P3623Integrating depression and acute coronary syndrome care in low-resource hospitals in china: primary results from the I-Care randomised clinical trial

Background

Depression and acute coronary syndromes (ACS) are significant public health challenges. Patients with ACS often experience depression, which adversely affects prognosis. Low-cost, sustainable, and effective service models that integrate depression care into the management of ACS patients to reduce depression and improve ACS outcomes are critically needed.

Purpose

I-CARE study is a multi-center, randomised clinical trial (RCT) to evaluate the efficacy of an 11-month integrated care (IC) intervention compared to usual care (UC) in the management of ACS patients.

Methods

The I-CARE RCT was conducted between October 2014 and March 2018 in 16 rural Chinese hospitals. A total of 4041 patients with ACS were consecutively enrolled and randomly assigned in a 1:1 ratio to an IC intervention consisting of nurse-led risk factor management, group-based counseling supplemented by individual problem solving therapy and antidepressant medications as needed, or UC. The primary outcome was change in Patient Health Questionnaire-9 (PHQ-9) scores from baseline to 6 and 12 months. Secondary outcomes included incidence of major adverse events (MAEs) after discharge, quality of life (EQ5D), and adherence to ACS secondary prevention medications. Data analysis used a multilevel mixed-effects model with hospital-level and subject-level random-effect intercepts and hospital-level random slope incorporated to adjust for clustering effect. Primary analyses followed the intent-to-treat principle.

Results

The mean age of the patients was 61±10 years and 63% were men; however, only 3.3% were classified as depressed based upon a cutoff of ≥10 on the PHQ-9, and 26.9% had PHQ-9 scores between 5 to 9 at the baseline. There were no significant differences in patients' clinical characteristics between IC and UC groups. Changes in PHQ-9 scores from baseline to 6- and 12-months did not differ between treatment groups (−1.47 in IC group vs −1.40 in UC group; adjusted mean difference, −0.04; 95% CI, −0.17 to 0.08 at 6-months; −1.62 in IC group vs −1.54 in UC group; adjusted mean difference, −0.06; 95% CI: −0.19 to 0.06 at 12-months).The risk of MAEs after discharge between IC and UC groups also did not differ significantly (42.1% vs 43.1%; p=0.307).

Conclusions

Results from the I-CARE trial showed that a nurse-coordinated ACS and depression IC intervention did not reduce depression or improve clinical outcomes among patients with ACS compared to usual care controls. The low prevalence of depression was unexpected and may have minimized the potential added benefits of the IC intervention on depression and clinical outcomes compared to UC.

Acknowledgement/Funding

This study is supported by a grant from the National Institute of Mental Health (R01MH100332).

Identification of key pathways and genes changes in pancreatic cancer cells (BXPC-3) after cross-talk with primary pancreatic stellate cells using bioinformatics analysis

Pancreatic ductal adenocarcinoma (PDAC) is one of the most malignant tumors with poor prognosis, and the interaction between activated pancreatic stellate cells (PSCs) and PDAC cells plays an important role in the development of PDAC. The aim of this study was to identify gene changes in BXPC-3 after cross-talk with PSCs and reveal their potential mechanisms. The gene expression profiling analysis of BXPC-3 was completed after co-culture with primary PSCs for 48 h. The gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes pathway (KEGG) enrichment analyses were performed, and the differentially expressed genes (DEGs) were identified by Agilent GeneSpring GX software. In total, 3657 DEGs were identified in BXPC-3, including 1881 up-regulated genes and 1776 downregulated genes. GO analysis results showed that upregulated DEGs were significantly enriched in biological processes (BP), including peptide metabolic process, response to stress and electron transport chain; the downregulated DEGs were significantly enriched in biological processes, including signaling, multicellular organism development and anatomical structure development. KEGG pathway analysis revealed that 19 pathways were upregulated and 32 pathways were downregulated, and that upregulated DEGs were enriched in protein export and glutathione metabolism, while the downregulated DEGs were enriched in axon guidance and focal adhesion. The top 10 upregulated genes and the top 10 downregulated genes were identified. By constructing PPI network, we selected out 10 key genes (TP53, SRC, IL6, JUN, ISG15, CAD, STAT1, OAS3, OAS1, VIM) and significant pathways. The associated survival analysis was performed and the SRC, IL-6, ISG15, STAT1, OAS3, OAS1 and VIM were proved to be related to worse overall survival time of PDAC patients. In conclusion, the present study indicated that the identified DEGs promote our understanding of the molecular mechanisms underlying the interaction between pancreatic cancer cells and PSCs and might be used as molecular targets in the future to study the role of tumor microenvironment in the progression of PDAC.

