Psychosis in neurosyphilis -- clinical aspects and implications

BACKGROUND

The World Health Organization estimates that 10-12 million new syphilis infections occur each year. Without treatment, years to decades after initial infection, 30% of affected individuals may develop tertiary syphilis, which can manifest as neurosyphilis. The aim of this review is to evaluate the research literature examining the psychopathological manifestations of psychosis in association with neurosyphilis.

METHOD

The authors performed a systematic electronic search for published studies (1995-2012). The following databases were used: Medline, Embase and the Cochrane Library as well as the search engines Scopus and Google Scholar.

RESULTS

61 articles were used for detailed analysis. Psychotic symptoms due to neurosyphilis are numerous and can inform differential diagnosis for many psychotic manifestations according to ICD-10 or DSM-IV.

CONCLUSION

Due to our results, current epidemiological data, and the difficulties in differential diagnosis of neurosyphilis, routine screening tests are still recommended in the psychiatric field. Long-term psychiatric input, with periodic syphilis titre controls, seems indicated in individuals affected by neurosyphilis with psychiatric symptoms. Furthermore, individuals with mental health problems may be at higher risk of acquiring syphilis.

Caspofungin: when and how? The microbiologist's view

The echinocandins are antifungal agents, which act by inhibiting the synthesis of β-(1,3)-D-glucan, an integral component of fungal cell walls. Caspofungin, the first approved echinocandin, demonstrates good in vitro and in vivo activity against a range of Candida species and is an alternative therapy for Aspergillus infections. Caspofungin provides an excellent safety profile and is therefore favoured in patients with moderately severe to severe illness, recent azole exposure and in those who are at high risk of infections due to Candida glabrata or Candida krusei. In vivo/in vitro resistance to caspofungin and breakthrough infections in patients receiving this agent have been reported for Candida and Aspergillus species. The types of pathogens and the frequency causing breakthrough mycoses are not well delineated. Caspofungin resistance resulting in clinical failure has been linked to mutations in the Fksp subunit of glucan synthase complex. European Committee for Antimicrobial Susceptibility Testing and Clinical and Laboratory Standards Institute need to improve the in vitro susceptibility testing methods to detect fks hot spot mutants. Caspofungin represents a significant advance in the care of patients with serious fungal infections.

Anidulafungin for the treatment of invasive candidiasis

Candidaemia/invasive candidiasis (C/IC) is the most frequently occurring invasive fungal infection worldwide, with a particularly strong impact and high incidence in the intensive-care unit, where there is a need for new treatment options and strategies. The echinocandin anidulafungin has broad in vitro activity against a wide range of Candida species, along with favourable pharmacokinetics that allow administration in hepatic and renal impairment and with any comedication without the need for dose adjustments. The efficacy and safety of anidulafungin for the treatment of C/IC were demonstrated in a number of clinical studies and by some limited data from clinical practice. In a randomized comparative trial for the treatment of C/IC in adults, 76% of patients receiving anidulafungin and 60% of those given fluconazole were treated successfully (95% CI for difference: 4-27; p 0.01). Post hoc analyses suggest that anidulafungin is significantly more effective than standard-dose fluconazole for the treatment of candidaemia in critically ill patients. Anidulafungin is generally well tolerated, with commonly reported side effects including headache, hypokalaemia, gastrointestinal symptoms, abnormal liver function test results, and rash. In pharmaco-economic analyses, anidulafungin compared favourably with fluconazole (in terms of overall costs and hospital resource use) as well as with other echinocandins. Echinocandins, including anidulafungin, are now generally recommended as first-line therapy in moderately to severely ill patients, those with prior azole exposure, and patients with C/IC caused by Candida glabrata or Candida krusei.

P02 - 369 - Neuroimaging of the various symptom dimensions in obsessive - compulsive disorder - a systematic review

Introduction

Several neuroimaging studies in obsessive-compulsive disorders (OCD) have shown a dysfunction in the orbito-fronto-striato-thalamamic neural circuitry as the fundamental neuropathological correlate, consistent across all symptom subtypes.

Therefore, the neurobiological differentiation of the various obsessive-compulsive symptoms is attracting increasing interest in neuroimaging as this clinical picture becomes increasingly subclassified.

Method

A systematic literature survey was used to search for original papers that studied the neurobiological correlates of the various symptom dimensions of OCD (symmetry, forbidden thoughts, washing, hoarding).

Results

It was possible to include a total of 15 original papers in the assessment. The “forbidden thoughts” factor, which also includes compulsion to control, is associated mainly with activations in brain structures of the cognitive control system, i.e. the basal ganglia and parts of the anterior cingulate cortex (ACC). Therefore, the neural representation pattern of “forbidden thoughts” differs clearly from that of “washing”, in which cerebral regions of emotional control seem to be particularly involved, i.e. the orbito-frontal cortex (OFC), ACC, the amygdala and insula. On the other hand, the “hoarding and collecting” dimension is primarily associated with brain areas involved in decision-making, i.e. the ventro-medial OFC, the dorsal ACC and the dorso-lateral prefrontal cortex (DLPC).

