and functional improvement were combined, 39 patients (97.5%) of the social skills training group and one patient (1.9%) of the customary treatment group achieved functional outcome.

CONCLUSION

The results emphasize the need for psychosocial interventions as conjoint to pharmacological treatment to improve functional outcome in schizophrenia patients.

Confirmation of effectiveness of tocilizumab by ultrasonography and magnetic resonance imaging in biologic agent-naïve early-stage rheumatoid arthritis patients

Efficacy of tocilizumab in active early-stage RA patients despite methotrexate was evaluated for 12 months. One out of 5 patients was quitted by infusion reaction whereas tocilizumab continued for 12 months in the remaining 4 patients. Power Doppler articular synovitis was reduced in every patient and disappeared in 2 patients. Marked MRI osteitis, found in 1 patient, had disappeared at 12 months. Present results confirm the efficacy of tocilizumab by ultrasonography and MRI.

[Therapeutic update in rheumatoid arthritis]

The treatment of rheumatoid arthritis (RA) was revolutionized by the introduction of the biologics. Their power and their good safety profile have allowed to define new objectives and procedures to reach them; it is the "treat to target" concept. New recommendations were published by EULAR or ACR to obtain the remission as soon as possible. Disease-modifying antirheumatic drugs, in particular the methotrexate (MTX), remain the cornerstone of RA treatment in association with symptomatic treatments. The use of corticosteroids can be necessary to control the disease activity in the waiting time of the DMARDs efficiency or to control a flare. The absence of remission after 3months after initiation of MTX should prompt the rheumatologist to intensify the treatment with biologics. The increasing number of biologics targeting different mechanisms (5 anti-tumor necrosis factor-α, antagonist of interleukine-1 [IL-1] receptor, antagonist of IL-6 receptor, anti-CD20, anti-cytotoxic T-lymphocyte antigen 4) asks the question of the strategy in their prescription. Besides, all the registers or meta-analysis plead in favor of a good safety subject to a moderate prescription and to a greater vigilance. Except the opportunist infections, it is more the comorbidities or the associated treatments such as corticoids or MTX, which would favor the infections than anti-TNFα. There is no indication that biologics may increase the risk of solid cancer compared with a population of RA patients not exposed to anti-TNFα. However, biologics could increase the risk of cutaneous cancers, including melanoma.

Addition of another disease-modifying anti-rheumatic drug to methotrexate reduces the flare rate within 2 years after infliximab discontinuation in patients with rheumatoid arthritis: an open, randomized, controlled trial

OBJECTIVES

We examined whether the addition of another conventional disease-modifying anti-rheumatic drugs (DMARDs) to methotrexate (MTX) upon infliximab (IFX) discontinuation in well-controlled rheumatoid arthritis (RA) patients could suppress subsequent disease flare.

METHODS

RA patients maintaining DAS28-CRP (Disease Activity Score of 28 joints with C-reactive protein) scores < 2.6 for ≥ 6 months with IFX were randomized either to receive addition of bucillamine (BUC) to MTX (BUC + MTX group; n = 24) or not (MTX group; n = 31) upon discontinuing IFX. The primary endpoint was the flare rate within 2 years of IFX discontinuation.

RESULTS

Six patients discontinuing MTX during the study were excluded from analyses. Seventeen patients (63.0%) experienced flares in the MTX group, which was significantly reduced in the BUC + MTX group (31.8%; p = 0.045). Further, the flare rates differed significantly between remission and non-remission by a Boolean definition upon IFX discontinuation in the MTX group (40.0% vs. 91.7%, respectively; p = 0.014), but they were comparable in the BUC + MTX group. BUC treatment was interrupted in seven patients due to rash, proteinuria and incompliance.

CONCLUSIONS

DMARDs combination therapy may be a better treatment strategy than MTX monotherapy for maintaining RA control after successful discontinuation of biological agents.

Remission from substance dependence: differences between individuals in a general population longitudinal survey who do and do not seek help

BACKGROUND

Only a minority of individuals who have substance use disorders receives treatment, and those who do typically have more severe disorders. The current study examines the relationship of help-seeking with remission from alcohol and/or drug dependence and other outcomes.

METHODS

Data from the Wave 1 (2001-2002) and Wave 2 (2004-2005) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to examine remission at Wave 2 among respondents who had past-year substance dependence disorders at Wave 1 (N=1262). Multi-group structural equation modeling was used to compare individuals with (n=356) and without (n=906) prior help-seeking at Wave 1 on subsequent help-seeking and other factors that influence outcomes.

RESULTS

Baseline help-seekers sought help at higher levels over the follow-up period (31% vs. 8%) and had lower rates of remission (50% vs. 68%), as compared with those without prior help-seeking, respectively. Among baseline help-seekers, there were stronger relationships between baseline stress and mental disorders and having sought help since baseline; age and past-year level of stress at follow-up; level of stress and health status at follow-up; and social support and mental disorders at follow-up. Among baseline non-help-seekers, there were stronger relationships between being female and past-year stress at follow-up, and between having sought help since baseline and physical health status at follow-up.

CONCLUSIONS

Findings extend our understanding of the factors associated with recovery from substance dependence, including "natural recovery", use of services outside of addiction treatment, and gender differences in help-seeking and remission.

Remitted major depression is characterized by reduced prefrontal cortex reactivity to reward loss

BACKGROUND

Major depression (MDD) is characterized by anhedonia. Although a growing body of literature has linked anhedonia in MDD to reduced frontostriatal activity during reward gains, relatively few studies have examined neural responsivity to loss, and no studies to date have examined neural responses to loss in euthymic individuals with a history of MDD.

METHODS

An fMRI monetary incentive delay task was administered to 19 participants with remitted MDD (rMDD) and 19 never depressed controls. Analyses examined group activation differences in brain reward circuitry during monetary loss anticipation and outcomes. Secondary analyses examined the association between self-reported rumination and brain activation in the rMDD group.

RESULTS

Compared to controls, the rMDD group showed less superior frontal gyrus activation during loss anticipation and less inferior and superior frontal gyri activation during loss outcomes (cluster corrected p's<.05). Ruminative Responses Scale scores were negatively correlated with superior frontal gyrus activation (r=-.68, p=.001) during loss outcomes in the rMDD group.

LIMITATIONS

Replication with a larger sample is needed.

CONCLUSIONS

Euthymic individuals with a history of MDD showed prefrontal cortex hypoactivation during loss anticipation and outcomes, and the degree of superior frontal gyrus hypoactivation was associated with rumination. Abnormal prefrontal cortex responses to loss may reflect a trait-like vulnerability to MDD, although future research is needed to evaluate the utility of this functional neural endophenotype as a prospective risk marker.

Trajectories of individual symptoms in remitters versus non-remitters with depression

BACKGROUND

It remains unclear regarding the contribution of each individual symptom in predicting the outcome in major depressive disorder (MDD). The objective of this analysis was to evaluate trajectories of individual symptoms over time to identify which specific depressive item(s) could predict subsequent clinical response.

METHODS

The data of 2874 outpatients with nonpsychotic MDD who received citalopram for up to 14 weeks in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial were analyzed. Average trajectories of individual symptoms over time were estimated for remitters and non-remitters. Moreover, specific symptoms whose improvement at week 2 predicted remission were identified, using binary logistic regression analysis.

RESULTS

Trajectories were significantly different between remitters and non-remitters in all depressive symptoms. All depressive symptoms in the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR16) in the two groups, except for hypersomnia and weight change in non-remitters, substantially improved within 2 weeks and gradually continued to improve thereafter throughout the 14 weeks. Early improvements in the following five symptoms, in order of magnitude, in the QIDS-SR16 were significantly associated with remission: sad mood, negative self-view, feeling slowed down, low energy, and restlessness (P<0.001, P<0.001, P=0.001, P=0.004, P=0.021).

