The management and nature of depressive illnesses in late life: a follow-through study

Since the long-term results of the treatment of elderly depressives admitted to the writer's care between 1949 and 1951 were communicated (1962), further experiences (e.g. Colwell and Post, 1959; Post, 1968) have confirmed that affective illnesses in late life are associated with much subsequent mental invalidism and needs for further treatment. It was hoped that these needs might be met by increased use of out-patient and community care as well as by the introduction of thymoleptic drugs. A follow-up investigation of a further consecutive series of depressives over the age of 60 receiving inpatient treatment from the same psychiatrist in the same hospital during the years 1966–67 was undertaken with the following aims in view:

Firstly, it was intended to test the proposition that the less reluctant use of electro-convulsive therapy in old persons, as well as the introduction of antidepressant drugs and of more active after-care measures, had improved the long term outlook in the affective illnesses of late life. It was realized that a comparison of two series of patients separated from one another by some 15 years might be vitiated by differences between the samples other than those due to changed methods of treatment. It would, however, have been unethical to withhold the new forms of management from a control group.

Creativity and psychopathology. A study of 291 world-famous men

BACKGROUND

This investigation sought to determine the prevalences of various psychopathologies in outstandingly creative individuals, and to test a hypothesis that the high prevalence of mental abnormalities reported in prominent living creative persons would not be found in those who had achieved and retained world status.

METHOD

The family background, physical health, personality, psychosexuality and mental health of 291 famous men in science, thought, politics, and art were investigated. The membership of the six series of scientists and inventors, thinkers and scholars, statesmen and national leaders, painters and sculptors, composers, and of novelists and playwrights was determined by the availability of sufficiently adequate biographies. Extracted data were transformed into diagnoses in accordance with DSM-III-R criteria, when appropriate.

RESULTS

All excelled not only by virtue of their abilities and originality, but also of their drive, perseverance, industry, and meticulousness. With a few exceptions, these men were emotionally warm, with a gift for friendship and sociability. Most had unusual personality characteristics and, in addition, minor 'neurotic' abnormalities were probably more common than in the general population. Severe personality deviations were unduly frequent only in the case of visual artists and writers. Functional psychoses were probably less frequent than psychiatric epidemiology would suggest, and they were entirely restricted to the affective varieties. Among other functional disorders, only depressive conditions, alcoholism, and, less reliably, psychosexual problems were more prevalent than expected in some professional categories, but strikingly so in writers.

CONCLUSIONS

Similar findings have been reported for living artists and writers, and this suggests that certain pathological personality characteristics, as well as tendencies towards depression and alcoholism, are causally linked to some kinds of valuable creativity.

Bipolar affective disorder in old age

In a retrospective study of 67 elderly bipolar patients the first manic attack occurred at about age 60, often after a long period from the time of the first affective episode, after which further depressive episodes occurred. This calls into question Perris' criteria for unipolar diagnosis. Among the men, a preponderance of cerebral-organic disorders was found. The evidence for sub-classification of bipolar disorders into secondary or symptomatic manias is discussed. The recurrent nature of the illness in old age stresses the need for further evaluation of lithium prophylaxis.

Spectrum of chronic kidney disease in HIV-infected patients

OBJECTIVES

The aim of the study was to investigate the prevalence and aetiology of chronic kidney disease (CKD) and trends in estimated glomerular filtration rate (eGFR) in HIV-infected patients.

METHODS

Ascertainment and review of CKD cases among patients attending King's College and Brighton Hospitals, UK were carried out. CKD was defined as eGFR <60 mL/min for > or =3 months. Longitudinal eGFR slopes were produced to examine trends in renal function before, during and after exposure to indinavir (IDV) or tenofovir (TFV).

RESULTS

CKD prevalence was 2.4%. While HIV-associated nephropathy accounted for 62% of CKD in black patients, 95% of CKD in white/other patients was associated with diabetes mellitus, hypertension, atherosclerosis and/or drug toxicity. Exposure to IDV or TFV was associated with an accelerated decline in renal function (4.6-fold and 3.7-fold, respectively) in patients with CKD. In patients initiating IDV, age > or =50 years increased the odds of CKD [odds ratio (OR) 4.9], while in patients initiating TFV, age > or =50 years (OR 5.4) and eGFR 60-75 mL/min (OR 17.2) were associated with developing CKD.

