Neuropsychiatric questionnaires in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) can be affected by a multitude of neurologic and psychiatric symptoms with a wide range of prevalence and severity. Irrespectively from attribution to SLE or other causes, neuropsychiatric (NP) symptoms strongly impact short-term and long-term outcomes, thus NP evaluation during routine clinical practice in SLE should be undertaken regularly. The assessment of NP involvement in SLE patients is challenging and the available diagnostic tools fail to guarantee optimal diagnostic accuracy, sensitivity to changes as well as feasibility in routine clinical care. Standardised questionnaires (both physician-administered and self-reported) can offer valuable help to the treating physician to capture all possible NP syndromes; few SLE-specific NP questionnaire have been developed but validation in large cohort or cross-cultural adaptations are still pending. On the other hand, general instruments have been largely applied to SLE patients. Both kinds of questionnaires can address all possible NP manifestations either globally or, more frequently, focus on specific NP symptoms. These latter have been mainly used in SLE to detect and classify mild and subtle symptoms, more likely to be overlooked during routine clinical assessment such as headache, cognitive impairment and psychiatric manifestations. In conclusion, this literature review highlights a clear case for validation studies in this area and the wider implementation of questionnaires to assess NP involvement is still warranted. The broader use of such instruments could have important consequences; first of all, by standardising symptom assessment, a better definition of the prevalence of NP manifestation across different centres could be achieved. Secondly, prospective studies could allow for the evaluation of clinical significance of mild symptoms and their impact on the patient's function and quality of life.

Poor sleep quality in systemic lupus erythematosus: does it depend on depressive symptoms?

Objectives

Sleep disturbances are frequently observed in rheumatic diseases including systemic lupus erythematosus (SLE). This study aimed at evaluating the prevalence of insomnia, poor sleep quality and their determinants in a cohort of SLE patients.

Methods

Eighty-one consecutive SLE female patients were evaluated in a cross-sectional study. The Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), the Beck Depression Inventory (BDI) and the Self-rating Anxiety Scale (SAS) were administered. Patients with previous diagnosis of obstructive sleep apnea or restless legs syndrome were excluded. Fifty-three women with hypertension (without SLE) were enrolled as control group (H).

Results

In the SLE cohort poor sleep quality (65.4% vs 39.6%, p < 0.01) and difficulty in maintaining sleep and/or early morning awakening (65.4% vs 22.6%, p < 0.001), but not insomnia (33.3% vs 22.6%, p = ns), were more prevalent than in H. Depressive symptoms were present in 34.6% of SLE vs 13.2% H patients ( p < 0.001) while state anxiety was more common in H patients (H 35.8% vs SLE 17.3%, p < 0.005). SLE was associated with a 2.5-times higher probability of presenting poor sleep quality in comparison to H (OR 2.5 [CI 1.21–5.16]). After adjusting for confounders, both depressive symptoms (OR 4.4, [1.4–14.3]) and use of immunosuppressive drugs (OR 4.3 [CI 1.3–14.8]) were significantly associated with poor sleep quality in SLE patients. Furthermore, poor sleep quality was not associated either with disease duration or activity.

Conclusions

In a cohort of SLE women, insomnia and poor sleep quality, especially difficulties in maintaining sleep, were common. Depressive symptoms might be responsible for the higher prevalence of poor sleep quality in SLE.

Sleep disorders and systemic lupus erythematosus

Objective

Sleep disturbances are often seen in rheumatic diseases, including systemic lupus erythematosus (SLE). However, the prevalence of sleep disorders in SLE as well as the contributing factors to their occurrence remain poorly understood. The aim of this paper is to review the clinical and psychobiological data on the relationship between sleep disturbances and SLE.

Method

We performed a systematic search of MEDLINE, EMBASE and PsychINFO, using MeSH headings and keywords for “sleep disorders” and “SLE.”

Results

Nine studies reporting the relationship between sleep disorders and SLE were found. Prevalence rates of sleep disorders ranged between 55% and 85%; differences in assessment techniques appeared to be a major source of this variability. In the majority of the studies an association between sleep disorders and disease activity, pain and fatigue has been reported. Psychosocial variables, depression, steroid use, and the role that sleep disruption has on pain, inflammation and cytokines, have been hypothesized as possible psychobiological factors.

