Contribution of NHE3 and dietary phosphate to lithium pharmacokinetics

Lithium is one of the mainstays for the treatment of bipolar disorder despite its side effects on the endocrine, neurological, and renal systems. Experimentally, lithium has been used as a measure to determine proximal tubule reabsorption based on the assumption that lithium and sodium transport go in parallel in the proximal tubule. However, the exact mechanism by which lithium is reabsorbed remains elusive. The majority of proximal tubule sodium reabsorption is directly or indirectly mediated by the sodium-hydrogen exchanger 3 (NHE3). In addition, sodium-phosphate cotransporters have been implicated in renal lithium reabsorption. In order to better understand the role of sodium-phosphate cotransporters involved in lithium (re)absorption, we studied lithium pharmacokinetics in: i) tubule-specific NHE3 knockout mice (NHE3^{loxloxPax8Cre}), and ii) mice challenged with low or high phosphate diets. Intravenous or oral administration of lithium did not result in differences in lithium bioavailability, half-life, maximum plasma concentrations, area under the curve, lithium clearance, or urinary lithium/creatinine ratios between control and NHE3^{loxloxPax8Cre} mice. After one week of dietary phosphate challenges, lithium bioavailability was ~30% lower on low versus high dietary phosphate, possibly the consequence of a smaller area under the curve after oral administration. This was associated with higher apparent lithium clearance after oral administration and lower urinary lithium/creatinine ratios on low versus high dietary phosphate. Collectively, renal NHE3 does not play a role in lithium pharmacokinetics; however, dietary phosphate could have an indirect effect on lithium bioavailability and lithium disposition.

The relationship between cognitive and social functioning in older patients with bipolar disorder

OBJECTIVES

Patients with bipolar disorder (BD) show specific cognitive impairments, especially in the domains of attention, executive functioning and memory. Social and occupational problems seem to exist in 30-60% of BD patients. This study analysed the relationship between cognitive and social functioning in older age BD (OABD) patients.

METHODS

This study included 63 OABD patients (aged > 60). Cognitive functioning was measured by an extensive neuropsychological assessment including global cognitive functioning, attention, learning and memory, executive functioning and verbal fluency. Social functioning, was obtained by clinical interview, including global social functioning, meaningful contacts and social participation. Linear regression analyses were conducted between cognitive performance and social functioning and the role of depression severity and disease duration was explored.

RESULTS

Global social functioning, number of meaningful contacts and social participation were not interrelated. Global cognitive functioning, learning and memory and executive functioning were positively associated with global social functioning. No associations were found between cognitive functioning and social participation or meaningful contacts. Depression severity and disease duration were no effect modifiers.

LIMITATIONS

Limitations include the use of a sample with relatively low cognitive and social impairments and the use of a cross-sectional research design.

CONCLUSIONS

Global social functioning judged by the clinician was found to be independent of social functioning defined by the number of social contacts and social participation as reported by the patient. Global social functioning was related to cognitive functioning. An integrative treatment intervention including cognitive training and addressing social functioning may improve daily functioning in OABD patients.

A nationwide study on concordance with multimodal treatment guidelines in bipolar disorder

Background

Most previous studies on concordance with treatment guidelines for bipolar disorder focused on pharmacotherapy. Few studies have included other treatment modalities.

Aims

To study concordance with the Dutch guideline of various treatment modalities in outpatient treatment settings for patients with bipolar disorder and to identity factors associated with concordance.

Methods

A nationwide non-interventional study using psychiatrists’ and patients’ surveys.

Results

839 patients with bipolar or schizoaffective disorder bipolar type were included. Concordance with the guideline was highest for participation of a psychiatrist in the treatment (98%) and for maintenance pharmacotherapy (96%), but lower for supportive treatment (73.5%), use of an emergency plan (70.6%), psychotherapy (52.2%), group psychoeducation (47.2%), and mood monitoring (47%). Presence of a written treatment plan, a more specialized treatment setting, more years of education, and diagnosis of bipolar I disorder versus bipolar II, bipolar NOS, or schizoaffective disorder were significantly associated with better concordance.

