A critical analysis and discussion of the appropriateness of the schizophrenia consensus remission criteria in clinical pharmaceutical trials

BACKGROUND

The aim of this paper is to apply the proposed consensus remission criteria to an acutely ill inpatient sample at admission and evaluate their adaptability in this patient population and pharmaceutical trials.

METHODS

The Remission in Schizophrenia Working Group's consensus criteria were applied to 272 acutely ill schizophrenia patients. Patients were examined using the PANSS, HAMD, UKU and SWN-K total scales at admission as well as the GAF, SOFAS and the Strauss-Carpenter Prognostic Scale. Sociodemographic and clinical baseline variables were assessed using a standardized documentation system.

RESULTS

33 patients (12%) fulfilled the symptom severity component of the proposed remission criteria already at baseline. Almost no significant differences were found when comparing patients with achieved and failed symptom severity component that would explain the hospitalization of the patients with achieved criteria despite their apparently mild psychopathological symptoms. The only explainable difference was that patients with an achieved symptom severity component had received significantly more antipsychotics and had suffered from significantly more life events before admission.

CONCLUSION

The present results raise the question whether the symptom severity threshold is adequate to identify patients in remission when applied in clinical trials.

The RSM-scale: a pilot study on a new specific scale for self- and observer-rated quality of life in patients with schizophrenia

PURPOSE

To develop and evaluate a self- and observer-rating scale on quality of life in patients suffering from schizophrenia with regard to the efficacy of atypical antipsychotics based on different dimensions and to apply within a pilot study.

METHODS

Following review of existing scales and a prevalidation phase, the Riedel-Spellmann-Musil (RSM) scale was developed comprising 36 items assigned to different subscales. As reference scales, the Quality of Life Scale (QLS) and the Subjective Well-being Under Neuroleptic Treatment Scale-short version (SWN-K) were performed, psychopathology and adverse events were measured at all visits. Reliability was assessed using Cronbach's alpha, Pearson's correlation coefficients were used to assess construct validity, and Intraclass Correlation Coefficients (ICCs) were used for test-retest reliability. T tests were performed in normal distributed samples; otherwise Wilcoxon tests were used.

RESULTS

One hundred and thirty-six patients were included in the study. Cronbach`s α was 0.917 for the self-rating and 0.915 for the interviewer-rating part. ICCs were >0.70 for all subscales. The self-rating part correlated strongly with the SWN-K and the observer part with the QLS. Changes in psychopathology over the study period and different levels of functioning were detected.

CONCLUSION

The RSM-scale is a new scale to assess the quality of life in different dimensions of patients with schizophrenia treated with antipsychotics and shows good internal consistency, test-retest reliability, construct and discriminant validity.

Outcome of suicidal patients with schizophrenia: results from a naturalistic study

OBJECTIVE

Purpose was to assess suicidality before and at the time of admission in patients with schizophrenia and compare outcome differences.

METHOD

Biweekly PANSS (Positive and Negative Syndrome Scale), HAMD (Hamilton Depression Rating Scale) and UKU (Udvalg for Klinske Undersogelser Side Effect Rating Scale) ratings were evaluated in 339 in-patients with schizophrenic spectrum disorders. Response was defined as an initial 20% PANSS total score reduction at discharge, remission was defined according to the proposed consensus criteria by the Remission in Schizophrenia Working Group.

RESULTS

Suicidal patients (22%) scored significantly higher on the PANSS negative subscore, PANSS insight item and HAMD total score at admission and at discharge. They developed significantly more side effects. No differences were found concerning response and remission between the two patient subgroups.

CONCLUSION

Despite receiving significantly more antidepressants the suicidal patients suffered from significantly more depressive symptoms up to discharge, yet without differing regarding response and remission.

Time course of antipsychotic treatment response in schizophrenia: results from a naturalistic study in 280 patients

OBJECTIVE

To describe the course of positive and negative symptoms during inpatient treatment and examine remission and response rates under routine clinical care conditions.

METHODS

Two hundred and eighty inpatients with schizophrenia (DSM-IV criteria) were assessed with the Positive and Negative Syndrome Scale (PANSS) at admission and at biweekly intervals until discharge from hospital. Remission was defined according to the symptom-severity component of the consensus criteria (Remission in Schizophrenia Working Group) as a rating of three or less in the relevant PANSS items at discharge, and response as a reduction of at least 20% in the PANSS total score from admission to discharge.