Conclusions

Sleep disorders appear to occur in more than half of patients with SLE and appear to be associated with disease activity. Pain and fatigue are also related to sleep disorders. Among the hypotheses on the possible mechanisms underlining the association between sleep disorders and SLE, psychosocial/psychological factors, especially depression, were the most frequently reported.

Optimal tolerability and high efficacy of a modified schedule of lapatinib-capecitabine in advanced breast cancer patients

PURPOSE

Diarrhea in relation to the lapatinib-capecitabine regimen is a common and debilitating side effect which may interfere with optimal treatment delivery. We performed a post hoc analysis in human epidermal growth factor receptor 2-positive advanced breast cancer patients treated with a modified schedule in its administration, aimed primarily to evaluate grade (G) ≥ 2 diarrhea incidence and, secondarily, treatment efficacy.

PATIENTS AND METHODS

Treatment schedule consisted of lapatinib 1,250 mg daily for the first 10 days, then in combination with capecitabine, 2,000 mg/m(2), starting day 11 for the first cycle, and thereafter from day 8, for 14 days of a 21-day cycle, in 3 daily administrations. Lapatinib was dissolved in water, and cholestyramine was continuously given twice a day.

RESULTS

Among 38 patients treated and analyzed, the incidence of G ≥ 2 diarrhea was 13.2 %. In 28 patients diarrhea was not observed, while G1-2 diarrhea was reported in 9 (23.7 %) patients; a single episode of G3 diarrhea was observed in 1 (2.6 %) patient. Overall response rate was 34.2 %, clinical benefit 55.3 %, and median progression-free survival 10 months.

CONCLUSION

The results of the present post hoc analysis are very encouraging, both in terms of tolerability and treatment efficacy, and all data compare favorably with previous reports of "conventional" administration of the lapatinib-capecitabine regimen.

Depression and systemic lupus erythematosus: a systematic review

Objective

Systemic lupus erythematosus (SLE) is a chronic, relapsing–remitting autoimmune disorder that involves multiple organ systems including the central nervous system. Among the items included in the nomenclature for neuropsychiatric SLE, mood disorders have been identified. The aim of this paper is to review the clinical and psychobiological relationship between depression and SLE.

Method

We performed a systematic search of MEDLINE, EMBASE, PsychINFO, using MeSH headings and keywords for ‘depression’ and ‘SLE’.

Results

Seventeen studies reported depressive disorders, with prevalence rates in the range 17–75%. Three studies reported the most frequent symptoms, which may be represented by fatigue, weakness, somatic disorders and sleep disorders. Suicide ideation was much higher than in the general population. Nine studies analysed the relationship to SLE disease activity. The results of the available literature are contradictory. Psychobiological hypotheses have been considered in 13 studies. Among the psychobiological hypotheses which might underline the plausibility of their relationship, ‘psychosocial factors’ were the most frequently reported.

Conclusions

Differences in assessment techniques appear to be the main explanation for the variability in findings and important methodological limitations are present in the available literature to definitively point to the prevalence of depression, type of depression and most prevalent symptoms. To date, the relationship between depression and SLE disease activity also appears controversial. Methodological limitations are present in the available literature and it would be necessary to develop evidence-based guidelines to improve the diagnosis of depression in SLE. Identification of SLE-specific biomarkers of depression also has high priority.

Quantitative evaluation of distant student psychophysical responses during the e-learning processes

Using 4 biometric sensors, including GSR (Galvanic Skin Response), BVP (Blood Volume Pulse), EKG (Electro Cardio Grapy) and EEG (Electro Encephalon Grapy), this paper proposes to attempt to correlate the presentation of relaxing, engaging or stressful content to the subjective measures provided by participants in experiments. Once the participant interacts with content from one of the 3 conditions, they may or may not be selectively relaxed, engaged or stressed, and their scores on a psychological self-questionnaire (STAI: State-Trait Anxiety Inventory) should show that. From correlating the subjective ratings with the experimental conditions, is proposed to allow to develop algorithms that can be used to classify learners' affective state during synchronous or asynchronous coursework. It is proposed that the algorithm could be used synchronously for the teacher to get student feedback in real time.