LIMITATIONS

The participants were limited to the nonpsychotic MDD outpatients who received citalopram. Further, symptomatology was not evaluated at the very beginning of treatment.

CONCLUSIONS

While the data pertain to citalopram and replication is necessary for other antidepressants, early improvements in certain core depressive symptoms may serve as a predictor of subsequent remission.

Cognitive-coping therapy for obsessive-compulsive disorder: a randomized controlled trial

Pharmacotherapy and cognitive-behavioral therapy (CBT) are widely used to treat obsessive-compulsive disorder (OCD). These treatments have helped many patients with OCD, but there still is room for improvement. Recently, a promising psychotherapy for OCD, cognitive-coping therapy (CCT), has been developed. Pharmacotherapy plus CCT (PCCT) demonstrates higher efficacy in a shorter period of time and lower relapses than pharmacotherapy or pharmacotherapy plus CBT. In this randomized controlled trial, we investigated the efficacy of CCT for OCD treatment. One hundred and forty-five OCD patients were randomly assigned into two groups: pharmacotherapy (N = 72) and PCCT (N = 73). In each group, drug-resistant (DR) and non-drug-resistant (NDR) OCD were further analyzed to examine the efficacy of CCT. Some clinical features and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) were blindly assessed pre-treatment and post-treatment at week 1, 2, 3, 4, and 12. The Y-BOCS scores were significantly lower in PCCT than in the pharmacotherapy group at any post-treatment time-point (P < 0.001). Compared with pre-treatment, the Y-BOCS scores were significantly reduced at any time-point (P < 0.001) in PCCT group, but only at week 12 (P < 0.001) in the pharmacotherapy group. In the PCCT group, there were no differences between DR and NDR groups' Y-BOCS scores at any post-treatment time-point. The response rates and remission rates were higher in PCCT than in the pharmacotherapy group. Three variables, the number of weeks of treatment, insight, and disregarding of obsessions, were significantly correlated with the Y-BOCS score. Therefore, CCT might be a potential treatment for OCD.

Short-term remission in schizophrenia as a combination of several outcome measures

Clinical, cognitive, metabolic and functioning variables have been evaluated in patients with schizophrenia in an 8-week trial with Ziprasidone. The aim of this post-hoc analysis is to investigate how these variables interact in determining short-term remission. Baseline values or the variation from baseline to endpoint were considered predictors. 262 schizophrenic patients were recruited. Two logistic regressions were conducted to determine which variables predict remission. The first was performed on baseline values as predictors. The second used the variation from baseline to endpoint (delta) of the outcome evaluations as predictors. Using literature reported criteria for remission, we distinguished 124 subjects (47.33%) in remission, and 138 not in remission at the end of the trial. The first logistic regression does not show a good fit. The second logistic regression, with delta scores as predictors, reports instead an overall good fit (71.8% of the predicted cases assigned to the right category). The analysis reveals that general score from Positive and Negative Syndrome Scale (PANSS), cholesterol LDL, subjective well-being under neuroleptic, Simpson-Angus Scale (SAS) delta scores, drug dosage and premorbid intelligence entered in the equation. These results suggest that indexes such as cognition, metabolic status, other than symptoms, have to be taken into account in order to refine the short-term remission prediction.

Is there a place for initial treatment with biological DMARDs in the early phase of RA?

The use of biological disease-modifying antirheumatic drugs (bDMARDs) has changed the face of rheumatoid arthritis (RA). Achieving remission, normal function and prevention of joint damage are now possible for many patients with RA. In clinical practice, however, particularly with cost considerations, bDMARDs are usually prescribed after failure of one or more conventional synthetic DMARDs. With evidence that early treatment has a greater impact than later on, the question regarding initial bDMARD therapy and their potential role within a window of opportunity to influence disease outcomes remain. The increasing emphasis on early diagnosis and research into the preclinical phase of the disease also heralds the question, 'Can bDMARDs prevent the development of RA?' The aim of this review is to review randomised controlled trials with bDMARDs as initial therapy in early RA and to discuss their role in early disease.

Cyclosporine-A Versus Prednisolone for Induction of Remission in Auto-immune Hepatitis: Interim Analysis Report of a Randomized Controlled Trial

BACKGROUND

Corticosteroids are used to induce remission in auto-immune hepatitis.They are not universally effective; therefore, alternative treatments are needed.In this study Cysclosporine-A has been compared with prednisolone as an alternativetreatment in a randomized controlled trial. This paper is an interimanalysis of an ongoing clinical trial.

METHODS

Sixteen years and older consenting patients were enrolled. Group-A receivedprednisolone and group-B cyclosporine-A according to a preset protocoland followed at regular intervals for 48 weeks. Final assessment was doneat week 48. Primary outcome was response rate as defined below. "Completeresponse" was defined as achieving AST and ALT in the normal range andabsence of any clinical signs of deterioration, and partial response was definedas a decrease in AST and ALT by less than half of their original values but notto within normal limit. Non-responding ones at week eight were switched tothe other arm.

RESULTS

Thirty-nine patients were enrolled (24 group-A, 9 male). Mean AST andALT at baseline were higher in group-B, but other variables were comparable.At week 12, 34.8% and 64.3% of group-A and B had achieved AST and ALTin the normal range (less than 40 IU/L) respectively (p=0.081). Correspondingfigures at week 48 were 50.0% and 47.6% (p=0.62 & 0.48 respectively).At week 12, 86.9% and 85.7% of patients had AST and ALT levels less thantwice upper normal limit in groups-A and B respectively (p=0.54 & 0.42).Corresponding figures at week 48 were 90.0% for both groups. There was onetreatment failure in group-B which did not respond to prednisolone either.Serious adverse events (death and liver transplantation) occurred in group-Aonly. Serum creatinine did not change during the study period in either group.

CONCLUSION

According to our data, Cyclosporine-A is as effective as prednisolone forinduction of remission in AIH. Adverse events and serious adverse events weremore common with prednisolone.

Anxiety symptoms among remitted depressed outpatients: prevalence and association with quality of life and psychosocial functioning

BACKGROUND

Prior studies of remission from depression have only examined the impact of residual depressive, but not anxiety, symptoms. Given that anxiety comorbidity in currently depressed patients is common and is associated with poorer outcomes, residual anxiety symptoms may play a significant role in remitted patients' well-being and vulnerability to relapse. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the frequency of residual anxiety symptoms among depressed outpatients in remission based on the HAM-D and associations among residual anxiety, psychosocial functioning and quality of life.

METHODS

We interviewed 274 psychiatric outpatients diagnosed with DSM-IV major depressive disorder. Patients completed measures of depression and anxiety symptoms, psychosocial functioning, and quality of life.

RESULTS

Nearly three-quarters of remitted depressed patients endorsed at least one residual anxiety symptom, with a majority experiencing more than one symptom. Anxiety severity was associated with reduced functioning and quality of life across all life domains. Controlling for depression severity, anxiety symptoms were independently related to reduced functioning and quality of life in several domains.

LIMITATIONS

We did not assess for specific pre-existing DSM-IV anxiety disorders nor particular treatments patients received, which may have influenced residual anxiety symptoms. Future studies should replicate the results using other measures of remission.

CONCLUSIONS

Anxiety symptoms are common in depressed patients in remission, and independently related to reduced functioning and quality of life. Thus, it is important to consider anxiety symptoms in evaluating the completeness of treatment response of depressed patients.