RESULTS

The mean duration of inpatient treatment was 54.8 days. Of the total sample, 78.5% achieved the criteria for response and 44.6% those for remission. Mean PANSS total scores decreased from 72.4 at admission to 52.5 at discharge (p<0.001). A reduction in PANSS total scores was found from visit to visit, up to week 8. The most pronounced decline was observed within the first two weeks of treatment.

CONCLUSION

Response rates were comparable to those found in efficacy studies, and remission rates were slightly higher. This may be explained by differences in the selection and the treatment of patients. Nevertheless, the findings might indicate that a complex naturalistic treatment approach is beneficial in terms of effectiveness.

Slippery surfaces of pitcher plants: Nepenthes wax crystals minimize insect attachment via microscopic surface roughness

Pitcher plants of the genus Nepenthes efficiently trap and retain insect prey in highly specialized leaves. Besides a slippery peristome which inhibits adhesion of insects they employ epicuticular wax crystals on the inner walls of the conductive zone of the pitchers to hamper insect attachment by adhesive devices. It has been proposed that the detachment of individual crystals and the resulting contamination of adhesive organs is responsible for capturing insects. However, our results provide evidence in favour of a different mechanism, mainly based on the stability and the roughness of the waxy surface. First, we were unable to detect a large quantity of crystal fragments on the pads of insects detached from mature pitcher surfaces of Nepenthes alata. Second, investigation of the pitcher surface by focused ion beam treatment showed that the wax crystals form a compact 3D structure. Third, atomic force microscopy of the platelet-shaped crystals revealed that the crystals are mechanically stable, rendering crystal detachment by insect pads unlikely. Fourth, the surface profile parameters of the wax layer showed striking similarities to those of polishing paper with low grain size. By measuring friction forces of insects on this artificial surface we demonstrate that microscopic roughness alone is sufficient to minimize insect attachment. A theoretical model shows that surface roughness within a certain length scale will prevent adhesion by being too rough for adhesive pads but not rough enough for claws.

Neurocognition and its influencing factors in the treatment of schizophrenia-effects of aripiprazole, olanzapine, quetiapine and risperidone

BACKGROUND

To examine influencing variables of neurocognition in patients with schizophrenia and to predict cognition during antipsychotic treatment.

METHODS

Data were obtained from patients with an acute episode of schizophrenia participating in two double-blind and one open label trial comparing the effects of different atypical antipsychotics on cognition. In total, 129 patients were enrolled in this analysis. Cognitive function was assessed at admission, week 4 and 8. Efficacy and tolerability were assessed weekly using the Positive and Negative Syndrome Scale (PANSS) and the Simpson Angus Sale (SAS). Patients were treated with aripirazole, olanzapine, quetiapine and risperidone. Regression analysis including mixed effect models was performed.

RESULTS

A significant improvement in all cognitive domains was observed from baseline to week 8. Regarding the antipsychotic treatment applied quetiapine seemed to achieve the most favourable cognitive improvement. Negative and depressive symptoms, the patient's age and the concomitant and antipsychotic treatment applied were observed to significantly influence and predict neurocognition.

CONCLUSION

The results may indicate that schizophrenia is a static disorder with trait and state dependent cognitive components especially in the memory domains. The influence of negative and depressive symptoms should be considered in daily clinical routine.

Effect of aripiprazole on cognition in the treatment of patients with schizophrenia

BACKGROUND

The aim of this study was to assess the cognitive effects of aripiprazole in inpatients with schizophrenia.

METHODS

This was an investigator-initiated, open label eight-week trial evaluating 56 inpatients with the DSM-IV diagnosis of schizophrenia. Efficacy was assessed weekly using the Positive and Negative Syndrome Scale (PANSS) and tolerability was assessed each week using the Udvalg for Klinske Undersogelser side effect rating scale (UKU). Cognitive function was assessed at baseline, week 4 and week 8.

RESULTS

Aripiprazole showed significant improvement in PANSS total score and all subscores between baseline and endpoint visit. The substance was very well tolerated. Patients improved significantly in verbal memory, reaction time and reaction quality/attention from baseline to week eight. Furthermore, mean z-values of individual cognitive domains summarized in a global cognitive index improved significantly from baseline to week eight.