PD-L1 Expression Patterns in Microsatellite Instability-High Intestinal Adenocarcinoma Subtypes

OBJECTIVES

To investigate patterns of programmed death protein-1 (PD-L1) expression in microsatellite instability (MSI)-high intestinal carcinomas and correlate them with pathologic and molecular features.

METHODS

One hundred and fifteen MSI-high and 41 microsatellite stable carcinomas were included. Tumor sections were immunohistochemically labeled for PD-L1. The results were correlated with histologic subtypes, MSI, and BRAF status.

RESULTS

As expected, MSI status was associated with PD-L1 expression. Among 115 MSI-high tumors, PD-L1 expression was observed on tumor cells in 28 tumors and on tumor-associated inflammatory cells in 77 tumors. Medullary carcinoma demonstrated more frequent PD-L1 expression on tumor cells than mucinous and typical adenocarcinoma. PD-L1 expression was more frequent in medullary and typical adenocarcinoma than in mucinous adenocarcinoma based on combined positive scores. Tumors with more nucleotide shifts by PCR-based MSI testing were more likely to express PD-L1.

CONCLUSIONS

Expression of PD-L1 is different among different histologic subtypes of MSI-high intestinal carcinomas.

A case report of clonal EBV-like memory CD4+ T cell activation in fatal checkpoint inhibitor-induced encephalitis

Checkpoint inhibitors produce durable responses in numerous metastatic cancers, but immune-related adverse events (irAEs) complicate and limit their benefit. IrAEs can affect organ systems idiosyncratically; presentations range from mild and self-limited to fulminant and fatal. The molecular mechanisms underlying irAEs are poorly understood. Here, we report a fatal case of encephalitis arising during anti-programmed cell death receptor 1 therapy in a patient with metastatic melanoma. Histologic analyses revealed robust T cell infiltration and prominent programmed death ligand 1 expression. We identified 209 reported cases in global pharmacovigilance databases (across multiple cancer types) of encephalitis associated with checkpoint inhibitor regimens, with a 19% fatality rate. We performed further analyses from the index case and two additional cases to shed light on this recurrent and fulminant irAE. Spatial and multi-omic analyses pinpointed activated memory CD4⁺ T cells as highly enriched in the inflamed, affected region. We identified a highly oligoclonal T cell receptor repertoire, which we localized to activated memory cytotoxic (CD45RO⁺GZMB⁺Ki67⁺) CD4 cells. We also identified Epstein-Barr virus-specific T cell receptors and EBV⁺ lymphocytes in the affected region, which we speculate contributed to neural inflammation in the index case. Collectively, the three cases studied here identify CD4⁺ and CD8⁺ T cells as culprits of checkpoint inhibitor-associated immune encephalitis.

Differential Cell Susceptibilities to KrasG12D in the Setting of Obstructive Chronic Pancreatitis

BACKGROUND & AIMS

Activating mutation of the KRAS gene is common in some cancers, such as pancreatic cancer, but rare in other cancers. Chronic pancreatitis is a predisposing condition for pancreatic ductal adenocarcinoma (PDAC), but how it synergizes with KRAS mutation is not known.

METHODS

We used a mouse model to express an activating mutation of Kras in conjunction with obstruction of the main pancreatic duct to recapitulate a common etiology of human chronic pancreatitis. Because the cell of origin of PDAC is not clear, Kras mutation was introduced into either duct cells or acinar cells.

RESULTS

Although KrasG12D expression in both cell types was protective against damage-associated cell death, chronic pancreatitis induced p53, p21, and growth arrest only in acinar-derived cells. Mutant duct cells did not elevate p53 or p21 expression and exhibited increased proliferation driving the appearance of PDAC over time.

CONCLUSIONS

One mechanism by which tissues may be susceptible or resistant to KRASG12D-initiated tumorigenesis is whether they undergo a p53-mediated damage response. In summary, we have uncovered a mechanism by which inflammation and intrinsic cellular programming synergize for the development of PDAC.

