Olanzapine or chlorpromazine plus lithium in first episode psychotic mania: An 8-week randomised controlled trial

Background

Treatment strategies for mental disorders may vary according to illness stage. However no data currently exist to guide treatment in first episode psychotic mania. The aim of this study was to compare the safety and efficacy profile of chlorpromazine and olanzapine, as add-on to lithium, in patients with a first episode of psychotic mania, expecting better safety profile and adherence to olanzapine but similar efficacy for both treatments.

Methods

Data from 83 patients were collected in an 8-week randomised controlled trial on clinical variables, side effects, vital signs, and weight. Analyses of treatment differences over time were based on intent-to-treat principles. Kaplan-Meier estimated survival curves were used to analyse time-to-event data and mixed effects models repeated measures analysis of variance were used to determine treatment group differences over time on safety and efficacy measures.

Results

Ethics committee approval to delay informed consent procedure until recovery from the acute episode allowed the inclusion of 83 patients highly representative of those treated in the public sector. Contrary to our hypotheses, safety profile of both medications was similar. A signal for higher rate (P=.032) and earlier occurrence (P= .043) of mania remission was observed in the olanzapine group which did not survive correction for multiple comparisons.

Conclusions

Olanzapine and chlorpromazine have a similar safety profile in a uniquely representative cohort of patients with first episode psychotic mania. The possibility for a greater impact of olanzapine on manic symptoms leading to earlier remission of the episode needs exploration in a large sample.

[Pseudo-adult Still's disease, anasarca, thrombotic thrombocytopenic purpura and dysautonomia: An atypical presentation of multicentric Castleman's disease. Discussion of TAFRO syndrome]

INTRODUCTION

Multicentric Castleman's disease can mimic adult-onset Still disease. It is exceptionally associated with anasarca, thrombotic microangiopathy and dysautonomia.

CASE REPORT

We report a 32-year-old woman with an association of oligoanuria, anasarca, thrombotic microangiopathy with features compatible with adult-onset Still disease. The outcome was initially favorable with corticosteroids, immunoglobulins and plasmapheresis but with the persistence of relapses marked by severe autonomic syndrome and necessity of high dose corticosteroids. The diagnosis of mixed type Castleman's disease, HHV8 and HIV negative, was obtained four years after the onset of symptoms by a lymph node biopsy. The outcome was favorable after tocilizumab and corticosteroids but tocilizumab had to be switched to anakinra to ensure a proper and long-lasting control of the disease.

CONCLUSION

Our patient partially fits the description of TAFRO syndrome (Thrombocytopenia, Anasarca, myeloFibrosis, Renal dysfunction, Organomegaly), a MCM rare variant, recently described in Japanese patients.

Efficacy of anti-TNF alpha in severe and/or refractory Behçet's disease: Multicenter study of 124 patients

OBJECTIVE

To report the efficacy and safety of anti-TNF agents in patients with severe and/or refractory manifestations of Behçet's disease (BD).

METHODS

We performed a multicenter study of main characteristics and outcomes of anti-TNF alpha treatments [mainly infliximab (62%), and adalimumab (30%)] in 124 BD patients [48% of men; median age of 33.5 (28-40) years].

RESULTS

Overall response (i.e. complete and partial) rate was 90.4%. Clinical responses were observed in 96.3%, 88%, 70%, 77.8%, 92.3% and 66.7% of patients with severe and/or refractory ocular, mucocutaneous, joint, gastro-intestinal manifestations, central nervous system manifestations and cardiovascular manifestations, respectively. No significant difference was found with respect to the efficacy of anti-TNF used as monotherapy or in association with an immunosuppressive agent. The incidence of BD flares/patient/year was significantly lower during anti-TNF treatment (0.2 ± 0.5 vs 1.7 ± 2.4 before the use of anti-TNF, p < 0.0001). The prednisone dose was significantly reduced at 6 and 12 months (p < 0.0001). In multivariate analysis, retinal vasculitis was negatively associated with complete response to anti-TNF (OR = 0.33 [0.12-0.89]; p = 0.03). The efficacy and relapse free survival were similar regardless of the type of anti-TNF agent used. After a median follow-up of 21 [7-36] months, side effects were reported in 28% of patients, including infections (16.3%) and hypersensitivity reactions (4.1%). Serious adverse events were reported in 13% of cases.

CONCLUSION

Anti-TNF alpha therapy is efficient in all severe and refractory BD manifestations. Efficacy appears to be similar regardless of the anti-TNF agent used (infliximab or adalimumab).

Multi-Institution Validation of an Emergency Ultrasound Image Rating Scale-A Pilot Study

BACKGROUND

As bedside ultrasound (BUS) is being increasingly taught and incorporated into emergency medicine practice, measurement of BUS competency is becoming more important. The commonly adopted experiential approach to BUS competency has never been validated on a large scale, and has some limitations by design.

