[The management and treatment of severe mental disorders in pregnancy]

The pharmacological treatment of serious mental disorders in the pregnancy, supposes a clinical dare by the possible repercussions on the fetus and the pregnancy: theratogenesis, perinatal syndrome or postnative sequels in the development. The electroconvulsive therapy (ECT) as much takes implicit a minimum risk for the mother as for the fetus and therefore, it must be located in the highest positions of the therapeutic decision trees. In the present article, are reviewed the consequences of the pharmacological treatment and the ECT in the serious mental disorders during the pregnancy. Is referenced to all of the pharmacological groups and with respect to the ECT: their indications, counterindications, complications and technical procedures advisables. Finally is reviewed the guide line for each syndromical group of psychiatric diseases.

Granulocyte-macrophage colony-stimulating factor in post-remission therapy of acute myeloid leukemia

The impact on occult leukemia of GM-CSF as a sensitizing agent has not been studied. We treated 41 adult patients with de novo acute myeloid leukemia, 25 of whom achieved complete remission and were given 1 to 3 post-remission courses, each course including GM-CSF begun 4 days prior to chemotherapy and given until day 3. After a median follow-up of 32 months, the probability of remaining in continuous complete remission was 17% at 46 months. GM-CSF in this setting was not associated with an improved outcome, arguing against a priming effect.

[Gender differences in mental health: epidemiological study in the general population of the island of Formentera]

The epidemiological data of prevalence of mental disorders according to gender differences are controversial. We analysed the prevalence among men and women via a two-stage epidemiological community study using the GHQ-28 and the SCAN on the island of Formentera (Spain). There are no sex differences in total prevalence; nevertheless some significant differences are detected when data is analysed on specific disorders. Affective disorders, sleep disorders and neurotic and somatoform disorders are more prevalent among women, whereas men have more psychoactive substance use disorders. Comorbidity with medical illness are higher in women but differences are not significant. These findings suggest the need to standardise procedures and instruments in these kinds of studies. This is because one of the bias could be the difference in the number of disorders included in the instrument design used (in our study, sleep disorders and psychoactive substance use disorders were included and personality disorders were excluded.

Regional cerebral blood flow pattern in normal young and aged volunteers: a 99mTc-HMPAO SPET study

The aim of this study was to investigate the normal pattern of regional cerebral blood flow (rCBF) distribution in normal young and aged volunteers using technetium-99m hexamethylpropylene amine oxime (99m-Tc-HMPAO) as a tracer. The region brain perfusion of young and aged subjects was compared, especially regarding rCBF differences due to age and gender, and interhemispheric rCBF asymmetries. Sixty-eight right-handed normal volunteers - 40 young (mean age 29. 5+/-6.3 years) and 28 aged (mean age 71.2+/-4.3 years) - were included in the study. rCBF was estimated on the basis of a semiquantitative approach by means of a left/right index and two region/reference ratios, using the cerebellum and the whole brain activity as references. A good correlation between these two region/reference ratios was found (P<0.005 in all cerebral regions). The highest rCBF ratios corresponded to the cerebellum, followed by the occipital lobe. The remaining cortical regions (temporal, parietal, frontal and basal ganglia) showed slightly lower values. The white matter showed rCBF ratios substantially lower than the grey matter. In neither young nor aged subjects were significant rCBF differences between the genders found in any of the two region/reference indices employed. Aged subjects showed significantly lower rCBF ratios than young subjects in the left frontal lobe and in the posterior region of the left temporal lobe. In both young and aged subjects, lower perfusion was found in the left hemisphere, except for the white matter region in both age groups and the frontal lobe in the young subjects. Aged subjects presented a slightly higher interhemispheric asymmetry in the frontal lobe. However, interhemispheric asymmetry was minimal (-1. 01% to 3.14%). Consequently, a symmetrical rCBF distribution can be assumed between homologous regions, independent of age.