Conclusion

In contrast to pharmacotherapy, psychosocial treatments are only implemented to a limited extend in everyday clinical practice in bipolar disorder. More effort is needed to implement non-pharmacological guideline recommendations for bipolar disorder.

[Surgical treatment of BPO: Standard and innovations]

INTRODUCTION AND OBJECTIVE

Surgical management of benign prostatic hyperplasia has dramatically changed in the recent years towards higher proportion of endoscopic treatment and fewer perioperative complications. Nevertheless the question of urinary and sexual quality of life after surgical treatment remains partially unresolved with a high proportion of retrograde ejaculation after conventional surgical treatments. Therefore mini-invasive alternatives to conventional surgery have been proposed. The objective of this literature review was to provide an overview of the alternatives to monopolar TURP currently available in France.

MATERIAL AND METHOD

A non-systematic review of the scientific literature was conducted from the PubMed database to retrieve the most relevant scientific publications. A first research was cross-referenced with the results of literature reviews already published and enriched by the authors of this review. A synthesis is proposed for each alternative technique mentioning its level of clinical development, but also its potential advantages and disadvantages compared to conventional surgical techniques.

RESULTS

The quality of life of patients after surgical or interventional management has become the main priority of urologists since the risks of perioperative complication have been reduced by the use of laser or bipolar endoscopic techniques. Thanks to the development of minimally invasive alternatives that are better and better evaluated by randomized trials versus interventional simulation and conventional surgical treatment, more personalized care is possible. Patients' expectations and their individual risk factors can thus be placed at the center of the therapeutic decision and the preoperative information.

CONCLUSION

The surgical and interventional management of LUTS due to BPH has evolved to lower perioperative morbidity with the help of numerous technological developments. Mini-invasive alternatives to standard treatment have also been proposed in order to improve the quality of postoperative sexual life. These alternatives provide significant improvement in LUTS that remains lower than after conventional treatments. Somme of these alternative are also not fully supported by clinical trials, which should urge urologists to act with caution when proposing these alternatives in daily clinical practice.

Prior suicide attempts predict worse clinical and functional outcomes in young people attending a mental health service

BACKGROUND

Mental disorders and suicidal thoughts and behaviours are common in help-seeking youth. Few studies report the longitudinal associations between these phenomena and clinical and functional outcomes. This study examined whether prior suicide attempts predict poorer outcomes in mental health service attendees.

METHODS

Clinical and functional data from 1143 individuals (aged 12-30) attending a primary care-based mental health service in Australia were collected over 3-60 months (median = 21 months). Odds ratios (OR) with 95% confidence intervals for the effect of a prior suicide attempt on follow-up outcomes were estimated (adjusted for confounders).

RESULTS

Prior suicide attempts were common (n = 164; 14%) and prospectively associated with suicidal thoughts (OR = 1.71), suicide attempts (OR = 2.59), self-harm (OR = 1.71), an increased likelihood of being diagnosed with bipolar disorder (OR = 2.99), and the onset of an alcohol/substance use disorder (OR = 2.87). Over the course of care, no suicide attempts were reported in 1052 (92%) individuals, but 25 (2%) had recurrent attempts, and 66 (6%) had new onset of an attempt. New onset was associated with being female and previous suicidal ideation or self-harm; recurrent attempts were associated with being older and comorbid alcohol/substance use disorder.

LIMITATIONS

The cohort includes only individuals who remained in clinical contact, and the consistency of their documentation varied (across clinicians and over time).

CONCLUSIONS

Young people with prior suicide attempts are vulnerable to ongoing suicidal behaviours, and poorer clinical and functional outcomes. More intensive management strategies may be needed to directly address these behaviours and the long-term risks they confer. These behaviours also emerge over the course of care among those with no previous history, which has important implications for active service-level strategies that target these behaviours for all of those who present to such services.