Peritoneal Carcinomatosis in Well-Differentiated Small-Intestinal Neuroendocrine Tumors with Mesenteric Tumor Deposits

OBJECTIVE

Well-differentiated small-intestinal neuroendocrine tumors (SI-NETs) tend to be biologically indolent. Despite this tendency, they have a predilection for metastasis. Peritoneal involvement is quite common as is unfortunately peritoneal carcinomatosis (PC). PC is a dreaded metastatic complication due to the significant morbidity it creates for patients as well as well as increasing their mortality risk. The risk factors for PC development in SI-NETs remain understudied; however, one such factor may be the presence of mesenteric tumor deposits (MTDs).

METHODS

We performed a retrospective analysis on 208 well-differentiated SI-NET patient samples, the majority with mesenteric masses, from the pathology archives of Vanderbilt University Medical Center. We sought to explore whether MTD presence was associated with PC, what other patient determinants were associated with PC and prognostic implication of these determinants.

RESULTS

Patients with MTDs had an OR of 3.9 (CI 1.6, 10.9) for PC compared to patients without MTDs in the analysis. Patients who developed PC fared more poorly than those who did not (p=0.044).

CONCLUSION

Our analysis, to the best of our knowledge, is the first to demonstrate an association between MTD presence and PC in this patient subgroup. We believe this finding warrants prospective evaluation given the possible therapeutic implications of being able to stratify SI-NET patients by their risk for developing PC based upon MTD presence.

Sustained Swimming Training Is Associated With Reversible Filet Texture Changes of European Sea Bass (Dicentrarchus labrax L.)

This present study aimed to investigate the effect of training and detraining on the growth, chemical composition, white muscle fibers, and filet texture of the European sea bass (Dicentrarchus labrax L.). Fish were divided into control and training groups, which were subjected to water velocities of 0.2 and 1.0 body length per second (bl s-1), respectively, for 32 days (phase I). Half of the fish in the training group were then randomly selected and detrained at a velocity of 0.2 bl s-1 for another 32 days (detraining group), while the velocity of the remaining fish in the training group (1 bl s-1), and control group (0.2 bl s-1) remained unchanged (phase II). The results showed that the growth, body composition, and white muscle fiber densities of the control and trained fish were not significantly different in either phase. Training significantly altered the muscle fiber distribution (P < 0.05), with the training group having fewer 80-90 μm fibers than the control and detraining group at the end of the experiment (P < 0.05). The training group also had significantly higher values for white fiber muscle textural parameters (hardness, adhesiveness, cohesiveness, springiness, gumminess, and chewiness) in phase I (P < 0.05), and these parameters correlated significantly with pH (P < 0.05). However, these differences in texture and the pH correlation weakened when the fish were detrained in phase II. These results indicated that an increase in muscle pH after training may alter the flesh texture characteristics of sea bass. In addition, sustained swimming could induce a reversible change in the filet texture of sea bass.

Identification of key pathways and genes changes in pancreatic cancer cells (BXPC-3) after cross-talked with primary pancreatic stellate cells using bioinformatics analysis

Pancreatic ductal adenocarcinoma (PDAC) is one of the most malignant tumors with poor prognosis, and the interaction between activated pancreatic stellate cells (PSCs) and PDAC cells plays an important role in the development of PDAC. The aim of this study was to identify gene changes in BXPC-3 after cross-talked with PSCs and reveal their potential mechanisms. The gene expression profiling analysis of BXPC-3 was completed after co-cultured with primary PSCs for 48 h. The gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes pathway (KEGG) enrichment analyses were performed, and the differentially expressed genes (DEGs) were identified by Agilent GeneSpring GX software. In total, 3657 DEGs were identified in BXPC-3, including 1881 up-regulated genes and 1776 downregulated genes. GO analysis results showed that up-regulated DEGs were significantly enriched in biological processes (BP), including peptide metabolic process, response to stress, and electron transport chain; the down-regulated DEGs were significantly enriched in biological processes, including signaling, multicellular organismal development, and anatomical structure development. KEGG pathway analysis revealed that 19 pathways were upregulated and 32 pathways were downregulated, and that up-regulated DEGs were enriched in protein export and glutathione metabolism, while the down-regulated DEGs were enriched in axon guidance and focal adhesion. The top 10 up-regulated genes, and the top 10 down-regulated genes were identified. By constructing PPI network, we selected out 10 key genes (TP53, SRC, IL6, JUN, ISG15, CAD, STAT1, OAS3, OAS1, VIM) and significant pathways. The associated survival analysis was performed and the SRC, IL-6, ISG15, STAT1, OAS3, OAS1 and VIM were proved to be related to worse overall survival time of PDAC patients. In conclusion, the present study indicated that the identified DEGs promote our understanding of the molecular mechanisms underlying the interaction between pancreatic cancer cells and PSCs and might be used as molecular targets in the future to study the role of tumor microenvironment in the progression of PDAC.