Time course for memory dysfunction in early-life and late-life major depression: a longitudinal study from the Juntendo University Mood Disorder Project

BACKGROUND

Previous studies have demonstrated that patients with depression also have memory dysfunctions during depressive episodes. These dysfunctions partially remain immediately after remission from a depressive state; however, it is unclear whether these residual memory dysfunctions may disappear through long-term remission from depression. The present study compared patients during early-life (age<60) and late-life (age ≥ 60) depression while in their remitted stage with healthy controls to elucidate the impact of a long-term course on memory.

METHODS

Logical memory from the Wechsler Memory Scale-Revised was administered to 67 patients with major depressive disorder (MDD) (47 patients with early-life depression and residual 20 patients with late-life depression) and 50 healthy controls. MDD patients received memory assessments at the time of their initial remission and at a follow-up three years after remission.

RESULTS

At the time of initial remission, scores for logical memory were significantly lower in both patient groups compared to matched controls. At follow-up, memory dysfunction for early-life MDD patients disappeared, whereas scores in the late-life MDD group remained significantly lower than those of matched controls.

LIMITATIONS

All patients in the present study were on antidepressant medications.

CONCLUSIONS

Our findings suggested that the progress of memory performance in late-life MDD patients may be different from early-life MDD patients.

Persistence of chronic major depression: a national prospective study

BACKGROUND

Chronic major depressive disorder (CMDD) is highly prevalent and associated with high personal and societal cost. Identifying risk factors for persistence and remission of CMDD may help in developing more effective treatment and prevention interventions.

METHODS

Prospective cohort study of individuals participating in the National Epidemiologic Survey on Alcohol and Related Conditions (Wave 1; n=43,093) and its 3-year follow-up (Wave 2; n=34,653) who met a diagnosis of CMDD at the Wave 1 assessment.

RESULTS

Among the 504 respondents who met criteria for present CMDD at Wave 1, only 63 (11.52%) of them continued to meet criteria of CMDD. A history of childhood sexual abuse, earlier onset of MDD, presence of comorbidity and a history of treatment-seeking for depression predicted persistence of CMDD three years after the baseline evaluation.

LIMITATIONS

Our sample is limited to adults, our follow-up period was only three-years and the diagnosis of CMDD at baseline was retrospective.

CONCLUSIONS

CMDD shows high rates of remission within three years of baseline assessment, although some specific risk factors predict a persistent course. Given the high personal and societal cost associated with CMDD, there is a need to develop and disseminate effective interventions for CMDD.

Predictors and persistence of new-onset clinical remission in rheumatoid arthritis patients

OBJECTIVE

To determine the prevalence and persistence of new-onset clinical remission in rheumatoid arthritis (RA) patients.

METHODS

The Consortium of Rheumatology Researchers of North America (CORRONA) cohort was used to examine the prevalence of remission and associated comorbidities and RA therapies according to the 2011 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) remission criteria. Factors influencing the likelihood of remaining in remission were identified by logistic regression with generalized estimating equations. Analysis of variance and Tukey's test were used to determine differences in disability according to whether RA patients had been in remission or only low disease activity (LDA).

RESULTS

A total of 2105 individuals met ACR/EULAR remission criteria at the most recent visit within CORRONA, yielding an 8% point prevalence of remission. Patients with certain comorbidities (e.g., heart failure) were significantly less likely to achieve or remain in remission compared to those without these conditions (p < 0.001 for each). Among prednisone users, the prevalence of remission was 1-6% (depending on dose) higher compared to those not on prednisone (10%). More than 50% of patients who had consistently been in remission for ≥1 year were able to remain in remission over the next year. Patients consistently in remission had less disability than patients who achieved LDA or who fluctuated between remission and LDA.

CONCLUSION

Patients consistently in remission for at least 1 year had a high likelihood to remain in remission. These individuals might be considered the most likely candidates for de-escalation or withdrawal of RA treatments.

What happens to depressed adolescents? A follow-up study into early adulthood

BACKGROUND

This study describes the mental illness and psychosocial outcomes of adolescents who experienced a depressive disorder and identifies predictors of full remission and recurrence.

METHODS

140 adolescents with major depressive disorder, dysthymic disorder, or depressive disorder NOS were offered psychosocial and/or antidepressant treatment across two clinical trials. Three to nine years later (mean 5.7 years), 111 adolescents and young adults completed self-, parent- and clinician-reported measures of psychopathology and psychosocial functioning in a naturalistic follow-up study. The Structured Clinical Interview for DSM-IV Axis 1 Disorders was used to determine the presence or absence of depressive disorder as well as other Axis 1 Disorders.

RESULTS

By the follow-up assessment, most adolescents made a full remission from their index depressive disorder (92.6%). Recurrence of depressive disorder (52.4%) during the follow-up period was common, as was the experience of other disorders including anxiety, substance abuse and eating disorders. Time to full remission and recurrence did not vary between baseline types of depressive disorder. Self-reported depressive symptoms and anxiety disorder were associated with failure to achieve full remission while socio-economic status, self-reported self-efficacy and depressive symptoms were associated with recurrence of depressive disorder.

LIMITATIONS

Due to different treatment starting times, the length of the follow up period varied by up to 5.2 years.

CONCLUSIONS

Adolescents who experience depressive disorder are at high risk of ongoing mental illness and psychosocial impairment. Predictors of the course of depressive disorder may be of use in determining which adolescents may require more intensive intervention.

Difference in remission in a Chinese population with anxious versus nonanxious treatment-resistant depression: a report of OPERATION study

BACKGROUND

A secondary analysis was conducted to compare treatment outcomes for anxious depression and nonanxious depression in previous published OPERATION trials of a variety of antidepressants and augmentation strategies for patients with treatment-resistant depression (TRD).

METHODS

A total of 375 patients that met DSM-IV criteria for major depressive disorder (MDD) and the stage 2 TRD criteria (described by Thase & Rush) were enrolled. Anxious depression was defined as MDD with a HRSD-17 anxiety/somatization factor score ≥7. Data were derived from an earlier study, designed to compare efficacy and tolerability of fixed dosage of extended-release venlafaxine, mitazapine, paroxetine, and risperidone, sodium valproate, buspirone, trazodone or thyroid hormone augmenting to paroxetine in those patients. Treatment outcomes were compared between patients with anxious and nonanxious TRD.

RESULTS

Nearly 70% of participants had anxious depression. Remission rates were significantly lower and ratings of adverse event frequency were significantly greater in patients with anxious TRD than in those with nonanxious TRD. Presence of anxious depression predicted worse outcomes.

LIMITATIONS

Lack of a placebo control arm prevents us from ruling out placebo effects. The two groups were non-randomly allocated to medications. Only patients with stage 2 TRD were enrolled, which may limit generalizablity to patients without a history of resistance. Comorbid anxiety disorders that might confound the specific treatment effects were not addressed.

CONCLUSIONS

The findings support and extend the hypothesis that anxious depression is associated with poorer outcomes. It suggests a dimensional assessment of co-occurring anxious features of MDD patients may be clinically feasible for countries like China where difficulties in making comorbidity diagnosis exist.

To a broader concept of remission: rating the health-related quality of life in bipolar disorder

BACKGROUND

The relationship between remission and quality of life in bipolar disorder is incompletely understood. This study aimed to determine cut-points on the 36-item Short-Form Health Survey (SF-36) and the European Quality of Life Index (EQ-5D) that corresponded with an objective clinical measure of remission in bipolar disorder patients.