Predictors of severe relapse in pregnant women with psychotic or bipolar disorders

Pregnancy in women with severe mental illness is associated with adverse outcomes for mother and infant. There are limited data on prevalence and predictors of relapse in pregnancy. A historical cohort study using anonymised comprehensive electronic health records from secondary mental health care linked with national maternity data was carried out. Women with a history of serious mental illness who were pregnant (2007-2011), and in remission at the start of pregnancy, were studied; severe relapse was defined as admission to acute care or self-harm. Predictors of relapse were analysed using random effects logistic regression to account for repeated measures in women with more than one pregnancy in the study period. In 454 pregnancies (389 women) there were 58 (24%) relapses in women with non-affective psychoses and 25 (12%) in women with affective psychotic or bipolar disorders. Independent predictors of relapse included non-affective psychosis (adjusted OR = 2.03; 95% CI = 1.16-3.54), number of recent admissions (1.37; 1.03-1.84), recent self-harm (2.24; 1.15-4.34), substance use (2.15; 1.13-4.08), smoking (2.52; 1.26-5.02) and non-white ethnicity (black ethnicity: 2.37; 1.23-4.57, mixed/other ethnicity: 2.94; 1.32-6.56). Women on no regular medication throughout first trimester were also at greater risk of relapse in pregnancy (1.99; 1.05-3.75). There was no interaction between severity of illness and medication status as relapse predictors. Therefore, women with non-affective psychosis and higher number of recent acute admissions are at significant risk of severe relapse in pregnancy. Continuation of medication in women with severe mental illness who become pregnant may be protective.

[Impact of psychoeducation on the disease concept in bipolar patients]

Aim of the investigation was the proof of influence of specific psychoeducation for bipolar disorder patients and their concept of illness. Additionally we looked in a subsample at the in literature described equal efficacy of peer to peer councelling and councelling by bipolar specialists in psychoeducationIn our investigation on 176 bipolar patients we could show in group psychoeducation that specific group psychoeducation by trained personal and by experts leads to a changed perception of the disorder concept. The participants relied more in medication and trusted doctors and agreed to suffer from a serious disorder. Our results show that the additional factor alcohol consumption abolishes the effect of psychoeducation in bipolar patients.The concept of the disease was only changed in patients without alcohol consumption. This group showed additional decrease of negetive expectancies and had a hopeful attitude regarding the further course of the disorder.In a subgroup where experts (peers) were trained for psychoeducation councelling and performed peer to peer psychoeducational groups we found the same positive changes in the attitude towards the disorder, but there was a significant higher proportion of dropouts in the peer leaded groups.

Evidence supporting a mechanistic role of sirtuins in mood and metabolic disorders

Sirtuins are NAD⁺-dependent histone deacetylases that play essential roles in cell survival, energy metabolism, inflammation, and aging; therefore, sirtuins are potential therapeutic targets in the treatment of type 2 diabetes, cancer, inflammatory and metabolic disorders, and neurodegenerative diseases. Available evidence provides the basis for hypothesizing that sirtuins 1, 2, and 3 (SIRT1, SIRT2, and SIRT3) may have a mechanistic role subserving mood disorders (i.e. downregulation) and associated co-morbidity (e.g. metabolic disorders). Specifically, the domains of general cognitive processes, as well as cognitive emotional processing may be particularly relevant to sirtuin physiology. Given the role of sirtuins in the perpetuation of circadian rhythmicity, and evidence of dysfunctional circadian cycling in mood disorders, sirtuins may be an underlying etiological factor that links circadian rhythm functionality with mood disorders. Caloric restriction, and caloric restriction mimetics (e.g. resveratrol) are all capable of upregulating sirtuin isoforms implicated in stress response syndromes. Repurposing existing treatments and/or discovery of novel agents capable of modulating sirtuin physiology may represent genuinely novel approaches for trans-diagnostic domains affected in mood disorders and other brain-based illnesses.

