Treatment retention with risperidone long-acting injection: 24-month results from the Electronic Schizophrenia Treatment Adherence Registry (e-STAR) in six countries

OBJECTIVE

To assess treatment retention on risperidone long-acting injection (RLAI) and outcomes in schizophrenia patients for whom 24 months of follow-up data in the electronic Schizophrenia Treatment Adherence Registry (e-STAR) were available.

RESEARCH DESIGN AND METHODS

e-STAR is an ongoing, international, multicenter, prospective, observational registry assessing use of antipsychotics in patients with schizophrenia or schizoaffective disorder in a normal clinical practice setting. Parameters were assessed prior to and post-initiation of RLAI. Data presented are from six European countries that enrolled patients in e-STAR after they initiated treatment with RLAI.

MAIN OUTCOME MEASURES

Clinical and demographic information were collected at baseline and treatment-related data, including RLAI discontinuation, psychiatric hospitalization and medication utilization, were collected prospectively every 3 months. Data collection continued for 24 months, even for patients who discontinued RLAI therapy. Hospitalization and medication utilization were also collected retrospectively by chart review for the 12-month period prior to RLAI initiation.

RESULTS

A total of 1659 patients (mean age, 39.2; 18.3% inpatients) completed the study. Twenty-four months after initiating therapy (initial RLAI dose = 33.6 mg) 85% of patients (n = 1410) remained on RLAI (completers) while 15% discontinued therapy. The main reasons for discontinuation were insufficient response (28.5%), patient/family choice (26.1%), adverse events (9.6%) and unacceptable tolerability (6.0%). At baseline, compared to completers, discontinuers were younger (37.4 vs. 39.6 years, p = 0.01), had schizophrenia for a shorter time (10.2 vs. 11.9 years, p = 0.02), had lower Global Assessment of Functioning (GAF) scores (43.5 vs. 48.0, p = 0.0001), higher utilization of benzodiazepines (56.5 vs. 43.3%) and more initiated therapy as inpatients (30 vs. 16%). With RLAI therapy GAF scores improved significantly (p < 0.001) for both groups but the 24-month value for discontinuers was lower than that of completers (55.4 vs. 67.2). Compared to the pre-RLAI initiation period, at 12 months post-initiation completers had greater reductions than discontinuers in the percent of patients hospitalized (66.2% reduction vs. 29.2%) and in the length (68% reduction vs. 0%) and number (80.0 vs. 14.3%) of hospital stays, differences that remained at 24 months. The most common adverse events while patients were taking RLAI were nervous system disorders (6.8%), psychiatric disorders (5.6%), weight increase (3.2%), reproductive system and breast disorders (2.5%) and gastrointestinal disorders (2.1%).

CONCLUSIONS

These observational data confirm that RLAI is an effective treatment in schizophrenia and high levels of adherence to therapy offers an opportunity for effective long-term disease management and significant sustained decreases in hospitalization.

Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients with chronic non-malignant pain

Background

There is little evidence that short-acting opioids as rescue medication for breakthrough pain is an optimal long-term treatment strategy in chronic non-malignant pain. We compared clinical studies of long-acting opioids that allowed short-acting opioid rescue medication with those that did not, to determine the impact of opioid rescue medication use on the analgesic efficacy and tolerability of chronic opioid therapy in patients with chronic non-malignant pain.

Methods

We searched MEDLINE (1950 to July 2006) and EMBASE (1974 to July 2006) using terms for chronic non-malignant pain and long-acting opioids. Independent review of the search results identified 48 studies that met the study selection criteria. The effect of opioid rescue medication on analgesic efficacy and the incidence of common opioid-related side-effects were analysed using meta-regression.

Results

After adjusting for potentially confounding variables (study design and type of opioid), the difference in analgesic efficacy between the ‘rescue’ and the ‘no rescue’ studies was not significant, with regression coefficients close to 0 and 95% confidence intervals that excluded an effect of more than 18 points on a 0–100 scale in each case. There was also no significant difference between the ‘rescue’ and the ‘no rescue’ studies for the incidence of nausea, constipation, or somnolence in both the unadjusted and the adjusted analyses.

Conclusions

We found no evidence that rescue medication with short-acting opioids for breakthrough pain affects analgesic efficacy of long-acting opioids or the incidence of common opioid-related side-effects among chronic non-malignant pain patients.