CONCLUSION

This study highlights the importance of metabolic and vascular disease to the burden of CKD in an ageing HIV-infected cohort. In patients who developed CKD, treatment with IDV or TFV was associated with an accelerated decline in renal function.

CD4 and total lymphocyte counts as predictors of HIV disease progression

CD4+ T-lymphocyte (CD4) counts are a standard laboratory marker of disease progression in HIV infection, but expense precludes their use in large parts of the world. Total lymphocyte counts (TLC), in contrast, are widely available. We compared CD4 and TLC counts as predictors of developing AIDS or death in 831 HIV-positive out-patients (582 males and 249 females with both homosexual (males, n = 316) and heterosexual (n = 515) transmission patterns. The first CD4 count < 200/microliter and first TLC < 1250/microliter predicted similar (p = 0.52) survival, irrespective of clinical stage. For each clinical stage, a significant difference in progression to AIDS and mortality was predicted by TLC above or below 1250/microliter (p < 0.03). Survival and progression to AIDS occurred at similar rates in patients with a TLC < 1250/microliter or a CD4 count < 200/microliter (p > 0.1), and patients with a TLC > 1250/microliter or a CD4 count > 200/microliter (p > 0.5). A TLC < 1250/microliter preceded the development of Pneumocystis carinii pneumonia or cerebral toxoplasmosis in 76% of patients. In this longitudinal study, TLC and CD4 counts were equal predictors of disease progression. A TLC < 1250/microliter could be considered an indication for commencing cotrimoxazole prophylaxis.

Pulmonary tuberculosis in HIV infection: radiographic appearance is related to CD4+ T-lymphocyte count

SETTING

An adult HIV outpatient clinic in Cape Town, South Africa.

OBJECTIVE

To investigate the relationship between the radiographic appearance of pulmonary tuberculosis (PTB) in HIV infected patients and CD4+ T-lymphocyte count.

DESIGN

Pretreatment radiographs of 150 patients with newly diagnosed PTB were reviewed. CD4+ T-lymphocyte count was used as a marker of HIV disease progression.

RESULTS

Upper zone infiltrate typical of PTB reactivation was present in 18 patients. This pattern was associated with early HIV infection (mean CD4+ T-cell count 389) and had 78% positive predictive value for identifying patients with > 200 CD4+ T-lymphocytes/microL. Pleural effusion was present in 32 patients and occurred over a wide intermediate range of CD4+ T-cell counts (mean 185). Lower or midzone infiltrates, adenopathy, interstitial pattern or normal radiograph occurred in 136 patients and were associated with advanced HIV disease (mean CD4+ T-cell count 105). These patterns had 84%, 89%, 89% and 100% positive predictive value, respectively, for identifying patients with < 200 CD4+ T-cell/microL.

CONCLUSION

Pulmonary tuberculosis in African HIV-positive patients presents with a spectrum of radiographic abnormalities predictive of stage of HIV disease progression. In patients dually infected with HIV and PTB, chest radiographs are a useful adjunct to clinical staging.

Verbal creativity, depression and alcoholism. An investigation of one hundred American and British writers

BACKGROUND

An earlier study of 291 world famous men had shown that only visual artists and creative writers were characterised, in comparison with the general population, by a much higher prevalence of pathological personality traits and alcoholism. Depressive disorders, but not any other psychiatric conditions, had afflicted writers almost twice as often as men with other high creative achievements. The present investigation was undertaken to confirm these findings in a larger and more comprehensive series of writers, and to discover causal factors for confirmed high prevalences of affective conditions and alcoholism in writers.

METHOD

Data were collected from post-mortem biographies and, where applicable, translated into DSM diagnoses. The frequencies of various abnormalities and deviations were compared between poets, prose fiction writers, and playwrights.

RESULTS

A high prevalence in writers of affective conditions and of alcoholism was confirmed. That of bipolar affective psychoses exceeded population norms in poets, who in spite of this had a lower prevalence of all kinds of affective disorders, of alcoholism, of personality deviations, and related to this, of psychosexual and marital problems, than prose fiction and play writers.