Manic temporality

Time-consciousness has long been a focus of research in phenomenology and phenomenological psychology. We advance and extend this tradition of research by focusing on the character of temporal experience under conditions of mania. Symptom scales and diagnostic criteria for mania are peppered with temporally inflected language: increased rate of speech, racing thoughts, flight-of-ideas, hyperactivity. But what is the underlying structure of temporal experience in manic episodes? We tackle this question using a strategically hybrid approach. We recover and reconstruct three hypotheses regarding manic temporality that were advanced and modeled by two pioneers of clinical phenomenology: Eugène Minkowski (1885-1972) and Ludwig Binswanger (1881-1966). We then test, critique, and refine these hypotheses using heterophenomenological methods in an interview-based study of persons with a history of bipolar and a current diagnosis of acute mania. Our conclusions support a central hypothesis due to Minkowski and Binswanger, namely, that disturbance in the formal structure of temporal experience is a core feature of mania. We argue that a suitably refined variant of Binswanger's model of disturbance in manic protention helps to explain a striking pattern of impaired insight and impaired reasoning in manic episodes.

Neuromonitoring During Robotic Cochlear Implantation: Initial Clinical Experience

During robotic cochlear implantation a drill trajectory often passes at submillimeter distances from the facial nerve due to close lying critical anatomy of the temporal bone. Additional intraoperative safety mechanisms are thus required to ensure preservation of this vital structure in case of unexpected navigation system error. Electromyography based nerve monitoring is widely used to aid surgeons in localizing vital nerve structures at risk of injury during surgery. However, state of the art neuromonitoring systems, are unable to discriminate facial nerve proximity within submillimeter ranges. Previous work demonstrated the feasibility of utilizing combinations of monopolar and bipolar stimulation threshold measurements to discretize facial nerve proximity with greater sensitivity and specificity, enabling discrimination between safe (> 0.4 mm) and unsafe (< 0.1 mm) trajectories during robotic cochlear implantation (in vivo animal model). Herein, initial clinical validation of the determined stimulation protocol and nerve proximity analysis integrated into an image guided system for safety measurement is presented. Stimulation thresholds and corresponding nerve proximity values previously determined from an animal model have been validated in a first-in-man clinical trial of robotic cochlear implantation. Measurements performed automatically at preoperatively defined distances from the facial nerve were used to determine safety of the drill trajectory intraoperatively. The presented system and automated analysis correctly determined sufficient safety distance margins (> 0.4 mm) to the facial nerve in all cases.

Integrated psychological therapy for people with bipolar disorder and co-morbid alcohol use: A feasibility and acceptability randomised controlled trial

BACKGROUND

Co-morbid substance misuse, particularly alcohol, is common in bipolar disorder (BD) and associated with worse treatment outcomes. Research into psychological interventions for substance misuse in BD is at an early stage and no studies have specifically targeted problematic alcohol use. This paper describes the context and protocol for a feasibility and acceptability randomised controlled trial (RCT) evaluating a novel intervention combining motivational interviewing and cognitive behavioural therapy (MI-CBT) for participants with BD and problematic alcohol use, developed in collaboration with people with lived experience of both issues.

METHODS AND DESIGN

An RCT will assess the feasibility and acceptability of MI-CBT in addition to treatment as usual (TAU) compared with TAU alone. Participants will be recruited from across the North West of England through NHS services and self-referral. The primary outcomes will be the feasibility and acceptability of the intervention assessed by recruitment to target, adherence to intervention, retention rate at follow-up, absence of adverse events and qualitative analysis of participants' reported experiences of intervention. The effect size of the impact of the intervention on alcohol use and mood outcomes will also be estimated. In addition, we will explore a number of potential process variables in therapy.

DISCUSSION

This is the first RCT evaluating MI-CBT for BD and problematic alcohol use. Given the prevalence and impact of alcohol problems in BD this novel integrated intervention may have potential to offer important improvements in clinical and functional outcomes.

Bipolar Dislocation of the Arm (Shoulder And Elbow): About One Case in an African Teaching Hospital

We report an exceptional clinical case of an ipsilateral dislocation fracture of the shoulder and right elbow, realizing a “swinging arm”. Following a violent road accident, patient S.I, a 43-year-old left-handed sports educator, presented with an antero-medial shoulder dislocation fracture and a posterolateral ipsilateral elbow fracture-dislocation. The reduction in urgency, followed by the orthopedic compression by Mayo Clinic and functional rehabilitation, allowed obtaining a good result after seven months. The ipsilateral bipolar dislocation of the shoulder and elbow is an exceptional lesional entity. Its adequate care in emergency makes it possible to obtain good anatomical and functional results.