OBJECTIVE

Our aim was to introduce and report preliminary testing of a novel emergency BUS image rating scale (URS).

METHODS

Gallbladder BUS was selected as the test case. Twenty anonymous BUS image sets (still images and clips) were forwarded electronically to 16 reviewers (13 attendings, 3 fellows) at six training sites across the United States. Each reviewer rated the BUS sets using the pilot URS that consisted of three components, with numerical values assigned to each of the following aspects: Landmarks, Image Quality, and Annotations. Reviewers also decided whether or not each BUS set would be "Clinically Useful." Kendall τs were calculated as a measure of concordance among the reviewers.

RESULTS

Among the 13 attendings, image review experience ranged from 2-15 years, 5-300 scans per week, and averaged 7.8 years and 60 images. Kendall τs for each aspect of the URS were: Landmarks: 0.55; Image Quality: 0.57; Annotation: 0.26; Total Score: 0.63, and Clinical Usefulness: 0.45. All URS elements correlated significantly with clinical usefulness (p < 0.001). The correlation coefficient between each attending reviewer and the entire group ranged from 0.48-0.69, and was independent of image review experience beyond fellowship training.

CONCLUSION

Our novel URS had moderate-to-good inter-rater agreement in this pilot study. Based on these results, the URS will be modified for use in future investigations.

Impairment of quality of life in patients with antiphospholipid syndrome

OBJECTIVES

Health-related quality of life (HRQoL) has not been fully explored in antiphospholipid syndrome (APS); therefore, we compared HRQoL between APS patients and the general population and assessed the impact of thromboembolic history.

METHODS

HRQoL was measured in a multicentre cohort study by the Medical Outcomes Study Short-Form 36 (MOS-SF-36) questionnaire. HRQoL scores were compared to the French general population norms. Factors significantly associated with an impaired HRQoL were identified.

RESULTS

A total of 115 patients with aPL and/or systemic lupus erythematosus (SLE) were included (mean age 42.7 ± 14.1 years old, 86 women). In 53 patients APS was diagnosed. Compared to general population norms, patients with APS had an impaired HRQoL. SLE-associated APS patients had the worst HRQoL scores (physical component summary (PCS)=40.8 ± 10.6; mental component summary (MCS)=40.6 ± 16.5) in comparison with SLE or aPL patients without thromboembolic history. In APS patients, history of arterial thrombosis significantly impaired HRQoL (PCS score: 42.2 ± 9.4 vs 49.2 ± 8.5; MCS score: 33.9 ± 13.7 vs 44.6 ± 10.3).

CONCLUSION

Compared to the general population, APS patients experienced a lower HRQoL. In these patients, a history of arterial thrombosis significantly impaired HRQoL. Therefore, measurements of HRQoL should be included in APS patient management to assess the burden of the disease from a patient's perspective and to provide patients with the support they need.

Treatment of early episode in patients with schizophrenia: the role of long acting antipsychotics

The use of long-acting injectable antipsychotics (LAIs) in schizophrenia is usually restricted to patients in long-term treatment, who prefer them to oral antipsychotics, and to patients with multiple relapses who have a history of non-adherence. However, preliminary evidence from patients in the early phases of the disease suggest that second generation LAIs may be superior to second generation oral medications with regard to the control of negative symptoms and psychosocial functioning. Moreover, several studies have found that psychiatrists are generally reluctant to prescribe LAI antipsychotics and under-estimate their acceptability by patients. Key elements to take into account when offering a LAI in the early course of schizophrenia should include their potential superiority in allowing early detection of non-adherence and in reducing the number of rehospitalisations and relapses.

[Expression, identification and experience of emotions in mental diseases. An overview]

Several studies in clinical neuroscience have focused on the analysis of expression of emotions, identification of emotions and experience of emotions. These empirical studies produced certain insights into emotional competency in different mental diseases, most of them in schizophrenia. The current article gives a description of the scientific data about alterations in emotional competency in several mental diseases (e.g. schizophrenia, depression, bipolar and borderline diseases) and links the data, if possible, with clinical relevance with a special focus on emotional competency in prodromal schizophrenia.

Obsessive-compulsive symptoms in at-risk mental states for psychosis: associations with clinical impairment and cognitive function

OBJECTIVE

Obsessive-compulsive symptoms (OCS) constitute a major comorbidity in schizophrenia. Prevalence estimations of OCS for patients with at-risk mental states (ARMS) for psychosis vary largely. It is unclear how ARMS patients with or without comorbid OCS differ regarding general psychosocial functioning, psychotic and affective symptoms and neurocognitive abilities.