METHODS

Data from a 2-year prospective observational study of bipolar and schizoaffective patients were analysed. Concordant with previous research, the Clinical Global Impression-Bipolar Version (CGI-BP) was used as an index of remission, specifically the severity scores of 1 (normal, not at all ill) and 2 (borderline mentally ill). The mean SF-36 standardized mental component (SMC) and standardized physical component (SPC) total scores as well as the EQ-5D index score that corresponded with a CGI-BP severity score of 1 or 2 were determined.

RESULTS

The mean SF-36 score that corresponded with a CGI-BP severity score of 1 or 2, was below 50 for the SPC (49.3) and below 49 for the SMC (48.3). The mean EQ-5D score that corresponded with a CGI-BP severity score of 1 or 2 was below 0.88 (0.87).

LIMITATIONS

Although the initial sample is sufficiently large (n=240), 49 patients scored 1 and 2 on the CGI-S, of which 12 had schizoaffective disorder.

CONCLUSIONS

This study suggests that a cut-off score of ≥50 for the SPC and ≥49 for the SMC of the SF-36 and ≥0.88 for the EQ-5D index approximates a CGI-BP definition of remission.

Differential impact of isolated psychotic symptoms on treatment outcome of major depressive disorder in the STAR*D cohort of Whites, Blacks and Latinos

OBJECTIVE

To determine whether isolated psychotic symptoms are more likely to be endorsed by depressed Latinos as opposed to other ethnic-racial groups; whether these symptoms affect Latinos similarly to other ethnic-racial groups in terms of treatment response; and whether they are more likely to be associated with anxiety disorders in depressed Latinos.

METHODS

We analyzed data from STAR*D subjects who self identified as White, Black, or Latino. Rates of isolated psychotic symptoms were assessed by the self-rated Psychiatric Diagnostic Screening Questionnaire (PDSQ) and compared between ethnic-racial groups. Depressive remission outcomes were compared within each ethnic-racial group between subjects who endorsed psychotic symptoms versus no psychotic symptoms. Associations between isolated psychotic symptoms and anxiety disorders were also examined.

RESULTS

Among 2597 eligible subjects with at least one post-baseline assessment and available PDSQ data excluding first-rank symptoms, the prevalence of auditory-visual hallucination was 2.5% in Whites (n=49/1928), 11.3% in Blacks (n=45/398) 6.3% in Latinos (n=17/270) (χ(2)=64.9; df=2; p<0.001). Prevalence of paranoid ideation was 15.5% in Whites (n=299/1927), 31.5% in Blacks (n=126/400), and 21.1% in Latinos (n=57/270) (χ(2)=57.3; df=2; p<0.001). Among Whites and Blacks but not Latinos, depressive remission rates were worse in subjects with auditory-visual hallucinations compared to those without them. Paranoid ideation had a significant negative impact on remission in Whites only. In all ethnic-racial groups, a significant association was found between auditory-visual hallucinations and PTSD and panic disorder.

LIMITATIONS

The STAR*D study did not include any structured clinician-based assessment of psychotic symptoms.

CONCLUSION

Latinos do not appear to have worse outcomes when treated for MDD with auditory-visual hallucinations, differently from Whites and Blacks.

Association between symptomatic profile and remission following antidepressant treatment in unipolar major depression

BACKGROUND

To evaluate, in patients affected by an acute major depressive episode, what predictive value certain baseline psychopathological characteristics have with regard to expected therapeutic remission following biological antidepressant treatment (pharmacological/electroconvulsive; non-psychological).

METHODS

Six predefined psychopathological characteristics in acute major depressive episode were evaluated using a logistic regression model through a protocolised antidepressant treatment to assess their predictive value with regard to expected remission rate.

RESULTS

The final study sample consisted of 129 subjects affected by an acute major depressive episode. From the baseline evaluation of the anguish/restlessness, reduced emotional reactivity, reduced attention, reduced motor response, feeling of worthlessness, and mood characteristics items, it was possible to correctly classify 88.1% of the sample as remitter/non-remitter with sensitivity of 0.77 and specificity of 0.96. Addition of the 17-item HRSD baseline variable to the regression model increased the capacity for correct classification of the baseline sample by only 0.09%.

LIMITATIONS

Protocolised antidepressant treatment was used. The results of this study may not be generalisable to pharmacological treatments not included in this protocol.

CONCLUSIONS

The results of this study suggest that certain baseline psychopathological characteristics (and perhaps other clinical variables too) of the acute major depressive episode may be of great use in establishing patient subgroups according to expected clinical remission to the administration of biological antidepressant treatment. This could have considerable consequences for individualised therapeutic decision-making and for future researches (clinical trials included).

Intrusion-based reasoning and depression: cross-sectional and prospective relationships

Intrusion-based reasoning refers to the tendency to form interpretations about oneself or a situation based on the occurrence of a negative intrusive autobiographical memory. Intrusion-based reasoning characterises post-traumatic stress disorder, but has not yet been investigated in depression. We report two studies that aimed to investigate this. In Study 1 both high (n = 42) and low (n = 28) dysphoric participants demonstrated intrusion-based reasoning. High-dysphoric individuals engaged in self-referent intrusion-based reasoning to a greater extent than did low-dysphoric participants. In Study 2 there were no significant differences in intrusion-based reasoning between currently depressed (n = 27) and non-depressed (n = 51) participants, and intrusion-based reasoning did not predict depressive symptoms at 6-month follow-up. Interestingly, previously (n = 26) but not currently (n = 27) depressed participants engaged in intrusion-based reasoning to a greater extent than never-depressed participants (n = 25), indicating the possibility that intrusion-based reasoning may serve as a "scar" from previous episodes. The implications of these findings are discussed.

Probability and predictors of cannabis use disorders relapse: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

This study aims to estimate the odds and predictors of Cannabis Use Disorders (CUD) relapse among individuals in remission.

METHODS

Analyses were done on the subsample of individuals with lifetime history of a CUD (abuse or dependence) who were in full remission at baseline (Wave 1) of the National Epidemiological Survey of Alcohol and Related Conditions (NESARC) (n=2350). Univariate logistic regression models and hierarchical logistic regression model were implemented to estimate odds of relapse and identify predictors of relapse at 3 years follow up (Wave 2).

RESULTS

The relapse rate of CUD was 6.63% over an average of 3.6 year follow-up period. In the multivariable model, the odds of relapse were inversely related to time in remission, whereas having a history of conduct disorder or a major depressive disorder after Wave 1 increased the risk of relapse.

CONCLUSIONS

Our findings suggest that maintenance of remission is the most common outcome for individuals in remission from a CUD. Treatment approaches may improve rates of sustained remission of individuals with CUD and conduct disorder or major depressive disorder.

Family history and frontal lobe seizures predict long-term remission in newly diagnosed cryptogenic focal epilepsy

PURPOSE

Cryptogenic focal epilepsy (CFE) is a heterogeneous clinical disorder including patients with severe refractory forms and patients with a fairly good prognosis. Predictors of prognosis in CFE are poorly understood. The aim of this retrospective study is to identify long-term (5-year) prognostic predictors in patients with newly diagnosed CFE.

METHODS

Subjects with cryptogenic focal epilepsy (CFE) seen from April 1987 to September 2011 in two twin Epilepsy Centres located in Reggio Calabria and Catanzaro, Calabria, Southern Italy, were screened. Patients were excluded if they had psychogenic seizures, major psychiatric disorders presence of brain lesions except for non-specific white matter T2-hyperintensities, short follow-up (less than five years) or for having received the diagnosis of CFE elsewhere. One hundred and eighty-six patients, firstly diagnosed in our Centres, constituted the study sample. Survival curves were generated according to the Kaplan-Meier method and compared with the log-rank test. The endpoint was the cumulative time-dependent chance of 5-year remission after treatment start. Independent predictors of remission were tested by multivariate analysis using Cox proportional hazards function models. The accuracy of the resulting model was tested with Receiver Operating Characteristics (ROC) curve analysis.