Neuropsychological Functioning in Euthymic Phase of Bipolar Affective Disorder

BACKGROUND

A substantial proportion of euthymic bipolar disorder patients have neuropsychological impairment which can have a significant impact on the overall functional recovery.

MATERIALS AND METHODS

A total of 60 bipolar disorder patients, currently in euthymic phase for the last 3 months with minimum duration of illness 2 years and current Young Mania Rating Scale <7 and Hamilton Depression Rating Scale <6, currently on medications were administrated various neuropsychological tests.

RESULTS

Approximately half of the patients have neuropsychological impairments in the areas of mental speed, sustained attention, verbal fluency, working memory, set shifting, verbal and visual memory, and visual-constructional ability.

CONCLUSION

Findings of the current study provides evidence of neuropsychological impairment in euthymic bipolar disorder patients, and type of medications also has an impact on neuropsychological functions.

Social stress response in adolescents with bipolar disorder

OBJECTIVE

Theoretical models posit that stressors contribute to the onset and maintenance of bipolar disorder in adolescence through disruptions in stress physiology, but physiological response to stressors has not been evaluated in adolescents with bipolar illness. The present study tests the hypothesis that adolescents with bipolar disorder will have greater reactivity to a laboratory social stress task than healthy adolescents.

METHOD

Adolescents with bipolar illness (n = 27) and healthy adolescents (n = 28) completed a modified version of the Trier Social Stress Task. Stress response was assessed using high frequency heart rate variability (HF-HRV), heart rate (HR), mean arterial blood pressure (MAP), salivary cortisol, and subjective stress. Multilevel models were used to test for group differences in resting-state physiology, and stress reactivity and recovery.

RESULTS

Adolescents with bipolar disorder had greater reactivity in HF-HRV (z = 3.32), but blunted reactivity in MAP (z = -3.08) and cortisol (z = -2.60), during the stressor compared to healthy adolescents. They also had lower resting HF-HRV (z = -3.49) and cortisol (z = -2.86), and higher resting HR (z = 3.56), than healthy adolescents.

CONCLUSIONS

These results indicate that bipolar disorder is associated with disruptions in autonomic and endocrine response to stress during adolescence, including greater HF-HRV reactivity. Further research should evaluate whether these individual differences in stress physiology precede and predict the onset of mood episodes.

Evidence for association between familial bipolar risk and ventral striatal volume

BACKGROUND

Recent genome-wide association studies (GWAS) of striatal volumes and bipolar disorder (BD) indicate these traits are heritable and share common genetic architecture, however little independent work has been conducted to help establish this relationship.

METHODS

Subcortical volumes (mm3) of young, healthy offspring of BD (N= 32) and major depressive disorder (MDD) patients (N= 158) were compared to larger healthy control sample (NRANGE= 925-1052) adjusting for potential confounds, using data from the latest release (S1200) of the Human Connectome Project. Based on recent GWAS findings, it was hypothesised that the accumbens and caudate would be smaller in offspring of BD, but not MDD patients.

RESULTS

After multiple comparison correction, there was a regional and BD specific relationship in the direction expected (Accumbens: F2,1067= 6.244, PFDR-CORRECTED= 0.014).

DISCUSSION

In line with recent GWAS, there was evidence supporting the hypothesis that reduced striatal volume may be part of the genetic risk for BD, but not MDD.

LIMITATIONS

It cannot be concluded whether this association was specific to BD or consistent with a broader psychosis phenotype, due to a small sample size for offspring of schizophrenia patients. Furthermore, one cannot rule out potential shared environmental influences of parental BD.

CONCLUSIONS

The common genetic architecture of BD may confer susceptibility via inherited genetic factors that affect striatal volume. Future work should establish how this relationship relates to specific BD symptomology. This work may also help to dissect clinical heterogeneity and improve diagnosis nosology.