CONCLUSIONS

A hypothesis is developed, which links the greater frequency of affective illnesses and alcoholism in playwrights and prose writers, in comparison with poets, to differences in the nature and intensity of their emotional imagination. This hypothesis could be tested by clinical psychologists collaborating with experts in literature on random samples of different kinds of writers.

Structural relaxation and nonexponential kinetics of CO-binding to horse myoglobin. Multiple flash photolysis experiments

The geminate recombination kinetics of CO-myoglobin strongly deviates from single exponential behavior in contrast to what is expected for unimolecular reactions (1). At low temperatures, this result was attributed to slowly exchanging conformational states which differ substantially in barrier height for ligand binding. Above 160 K the kinetics apparently slow down with temperature increase. Agmon and Hopfield (2) explain this result in terms of structural relaxation perpendicular to the reaction coordinate, which enhances the activation energy. In their model, structural relaxation homogenizes the kinetic response. Recently, Steinbach et al. (3) proposed a relaxation model which conserves the kinetic inhomogeneity. Below we test these conjectures by single and multiple excitation experiments. This method allows for discrimination between parallel (inhomogeneous) and sequential (homogeneous) kinetic schemes. The kinetic anomaly above 160 K is shown to result from a homogeneous, structurally relaxed intermediate. However a second anomaly is found above 210 K concerning the inhomogeneous phase which may indicate either a shift in activation energy or entropy.

Mycobacterium tuberculosis 19-kilodalton lipoprotein inhibits Mycobacterium smegmatis-induced cytokine production by human macrophages in vitro

Vaccination of mice with Mycobacterium vaccae or M. smegmatis induces some protection against M. tuberculosis challenge. The 19-kDa lipoprotein of M. tuberculosis, expressed in M. vaccae or M. smegmatis (M. smeg19kDa), abrogates this protective immunity. To investigate the mechanism of this suppression of immunity, human monocyte-derived macrophages (MDM) were infected with M. smeg19kDa. Infection resulted in reduced production of tumor necrosis factor alpha (TNF-alpha) (P < 0.01), interleukin-12 (IL-12) (P < 0.05), IL-6 (P < 0.05), and IL-10 (P < 0.05), compared to infection with M. smegmatis vector (M. smegV). Infection with M. smeg19kDa and with M. smegV had no differential effect on expression of costimulatory molecules on MDM, nor did it affect the proliferation of presensitized T cells cocultured with infected MDM. When MDM were infected with M. smegmatis expressing mutated forms of the 19-kDa lipoprotein, including non-O-glycosylated (M. smeg19NOG), nonsecreted (M. smeg19NS), and nonacylated (M. smeg19NA) variants, the reduced production of TNF-alpha or IL-12 was not observed. When the purified 19-kDa lipoprotein was added directly to cultures of infected monocytes, there was little effect on either induction of cytokine production or its inhibition. Thus, the immunosuppressive effect is dependent on glycosylated and acylated 19-kDa lipoprotein present in the phagosome containing the mycobacterium. These results suggest that the diminished protection against challenge with M. tuberculosis seen in mice vaccinated with M. smegmatis expressing the 19-kDa lipoprotein is the result of reduced TNF-alpha and IL-12 production, possibly leading to reduced induction of T-cell activation.

Treatment-limiting renal tubulopathy in patients treated with tenofovir disoproxil fumarate

OBJECTIVES

Tenofovir disoproxil fumarate (TDF) is widely used in the treatment or prevention of HIV and hepatitis B infection. TDF may cause renal tubulopathy in a small proportion of recipients. We aimed to study the risk factors for developing severe renal tubulopathy.

METHODS

We conducted an observational cohort study with retrospective identification of cases of treatment-limiting tubulopathy during TDF exposure. We used multivariate Poisson regression analysis to identify risk factors for tubulopathy, and mixed effects models to analyse adjusted estimated glomerular filtration rate (eGFR) slopes.