KEY FINDINGS

The cumulative incidence of remission was 23%. At Kaplan-Meier analysis, the only factor predicting remission was family history of epilepsy or febrile seizures (FS; p=0.02). At Cox regression, family history and frontal lobe epilepsy showed to be independent predictors of outcome (p=0.02 and 0.03, respectively). The accuracy of these predictors was good (area under ROC curve 0.648, 95% CI 0.575-0.716). Interestingly, we also found a considerable (7 years) diagnostic delay that did not result in a worse prognosis.

SIGNIFICANCE

About one quarter of subjects with newly diagnosed CFE attains 5-year seizure remission during follow-up. Family history of epilepsy or FS and frontal localization are independent prognostic predictors.

Pharmacogenetics in major depression: a comprehensive meta-analysis

A number of candidate gene studies focused on major depression (MD) and antidepressant (AD) efficacy have been carried out, but results mainly remain inconclusive. We performed a comprehensive meta-analysis of published candidate gene studies focused on AD efficacy in MD to evaluate the cumulative evidence. A random-effect model was applied to study the polymorphisms with genotypic counts available from at least three independent studies. On the base of previous evidence, the analysis was stratified by ethnicity (Caucasian, Asian, and other/mixed), and AD class (SSRIs and mixed/other ADs). Genotypic data were available for 16 polymorphisms in 11 genes. After the exclusion of 5-HTTLPR in SLC6A4 included in another recent meta-analysis, 15 polymorphisms in 11 genes were included in the present meta-analysis (BDNF rs6265, SLC6A4 STin2, HTR1A rs6295, HTR2A rs6311, rs6313 and rs7997012, HTR6 rs1805054, TPH1 rs1800532, SLC6A2 rs5569, COMT rs4680, GNB3 rs5443, FKBP5 rs1360780 and rs3800373, and ABCB1 rs1045642 and rs2032582). Our results suggested that BDNF rs6265 (Val66Met) heterozygous genotype was associated with better SSRIs response compared to the homozygous genotypes, particularly in Asians (OR=1.53, 95%CI 1.12-2.07, p=0.007). SLC6A4 STin2, HTR2A rs6311 and rs7997012, GNB3 rs5443, FKBP5 rs1360780 and rs3800373, and ABCB1 rs2032582 showed associations with AD efficacy, but these results were highly dependent on one or two single studies. In conclusion, our findings suggested the BDNF Val66Met as the best single candidate involved in AD response, with a selective effect on SSRI treatment. Our overall results supported no major effect of any single gene variant on AD efficacy.

Music in depression: Neural correlates of emotional experience in remitted depression

AIM: To investigate neural and behavioral correlates of emotional experiences as potential vulnerability markers in remitted depression.

METHODS: Fourteen remitted participants with a history of major depression and fourteen closely matched healthy control participants took part in the study. We used two psychiatric interviews (Hamilton Depression Rating Scale, Montgomery-Asberg Depression Rating Scale) and one self-report scale (Beck Depression Inventory) to assess remission. Healthy control participants were interviewed by an experienced psychiatrist to exclude those who showed any current or lifetime psychiatric or neurological disorders. To explore psychosocial and cognitive-interpersonal underpinnings of potential vulnerability markers of depression, early life stress, coping styles and alexithymia were also assessed. We induced pleasant and unpleasant emotional states using congruent combinations of music and human emotional faces to investigate neural and behavioral correlates of emotional experiences; neutral stimuli were used as a control condition. Brain responses were recorded using functional magnetic resonance imaging. Behavioral responses of pleasantness, arousal, joy and fear were measured via button-press inside the resonance imaging scanner.

RESULTS: The mean age of the sample was 54.9 (± 11.3) years. There were no differences between remitted depressed (RD) (n = 14; 9 females and 5 males) and healthy participants (n = 14; 8 females and 6 males) regarding age, current degree of depression, early life stress, coping styles and alexithymia. On a neural level, RD participants showed reduced activations in the pregenual anterior cingulate cortex (pgACC) in response to pleasant [parameter estimates: -0.78 vs 0.32; t(26) = -3.41, P < 0.05] and unpleasant [parameter estimates: -0.88 vs 0.56; t(26)= -4.02, P < 0.05] emotional stimuli. Linear regression analysis revealed that pgACC activity was modulated by early life stress [β = -0.48; R² = 0.23, F(1,27) = 7.83, P < 0.01] and task-oriented coping style [β = 0.63; R² = 0.37, F(1,27) = 16.91, P < 0.001]. Trait anxiety modulated hippocampal responses to unpleasant stimuli [β = 0.62; R² = 0.38, F(1,27) = 15.95, P < 0.001]. Interestingly, in their reported experiences of pleasantness, arousal, happiness and fear in response to pleasant, unpleasant and neutral stimuli, RD participants did not differ significantly from healthy control participants. Adding trait anxiety or alexithymia as a covariate did not change the results.

CONCLUSION: The present study indicates that, in euthymic individuals, depression history alters neural correlates, but not the subjective dimension of pleasant and unpleasant emotional experiences.

MuSK-Ab positive myasthenia: not always grave

Antibodies (Abs) to muscle-specific tyrosine kinase (MuSK) are detected in approximately 40% of generalized acetylcholine receptor antibody-negative myasthenia gravis (MG). Anti-MuSK Abs are nearly always associated with generalized symptoms, with prevalent involvement of craniobulbar, cervical and respiratory muscles and with a striking preponderance in women. The typical course of MuSK-MG is acute onset, rapid progression, brittle course in the first years, early respiratory crises and unprovoked relapses in spite of high-dose immunosuppression. Patients often require long-term management with multiple immunosuppressive (IS) agents and many of them remain dependent on IS treatment. The majority of anti-MuSK Abs are of the non-complement-binding IgG4 subclass. We report the case of a Greek female MuSK-MG patient with typical phenotype but clearly atypical clinical course during 12 years of follow-up. The patient received only corticosteroid treatment for one year and showed mild and stable MG symptoms under no treatment for the rest of the observation period, except for postpartum mild and short-lived exacerbation. In mildly symptomatic stable state, anti-MuSK Abs were of the IgG4 subclass and no other immunological peculiarity was detected.

Remission of benign epilepsy with rolandic spikes: an EEG-based connectivity study at the onset of the disease and at remission

PURPOSE

The neuronal mechanisms of remission of epilepsy are not known. Based on the principles of the "network theory of epilepsy" we postulated the existence of abnormal cortico-cortical interactions at the onset of epilepsy (Hypothesis-1), and postulated that remission is associated with the decrease or disappearance of the abnormal quantitative EEG findings (Hypothesis-2).

METHODS

Four children with benign epilepsy with rolandic sharp waves (BERS) were investigated. 21-channel EEG was recorded at the onset of the disease (Setting No. 1) and in remission (Setting No. 2). Local EEG synchronization was estimated by LORETA (low resolution electromagnetic tomography). Remote EEG synchronization (intra-hemispheric, cortico-cortical EEG functional connectivity, EEGfC) was computed by the LSC (LORETA Source Correlation) method, among 23 regions of interest (ROI) in both hemispheres. Both local and remote EEG synchronization were evaluated in very narrow frequency bands of 1Hz bandwidth (VNB), from 1 to 25Hz.