Clinical and resource-use outcomes of risperidone long-acting injection in recent and long-term diagnosed schizophrenia patients: results from a multinational electronic registry

BACKGROUND

Non-adherence to pharmacological treatment leading to frequent relapses and rehospitalizations is a major issue of concern among schizophrenia patients, especially those who are recently diagnosed. Risperidone long-acting injection (RLAI) has been shown to be efficacious, improve compliance, and increase long-term retention rate on therapy.

OBJECTIVE

To determine clinical outcomes and hospitalizations before and after the initiation of RLAI among schizophrenia patients with recent (< or =2 years) diagnosis relative to those who had long-term (> 2 years) diagnosis.

RESEARCH DESIGN AND METHODS

The electronic Schizophrenia Treatment Adherence Registry (e-STAR) is an observational study of patients with schizophrenia who start treatment with RLAI. Data were recorded at baseline, retrospectively for the 12 months prior to baseline, and prospectively every 3 months for 24 months. Data on patients with a defined length of diagnosis were pooled from eight countries.

MAIN OUTCOME MEASURES

Clinical Global Impression of Illness Severity (CGI-S), Global Assessment of Functioning (GAF) scores, and hospitalization data were key outcomes.

RESULTS

The magnitude of improvement in CGI-S scores was greater in the recent versus long-term diagnosis group [Delta -1.48 vs. Delta -0.95 (12 months); Delta -1.6 vs. Delta -1.09 (24 months)]. There were parallel improvements in GAF scores [Delta 19.4 vs. Delta 13.7 (12 months); Delta 22.3 vs. Delta 16.8 (24 months)]. The decline in the proportion of patients hospitalized from the retrospective to the prospective period was greater in the recent versus long-term diagnosis group (Delta -36.0 vs. Delta -19%, respectively) at 12 months. This was also true for the number of hospital stays (Delta -0.6 vs. Delta -0.3, respectively) and length of stay (days) (Delta -20.9 vs. Delta -6.9, respectively) at 12 months. Common adverse events in both groups included psychiatric, gastrointestinal, musculoskeletal and reproductive system and breast disorders.

CONCLUSIONS

Treatment with RLAI is associated with improved outcomes in recently diagnosed and chronic patients. However, the magnitude of improvement was higher in recently diagnosed patients.

Experimental observation of the improvement in MTF from backthinning a CMOS direct electron detector

The advantages of backthinning monolithic active pixel sensors (MAPS) based on complementary metal oxide semiconductor (CMOS) direct electron detectors for electron microscopy have been discussed previously; they include better spatial resolution (modulation transfer function or MTF) and efficiency at all spatial frequencies (detective quantum efficiency or DQE). It was suggested that a 'thin' CMOS detector would have the most outstanding properties [1-3] because of a reduction in the proportion of backscattered electrons. In this paper we show, theoretically (using Monte Carlo simulations of electron trajectories) and experimentally that this is indeed the case. The modulation transfer functions of prototype backthinned CMOS direct electron detectors have been measured at 300keV. At zero spatial frequency, in non-backthinned 700-mum-thick detectors, the backscattered component makes up over 40% of the total signal but, by backthinning to 100, 50 or 35mum, this can be reduced to 25%, 15% and 10%, respectively. For the 35mum backthinned detector, this reduction in backscatter increases the MTF by 40% for spatial frequencies between 0.1 and 1.0 Nyquist. As discussed in the main text, reducing backscattering in backthinned detectors should also improve DQE.

Back pain associated with endobronchial mucus impaction due to Bipolaris australiensis colonization representing atypical Allergic Bronchopulmonary Mycosis

A 40-year-old white male had a two-year history of right sided upper back pain without dyspnea or coughing. His past history was significant for allergic rhinitis and asthma. Conservative outpatient management of the back pain including medications, rest and physical therapy were ineffective. CT scan of the chest revealed a mass in the lower lobe of the right lung. Bronchial biopsy and lavage revealed eosinophilic and neutrophilic inflammation without tissue invasion. A pure culture of Bipolaris australiensis was confirmed by DNA typing. Hematological, serological and radiological studies were not compatible with Allergic Bronchopulmonary Mycosis (ABPM), fungus ball, hypersensitivity pneumonitis or invasive fungal infection. However, the mucus plugging may have represented an atypical localized form of ABPM. Resolution of the endobronchial mucus impaction occurred after three bronchoscopies with vigorous suction, anti fungal therapy and prednisone.