RESULTS

Between October 2002 and June 2013, 60 (0.4%) of 15,983 patients who had received TDF developed tubulopathy after a median exposure of 44.1 (IQR 20.4, 64.4) months. Tubulopathy cases were predominantly male (92%), of white ethnicity (93%), and exposed to antiretroviral regimens that contained boosted protease inhibitors (PI, 90%). In multivariate analysis, age, ethnicity, CD4 cell count and use of didanosine or PI were significantly associated with tubulopathy. Tubulopathy cases experienced significantly greater eGFR decline while receiving TDF than the comparator group (-6.60 [-7.70, -5.50] vs. -0.34 [-0.43, -0.26] mL/min/1.73 m²/year, p < 0.0001).

CONCLUSIONS

Older age, white ethnicity, immunodeficiency and co-administration of ddI and PI were risk factors for tubulopathy in patients who received TDF-containing antiretroviral therapy. The presence of rapid eGFR decline identified TDF recipients at increased risk of tubulopathy.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

The transition from inhomogeneous to homogeneous kinetics in CO binding to myoglobin

Heme proteins react inhomogeneously with ligands at cryogenic temperatures and homogeneously at room temperature. We have identified and characterized a transition from inhomogeneous to homogeneous behavior at intermediate temperatures in the time dependence of CO binding to horse myoglobin. The turnover is attributed to a functionally important tertiary protein relaxation process during which the barrier increases dynamically. This is verified by a combination of theory and multipulse measurements. A likely biological significance of this effect is in the autocatalysis of the ligand release process.

Differences in cognitive status between healthy, psychiatrically ill, and diffusely brain-damaged elderly subjects

It has recently been pointed out by several authors that the psychometric assessment of the elderly patient has largely been geared to, or preoccupied with, the solution of diagnostic problems, measuring deterioration or discovering early dementia (Post, 1966; Inglis, 1962). Therefore, it appears that little attention has been paid to the use of psychometric tests in the broad area of prognosis. Often the psychiatric diagnosis of an elderly patient is quite clear, and in these circumstances it would be valuable to be able to discern reliable and significant changes in the cognitive status of such patients. For example, it may well prove quite significant, prognostically, to measure the rate of change in cognition of an elderly person suffering from a progressive cerebral disease. The rate of decline could be a prognostic indicator for the future disposal of the patient or for impending death. A variety of studies have shown that scores on measures of physical and cognitive abilities can predict death or discharge from hospital (Cosin et al., 1957; Inglis, 1959; Kleemeier, 1961; Kral, 1963). In the case of patients suffering from depressive “pseudo-dementia” (Post, 1965) it will probably be valuable to know if their cognitive status reflects changes in their clinical status. But probably the most important aspect of the psychometric assessment of the geriatric patient will be found to lie in measuring changes in function which may be the sequelae of treatment affecting brain function in general, i.e. anti-depressant preparations and electroconvulsive therapy.

Averaged evoked responses in relation to cognitive and affective state of elderly psychiatric patients

Averaged cortical evoked responses to auditory and somatosensory stimuli were recorded in elderly depressives, dements, patients with a combination of depression and dementia and normal elderly controls. The subjects were also given a battery of cognitive tests and clinical ratings at stated intervals. The latency of the auditory response was significantly longer in dements than in controls. Depressives had intermediate latencies which did not return to normal after recovery. Although somatosensory stimulu produced the results that pointed in the same direction, the mean response latencies were not statistically significant. Mixed cases were too few for separate statistical analysis but their latencies fell between those of the dements and those of the depressives. Significant correlations emerged between latencies of auditory responses and some cognitive tests, but not with measures of depressive symptomatology. The delay in response to auditory stimuli may be a useful adjunct to diagnosis: in depressives it may reflect organic cerebral change playing a part in the emergence of depressive symptoms in old age.

Antiretroviral therapy CNS penetration and HIV-1-associated CNS disease

OBJECTIVE

The impact of different antiretroviral agents on the risk of developing or surviving CNS disease remains unknown. The aim of this study was to investigate whether using antiretroviral regimens with higher CNS penetration effectiveness (CPE) scores was associated with reduced incidence of CNS disease and improved survival in the UK Collaborative HIV Cohort (CHIC) Study.

METHODS

Adults without previous CNS disease, who commenced combination antiretroviral therapy (cART) between 1996 and 2008, were included (n = 22,356). Initial and most recent cART CPE scores were calculated. CNS diseases were HIV encephalopathy (HIVe), progressive multifocal leukoencephalopathy (PML), cerebral toxoplasmosis (TOXO), and cryptococcal meningitis (CRYPTO). Incidence rates and overall survival were stratified by CPE score. A multivariable Poisson regression model was used to identify independent associations.