Intraductal proliferative lesions of the breast-terminology and biology matter: premalignant lesions or preinvasive cancer?

Morphological criteria for the diagnosis of intraductal proliferative lesions of the breast have been an object of research and much controversy, and its terminology is rather confusing. Knowledge of the molecular aspects of this disease probably necessitates further research to clarify if these entities can be identified as breast cancer precursors or as a malignant preinvasive disease. These issues are of great interest not only for their biological implications, but also to the clinician who must understand the disease and direct therapies. Molecular studies have shown that epitheliosis (usual ductal hyperplasia) is not monoclonal, while malignant lesions (atypical ductal hyperplasia, flat epithelial atypia, low-grade and high-grade intraductal carcinoma) constantly show these characteristics. These malignant lesions, classified with a DIN grading system (ductal intraepithelial neoplasia), are not obligate precursors of invasive ductal carcinoma and do not represent different evolving grades in a linear model of cancerogenesis. Breast cancerogenesis probably has different pathways with different morphologic precursors.

Predictors of response among patients with panic disorder treated with medications in a naturalistic follow-up: the role of adult separation anxiety

BACKGROUND

Efficacy of treatments for panic disorder is well established, but not all patients respond. Adult separation anxiety has been found to predict poorer response to CBT, but its effect on response to medication has not been previously explored.

STUDY AIM

The aim of this study is to investigate if panic-agoraphobic spectrum factors, including 'separation anxiety' factor predict treatment outcome in patients with panic disorder.

STUDY SAMPLE

Participants who met criteria for PD (n=57) completed baseline assessment and 12 months follow-up. Patients were administered the Panic Agoraphobic Spectrum Self-Report (PAS-SR, Lifetime and Last-Month Versions), and the Panic Disorder Severity Scale (PDSS). We examined patients who met the following criteria at baseline: 1) PDSS total score>7; 2) no current Axis I comorbidity with major depression; 3) no lifetime or current bipolar disorder. All patients were treated with evidence-based psychopharmacological treatment for panic disorder during the 12-month observation period.

RESULTS

Twenty eight patients (48.1%) achieved remission during the follow-up period. In a logistic regression model, controlling for baseline severity, gender and age, only the last-month PAS-SR 'separation anxiety' factor was associated with a lower likelihood of remission.

CONCLUSIONS

Signs and symptoms of separation anxiety in adulthood, as assessed with the PAS-SR Last Month version, are predictors of poor treatment outcome in patients with PD. We submit that the assessment of panic-agoraphobic spectrum features, including adult separation anxiety, should become routine of clinical assessment of patients with PD. It is likely that a better psychopathological characterization of patients may inform treatment selection, and result in better treatment outcome.

[Fever in a patient with a central vein catheter]

A 75-year old male, operated on three weeks earlier due to descending colon cancer and reoperated 9 days later due to suture dehiscence, began with fever without clinical focality suggestive of surgical bed infection. The patient has a bilumen catheter in the right jugular vein, through which he receives different medications and parenteral nutrition. How can catheter-related infection be diagnosed? What should be done with the catheter? When and which antibiotics are appropriate to begin treatment? What risk factors for resistant bacteria should be considered? How should S. aureus bacteraemia be treated? Is it possible to reduce the rates of catheter-related infection? These and other questions are answered in this article and a working algorithm is presented.

Neurocognitive functioning in bulimia nervosa: the role of neuroendocrine, personality and clinical aspects

BACKGROUND

Studies investigating neurocognitive impairment in subjects with eating disorders (EDs) have reported heterogeneous patterns of impairment and, in some instances, no dysfunction. The present study aimed to define the pattern of neurocognitive impairment in a large sample of bulimia nervosa (BN) patients and to demonstrate that neuroendocrine, personality and clinical characteristics influence neurocognitive performance in BN.

METHOD

Attention/immediate memory, set shifting, perseveration, conditional and implicit learning were evaluated in 83 untreated female patients with BN and 77 healthy controls (HC). Cortisol and 17β-estradiol plasma levels were assessed. Cloninger's Temperament and Character Inventory - Revised (TCI-R), the Bulimic Investigation Test Edinburgh (BITE) and the Montgomery-Asberg Depression Rating Scale (MADRS) were administered.