METHOD

At-risk mental states patients (n = 233) from the interventional trial PREVENT (Secondary Prevention of Schizophrenia) were stratified according to the presence or absence of comorbid OCS and compared on several clinical variables.

RESULTS

Patients, who fulfilled the criteria for obsessive-compulsive disorder (OCD) or presented with subclinical OCS (ARMSposOCS sample), did not significantly differ from patients without OCS (ARMSnegOCS) with regard to gender, age, premorbid verbal intelligence and levels of education. Furthermore, similar severity of depressive syndromes, basic cognitive, attenuated psychotic and brief limited intermittent psychotic symptoms were found. However, ARMSposOCS patients showed more impairment of psychosocial functioning and higher general psychopathology. In contrast, they scored higher in cognitive tasks measuring working memory and immediate verbal memory.

CONCLUSION

Findings extend upon previous results due to the multidimensional assessment. Subsequent longitudinal studies might elucidate how comorbid OCS influence differential treatment response, especially to cognitive behavioural interventions and the transition rates to psychosis.

Charcot spinal arthropathy in a diabetic patient

We report a case of Charcot spinal arthropathy in a diabetic patient and emphasize the clinical reasoning leading to the diagnosis, discuss the differential diagnosis, and insist on the crucial role of the radiologist and pathologist which allows the distinction between Charcot spinal arthropathy and infectious or tumoural disorders of the spine.

Systemic capillary leak syndrome revealing a diffuse large B-cell lymphoma

We report on a 75-year-old woman who presented with recurrent episodes of hypotension, anasarca, renal failure, hypoalbuminaemia without proteinuria, suggestive of systemic capillary leak syndrome (SCLS). Further investigations led to a diagnosis of diffuse large B-cell lymphoma. Secondary SCLS associated with non-Hodgkin lymphoma is reviewed.

[Services for the early recognition of psychoses and bipolar disorders in Germany: inventory survey study]

BACKGROUND

In order to successfully implement early recognition and intervention services in psychiatry, it is crucial to improve the attention to and recognition of severe mental disorders and to establish low threshold services that are available at short notice for diagnostic and treatment procedures.

MATERIAL AND METHODS

For this inventory survey study, questionnaires regarding the presence and type of early recognition services for psychoses and bipolar disorders were sent separately to German psychiatric hospitals by mail in September and October 2012. Additionally, an internet search and telephone inquiries as well as an alignment of responses from the two surveys and with network lists from published and ongoing early recognition studies were performed.

RESULTS

Response rates in the psychosis and bipolar disorder surveys were 21 % (51/246) and 36 % (91/255), respectively. Three quarters of participating institutions reported at least an interest in creating an early recognition service for psychoses and one half for bipolar disorders. Overall, 26 institutions were identified that already offer early recognition of psychoses and 18 of bipolar disorders. Of these 16 are low threshold early recognition centres with direct access at short notice for first-episode patients and person from at-risk groups and separate specific public relations work. Of these early recognition centres five have a separate and easy to find homepage available; in an additional 15 institutions the specific websites are part of the institutions homepage.

CONCLUSION

Despite widespread interest and the increasingly recognized importance of early recognition and intervention services in psychiatry, there is currently no nationwide coverage with early recognition services for severe mental disorders in Germany. Public relations and information activities are not (yet) sufficiently provided to reach affected persons and their environment. Common standards are (still) missing and interdisciplinary models are sparse. To correct these shortcomings, amongst other factors, acquisition of sufficient funding for such services is required.

A novel LKB1 isoform enhances AMPK metabolic activity and displays oncogenic properties

The LKB1 tumor suppressor gene encodes a master kinase that coordinates the regulation of energetic metabolism and cell polarity. We now report the identification of a novel isoform of LKB1 (named ΔN-LKB1) that is generated through alternative transcription and internal initiation of translation of the LKB1 mRNA. The ΔN-LKB1 protein lacks the N-terminal region and a portion of the kinase domain. Although ΔN-LKB1 is catalytically inactive, it potentiates the stimulating effect of LKB1 on the AMP-activated protein kinase (AMPK) metabolic sensor through a direct interaction with the regulatory autoinhibitory domain of AMPK. In contrast, ΔN-LKB1 negatively interferes with the LKB1 polarizing activity. Finally, combining in vitro and in vivo approaches, we showed that ΔN-LKB1 has an intrinsic oncogenic property. ΔN-LKB1 is expressed solely in the lung cancer cell line, NCI-H460. Silencing of ΔN-LKB1 decreased the survival of NCI-H460 cells and inhibited their tumorigenicity when engrafted in nude mice. In conclusion, we have identified a novel LKB1 isoform that enhances the LKB1-controlled AMPK metabolic activity but inhibits LKB1-induced polarizing activity. Both the LKB1 tumor suppressor gene and the oncogene ΔN-LKB1 are expressed from the same locus and this may account for some of the paradoxical effects of LKB1 during tumorigenesis.