RESULTS

The median (interquartile range) CPE score for initial cART regimen increased from 7 (5-8) in 1996-1997 to 9 (8-10) in 2000-2001 and subsequently declined to 6 (7-8) in 2006-2008. Differences in gender, HIV acquisition risk group, and ethnicity existed between CPE score strata. A total of 251 subjects were diagnosed with a CNS disease (HIVe 80; TOXO 59; CRYPTO 56; PML 54). CNS diseases occurred more frequently in subjects prescribed regimens with CPE scores ≤ 4, and less frequently in those with scores ≥ 10; however, these differences were nonsignificant. Initial and most recent cART CPE scores ≤ 4 were independently associated with increased risk of death.

CONCLUSION

Clinical status at time of commencing cART influences antiretroviral selection and CPE score. This information should be considered when utilizing CPE scores for retrospective analyses.

Outcome of AIDS-associated cryptococcal meningitis initially treated with 200 mg/day or 400 mg/day of fluconazole

Background

AIDS-associated cryptococcal meningitis has a high mortality. Fluconazole was the only systemic antifungal therapy available in our centre. From 1999–2001 we used low-dose fluconazole (200 mg daily initially), and did not offer therapy to patients perceived to have poor prognoses. In 2001 donated fluconazole became available, allowing us to use standard doses (400 mg daily initially). Antiretroviral therapy was not available during the study period.

Methods

Retrospective chart review of adult patients before and after the fluconazole donation.

Results

205 patients fulfilled the inclusion criteria, 77 before and 128 after the donation. Following the donation fewer patients received no antifungal treatment (5% vs 19%, p = 0.002), and more patients received standard-dose fluconazole (90% vs 6%, p < 0.001). In-hospital mortality was 25%. Impaired consciousness, no antifungal treatment received and cerebrospinal fluid antigen titre > 1,000 were independent predictors of in-hospital mortality. Concomitant rifampicin did not affect in-hospital survival. Thirteen patients were referred to the tertiary referral hospital and received initial treatment with amphotericin B for a mean of 6 days – their in-hospital survival was not different from patients who received only fluconazole (p = 0.9). Kaplan-Meier analysis showed no differences in length of survival by initial treatment with standard or low doses of fluconazole (p = 0.27 log rank test); median survival was 76 and 82 days respectively.

Conclusion

Outcome of AIDS-associated cryptococcal meningitis is similar with low or standard doses of fluconazole. The early mortality is high. Initial therapy with amphotericin B and other measures may be needed to improve outcome.

Towards person-centred care for people living with HIV: what core outcomes matter, and how might we assess them? A cross-national multi-centre qualitative study with key stakeholders

OBJECTIVES

People living with HIV (PLWH) have multidimensional concerns requiring person-centred care. Routine use of patient-reported outcome measures (PROMs) improves outcomes. No brief PROM currently reflects the breadth of concerns for PLWH. This study sought to identify priority outcomes for PLWH, model current practice, explore views on introducing PROMs into routine care, and devise a model for person-centred care incorporating the PROM.

METHODS

A cross-national multi-centre study (London, Brighton and Dublin) was carried out. Semi-structured qualitative interviews with adult PLWH, HIV health care professionals and HIV commissioners (responsible for planning and commissioning services) were performed. Interviews were analysed using thematic and framework analysis.

RESULTS

PLWH (n = 28), professionals (n = 21) and commissioners (n = 8) described concerns related to living with HIV across six domains: physical (e.g. pain and gastrointestinal symptoms), cognitive (e.g. memory and sleep), psychological (e.g. anxiety and depression), social (e.g. isolation and intimacy), welfare (e.g. finances and fears regarding change of immigration status), and information (e.g. long-term outcomes) needs. Themes were highly inter-related, impacting across domains of need (e.g. physical and cognitive problems impacting on psychological and social wellbeing). Perceived benefits of using PROMs in routine HIV care included improved person-centredness, patient empowerment, fewer missed concerns, increased engagement with services, and informed planning of services. Potential challenges included heterogeneity of PLWH, literacy, and utility for those who struggle to engage with care.