Discussion

The results confirm the hypothesis that all dimensions of OCD are based on different neuronal networks, which underlines the neurobiological heterogeneity of the clinical picture of OCD, thus pointing the way for future research strategies.

Does a high degree of instability during psychotherapy enhance a positive therapy-response? - an evaluation of an in-patient behavior therapy of obsessive-compulsive disorder

Introduction

The study evaluates a central hypothesis of synergetic psychotherapy research according to which a marked instability in the psychotherapeutic process is associated with high response rates.

Methods

14 patients with obsessive-compulsive disorder (OCD) successfully completed an eight-week in-patient course of multi-modal behavior therapy with exposure exercises followed by response management. The instability during the course of the therapy was recorded by daily self-assessment by the patient using the Synergetic Navigation System (SNS), an Internet-based real-time monitoring procedure.

Results

There was a negative correlation between the degree of the instability and the percentage reduction in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (r = −0.395; P = 0.199), the “Global Severity Index” (GSI) of the symptom check-list (SCL-90-R) (r = −0.718; P = 0.013), the scale value for obsessive-compulsiveness in the SCL-90-R (r = −0.782; P = 0.004) and the remaining sub-scales of this data-gathering instrument.

Conclusions

An unstable progress of the psychotherapy causes a smaller reduction in symptoms than a stable one. The contradiction relative to the study hypothesis is possibly based on the special features of OCD, with a high level of patient insecurity when anticipating new, non-obsessive-compulsive ways of thought and behavior. The relationships between instability and reduction in symptoms appear to be diagnosis-specific.

CS03-03 - Sleep and sleep disorders in somatoform pain disorder

Introduction

Somatoform pain disorder (SPD) is frequently associated with sleep disorders, specifically restless legs syndrome and insomnia, which in turn lowers the pain threshold and worsens pain.

Objectives

The aim of the present study was to investigate differences in wake-EEG by low-resolution electromagnetic tomography (LORETA) and objective and subjective sleep and awakening quality in SPD patients as compared with controls and study acute and chronic effects of trazodone CR on these variables and pain measures.

Methods

Fifteen patients with SPD (F45.4) and co-morbid insomnia (F51.0) were compared with 15 controls and participated in a single-blind, placebo-controlled, cross-over study on the acute effect of 100 mg trazodone CR, followed by a six-week open titration period. Statistics involved clinical, EEG-LORETA, PSG and psychometry.

Results

LORETA showed reduced power, mainly in the beta band in almost all pain matrix areas (SI, SII, ACC, SMA, PFC, PPC, insula, amygdala, hippocampus). PSG demonstrated a lack of deep sleep and increased arousals and stage shifts, with opposite changes induced by trazodone after acute and chronic therapy. Improvement of sleep was associated with improvement of pain, evaluated by visual-analog scales.

Conclusion

Our LORETA findings demonstrate a dysfunctional pain modulation in SPD. Trazodone induced changes in subjective and objective sleep and awakening quality that were opposite to the differences between SPD patients and controls (key-lock principle) and associated with pain improvement.

Stigma perception and depression among patients suffering from chronic somatoform disorders

Introduction

Several studies indicate a significant longitudinal comorbidity of depression and chronic pain. Also, perceived stigma is a barrier to recovery. This study wanted to evaluate the correlations.

Objectives

To investigate to what degree chronic pain patients suffer from depression and stigma fears 132 (66% females) consecutive in- and out-patients with somatoform pain disorders who presented at the Department of Psychiatry and Psychotherapy (MUV) were investigated using the Stigma Questionnaire by Link and the Beck Depression Inventory (BDI).

Aims

The aim of this study was to survey the attitudes of 132 patients with the diagnosis somatoform pain disorder, toward mental illness stigma and the influence of depressive symptoms.

Methods

The BDI was employed for measuring of the severity of depression and the modified 12-item version of Links Stigma Questionnaire to evaluate stigma perception.

Results

Three third of the patients expect discrimination because of their psychiatric diagnosis and two third of the chronic pain patients also showed depressive symptoms. The overall results show a significant correlation between stigma perception and depressive symptoms.

Conclusion

Fear of stigma increases with depressive symptoms and both are a risk for treatment delay. Goal of future research should be the question how to reduce depression and fear of stigma in order to help them enter psychiatric treatment early and gain self-confidence and mental health back again.

Antipsychotics in obsessive-compulsive disorder - an auspicious approach for treatment-resistant patients?

Introduction

Because only 40 – 60% of all patients with obsessive-compulsive disorder (OCD) respond to selective serotonin reuptake inhibitors (SSRIs), the evaluation of alternative therapy methods in the presence of treatment resistance has high clinical relevance. In this context, many studies have examined additive medication with antipsychotics.

Method

All double-blind randomised controlled trials (DBRCTs) that evaluated the efficacy of a combination therapy of antipsychotics and SSRIs in treatment-resistant OCD were covered by systematic literature searches.

