International consensus on the diagnosis and management of pediatric patients with hereditary angioedema with C1 inhibitor deficiency

Background

The consensus documents published to date on hereditary angioedema with C1 inhibitor deficiency (C1‐INH‐HAE) have focused on adult patients. Many of the previous recommendations have not been adapted to pediatric patients. We intended to produce consensus recommendations for the diagnosis and management of pediatric patients with C1‐INH‐HAE.

Methods

During an expert panel meeting that took place during the 9th C1 Inhibitor Deficiency Workshop in Budapest, 2015 (www.haenet.hu), pediatric data were presented and discussed and a consensus was developed by voting.

Results

The symptoms of C1‐INH‐HAE often present in childhood. Differential diagnosis can be difficult as abdominal pain is common in pediatric C1‐INH‐HAE, but also commonly occurs in the general pediatric population. The early onset of symptoms may predict a more severe subsequent course of the disease. Before the age of 1 year, C1‐INH levels may be lower than in adults; therefore, it is advisable to confirm the diagnosis after the age of one year. All neonates/infants with an affected C1‐INH‐HAE family member should be screened for C1‐INH deficiency. Pediatric patients should always carry a C1‐INH‐HAE information card and medicine for emergency use. The regulatory approval status of the drugs for prophylaxis and for acute treatment is different in each country. Plasma‐derived C1‐INH, recombinant C1‐INH, and ecallantide are the only agents licensed for the acute treatment of pediatric patients. Clinical trials are underway with additional drugs. It is recommended to follow up patients in an HAE comprehensive care center.

Conclusions

The pediatric‐focused international consensus for the diagnosis and management of C1‐INH‐HAE patients was created.

Life events and escape in conversion disorder

BACKGROUND

Psychological models of conversion disorder (CD) traditionally assume that psychosocial stressors are identifiable around symptom onset. In the face of limited supportive evidence such models are being challenged.

METHOD

Forty-three motor CD patients, 28 depression patients and 28 healthy controls were assessed using the Life Events and Difficulties Schedule in the year before symptom onset. A novel 'escape' rating for events was developed to test the Freudian theory that physical symptoms of CD could provide escape from stressors, a form of 'secondary gain'.

RESULTS

CD patients had significantly more severe life events and 'escape' events than controls. In the month before symptom onset at least one severe event was identified in 56% of CD patients - significantly more than 21% of depression patients [odds ratio (OR) 4.63, 95% confidence interval (CI) 1.56-13.70] and healthy controls (OR 5.81, 95% CI 1.86-18.2). In the same time period 53% of CD patients had at least one 'high escape' event - again significantly higher than 14% in depression patients (OR 6.90, 95% CI 2.05-23.6) and 0% in healthy controls. Previous sexual abuse was more commonly reported in CD than controls, and in one third of female patients was contextually relevant to life events at symptom onset. The majority (88%) of life events of potential aetiological relevance were not identified by routine clinical assessments. Nine per cent of CD patients had no identifiable severe life events.

CONCLUSIONS

Evidence was found supporting the psychological model of CD, the Freudian notion of escape and the potential aetiological relevance of childhood traumas in some patients. Uncovering stressors of potential aetiological relevance requires thorough psychosocial evaluation.

Facilitating mental health research for patients, clinicians and researchers: a mixed-method study

OBJECTIVES

Research registers using Consent for Contact (C4C) can facilitate recruitment into mental health research studies, allowing investigators to contact patients based on clinical records information. We investigated whether such a register was useful for mental health research, seeking the perspectives of patients and research investigators.

SETTING AND DESIGN

In 2012, a C4C register was developed in a large secondary mental health provider within the UK; almost 9000 patients have joined. This mixed-method study audited the effectiveness of the register.

PARTICIPANTS

A 'mystery shopper' exercise was conducted, and patients (n=21) were recruited to ask clinicians about the availability of research opportunities. Structured interviews were conducted with patients (n=52) about their experiences of being on the register. Similar interviews were conducted with 18 investigators from 19 studies, who had attempted to use the register to recruit participants.

OUTCOME MEASURES

The impact of C4C on study recruitment, and whether it helped patients learn about research.

RESULTS

So far, the register has provided 928 individuals with 1085 research opportunities (in 60% of cases, the individual agreed to participate in the study). Clinicians were willing to link patients to research opportunities, but often lacked information about studies. For patients, the register provided opportunities which they may not otherwise have; 27 of 52 had participated in studies since joining the register (18 participating for the first time). Most investigators used the register to supplement recruitment to their studies, but described problems in prescreening potential participants from a clinical record for complex studies.

CONCLUSIONS

Although the register helped investigators recruit for studies, and provided patients with research opportunities, clinicians' input is still useful for identifying suitable participants. C4C registers should be adapted to provide clinicians with automatically updated information on local studies allowing them to match patients on their caseload with active studies.

Following the Francis report: investigating patient experience of mental health in-patient care

BACKGROUND

The Francis report highlights perceptions of care that are affected by different factors including ward structures.

AIMS

To assess patient and staff perceptions of psychiatric in-patient wards over time.

METHOD

Patient and staff perceptions of in-patient psychiatric wards were assessed over 18 months. We also investigated whether the type of ward or service structure affected these perceptions. We included triage and routine care. The goal was to include at least 50% of eligible patients and staff.

RESULTS

The most dramatic change was a significant deterioration in all experiences over the courseof the study. Systems of care or specific wards did not affect patient experience but staff were more dissatisfied in the triage system.

CONCLUSIONS

This is the first report of deterioration in perceptions of the therapeutic in-patient environment that has been captured in a rigorous way. It may reflect contemporaneous experiences across the National Health Service of budget reductions and increased throughput. The ward systems we investigated did not improve patient experience and triage may have been detrimental to staff.