RESULTS

Individual results were presented. Abnormal but topographically very dissimilar LORETA and LSC findings were found at the onset of the disease. The disappearance of the initial abnormalities was found in Setting No. 2. An unforeseen finding was the presence of abnormal EEGfC results in Setting No. 2.

DISCUSSION

The authors confirmed both hypotheses. The dissimilarity of the initial abnormalities is in accord with the network concept of epilepsy and the etiology of BERS. The disappearance of the initial abnormalities reflects "normalization" of network dynamics while the emergence of new EEGfC abnormalities is interpreted as "compensation".

CONCLUSION

EEG-based local and remote connectivity (EEGfC) are appropriate tools to describe network dynamics in the active state of BERS and in remission.

Spontaneous remission of epstein-barr virus-positive diffuse large B-cell lymphoma of the elderly

A 94-year-old female patient presented with anorexia and left axillar lymphadenopathy on admission. Her past history was angina pectoris at 83 years of age and total gastrectomy due to gastric cancer at 87 years. The family history revealed that her son had had a malignant lymphoma, the histopathological diagnosis of which was diffuse large B-cell lymphoma. A physical examination showed both cervical, axillar, and inguinal lymphadenopathy without tenderness. She had elevated lactate dehydrogenase, ferritin, and soluble interleukin-2 receptor (sIL-2R). Whole-body computed tomography confirmed the cervical, axillary, and inguinal lymphadenopathy. Gallium-68 imaging revealed positive accumulation in these superficial lymph nodes. A right inguinal lymph node biopsy showed features of Epstein-Barr virus-associated lymphoproliferative disorder. Immunohistological studies on this lymph node biopsy showed CD20-positive large cells, CD3-positive small cells, and CD30-partly-positive large cells. In situ hybridization showed Epstein-Barr virus-positive, LMP-partly-positive, and EBNA2-negative cells. She refused chemotherapy as her son had died from hematemesis during chemotherapy. She received intravenous hyperalimentation for 1 month after admission. No palpable lymph nodes were identified by physical examination or computed tomography 3 months after admission, and regression of lactate dehydrogenase, ferritin, and sIL-2R was observed. She recovered from anorexia and was discharged. She died from pneumonia 10 months later after initial symptoms of anorexia. The autopsy showed no superficial lymphadenopathy.

Duration of remission phase of 36 Korean patients with glossopharyngeal neuralgia

BACKGROUND

Glossopharyngeal neuralgia has the characteristic of a long remission phase between the pain attack phases. Although the concept of remission is very important for the treatment of patients with glossopharyngeal neuralgia, due to the rarity of the disease, clear statistical studies on the remission phase for glossopharyngeal neuralgia are almost non-existent.

METHODS

Previous chart reviews and phone interviews were conducted on a total of 38 patients. Among these study subjects, two patients were excluded because of their known secondary glossopharyngeal neuralgia from their brain tumors. Hence, the average duration of remission was investigated on 36 patients with idiopathic glossopharyngeal neuralgia.

RESULTS

For the 27 patients who experienced their first remission, the average duration of the remission was 3.1 years. Among them, the average duration of the second remission of the 17 patients was 2.5 years, and for 4 patients who experienced a third remission, the average duration of the remission phase was 1.9 years.

CONCLUSIONS

The difference in the mean duration of the remission phase of the 1(st), 2(nd), and 3(rd) are not statistically significant, and the occurrence rate of the left or right side and of the gender, male or female, are also statistically insignificant. However, it is possible to infer that a patient might face a pain attack phase when his or her remission phase has lapsed for about three years. This prediction may be applied when developing treatment plans for patients with glossopharyngeal neuralgia.

Predictors of initial and sustained remission from alcohol use disorders: findings from the 30-year follow-up of the San Diego Prospective Study

BACKGROUND

Individuals who report problematic drinking early in life often recover from alcohol-related disorders, with or without formal treatment. While risk factors associated with developing alcohol use disorders (AUDs), such as a family history of alcoholism and the genetically influenced low level of response (LR) to alcohol, have been identified, less is known about characteristics that relate to remission from AUDs.

METHODS

The male subjects (98% Caucasian) for this study were 129 probands from the San Diego Prospective Study who were first evaluated at age 20 as drinking but not alcohol-dependent young men, most of whom were college graduates by follow-up. The individuals evaluated here met criteria for an AUD at their first follow-up at ages 28 to 33 and were followed every 5 years for the next 2 decades. Discrete-time survival analysis was used to examine rates of initial and sustained AUD remission and to evaluate the relationships of premorbid characteristics and other risk factors to these outcomes.

RESULTS

Sixty percent of the sample met criteria for an initial AUD remission of 5 or more years, including 45% with sustained remission (i.e., no subsequent AUD diagnosis). Higher education, lower drinking frequency, and having a diagnosis of alcohol abuse (rather than dependence) were associated with higher rates of initial AUD remission. A lower LR to alcohol at age 20, as well as lower drinking frequency, having received formal alcohol treatment, and older age at the first follow-up all predicted a greater likelihood of sustained AUD remission.

CONCLUSIONS

This study identified key factors associated with initial and sustained AUD remission in subjects diagnosed with AUD in young adulthood. Characteristics associated with better outcomes early in the life span, such as lower drinking frequency and early treatment, appear to have a lasting impact on remission from AUD across adulthood.

Efficacy of infliximab in acute severe ulcerative colitis: A single-centre experience

AIM: To suggest infliximab (IFX) is effective for acute severe ulcerative colitis, from real-life clinical practice.

METHODS: All patients receiving IFX for the treatment of acute severe ulcerative colitis in a single centre were included. Data were extracted from clinical records in order to assess response to IFX therapy. The primary endpoint was colectomy-free survival, and secondary outcomes included glucocorticosteroid-free remission and safety, which was evaluated by recording deaths and adverse events. Demographic and clinical characteristics of those who underwent colectomy and those who were colectomy-free, both at discharge from their index admission, and during follow-up after an initial response to IFX were compared.

RESULTS: Forty-four patients (16 females, mean age 36 years) received IFX between May 2006 and January 2012 for acute severe ulcerative colitis. The median duration of follow-up post-first infusion was 396 d (interquartile range = 173-828 d). There were 21 (47.7%) patients with < 1 year of follow-up, 10 (22.7%) with 1 years to 2 years of follow-up, and 13 (29.5%) with > 2 years of follow-up post-first infusion of IFX. Overall, 35 (79.5%) responded to IFX, avoiding colectomy during their index admission, 29 (65.9%) were colectomy-free at last point of follow-up (median follow-up 396 d), and 25 (56.8%) were in glucocorticosteroid-free remission at end of follow-up. There was one death from post-operative sepsis, 20 d after a single IFX infusion. Colectomy rates were generally lower among those “bridging” to thiopurine. Of 18 patients “bridged” to thiopurine therapy, 17 (94.4%) were colectomy-free, and 15 (83.3%) were in glucocorticosteroid-free remission at study end. No predictors of response were identified.

CONCLUSION: IFX is effective for acute severe ulcerative colitis in real-life clinical practice. Two-thirds of patients avoided colectomy, and more than 50% were in glucocorticosteroid-free remission.

Retrospective study of steroid therapy for patients with autoimmune pancreatitis in a Chinese population

AIM: To explore the optimal steroid therapeutic strategy for autoimmune pancreatitis (AIP).

METHODS: This study was conducted retrospectively in two large institutions in China. Patients with clinically, radiologically and biochemically diagnosed AIP were enrolled. The performed radiological investigations and biochemical tests, the regimen of the given steroid treatment, remission and relapse whether with and without steroid therapy were analyzed.