BMP Signaling in Regulating Mesenchymal Stem Cells in Incisor Homeostasis

Bone morphogenetic protein (BMP) signaling performs multiple essential functions during craniofacial development. In this study, we used the adult mouse incisor as a model to uncover how BMP signaling maintains tissue homeostasis and regulates mesenchymal stem cell (MSC) fate by mediating WNT and FGF signaling. We observed a severe defect in the proximal region of the adult mouse incisor after loss of BMP signaling in the Gli1+ cell lineage, indicating that BMP signaling is required for cell proliferation and odontoblast differentiation. Our study demonstrates that BMP signaling serves as a key regulator that antagonizes WNT and FGF signaling to regulate MSC lineage commitment. In addition, BMP signaling in the Gli1+ cell lineage is also required for the maintenance of quiescent MSCs, suggesting that BMP signaling not only is important for odontoblast differentiation but also plays a crucial role in providing feedback to the MSC population. This study highlights multiple important roles of BMP signaling in regulating tissue homeostasis.

Identification of key pathways and gene changes in primary pancreatic stellate cells after cross-talk with pancreatic cancer cells (BXPC-3) using bioinformatics analysis

It is well known that as the king of cancer, pancreatic ductal adenocarcinoma (PDAC) has relatively malignant biological behavior and poor prognosis. The interaction between pancreatic stellate cells and PDAC cells promotes the development of PDAC. The aim of this study was to describe gene characteristics in pancreatic stellate cell (PSCs) after cross-talked with BXPC-3 and unravel their underlying mechanisms. The expression profiling analysis of genes in PSCs was completed after co-cultured with primary BXPC-3 for 48h. The Kyoto Encyclopedia of Genes and Genomes pathway (KEGG) enrichment analysis and gene ontology (GO) analysis were performed, and the differentially expressed genes (DEGs) were identified by Agilent GeneSpring GX program. In total, 1804 DEGs were filtered out in PSCs, including 958 up-regulated genes and 846 downregulated genes. GO analysis showed that the up-regulated DEGs were significantly enriched in biological processes (BP) such as defense response, immune system process and immune response; the down-regulated DEGs were significantly enriched in biological regulation and cytoskeleton organization. KEGG pathway analysis showed that 28 pathways were upregulated and 5 were downregulated. By constructing PPI network, we selected out 10 key genes (IL6，IL8, IL1B, BCL2, CCL2, CSF2, KIT, ICAM1, PTPRC and IGF1) and significant enriched pathways. In conclusion, the current study suggests that the filtered DEGs contribute to our understanding of the molecular mechanisms underlying the interaction between PSCs and pancreatic cancer cells, and might be used as molecular targets to further the study the role of tumor microenvironment in the progression of PDAC.

Gate tunable graphene-integrated metasurface modulator for mid-infrared beam steering

The ability to integrate graphene into metasurface devices has attracted enormous interest as a means of achieving dynamic electrical control of their electromagnetic response. In this manuscript, we experimentally demonstrate a graphene-integrated metasurface modulator that establishes the potential to actively control the amplitude and phase of mid-infrared light with high modulation depth and speed, in good agreement with simulation results. Our simulations also show it is possible to construct a reconfigurable surface with tunable phase profile by incorporating graphene-integrated metasurface modulators with specific geometric parameters. This reconfigurable surface is able to manipulate the orientation of the wave reflected from it, achieving a high-speed, switchable beam steering reflective interface. The results here could inspire research on dynamic reflective display and holograms.