CONCLUSIONS

This study presents a novel model of person-centred care incorporating an HIV-specific PROM. The model reflects priorities of key stakeholders. Explicit use of PROMs in routine HIV care could afford benefits for PLWH, clinical teams and commissioners.

Switching to coformulated rilpivirine (RPV), emtricitabine (FTC) and tenofovir alafenamide from either RPV, FTC and tenofovir disoproxil fumarate (TDF) or efavirenz, FTC and TDF: 96-week results from two randomized clinical trials

Objectives

The single‐tablet regimen rilpivirine, emtricitabine and tenofovir alafenamide (RPV/FTC/TAF) for treatment of HIV‐1‐infected adults was approved based on bioequivalence. We assessed the clinical efficacy, safety and tolerability of switching to RPV/FTC/TAF from either RPV/FTC/tenofovir disoproxil fumarate (TDF) or efavirenz (EFV)/FTC/TDF.

Methods

We conducted two distinct randomized, double‐blind, active‐controlled, noninferiority trials in participants taking RPV/FTC/TDF (Study 1216) and EFV/FTC/TDF (Study 1160). Each study randomized virologically suppressed (HIV‐1 RNA < 50 copies/mL) adults (1:1) to switch to RPV/FTC/TAF or continue their current regimen for 96 weeks. We evaluated efficacy as the proportion with HIV‐1 RNA < 50 copies/mL using the Food and Drug Administration snapshot algorithm and prespecified bone and renal endpoints at week 96.

Results

We randomized and treated 630 participants in Study 1216 (RPV/FTC/TAF, n = 316; RPV/FTC/TDF, n = 314) and 875 in Study 1160 (RPV/FTC/TAF, n = 438; EFV/FTC/TDF, n = 437). In both studies, the efficacy of switching to RPV/FTC/TAF was noninferior to that of continuing baseline therapy at week 96, with respective percentages of patients with HIV RNA < 50 copies/mL being 89.2% versus 88.5% in Study 1216 [difference 0.7%; 95% confidence interval (CI) −4.3 to +5.8%] and 85.2% versus 85.1% in Study 1160 (difference 0%; 95% CI −4.8 to +4.8%). No participant on RPV/FTC/TAF developed treatment‐emergent resistance versus two on EFV/FTC/TDF and one on RPV/FTC/TDF. Compared with continuing baseline therapy, significant improvements in bone mineral density and renal tubular markers were observed in the RPV/FTC/TAF groups (P < 0.001).

Conclusions

Switching to RPV/FTC/TAF from RPV/FTC/TDF or EFV/FTC/TDF was safe and effective and improved bone mineral density and renal biomarkers up to 96 weeks with no cases of treatment‐emergent resistance.

Barbiturate tolerance and psychological functioning in elderly depressed patients

Increases in barbiturate tolerance and in scores on certain cognitive tests were found to have occurred after the treatment of elderly depressives. These changes were related to original severity of illness and to the extent of improvement, as well as to a number of other clinical features including age at first attack. The reported findings lent support to theories linking depressive illness with reduction in cortical arousability.

Schizo-affective symptomatology in late life

Kasanin (10) seems to have been the first author to use the term 'schizo-affective psychosis'. He drew attention to Lange's observations of catatonic features in mania, and to Claude's concept of 'schizomanie’. The case records of his young and acutely ill patients make one wonder, however, whether Kasanin had been sufficiently ready to recognize mixed manic-depressive states. Arising from the study of more prolonged illnesses, the Kleist-Leonhard school attempted to construct a number of sub-categories of schizophrenia in order to accommodate ‘cycloid’ cases. In this country, the term 'schizo-affective’ is at the present time in bad odour. Aubrey Lewis (11), employing very searching criteria, discovered schizophrenic symptoms in 23 of his 61 patients with affective psychoses, but derived them from hereditary and personality factors. Both Batchelor (2) and Mayer-Gross, Slater, and Roth (13), while admitting the occasional co-existence of manic-depressive and schizophrenic psychoses largely ascribed to mixed inheritance, have indicated that the schizo-affective label could be avoided by a more rigorous diagnostic approach and follow-up. These were employed recently by Clayton et al. (6), and of 39 schizo-affective patients 33 were re-assessed after at least one year; only 13 were still ill; and although 5 of them continued to show some schizophrenic symptoms, the authors interpreted their findings to indicate that schizophrenic deterioration was not a usual result of schizo-affective illness. Moreover, the family histories suggested a very strong relationship with ordinary affective illnesses rather than with schizophrenia or schizo-affective psychoses. These workers did not, therefore, confirm the claims of others (e.g. those arising from Mitsuda's (14) twin studies) to the effect that atypical psychoses were in a genetically different category from schizophrenia and manic-depression. The concept of 'schizo-affective’ has been devastatingly criticized by Foulds and Caine (7) on logical grounds.