Results

A total of ten DBRCTs were identified (four for quetiapine, three for risperidone, two for olanzapine and one for haloperidol) with a participant collective comprising in total 316 treatment-resistant OCD patients. After the augmentation therapy, significantly more subjects in the intervention group (antipsychotic + SSRI), 32% of the patients, fulfilled the response criterion (reduction in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) ≥ 35%) than in the control group (placebo + SSRI) (relative risk (RR) = 2.08; 95% CI: 1.3 – 3.32). The standardised mean difference (SMD) of the Y-BOCS reduction between the pooled two study-groups revealed an effect size of 0,62. The sub-group analyses showed significant efficacy only for haloperidol and risperidone. Further significant differences existed regarding the duration of SSRI medication before the augmentation phase.

Conclusion / Discussion

Based on the favourable benefit-risk-ratio, risperidone can be regarded as the agent of first choice for augmentation treatment with an SSRI. Overall, about one third of patients benefit from this therapy option. However, further scientific studies are needed before sufficiently empirically secured pharmacological treatment recommendations can be expressed.

Expression of an ASCL2 related stem cell signature and IGF2 in colorectal cancer liver metastases with 11p15.5 gain

BACKGROUND AND AIMS

Liver metastases are the leading cause of death in colorectal cancer. To gain better insight into the biology of metastasis and possibly identify new therapeutic targets we systematically investigated liver-metastasis-specific molecular aberrations.

METHODS

Primary colorectal cancer (pCRC) and matched liver metastases (LMs) from the same patients were analysed by microarray-based comparative genomic hybridisation in 21 pairs and gene expression profiling in 18 pairs. Publicly available databases were used to confirm findings in independent datasets.

RESULTS

Chromosome aberration patterns and expression profiles of pCRC and matched LMs were strikingly similar. Unsupervised cluster analysis of genomic data showed that 20/21 pairs were more similar to each other than to any other analysed tumour. A median of only 11 aberrations per patient was found to be different between pCRC and LM, and expression of only 16 genes was overall changed upon metastasis. One region on chromosome band 11p15.5 showed a characteristic gain in LMs in 6/21 patients. This gain could be confirmed in an independent dataset of LMs (n=50). Localised within this region, the growth factor IGF2 (p=0.003) and the intestinal stem cell specific transcription factor ASCL2 (p=0.029) were found to be over-expressed in affected LM. Several ASCL2 target genes were upregulated in this subgroup of LM, including the intestinal stem cell marker OLFM4 (p=0.013). The correlation between ASCL2 expression and four known direct transcriptional targets (LGR5, EPHB3, ETS2 and SOX9) could be confirmed in an independent expression dataset (n=50).

CONCLUSIONS

With unprecedented resolution a striking conservation of genomic alterations was demonstrated in liver metastases, suggesting that metastasis typically occurs after the pCRC has fully matured. In addition, we characterised a subset of liver metastases with an ASCL2-related stem-cell signature likely to affect metastatic behaviour of tumour cells.

How depressive symptoms correlate with stigma perception of mental illness

INTRODUCTION

The aim of this study was to survey the attitudes of 115 patients with the diagnosis of somatoform pain disorder, toward anticipated discrimination and mental illness stigma and how it is influenced by depressive symptoms.

METHOD

115 consecutive in- and outpatients with somatoform pain disorder (mean age: 50 +/- 11 years; 62% female) from the Department of Psychiatry and Psychotherapy, Medical University of Vienna, were administered a modified 12-item version of Link's Perceived Stigma Questionnaire and the Beck Depression Inventory.

RESULTS

With regard to close personal relationships, such as taking care of children or dating, somatoform pain patients showed a rather high perceived stigma score (over 70% for both items). Also nearly 70% think that 'most employers' would pass over the application of a psychiatric patient in favour of another applicant. The overall results show a significant correlation with depressive symptoms (r = 0.228 and p = 0.014).

CONCLUSION

Fear of stigma increases with depressive symptoms and both are a risk for treatment delay. The goal of future research should be the question how to reduce subjective stigma experiences of the patients affected in order to help them enter psychiatric treatment early and gain self-confidence and mental health back again.

The stigma of mental illness: anticipation and attitudes among patients with epileptic, dissociative or somatoform pain disorder

The aim of this study was to survey the attitudes of 101 consecutive in- and out-patients with epileptic, dissociative or somatoform pain disorders (mean age: 43 [+/-11] years; 58% female) from either the Department of Psychiatry or Neurology toward anticipated mental illness stigma. The patients were administered a modified 12-item version of Links Stigma Questionnaire. Nearly 60% of all 101 patients believe that "most people" would not allow a mental patient "to take care of their children", "most young women" would be "reluctant to date a man" who has been treated for a mental illness and "most employers would pass over" the application of a psychiatric patient in favour of another applicant. Fifty five percent of the respondents assume that "most people think less of a person who has been in a mental hospital" and over a half of all patients interviewed assert that the general population thinks that psychiatric patients are "less intelligent, less trustworthy and that their opinion is taken less seriously by others". Gender, age and education had no influence on the overall results. There is a high stigmatisation concerning psychiatry even in patients with epilepsy and somatoform/dissociative symptoms with psychiatric comorbidity. Fear of being stigmatized is more pronounced among somatoform pain patients as compared to patients suffering from epileptic or dissocative disorders, with particular reference to close personal relationships.