Deubiquitinase USP10 regulates Notch signaling in the endothelium

Notch signaling is a core patterning module for vascular morphogenesis that codetermines the sprouting behavior of endothelial cells (ECs). Tight quantitative and temporal control of Notch activity is essential for vascular development, yet the details of Notch regulation in ECs are incompletely understood. We found that ubiquitin-specific peptidase 10 (USP10) interacted with the NOTCH1 intracellular domain (NICD1) to slow the ubiquitin-dependent turnover of this short-lived form of the activated NOTCH1 receptor. Accordingly, inactivation of USP10 reduced NICD1 abundance and stability and diminished Notch-induced target gene expression in ECs. In mice, the loss of endothelial Usp10 increased vessel sprouting and partially restored the patterning defects caused by ectopic expression of NICD1. Thus, USP10 functions as an NICD1 deubiquitinase that fine-tunes endothelial Notch responses during angiogenic sprouting.

Upregulated claudin-1 expression promotes colitis-associated cancer by promoting β-catenin phosphorylation and activation in Notch/p-AKT-dependent manner

In IBD patients, integration between a hyper-activated immune system and epithelial cell plasticity underlies colon cancer development. However, molecular regulation of such a circuity remains undefined. Claudin-1(Cld-1), a tight-junction integral protein deregulation alters colonic epithelial cell (CEC) differentiation, and promotes colitis severity while impairing colitis-associated injury/repair. Tumorigenesis is a product of an unregulated wound healing process and therefore we postulated that upregulated Cld-1 levels render IBD patients susceptible to the colitis-associated cancer (CAC). Villin Cld-1 mice is used to carryout overexpressed studies in mice. The role of deregulated Cld-1 expression in CAC and underlying mechanism using a well-constructed study scheme and mouse models of DSS colitis/recovery and CAC. Using an inclusive investigative scheme, we here report that upregulated Cld-1 expression promotes susceptibility to the CAC and its malignancy. Increased mucosal inflammation, defective epithelial homeostasis accompanied the increased CAC in Villin-Cld1-Tg mice. We further found significantly increased levels of pro-tumorigenic M2 macrophages and β-CateninSer552 (β-CatSer552) expression in the CAC in Cld-1Tg versus WT mice. Mechanistic studies identified the role of PI3K/Akt signaling in Cld-1 dependent activation of the β-CatSer552, which, in turn, was dependent on pro-inflammatory signals. Our studies identify a critical role of Cld-1 in promoting susceptibility to CAC. Importantly, these effects of deregulated Cld-1 were not associated with altered tight junction integrity, but on its non-canonical role in regulating Notch/PI3K/Wnt/ β-CatSer552 signaling. Overall, outcome from our current studies identifies Cld-1 as potential prognostic biomarker for IBD severity and CAC, and a novel therapeutic target.

Construction of a novel DNA vaccine candidate targeting F gene of genotype VII Newcastle disease virus and chicken IL-18 delivered by Salmonella

AIMS

Genotype VII Newcastle disease (ND) is one of the most epidemic and serious infectious diseases in the poultry industry. A novel vaccine targeting VII Newcastle disease virus (NDV) is still proving elusive.

METHODS AND RESULTS

In this study, we constructed regulated delayed lysis Salmonella strains expressing either a fusion protein (F) alone under an eukaryotic CMV promoter or together with chicken IL-18 (chIL-18) as a molecular adjuvant under prokaryotic P_trc promoter, named pYL1 and pYL23 respectively. Oral immunization with recombinant strains induced NDV-specific serum IgG antibodies in both pYL1- and pYL23-immunized chickens. The presence of chIL-18 significantly increased lymphocyte proliferation in immunized chickens, as well as the percentages of CD3⁺ CD4⁺ and CD3⁺ CD8⁺ T cells in serum, even if a statistically significant difference did not exist. After a virulent challenge, pYL23 immunization provided about 80% protection at day 10 postinfection, compared with 60% of protection offered by pYL1 immunization and 100% protection in the inactivated vaccine group, indicating the enhanced immune response provided by chIL-18, which was also confirmed by histochemical analysis.

CONCLUSIONS

Recombinant lysis Salmonella-vectored DNA vaccine could provide us a novel potential option for controlling NDV infection.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study took use of a regulated delayed lysis Salmonella vector for the design of an orally administrated vaccine against NDV.