Depression, lifestyle factors and cognitive function in people living with HIV and comparable HIV-negative controls

Objectives

We investigated whether differences in cognitive performance between people living with HIV (PLWH) and comparable HIV‐negative people were mediated or moderated by depressive symptoms and lifestyle factors.

Methods

A cross‐sectional study of 637 ‘older’ PLWH aged ≥ 50 years, 340 ‘younger’ PLWH aged < 50 years and 276 demographically matched HIV‐negative controls aged ≥ 50 years enrolled in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) study was performed. Cognitive function was assessed using a computerized battery (CogState). Scores were standardized into Z‐scores [mean = 0; standard deviation (SD) = 1] and averaged to obtain a global Z‐score. Depressive symptoms were evaluated via the Patient Health Questionnaire (PHQ‐9). Differences between the three groups and the effects of depression, sociodemographic factors and lifestyle factors on cognitive performance were evaluated using median regression. All analyses accounted for age, gender, ethnicity and level of education.

Results

After adjustment for sociodemographic factors, older and younger PLWH had poorer overall cognitive scores than older HIV‐negative controls (P < 0.001 and P = 0.006, respectively). Moderate or severe depressive symptoms were more prevalent in both older (27%; P < 0.001) and younger (21%; P < 0.001) PLWH compared with controls (8%). Depressive symptoms (P < 0.001) and use of hashish (P = 0.01) were associated with lower cognitive function; alcohol consumption (P = 0.02) was associated with better cognitive scores. After further adjustment for these factors, the difference between older PLWH and HIV‐negative controls was no longer significant (P = 0.08), while that between younger PLWH and older HIV‐negative controls remained significant (P = 0.01).

Conclusions

Poorer cognitive performances in PLWH compared with HIV‐negative individuals were, in part, mediated by the greater prevalence of depressive symptoms and recreational drug use reported by PLWH.

The spectrum of endocrine dysfunction in active pulmonary tuberculosis

OBJECTIVE

Substantial variation in the prevalence (0-55%) of hypoadrenalism in tuberculosis (TB) has been reported. The aim of this study was to prospectively evaluate adrenal, thyroid and gonadal function in patients presenting with active pulmonary TB.

DESIGN

A prospective study of 50 patients admitted to a single hospital.

PATIENTS

Fifty hospitalized adults with newly diagnosed sputum positive pulmonary TB (mean age 38 years, mean body mass index 18 kg/m2, mean albumin 28 g/l) were studied.

MEASUREMENTS

Adrenal reserve was assessed by intravenous tetracosactrin administration with measurement of basal and stimulated cortisol concentrations. Basal ACTH, thyroid and gonadal hormones were also measured.

RESULTS

The mean basal serum cortisol was 625 nmol/l (range 394-1185). Basal plasma ACTH was undetectable (< 4.4 pmol/l) in 32, normal in 17 (mean 11.45, range 4.4-24.9 pmol/l) and elevated in one (54.2 pmol/l) subjects and did not correlate with cortisol. The mean increment in cortisol following tetracosactrin was 256 nmol/l (range 0-650) and was unrelated to basal cortisol or ACTH. All 50 patients had a stimulated plasma cortisol exceeding 550 nmol/l, indicating intact adrenal reserve. Ninety-two per cent of patients had the sick euthyroid syndrome, 72% of males had hypogonadotrophic hypogonadism and 4% of patients tested positive for the human immunodeficiency virus.

CONCLUSIONS

Hypoadrenalism is uncommon in active pulmonary TB despite frequent dysfunction of the thyroid and gonadal axes.