RESULTS: Twenty-eight patients with AIP received steroid treatment, while 40 patients were treated surgically by pancreatoduodenectomy, distal pancreatectomy and choledochojejunostomy, radiofrequency ablation for the enlarged pancreatic head, percutaneous transhepatic biliary drainage and endoscopic biliary drainage. The starting oral prednisolone dose was 30 mg/d in 18 (64.3%) patients and 40 mg/d in 10 (35.7%) patients administered for 3 wk. The remission rate of AIP patients with steroid treatment (96.4%) was significantly higher than in those without steroid treatment (75%). Maintenance therapy (oral prednisolone dose 5 mg/d) was performed after remission for at least 6-12 mo to complete the treatment course. Similarly, the relapse rate was significantly lower in AIP patients with steroid treatment (28.6%) than in those without steroid treatment (42.5%). Steroid re-treatment was effective in all relapsed patients with or without steroid therapy.

CONCLUSION: Steroid therapy should be considered in all patients with active inflammatory phase of AIP. However, the optimal regimen still should be trailed in larger numbers of patients with AIP.

Measurements of treatment response in childhood acute leukemia

Measuring response to chemotherapy is a backbone of the clinical management of patients with acute leukemia. This task has historically relied on the ability to identify leukemic cells among normal bone marrow cells by their morphology. However, more accurate ways to identify leukemic cells have been developed, which allow their detection even when they are present in small numbers that would be impossible to be recognized by microscopic inspection. The levels of such minimal residual disease (MRD) are now widely used as parameters for risk assignment in acute lymphoblastic leukemia (ALL) and increasingly so in acute myeloid leukemia (AML). However, different MRD monitoring methods may produce discrepant results. Moreover, results of morphologic examination may be in stark contradiction to MRD measurements, thus creating confusion and complicating treatment decisions. This review focusses on the relation between results of different approaches to measure response to treatment and define relapse in childhood acute leukemia.

Complete Remission of del(5q) Myelodysplastic Syndrome after 7 Days of Lenalidomide Therapy Gives an Alert!

Myelodysplastic syndrome (MDS) refers to a group of haematological, monoclonal disorders. A 50-year-old woman was diagnosed with MDS 5q deletion syndrome [del(5q)], becoming dependent on blood transfusion after long-term treatment with cytotoxic drugs for chronic scleritis. Lenalidomide therapy (10 mg/day) led to profound pancytopaenia, followed by recovery of her blood cell counts. A cytogenetic study, repeated 4 months after lenalidomide treatment, revealed complete remission after only 1 week of lenalidomide therapy. Lenalidomide was approved for low- and intermediate-1-risk MDS, where it normalises platelet counts and induces haematological and cytogenetic remission. This patient has remained transfusion independent for 3 years by continuing on a minimal maintenance dose of lenalidomide. Starting MDS patients on lenalidomide has to be done cautiously or with only 5 mg/day because of the potentially high sensitivity of the stem cells to this immunomodulatory agent in MDS patients.

Surgery for Crohn’s disease in the era of biologicals: A reduced need or delayed verdict?

Crohn’s disease (CD) is a chronic inflammatory bowel disease that can affect the entire gastrointestinal tract. Ultimately, up to 70% of all patients will need surgery, despite optimized medical therapy. Moreover, about half of the patients will need redo-surgery because of disease recurrence. The introduction of anti-tumor necrosis factor (TNF) drugs (Infliximab in 1998) revolutionized the treatment of CD. Different randomized trials assessed the efficacy of anti-TNF treatment not only to induce, but also to maintain, steroid-free remission. Furthermore, these agents can rapidly lead to mucosal healing. This aspect is important, as it is a major predictor for long-term disease control. Subgroup analyses of responding patients seemed to suggest a reduction in the need for surgery at median-term follow up (1-3 years). However if one looks at population surveys, one does not observe any decline in the need for surgery since the introduction of Infliximab in 1998. The short follow-up term and the exclusion of patients with imminent surgical need in the randomized trials could bias the results. Only 60% of patients respond to induction of anti-TNF therapy, moreover, some patients will actually develop resistance to biologicals. Many patients are diagnosed when stenosing disease has already occurred, obviating the need for biological therapy. In a further attempt to change the actual course of the disease, top down strategies have been progressively implemented. Whether this will indeed obviate surgery for a substantial group of patients remains unclear. For the time being, surgery will still play a pivotal role in the treatment of CD.

Induction of remission is difficult due to frequent relapse during tapering steroids in Korean patients with polymyalgia rheumatica

Polymyalgia rheumatica is an inflammatory disease affecting elderly and involving the shoulder and pelvic girdles. No epidemiological study of polymyalgia rheumatica was conducted in Korea. We retrospectively evaluated patients with polymyalgia rheumatica followed up at the rheumatology clinics of 10 tertiary hospitals. In total 51 patients, 36 patients (70.6%) were female. Age at disease onset was 67.4 yr. Twenty-three patients (45.1%) developed polymyalgia rheumatica in winter. Shoulder girdle ache was observed in 45 patients (90%) and elevated erythrocyte sedimentation rate (> 40 mm/h) in 49 patients (96.1%). Initial steroid dose was 23.3 mg/d prednisolone equivalent. Time to normal erythrocyte sedimentation rate was 4.1 months. Only 8 patients (15.7%) achieved remission. Among 41 patients followed up, 28 patients (68.3%) had flare at least once. Number of flares was 1.5 ± 1.6. The frequency of flare was significantly lower in patients with remission (P = 0.02). In Korea, polymyalgia rheumatica commonly develops during winter. Initial response to steroid is fairly good, but the prognosis is not benign because remission is rare with frequent relapse requiring long-term steroid treatment.

Low Grade Gastric Mucosa-associated Lymphoid Tissue Lymphoma: Clinicopathological Factors Associated with Helicobacter pylori Eradication and Tumor Regression

BACKGROUND/AIMS

Eradication of Helicobacter pylori is widely accepted as initial therapy for low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma. However, approximately 20% of patients with this disease are not responsive to H. pylori eradication therapy. The aim of this study was to assess remission and relapse rates of low-grade gastric MALT lymphoma after H. pylori eradication and identify the clinical factors that affect remission.

METHODS

Thirty-nine patients diagnosed with gastric MALT lymphoma (May 2003 to May 2010) were retrospectively analyzed.

RESULTS

Of the 39 patients, 30 (77%) had a H. pylori infection. There were 35/39 (90%) patients with stage I. Among stage I, 25 patients with the infection underwent eradication therapy and 22/25 (88%) achieved remission. The total regression rate with eradication only in stage I was 24/28 (86%). The median time to remission was 98 days (range, 22 to 397 days). Age, tumor location, invasion depth, H. pylori burden, and severity of mononuclear leukocyte and neutrophil infiltration were not related to remission. However, patients with less neutrophil infiltration were more likely to achieve a successful first H. pylori eradication (p=0.049).

CONCLUSIONS

The results show that the rate of low-grade gastric MALT lymphoma regression (86%) with H. pylori eradication alone was higher than that in Western studies (77.8%) and that neutrophil infiltration was inversely related to success of the first H. pylori eradication procedure.

[No best treatment for severe outbreaks: Maintenance, the key in colitis]

Several drugs are currently available to maintain remission in patients who have responded after one or other type of induction therapy, depending on the initial severity of the outbreak. Salicylates are the drugs of choice to maintain remission after a mild-to-moderate outbreak controlled by salicylates or oral corticosteroids. To maintain remission after a severe outbreak or in patients with corticosteroid dependence or resistance, thiopurines are the drugs of choice. In patients who have failed to respond to thiopurines and in those with thiopurine intolerance, biological agents, mainly infliximab, can be used to maintain remission in patients after induction therapy with infliximab for a severe outbreak. However, these scenarios may not reflect reality of gastroenterologists' daily clinical practice. Treatment will therefore be based on the patient's individual characteristics (age, clinical course, previous treatment, adverse effects and personal preferences) as well as the physician's medical art.