Baseline, visual deprivation and visual stimulation 99TCm-HMPAO-related changes in visual cortex can be detected with a single-head SPET system

To determine the sensitivity of 99TCm-hexamethylpropylene amine oxime (99TCm-HMPAO) and a single-head SPET (single photon emission tomography) system in the detection of perfusion changes in the visual cortex due to different visual conditions, six normal healthy volunteers were studied under conditions of visual deprivation (blindfolded), visual stimulation (stroboscopic light) and baseline (dim light and eyes open). Visual cortex/whole-brain activity ratios, and the percentage of activity change between the different visual conditions were calculated after three-dimensional realignment of the images. The activity in the visual cortex was higher during visual stimulation than during the visual deprivation (P = 0.002, 17.6 +/- 8.6% increase) and baseline conditions (P = 0.009, 8.8 +/- 5.6% increase). Furthermore, the activity in the visual cortex was lower during the visual deprivation than in the baseline condition (P = 0.001, 8.1 +/- 2.9% decrease). 99TCm-HMPAO SPET, even with a single-head system, is capable of detecting changes in rCBF in the striate cortex, not only between conditions of visual stimulation and deprivation, but also between these two conditions and the baseline state.

[Patterns of the use of electroconvulsive therapy in Barcelona]

BACKGROUND

To study the prevalence of use and the characteristics of current utilization of electroconvulsive therapy (ECT) in Barcelona.

METHODS

A descriptive study was carried out in August of 1993. A structured interview designed by the authors was administered to psychiatrists in 20 hospitals, including general hospitals with Department of Psychiatry and psychiatric hospitals.

RESULTS

In 12 hospitals of the sample (60%) ECT was practised. The most frequent indication was depression (83%) followed by schizophrenia (17%). In all these hospitals pharmacological treatment was simultaneously used and the application of electrodes was bilateral. Most of them used stimulation by sinusoidal wave, thiopental was used as anesthetic agent, the duration of seizures was not evaluated, EEG monitoring was not performed and treatment in a surgeon's room was not applied. In 10 hospitals written consent was obtained.

CONCLUSIONS

ECT was used in general hospitals with psychiatric department of Barcelona, Spain, with high coincidence in indications but not in the technical aspects.

Mucinous carcinoma of the breast: a pathologic study of 82 cases

A series of 82 consecutive cases of mucinous carcinomas of the female breast was investigated for their clinical, morphological, and histochemical features and for the influence of some tumor characteristics on its prognosis. Two groups, a "pure" subtype (n = 58) and a "mixed" subtype (n = 24), were considered, according to the absence or the presence of concomitant areas with typical infiltrating ductal carcinoma. Eighty patients were followed with an average of 7.4 years. The actuarial survival was 58.5% at 10 years. The group of pure mucinous carcinomas showed a statistically significant better prognosis (P = 0.0007) than that of the group of mixed tumors, as well as a lower percentage of axillary nodal metastasis. Tumor dimension of both pure and mixed mucinous carcinomas influenced the prognosis, since patients with T1 tumors had longer survival than those with T2 tumors (P = 0.05) and the latter showed less mortality than T3 tumor cases (P = 0.036). Node-negative patients also had a more favorable outcome with lower mortality than node positive patients (P = 0.007). None of the T1 pure mucinous carcinomas had axillary metastasis, which may have implications for the surgical protocols. The evaluation of quantitative and qualitative content in mucosubstances did not correlate with the prognosis. However, sulfomucins were demonstrated in 30.5% of cases; this fact points to add breast carcinoma to the group of neoplasms that may present as a metastatic sulfomucin-producing adenocarcinoma.

Haloperidol: therapeutic window in schizophrenia

Twenty-two schizophrenic inpatients were treated for 3 weeks with three randomly fixed oral doses of haloperidol (10, 20, or 30 mg). Analysis of the results by a nonlinear regression model revealed a curvilinear relationship between haloperidol levels in plasma and clinical response, as assessed on the Brief Psychiatric Rating Scale (pseudo-R2 = 0.85, F = 17.7, p < 0.001, correlation between coefficients ranged from 0.99 to -0.52). This curve defines roughly three drug level ranges (low, < 5.5 ng/ml; optimal, 5.5 to 14.4 ng/ml; and high or toxic, > 14.4 ng/ml), which are significant for clinical practice. Patients with high levels improve to a lesser extent or even worsen in negative symptoms, showing a nonstatistically significant trend to present more extrapyramidal symptoms. Our data thus support the existence of a therapeutic window for haloperidol. Schizophrenic patients with acute exacerbation and drug levels in this range would have a greater probability of global clinical improvement.