RESULTS

No impairment of cognitive performance was found in subjects with BN compared with HC. Cortisol and 'Self-directedness' were associated with better performance on conditional learning whereas 17β-estradiol had a negative influence on this domain; 'Reward dependence' was associated with worse performance on implicit learning; and depressive symptomatology influenced performance on the Wisconsin Card Sorting Test (WCST) negatively.

CONCLUSIONS

No cognitive impairment was found in untreated patients with BN. Neuroendocrine, personality and clinical variables do influence neurocognitive functioning and might explain discrepancies in literature findings.

Impact of gender differences on the outcome of Alzheimer's disease

BACKGROUND AND AIMS

Since little is known about the role of gender in the course of Alzheimer's disease (AD), a prospective epidemiological study was conducted to detect gender differences in relation to AD evolution and outcome.

METHODS

Six hundred AD patients, 214 men and 386 women, first seen between September 2000 and December 2003, were enrolled; the follow-up period lasted until December 2008.

RESULTS

The men had greater comorbidity and higher mortality than the women, who instead recorded more disability and longer survival. Survival curves showed that women reach partial loss of autonomy faster than men. Higher Neuropsychiatric Inventory scores at baseline showed a predictive value for loss of autonomy regardless of gender. Pharmacological treatment seems to have a protective role on disability and mortality.

CONCLUSIONS

Gender influences disease evolution not only directly but also through other factors such as comorbidity.

Panic disorder as a risk factor for post-partum depression: Results from the Perinatal Depression-Research & Screening Unit (PND-ReScU) study

BACKGROUND

Although the role of anxiety disorders on the development of Post-partum Depression (PPD) have already been studied in literature, that of individual anxiety disorders has not received specific attention. The aim of this study is to investigate the role of Panic Disorder (PD) and family history for PD as risk factors for PPD.

METHODS

Six hundred women were recruited in a prospective, observational study at the 3rd month of pregnancy and followed up until the 6th month after delivery. At baseline, risk factors for PPD, Axis-I disorders and family history for psychiatric disorders were assessed. We investigated minor and major depression (mMD) occurred at 1st, 3rd and 6th months post-partum. Logistic regression models were used to estimate the association between PD, family history for PD and PPD.

RESULTS

Forty women had mMD in the post-partum. PD during pregnancy (RR=4.25; 95%CI:1.48-12.19), a history of PD (RR 2.47; 95%CI:1.11-5.49) and family history for PD (RR=2.1; 95%CI:1.06-4.4) predicted PPD after adjusting for lifetime depression and risk factors for PPD.

LIMITATIONS

The response rate is moderately low, but it is similar to other studies. The drop out rate is slightly high, however the 600 women who completed the 6th month follow-up did not differ from the presence of PD at baseline.

CONCLUSIONS

PD is an independent risk factor for PPD, underscoring need to assess PD symptoms during pregnancy. Furthermore, PD represents an important risk factor for the development of PPD and should be routinely screened in order to develop specific preventive interventions.

Developmental alterations of the prefrontal cerebral cortex in sudden unexplained perinatal and infant deaths

The aim of this study was to investigate the developmental patterns of the human prefrontal cortex involved in breathing control in a wide cohort of fetal and infant death victims, aged from the 22(nd) gestational week to 10 months of life, and to evaluate whether morpho-functional disorders are present in this specific cortical area in victims of sudden unexplained death. A further aim was to determine whether prenatal absorption of nicotine could also affect the maturational processes of the prefrontal cortex. A pronounced radial organization of the cerebral wall was evident from the 26(th) gestational week. By 36 gestational weeks this columnar structure disappeared, coinciding with the formation of a laminar cyto-architecture. The mature cortex, observable from the 4(th) month of life, was organized horizontally into six laminae. In 33% of the sudden death victims the prefrontal cortex showed morphological alterations with anomalous laminar patterns and delayed neuronal maturation. A significant correlation with prenatal cigarette exposure was found.