Therapeutic management of diabetic kidney disease

During the past 10 years, a global pandemic of end-stage renal disease (ESRD) attributed to diabetes mellitus has changed the therapeutic strategies based on landmark trials that have shown that diabetic micro- and macrovascular complications might be preventable. However, the remaining risk of the progression of diabetic kidney disease to ESRD is still high, despite newly introduced anti-diabetic, antihypertensive and dyslipidemic drugs in the 21st century. Here, we show the importance of targeting remission and regression of microalbuminuria in type 2 diabetic patients. To achieve the remission and regression of microalbuminuria, physicians have revised the management strategy of diabetic patients and have to act immediately. Early detection of microalbuminuria with continuous screening, the use of renin-angiotensin system blockades, and targets for HbA1c of <7.35% and systolic blood pressure of <130 mmHg are closely associated with the remission and regression of microalbuminuria, resulting in protection against the progression of diabetic kidney disease, as well as cardiovascular events. Our concept of the natural history of diabetic kidney disease has to be modified by our results and others. Reducing microalbuminuria is therefore considered to be an important therapeutic target and could be a pivotal biomarker of therapeutic success in diabetic patients. (J Diabetes Invest, doi:10.1111/j.2040-1124.2011.00112.x, 2011).

Immune phenotype in children with therapy-naïve remitted and relapsed Crohn’s disease

AIM: To characterize the prevalence of subpopulations of CD4⁺ cells along with that of major inhibitor or stimulator cell types in therapy-naïve childhood Crohn’s disease (CD) and to test whether abnormalities of immune phenotype are normalized with the improvement of clinical signs and symptoms of disease.

METHODS: We enrolled 26 pediatric patients with CD. 14 therapy-naïve CD children; of those, 10 children remitted on conventional therapy and formed the remission group. We also tested another group of 12 children who relapsed with conventional therapy and were given infliximab; and 15 healthy children who served as controls. The prevalence of Th1 and Th2, naïve and memory, activated and regulatory T cells, along with the members of innate immunity such as natural killer (NK), NK-T, myeloid and plasmocytoid dendritic cells (DCs), monocytes and Toll-like receptor (TLR)-2 and TLR-4 expression were determined in peripheral blood samples.

RESULTS: Children with therapy-naïve CD and those in relapse showed a decrease in Th1 cell prevalence. Simultaneously, an increased prevalence of memory and activated lymphocytes along with that of DCs and monocytes was observed. In addition, the ratio of myeloid /plasmocytoid DCs and the prevalence of TLR-2 or TLR-4 positive DCs and monocytes were also higher in therapy-naïve CD than in controls. The majority of alterations diminished in remitted CD irrespective of whether remission was obtained by conventional or biological therapy.

CONCLUSION: The finding that immune phenotype is normalized in remission suggests a link between immune phenotype and disease activity in childhood CD. Our observations support the involvement of members of the adaptive and innate immune systems in childhood CD.

The predictive role of histopathological findings in renal insufficiency and complete remission in a sample of Iranian adults with primary focal segmental glomerulosclerosis

BACKGROUND

Primary focal segmental glomerulosclerosis (FSGS) is defined by the presence of proteinuria, often in nephrotic range and pathologically by segmental scars (SS). The aim of this study is to identify the possible predictors of complete remission or progression to chronic kidney disease in Iranian adults with primary focal segmental glomerulosclerosis.

METHODS

In this historical cohort study, pathological findings of 50 patients with primary FSGS were reviewed by single renal pathologist without knowing about patients' identities or outcomes. Patients were divided based on their histopathological findings and outcomes were compared among these groups.

RESULTS

There were significant differences in the complete remission rate in subjects with and without mesangial hypercellularity (p < 0.05), and in patients with and without hyalinosis (p < 0.05). According to the cut off points based on ROC curve analysis for the quantitative data, there was significant difference in renal insufficiency between the patients with and without global scars more than 12% (p < 0.05). Also multiple logistic regression analysis strongly suggests the association of mesangial hypercellularity and global scar with no complete remission and progression to renal insufficiency, respectively.

CONCLUSIONS

In the studied patients, presence of mesangial hypercellularity and hyalinosis has been suggested as prognostic factors for lower remission rate. According to multivariate analysis, only mesangial hypercellularity and global scar were found to act as independent prognostic predictors of lower complete remission rate and progression to renal insufficiency in patients with FSGS, respectively.

The effect of cognitive behavior therapy-based psychotherapy applied in a forest environment on physiological changes and remission of major depressive disorder

OBJECTIVE

Psychotherapeutic intervention combined with pharmacotherapy is helpful for achieving remission of depressive disorder. We developed and tested the effect of cognitive behavior therapy (CBT)-based psychotherapy applied in a forest environment on major depressive disorder.

METHODS

We performed 4 sessions during 4 weeks (3 hours/session) in patients with major depressive disorder during pharmacotherapy. For the forest group, sessions were performed in the forest; for the hospital group, sessions were performed in the hospital. The control group was treated with the usual outpatient management.

RESULTS

A total of 63 patients completed the study: 23 in the forest group, 19 in the hospital group, and 21 in the control group. Hamilton Rating Scales for Depression (HRSD) scores of the forest group were significantly decreased after 4 sessions compared with controls. Montgomery-Asberg Depression Rating Scales (MADRS) scores of the forest group were significantly decreased compared with both the hospital group and the controls. The remission rate (7 and below in HRSD) of the forest group was 61% (14/23), significantly higher than both the hospital group (21%, 4/19) and the controls (5%, 1/21). In heart rate variability (HRV) analysis, some measurements representing HRV and parasympathetic nerve tone were increased in the forest group after 4 sessions. The salivary cortisol levels of the forest group were significantly decreased.

CONCLUSION

CBT-based psychotherapy applied in the forest environment was helpful in the achievement of depression remission, and its effect was superior to that of psychotherapy performed in the hospital and the usual outpatient management. A good environment such as a forest helps improve the effect of psychotherapeutic intervention because it includes various natural instruments and facilitators in the treatment of depression.

Individually administered or co-prescribed thiopurines and mesalamines for inflammatory bowel disease

Data from both basic research and clinical experience continue to suggest that mesalamines and thiopurines are effective and efficient for the maintenance of remission of inflammatory bowel diseases. Several decades following the formalization of their indications, attention on these two drugs has been fostered by recent achievements. Demonstration of the ability of mesalamine to activate a colonocyte differentiation factor has shed light on its chemopreventive effects on colorectal cancer; in addition to their anti-proliferative efficacy, thiopurines have been shown to be specific regulators of apoptosis. The two drugs are often co-administered in clinical practice. Recent advancements have shown that mesalamines exert a positive synergism in this context, insofar as they can inhibit side-methylation of thiopurines and hasten the function of the main immunosuppressive pathways. Considering that up to 40% of patients cannot tolerate thiopurines, such renovated targets have stimulated efforts to improve compliance by research on the toxicity mechanisms. The definition of genetic polymorphisms in the enzymes of thiopurine metabolism, and the uncovering of synergistic drug interactions, such as that with allopurinol, are just two of the results of such efforts. Interaction between basic research and clinical practice has continued to inform indications and refine the prescriptions of mesalamines and thiopurines; these have not been restrained (they have been implemented in some cases) by the advent of the novel biological molecules with anti-cytokine activity.