DISCUSSION

Our results suggest that aripiprazole provides a valuable treatment option for patients with schizophrenia.

Gangliocytomas of the sellar region--a review

Gangliocytomas are benign, slow growing neuronal tumors and are found for the most part in children and young adults. They are most often localized in either the spinal cord or the cerebral hemispheres. Gangliocytomas in the sellar region are extremely rare and only 43 such tumors (including 4 own cases) have ever been described in the literature. Although these tumors are genuine rarities without any epidemiological importance, they do provide some interesting information on tumorigenesis of pituitary adenomas: 65% of the sellar gangliocytomas are associated with a pituitary adenoma. 74% of patients with these tumors suffered hormonal oversecretion of at least one of the pituitary hormones (mostly growth hormone). With only one exception, the hypothalamic releasing hormone corresponding to the hormonal oversecretion syndrome could be demonstrated in the gangliocytoma immunohistochemically. Ultrastructural studies could demonstrate close cell to cell contacts between adenoma and gangliocytome cells. All these data support the hypothesis that chronic overstimulation by hypothalamic releasing hormones play a role in the development of hormone secreting pituitary adenomas. However, in contrast to sellar gangliocytemas, extrahypothalamic tumors secreting excessive hypothalamic hypophysiotropic hormones have never been associated with a pituitary adenoma. They have only been associated with pituitary cell hyperplasia. Therefore, the hypothesis can be made that hypothalamic releasing hormones only promote but do not initiate tumorigenesis of pituitary adenomas.

Growth hormone therapy in adults: rationales, results, and perspectives

This review outlines the present knowledge of the rationales, clinical aspects, and perspectives of a therapy with recombinant human growth hormone (rhGH) in adults. In patients with hypopituitarism the effects of rhGH replacement have been extensively studied. Recent clinical trials show that rhGH treatment improves most alterations of body composition and psychological performance, but many of the metabolic actions of GH remain equivocal. Although side effects after short-term administration are usually mild, the risks of severe long-term adverse effects are still uncertain. A supplementation with rhGH is also suggestive in advanced age and obesity, but the clinical results are controversial so far. The anabolic actions of rhGH were exploited in several recent trials including patients who were severely ill, malnourished, on chronic haemodialysis, or on total parenteral nutrition. Although nitrogen-sparing effects of GH have been demonstrated in most cases, the data do not indicate a clinical benefit in terms of reduced mortality, improved outcome, or accelerated recovery. Therefore, recommendations for the use of rhGH do not have any rationale in these patients yet. The efficacy of rhGH in the treatment of reproductive or immunological disorders remains elusive and needs further investigation. In conclusion, the application of rhGH is still an experimental therapy which should be performed under close observation in well-controlled clinical studies.

Quality of life in patients with Addison's disease: effects of different cortisol replacement modes

This study compares the impact of different modes of cortisol replacement therapy on the health perception and general well-being in patients with primary adrenocortical failure. 14 adults (8 female, 6 male) with Addison's disease on chronic cortisol replacement participated in the study. In a randomized double-blind cross-over design, all patients were treated with 3 modes of cortisol replacement for one week each (mode I: 20 mg hydrocortisone (HC) at 0700 h and 10 mg HC at 1900 h; mode II: 30 mg HC at 0700 h and placebo at 1900 h; mode III: placebo at 0700 h and 30 mg HC at 1900 h). Following the third week, the replacement modes were repeated in a different random order. For quality-of-life assessment the patients completed three different questionnaires (Addison-questionnaire, Basler Befindlichkeits-Skala, Beschwerde-Liste) and were interviewed about their general contentment at the last day of each treatment week. General well-being in terms of subjective contentment was best established during mode I (in 64% of patients) and less often stated with mode II (in 29%) and III (in 14%) (p < 0.05 mode I vs III). With the twice-daily replacement (mode I), sum scores of all questionnaires were changed towards improvement compared to both once-daily regimens (p < 0.05 vs mode II and III), but did not reach normal values of healthy subjects. Differences between mode II and III were insignificant. We conclude that quality of life in Addison patients is mainly influenced by the mode of cortisol replacement therapy.(ABSTRACT TRUNCATED AT 250 WORDS)