Peroxisome Proliferator-Activated Receptor Gamma Coactivator-1 Alpha as a Novel Target for Bipolar Disorder and Other Neuropsychiatric Disorders

Peroxisome proliferator-activated receptor gamma coactivator-1 alpha (PGC-1 alpha) is a protein that regulates metabolism and inflammation by activating nuclear receptors, especially the family of peroxisome proliferator-activated receptors (PPARs). PGC-1 alpha and PPARs also regulate mitochondrial biogenesis, cellular energy production, thermogenesis, and lipid metabolism. Brain energy metabolism may also be regulated in part by the interaction between PGC-1 alpha and PPARs. Because neurodegenerative diseases (Huntington's disease, Parkinson's disease, and amyotrophic lateral sclerosis) and bipolar disorder have been associated with dysregulated mitochondrial and brain energy metabolism, PGC-1 alpha may represent a potential drug target for these conditions. The purpose of this article is to review the physiology of PGC-1 alpha, PPARs, and the role of PPAR agonists to target PGC-1 alpha to treat neurodegenerative diseases and bipolar disorder. We also review clinical trials of repurposed antidiabetic thiazolidines and anti-triglyceride fibrates (PPAR agonists) for neurodegenerative diseases and bipolar disorder. PGC-1 alpha and PPARs are innovative potential targets for bipolar disorder and warrant future clinical trials.

Cognitive effects of transcranial direct current stimulation treatment in patients with major depressive disorder: An individual patient data meta-analysis of randomised, sham-controlled trials

Transcranial direct current stimulation (tDCS) has emerged as a promising new treatment for major depression. While recent randomised, sham-controlled studies found tDCS to have antidepressant effects, it remains to be determined whether a tDCS treatment course may also enhance cognitive function independent of mood effects in depressed patients. This systematic review and individual patient data (IPD) meta-analysis examined cognitive outcomes from randomised, sham-controlled trials of tDCS treatment for major depression. Seven randomised, sham-controlled trials (n = 478 participants, 260 in active and 218 in sham) of tDCS for major depression were included. Results showed no cognitive enhancement after active tDCS compared to sham for the 12 cognitive outcomes investigated. Active relative to sham tDCS treatment was associated with reduced performance gains on a measure of processing speed (β = -0.33, 95% CI -0.58; -0.08, p = 0.011). Active tDCS treatment for depression did not show cognitive benefits independent of mood effects. Rather, tDCS treatment relative to sham stimulation for major depression may instead be associated with a reduced practice effect for processing speed.

Case series of diagnostic shift from bipolar disorder to schizoaffective disorder

OBJECTIVE

To describe three cases of diagnostic shift from bipolar I disorder (BD) to schizoaffective disorder (SAD).

METHODS

BD patients were clinically assessed and followed up in a mood disorder program. A questionnaire was applied to assess clinical and socio-demographic characteristics, and a Structured Clinical Interview (SCID-I) was conducted.

RESULTS

We identified three patients with diagnosis conversion to SAD from 2005 to 2016. The mean time between BD diagnosis and the diagnostic shift to SAD was 9 years.

CONCLUSIONS

Psychotic symptoms may become persistent, chronic and unrelated to the presence of mood episodes many years after the beginning of BD. Psychiatrists should be aware of this and reassess the diagnosis during the longitudinal course of BD, especially in those patients who present psychotic symptoms.

Reasons for revision of failed hemiarthroplasty: Are there any differences between unipolar and bipolar?

BACKGROUND

Hemiarthroplasty (HA) is an effective procedure for treatment of femoral neck fracture. However, it is debatable whether unipolar or bipolar HA is the most suitable implant.

OBJECTIVE

The purpose of this study was to compare the causes of failure and longevity in both types of HA.

MATERIALS AND METHODS

We retrospectively reviewed 133 cases that underwent revision surgery of HA between 2002 and 2012. The causes of revision surgery were identified and stratified into early (≤ 5 years) failure and late (> 5 years) failure. Survival analyses were performed for each implant type.