A correlation between severe haemolytic disease of the fetus and newborn and maternal ABO blood group

OBJECTIVE

To analyse anti-D quantification levels and frequency of intrauterine transfusion (IUT), per maternal ABO blood group.

BACKGROUND

Maternally derived red cell allo-antibodies can target fetal red cell antigens in utero leading to haemolytic disease and fetal anaemia. When a clinically significant allo-antibody is formed the priority is ascertaining the risk to the fetus and maternal ABO blood groups are not considered relevant.

MATERIALS AND METHODS

This was a 10-year retrospective, observational study carried out on women referred for anti-D quantification (n = 1106), and women whose fetuses required an IUT to treat fetal anaemia (n = 62) due to anti-D, in the Republic of Ireland.

RESULTS

Relative to the overall incidence of RhD allo-immunisation by blood group, women of blood group A were more likely to require IUT compared with those who were blood group O (P = 0.002).

CONCLUSION

It is known that ABO feto-maternal compatibility can influence the incidence and level of red cell allo-antibodies in pregnancy; however, it does not account for the significantly high rate of severe haemolytic disease requiring IUT seen in blood group A women.

[Long-term treatment of schizophrenia spectrum disorders: focus on pharmacotherapy]

Schizophrenia spectrum disorders (SSD) constitute a group of psychiatric illnesses which frequently lead to persisting mental impairment. Although some patients show a clinical course with few episodes and good long-term outcome, the course of the disease is often chronic and unfavorable. Long-term treatment (LTT) of SSD pertains to the postacute stabilization period and the remission period following pharmacological and psychosocial therapy of an acute illness episode. This article provides an overview of treatment recommendations concerning long-term pharmacotherapy, dealing with side effects, treatment of non-response and therapy resistance and the treatment of psychiatric comorbidities. Furthermore, an overview of non-pharmacological treatment options is presented. An integrated therapeutic setting combining evidence-based pharmacotherapy, psychosocial interventions, and supportive therapies is recommended for optimal LTT of SSD. Considering the limited financial resources available in the healthcare system, one of the major challenges is to provide patients with access to the evidence-based treatment options available.

Defensive strategies in rugby union

Success in rugby union competition is dependent partly on the defensive strategies of a team. Despite this, little empirical evidence exists about effective defensive strategies used during play. This study attempted to identify defensive characteristics associated with increased likelihood of a successful outcome in rugby union, while considering the game situation. Twenty-one matches of the 2010 Super 14 competition were analysed, amounting to 2,394 coded tackle contacts. The likelihood of the defending team winning the breakdown (the post-tackle contact situation where opposing teams compete for possession of the ball) increased as the match progressed. Defensive speed, measured as the speed of the defence in response to the attacking line, was a statistically significant predictor of breakdown wins and preventing the attacking team from advancing towards the gain line. Identifying the relative effectiveness of such strategies allows understanding of rugby match behaviour and may be applied to improve organisation, design, training, teaching and learning the game.

Insulin secretion and its association with physical activity, fitness and screen time in children

OBJECTIVES

To determine the independent associations of moderate to vigorous physical activity (MVPA), fitness, screen time, and adiposity with insulin secretion in children.

DESIGN AND METHODS

Caucasian youth (n = 423/630), 8-10 years old, with at least one obese biological parent, were studied (QUALITY cohort). Insulin secretion was measured using HOMA2-%B, area under the curve (AUC) of insulin to glucose over the first 30 minutes (AUC I/G(t30min)) of the OGTT and AUC I/G(t120min) over 2 hours. Fitness was measured by VO₂peak ; percent fat mass (PFM) by DXA; 7-day MVPA by accelerometry; self-reported screen time included television, video game, or computer use. Models were adjusted for age, sex, season, puberty, PFM, and insulin sensitivity [IS] (HOMA2-IS, Matsuda-ISI).

RESULTS

PFM was strongly associated with insulin secretion, even after adjustment for IS: for every 1% increase in PFM, insulin secretion increased from 0.3% to 0.8% across indices. MVPA was negatively associated with HOMA2-%B (P < 0.05), but not with OGTT-derived measures. Fitness was negatively associated with AUC I/G(t120min) (P < 0.05). Screen time showed a trend toward higher HOMA2-%B in girls (P = 0.060).

CONCLUSIONS

In children with an obese parent, lower insulin secretion is associated with lower adiposity, higher MVPA, better fitness, and possibly reduced screen time.