Prefrontal dysfunction in young acute neuroleptic-naive schizophrenic patients: a resting and activation SPECT study

Regional cerebral blood flow (rCBF) was measured with single photon emission computed tomography (SPECT) in six neuroleptic-naive, young, acute schizophrenic patients and six normal control subjects. We evaluated rCBF changes in prefrontal areas at rest and during a prefrontal activation task, the Wisconsin Card Sorting Test (WCST). Schizophrenic patients had significantly higher prefrontal blood flow than did control subjects during the resting conditions. During activation, the control group showed significant increases in prefrontal blood flow, whereas the schizophrenic group did not. These results suggest that at rest there is no evidence of hypofrontality, whereas hyperfrontality seems to be the most frequent pattern in our selected sample of young acute neuroleptic-naive schizophrenic patients. Furthermore, schizophrenic patients seem to be unable to increase prefrontal blood flow under conditions that challenge the prefrontal cortex.

Prefrontal and temporal blood flow in schizophrenia: resting and activation technetium-99m-HMPAO SPECT patterns in young neuroleptic-naive patients with acute disease

This study assesses prefrontal and temporal regional cerebral blood flow (rCBF) changes in young, neuroleptic-naive schizophrenic patients with acute disease.

METHODS

A selected population of 10 young, never-treated schizophrenic women with acute disease was studied by two hexamethylpropyleneamine oxime (HMPAO) brain SPECT sessions, performed 48 hr apart, both at rest and during a prefrontal activation task using the Wisconsin Card Sort Test (WCST). All patients met Diagnostic and Statistical Manual of Mental Disorders, 3rd edition-revised criteria for schizophrenia or schizophreniform disorder, were neuroleptic-naive and had acute symptoms.

RESULTS

Under resting conditions, the schizophrenic group had significantly higher rCBF in the prefrontal regions, mainly in the left side and including the anterior cingulate, than did the controls. In addition, schizophrenic patients showed significant interhemispheric differences in prefrontal and posterior temporal index values at rest (left hyperfrontality and left hypotemporality). During WCST activation, the control group showed significant increases in prefrontal blood flow, whereas the schizophrenic group did not.

CONCLUSION

These results support a physiologic dysfunction of the prefrontal cortex in schizophrenia that is present at the onset of the illness prior to neuroleptic treatment. Furthermore, both left hyperfrontality and left hypotemporality may indicate a brain lateralization defect in schizophrenia.

Positive versus negative symptoms in schizophrenia: response to haloperidol

1. Clinical response to treatment with haloperidol was studied in 20 schizophrenic inpatients with acute exacerbation (DSM-IIIR). 2. Patients were assigned to fixed doses of haloperidol (10, 20 or 30 mg/day) for three weeks. Clinical assessment was made using scales SAPS, SANS, BPRS and Simpson-Angus Scale for rating of extrapyramidal side effects. 3. Sixteen patients showed forty per cent or more decrease in positive symptoms assessed by SAPS, being considered the group of responders. Six out of the twenty patients showed improvement in negative symptoms assessed by SANS (improvement above 30%). 4. Clinical predictors of response were only identified for SAPS. The group of responders showed higher basal scores in total scale and formal thought disorder. 5. Negative symptoms responsive to treatment were affective flattening and alogia. Improvement in negative symptoms was independent from that in positive ones. 6. Socio-demographic predictors of clinical response were not found. No differences in clinical response were found in relation to the dose administered. 7. The results of our study suggest that negative symptomatology improves in a scheduled treatment with haloperidol. Assessment of negative symptoms may be useful in the evaluation of treatment of acute schizophrenia.