RESULTS

The common causes for revision were aseptic loosening (49.6%), infection (22.6%) and acetabular erosion (15.0%). Unipolar and bipolar HA were not different in causes for revision, but the unipolar group had a statistically significantly higher number of acetabular erosion events compared with the bipolar group (p = 0.002). In the early period, 24 unipolar HA (52.9%) and 28 bipolar HA (34.1%) failed. There were no statistically significant differences in the numbers of revised HA in each period between the two groups (p = 0.138). The median survival times in the unipolar and bipolar groups were 84.0 ± 24.5 and 120.0 ± 5.5 months, respectively. However, the survival times of both implants were not statistically significantly different.

CONCLUSIONS

Aseptic loosening was the most common reason for revision surgery after hemiarthroplasty surgery in early and late failures. Unipolar and bipolar hemiarthroplasty were not different in terms of causes of failure and survivorship except bipolar hemiarthroplasty had many fewer acetabular erosion events.

The P1 visual-evoked potential, red light, and transdiagnostic psychiatric symptoms

A reduced P1 visual-evoked potential amplitude has been reported across several psychiatric disorders, including schizophrenia-spectrum, bipolar, and depressive disorders. In addition, a difference in P1 amplitude change to a red background compared to its opponent color, green, has been found in schizophrenia-spectrum samples. The current study examined whether specific psychiatric symptoms that related to these P1 abnormalities in earlier studies would be replicated when using a broad transdiagnostic sample. The final sample consisted of 135 participants: 26 with bipolar disorders, 25 with schizophrenia-spectrum disorders, 19 with unipolar depression, 62 with no current psychiatric disorder, and 3 with disorders in other categories. Low (8%) and high (64%) contrast check arrays were presented on gray, green, and red background conditions during electroencephalogram, while an eye tracker monitored visual fixation on the stimuli. Linear regressions across the entire sample (N = 135) found that greater severity of both clinician-rated and self-reported delusions/magical thinking correlated with a reduced P1 amplitude on the low contrast gray (neutral) background condition. In addition, across the entire sample, higher self-reported constricted affect was associated with a larger decrease in P1 amplitude (averaged across contrast conditions) to the red, compared to green, background. All relationships remained statistically significant after covarying for diagnostic class, suggesting that they are relatively transdiagnostic in nature. These findings indicate that early visual processing abnormalities may be more directly related to specific transdiagnostic symptoms such as delusions and constricted affect rather than specific psychiatric diagnoses or broad symptom factor scales.

Pattern recognition of magnetic resonance imaging-based gray matter volume measurements classifies bipolar disorder and major depressive disorder

BACKGROUND

Bipolar Disorder (BD) cannot be reliably distinguished from Major Depressive Disorder (MDD) until the first manic or hypomanic episode. Consequently, many patients with BD are treated with antidepressants without mood stabilizers, a strategy that is often ineffective and carries a risk of inducing a manic episode. We previously reported reduced cortical thickness in right precuneus, right caudal middle-frontal cortex and left inferior parietal cortex in BD compared with MDD.

METHODS

This study extends our previous work by performing individual level classification of BD or MDD in an expanded, currently unmedicated, cohort using gray matter volume (GMV) based on Magnetic Resonance Imaging and a Support Vector Machine. All patients were in a Major Depressive Episode and a leave-two-out analysis was performed.

RESULTS

Nineteen out of 26 BD subjects and 20 out of 26 MDD subjects were correctly identified, for a combined accuracy of 75%. The three brain regions contributing to the classification were higher GMV in bilateral supramarginal gyrus and occipital cortex indicating MDD, and higher GMV in right dorsolateral prefrontal cortex indicating BD.

LIMITATIONS

This analysis included scans performed with two different headcoils and scan sequences, which limited the interpretability of results in an independent cohort analysis.

CONCLUSIONS

Our results add to previously published data which suggest that regional gray matter volume should be investigated further as a clinical diagnostic tool to predict BD before the appearance of a manic or hypomanic episode.