Biological and psychosocial risk factors for psychotic major depression

AIMS

Few studies have investigated risk factors for psychotic major depression (PMD). We aimed to investigate the biological and psychosocial risk factors associated with PMD compared with other psychotic disorders.

METHODS

Based on the aetiology and ethnicity in schizophrenia and other psychoses (ÆSOP) study, we used a case-control study to identify and recruit, at baseline and 10-year follow-up, all first episode cases of psychosis, presenting for the first time to specialist mental health services in defined catchment areas in the UK. Population-based controls were recruited from the same areas. Data were collected on: sociodemographics; social isolation; childhood adversity; life events; minor physical anomalies; and neurological soft signs.

RESULTS

Living alone (aOR = 2.26, CI = 1.21-4.23), basic level qualification (aOR = 2.89, CI = 1.08-7.74), being unemployed (aOR = 2.12, CI = 1.13-3.96), having contact with friends less than monthly (aOR = 4.24, CI = 1.62-11.14), having no close confidants (aOR = 4.71, CI = 2.08-10.68), having experienced childhood adversity (aOR = 2.57, CI = 1.02-6.44), family history of mental illness (aOR = 10.68, CI = 5.06-22.52), family history of psychosis (aOR = 12.85, CI = 5.24-31.51), and having more neurological soft signs (aOR = 1.15, CI = 1.07-1.24) were all associated with a follow-up diagnosis of PMD and schizophrenia. Few variables associated with PMD were also associated with a diagnosis of bipolar disorder. Minor physical anomalies were associated with a follow-up diagnosis of schizophrenia and bipolar disorder, but not PMD.

CONCLUSIONS

Risk factors associated with PMD appear to overlap with those for schizophrenia, but less so for bipolar disorder. Future work on the differential aetiology of PMD, from other psychoses is needed to find the 'specifier' between PMD and other psychoses. Future research on aetiology in PMD, and perhaps other psychoses, should account for diagnostic change.

Phase II study results of a replacement therapy for hereditary angioedema with subcutaneous C1-inhibitor concentrate

BACKGROUND

Hereditary angioedema (HAE) due to C1 inhibitor deficiency manifests as recurrent swelling attacks that can be disabling and sometimes fatal. Long-term prophylaxis with twice-weekly intravenous injections of plasma-derived C1-inhibitor (pdC1-INH) has been established as an effective treatment. Subcutaneous (SC) administration of pdC1-INH has not been studied in patients with HAE.

METHODS

This open-label, dose-ranging, crossover study (COMPACT Phase II) was conducted in 18 patients with type I or II HAE who received two of twice-weekly 1500, 3000, or 6000 IU SC doses of highly concentrated volume-reduced CSL830 for 4 weeks each. The mean trough plasma levels of C1-INH functional activity, C1-INH and C4 antigen levels during Week 4, and overall safety and tolerability were evaluated. The primary outcome was model-derived steady-state trough C1-INH functional activity.

RESULTS

After SC CSL830 administration, a dose-dependent increase in trough functional C1-INH activity was observed. C1-INH and C4 levels both increased. The two highest dose groups (3000 and 6000 IU) achieved constant C1-INH activity levels above 40% values, a threshold that was assumed to provide clinical protection against angioedema attacks. Compared with intravenous injection, pdC1-INH SC injection with CSL830 showed a lower peak-to-trough ratio and more consistent exposures. All doses were well tolerated. Mild-to-moderate local site reactions were noted with pain and swelling being the most common adverse event.

CONCLUSIONS

Subcutaneous volume-reduced CSL830 was well tolerated and led to a dose-dependent increase in physiologically relevant functional C1-INH plasma levels. A clinical outcome study of SC CSL830 in patients with HAE warrants further investigation.

Efficacy of a triage system to reduce length of hospital stay

BACKGROUND

Attempts have been made to improve the efficiency of in-patient acute care. A novel method has been the development of a 'triage system' in which patients are assessed on admission to develop plans for discharge or transfer to an in-patient ward.

AIMS

To compare a triage admission system with a traditional system.

METHOD

Length of stay and readmission data for all admissions in a 1-year period between the two systems were compared using the participating trust's anonymised records.

RESULTS

Despite reduced length of stay on the actual triage ward, the average length of stay was not reduced and the triage system did not lead to a greater number of readmissions. There was no significant difference in costs between the two systems.

CONCLUSIONS

Based on our findings we cannot conclude that the triage system reduced length of stay, but we can conclude that it does not increase the number of readmissions as some have feared.

Occupational functioning in early non-affective psychosis: the role of attributional biases, symptoms and executive functioning

Aims. Occupational functioning is severely impaired in people with psychosis. Social cognition has recently been found to be a stronger predictor of functioning than neurocognition. This study is the first to investigate if externalizing attributional biases that are typically associated with psychosis play a role in the vocational pathways of people with early psychosis. Methods. A cross-sectional design was used. Fifty participants with early psychosis were recruited from a cohort of 144 participants of the Lambeth Early Onset randomized control trial at 18-month follow-up. Information on occupational functioning was obtained using case notes and interview. Severity of symptoms was assessed and participants completed measures on attributional style and executive functioning. Results. Although executive functioning and positive symptoms were associated with poor occupational functioning, an externalizing attributional style for failures and reduced engagement in occupational activities during the previous 18 months emerged as the only predictors of poor occupational functioning at 18-month follow-up. Conclusions. An externalizing attributional bias is associated with poor occupational functioning. Further research is needed to investigate the direction of this relationship and whether attributional biases mediate the impact of symptoms and cognitive impairment on functioning.