Src kinase inhibition restores E-cadherin expression in dasatinib-sensitive pancreatic cancer cells

The Src family of non-receptor tyrosine kinases are frequently activated in pancreatic ductal adenocarcinoma (PDAC), contributing to disease progression through downregulation of E-cadherin and induction of epithelial-to-mesenchymal transition (EMT). The purpose of this study was to examine the efficacy of Src kinase inhibition in restoring E-cadherin levels in PDAC. Immunohistochemical analysis of human PDAC samples showed Src activation is inversely correlated with E-cadherin levels. Protein and mRNA levels of E-cadherin, the gene expression of its various transcriptional repressors (Zeb1, Snail, Slug, LEF-1, TWIST), and changes in sub-cellular localization of E-cadherin/β-catenin in PDAC cells were characterized in response to treatment with the Src inhibitor, dasatinib (DST). DST repressed Slug mRNA expression, promoted E-cadherin transcription, and increased total and membranous E-cadherin/β-catenin levels in drug-sensitive PDAC cells (BxPC3 and SW1990), however no change was observed in drug-resistant PANC1 cells. BxPC3, PANC1, and MiaPaCa-2 flank tumor xenografts were treated with DST to examine changes in E-cadherin levels in vivo. Although DST inhibited Src phosphorylation in all xenograft models, E-cadherin levels were only restored in BxPC3 xenograft tumors. These results suggest that Src kinase inhibition reverses EMT in drug-sensitive PDAC cells through Slug-mediated repression of E-cadherin and identifies E-cadherin as potential biomarker for determining response to DST treatment.

Peritoneal carcinomatosis (PC) in well-differentiated (WD) small-intestinal neuroendocrine tumor (SI-NET) patients (Pts) with mesenteric tumor deposits (MTDs)

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Background: Although WD SI-NETs are typically biologically indolent, they tend to metastasize. PC is a dreaded regional metastatic complication in pts with SI-NETs and contributes to significant morbidity and mortality. Risk factors for PC development in these pts are not well studied, however one factor may be MTD presence. Our analysis is the first to suggest an association between MTD presence and PC in this pt subgroup. Methods: We performed a retrospective analysis on 191 WD SI-NET samples from Vanderbilt University Medical Center with mesenteric masses identified on gross pathology or radiographic review. Of 138 samples with suspected MTDs, 79 were confirmed definitively by detailed pathologic review and 59 were considered likely based on descriptions from surgical pathology reports. We assessed whether pts in our cohort with MTDs had greater rates of PC compared to those without MTDs. We also assessed what other patient determinants were associated with PC and the prognostic role of these determinants. Results: Pts with suspected MTDs had an odds ratio (OR) of 3.9 for PC compared to pts without MTDs. Rates of PC in pts with definitive MTDs and those with likely MTDs were not significantly different (OR 1, p = 1.00). Although suspected MTD presence was not associated with poorer OS (p = 0.97), pts with confirmed MTDs had a trend toward poorer overall survival (OS) than pts with likely MTDs (p = 0.05). PC was a negative prognostic factor in all pts with regards to OS (p = 0.044). Conclusions: SI-NET pts with MTDs appear to have significantly increased rates of PC compared to those without mesenteric deposits. We believe this observation merits prospective evaluation given its potential therapeutic implications. If confirmed prospectively, pts with MTDs could benefit from earlier use of cytoreductive therapies to hinder development of PC. [Table: see text]

Forensic Analysis of 24 Cases of Long-term Antipsychotics Use-Induced Sudden Unexpected Deaths

OBJECTIVES

To analyze the forensic characteristics of 24 psychiatric patients who died of long-term use of psychotropic drugs.

METHODS

Cases of sudden death of psychiatric patients from 2011 to 2016 were collected. The forensic characteristics of these sudden deaths were retrospectively analyzed by systematic investigation plus results of autopsy and toxics （drugs）.

RESULTS

Among the 24 psychiatric patients who died of long-term use of psychotropic substances, the ratio of male to female was 1.7∶1, and the average age was （59.0±8.8） years. Fifteen patients had clear disease durations （14.4±8.2） years, and other the nine were known to have disease durations of over 3 years. The death time of 62.5% of patients was the daytime in working days, and 91.7% of the patients died at home. Most patients complained different degrees of physical discomfort before death. Patients with schizophrenia （20 cases） were the most common, followed by depression （4 cases）. All patients had the history of taking psychotropic drugs, with clozapine and chlorpromazine being the mostly detected ones. The causes of death were mainly circulatory diseases （15 cases）, with the most common being myocarditis （11 cases） followed by pneumonia （4 cases）.

CONCLUSIONS

Critical attention should be paid to the risk of antipsychotics-induced sudden unexpected deaths for psychiatric patients, particularly for those with schizophrenia.