Clinical utility of biomarkers of the hand in the diagnosis of schizophrenia

A number of biomarkers were assessed in photos and prints of the hands of 95 patients with a variety of mental disorders to determine whether patients with schizophrenia could be distinguished from the others. Patients were recruited as consecutive admissions from an outpatient psychiatric day hospital population. Fourteen patients were diagnosed with schizophrenia/schizoaffective disorder and 81 were diagnosed with other mental disorders. A discriminant analysis yielded an overall 80% correct classification, with a sensitivity (schizophrenia patients identified correctly) of 78.6% and a specificity (non-schizophrenia patients identified correctly) of 80.2%. Significant differences were noted in the proximal interphalangeal joint, eponychium of the middle digit and fingernails. To determine biomarker frequency distribution patients with bipolar disorder were then compared to those with schizophrenia/schizoaffective disorder and then to patients with PTSD. The former yielded an overall 78.6% correct classification, with a sensitivity of 71.4% and a specificity of 85.7% and with similar biomarker frequency distribution for bipolar disorder as for the entire non schizophrenia group. The latter comparison yielded an overall 58.6% correct classification, with no significant differences between the features. The application of these biomarkers in clinical practice could constitute an additional tool for the psychiatrist in cases lacking diagnostic clarity.

Successful recruitment to trials: findings from the SCIMITAR+ Trial

Background

Randomised controlled trials (RCT) can struggle to recruit to target on time. This is especially the case with hard to reach populations such as those with severe mental ill health. The SCIMITAR+ trial, a trial of a bespoke smoking cessation intervention for people with severe mental ill health achieved their recruitment ahead of time and target. This article reports strategies that helped us to achieve this with the aim of aiding others recruiting from similar populations.

Methods

SCIMITAR+ is a multi-centre pragmatic two-arm parallel-group RCT, which aimed to recruit 400 participants with severe mental ill health who smoke and would like to cut down or quit. The study recruited primarily in secondary care through community mental health teams and psychiatrists with a smaller number of participants recruited through primary care. Recruitment opened in October 2015 and closed in December 2016, by which point 526 participants had been recruited. We gathered information from recruiting sites on strategies which led to the successful recruitment in SCIMITAR+ and in this article present our approach to trial management along with the strategies employed by the recruiting sites.

Results

Alongside having a dedicated trial manager and trial management team, we identified three main themes that led to successful recruitment. These were: clinicians with a positive attitude to research; researchers and clinicians working together; and the use of NHS targets. The overriding theme was the importance of relationships between both the researchers and the recruiting clinicians and the recruiting clinicians and the participants.

Conclusions

This study makes a significant contribution to the limited evidence base of real-world cases of successful recruitment to RCTs and offers practical guidance to those planning and conducting trials. Building positive relationships between clinicians, researchers and participants is crucial to successful recruitment.

Percutaneous radiofrequency ablation of painful spinal metastasis: a systematic literature assessment of analgesia and safety

PURPOSE

Radiofrequency ablation (RFA) is the most common percutaneous technique applied to treat painful spinal metastasis; however, experience in this field is somehow still limited. A systematic literature research was performed to understand the effects of RFA in terms of analgesia and safety.

MATERIALS AND METHODS

Inclusion criteria for the studies were as follows: (1) randomised controlled or non-randomised studies with a prospective or retrospective design; (2) population made up of adults with spinal metastasis; (3) spinal metastasis treated with RFA alone or in combination/comparison with other treatments; (4) studies reporting about patients' pain before and at least one time-point following RFA; and (5) English-language studies.

RESULTS

Seven hundred and thirty-three articles were screened and 8 (4 prospective, 4 retrospective) matched the inclusion criteria. Study population ranged between 10 and 92 patients across studies. Five out of eight studies reported a highly effective pain management (≥4 points of pain reduction between baseline and the last time-point available); 2/8 studies reported moderate results (≥2 points of pain reduction between baseline and the last time-point available). All studies combined RFA with cement augmentation in the vast majority of patients (40-100%) or metastasis (94-95.8%). Grade I-IIIa neural complications were reported in up to 16% of the cases and were always managed conservatively or with steroids.

CONCLUSIONS

RFA, combined with vertebral augmentation in most of the cases, is effective and safe in achieving short- to mid-term (from 1 week to 6 months) analgesia in patients affected by painful spinal metastasis.