Clinical and capillaroscopic findings in patients with liver disease and proximal apparent leukonychia (Terry nails and its variants)

Terry nails and Lindsay nails are similar forms of proximal apparent leukonychia (PAL). A change in nail bed vascularity is thought to be responsible for PAL. The study was aimed at investigating the frequency of PAL in patients attending a liver disease clinic, the factors associated with its presence, its value for detecting cirrhosis, its prognostic value for mortality, and associated capillaroscopic findings.A total of 521 patients were included (age range, 18-94 years; 69% men). Systematic nail photographs were evaluated by 2 independent investigators. Disease-related data were obtained from the medical records. Mortality was evaluated after 7 years of follow-up. Nailfold capillaroscopy was performed on a subset of 80 patients.PAL was present in 228 patients (43.8%; Terry nails in 205, Lindsay nails in 20, and both in 3). The kappa-coefficient of interobserver agreement was 0.82. The presence of PAL was associated with cirrhosis and, accordingly, with portal hypertension and hepatocellular dysfunction. The positive likelihood ratio of PAL for the diagnosis of cirrhosis was 1.6 (95% CI 1.3-1.92). PAL was independently associated with chronic alcohol abuse and was not a significant predictor of mortality. Venous loop dilatation and prominence of the venous plexus were observed on capillaroscopy in patients with cirrhosis but were not significantly associated with PAL.In summary, PAL is a common finding in patients from a liver clinic; it is associated with liver cirrhosis and with alcohol abuse. PAL is not associated with specific capillaroscopic findings. We propose the generic term proximal apparent leukonychia instead of classic eponymous titles to avoid confusion in the literature.

[Genetic bases of attention deficit hyperactivity disorder]

AIMS

The purpose of this study is to update the information available on the main group of genes that have been related with a susceptibility to attention deficit hyperactivity disorder (ADHD) or with the pharmacological response to different drugs used in the treatment of ADHD, in a number of different association and meta-analysis studies.

DEVELOPMENT

Different studies have provided evidence of the importance of the genetic load in the susceptibility to ADHD. The work carried out to date point to genes in the dopaminergic system, such as the gene that codes for the dopamine transporter (DAT1 or SLC6A3) and for the dopamine receptor D4 (DRD4); in the noradrenergic system, like the gene coding for the adrenergic alpha-2A receptor (ADRA2A), the COMT gene, which codes for the enzyme catechol-O-methyltransferase and the gene that codes for latrophilin 3 (LPHN3), as genes that are candidates for playing a part in the susceptibility to ADHD, and being involved in the pharmacological response as well as in the risk of presenting associated behavioural disorders. On the other hand, the genes involved in regulating the metabolism of the drugs used in the treatment of ADHD, such as the gene CYP2D6 and gene CES1, play a role in the efficiency and tolerance of these psycho-pharmaceuticals.

CONCLUSIONS

Although in recent years there has been an increase in the number of pharmacogenetic studies conducted on ADHD, findings differ significantly from one study to another. Integrating and meta-analytical studies are needed to be able to develop a more personalised treatment for ADHD.

Insight correlates in child- and adolescent-onset first episodes of psychosis: results from the CAFEPS study

BACKGROUND

The correlates of insight in early-onset psychosis have received little previous attention.

METHOD

We studied clinical correlates of insight in a sample of 110 adolescent recent-onset psychosis patients (mean age 15.53 years; psychotic symptoms present for <6 months). Insight was measured with the Scale to Assess Unawareness of Mental Disorder (SUMD) at baseline, 6 months and 12 months follow-up.

RESULTS

Insight improved over the early phases of the illness, in parallel with psychopathological improvement. Poor insight at baseline and 6 months correlated with poor functioning at 6 and 12 months respectively. Schizophrenia patients had poorer insight than patients with bipolar disorder at 6 and 12 months but not at baseline. Logistic and linear regressions were used to predict 12-month diagnoses and functioning based on insight measurements. Baseline awareness of illness was a significant predictor for diagnosis [odds ratio (OR) 1.4, 95% confidence interval (CI) 1.05-1.97]. Treatment compliance at 6 months did not correlate with baseline SUMD subscores, but correlated with insight into having a disorder (Spearman's rho=0.21, p=0.039), its consequences (Spearman's rho=0.28, p=0.006) and the need for treatment (Spearman's rho=0.26, p=0.012) at 6 months. The 'attribution of symptoms' dimension of insight is poorly correlated with other insight dimensions and with other clinical variables.

CONCLUSIONS

Poor insight correlates with symptom severity and global functioning but also has some trait value for schizophrenia, which is apparent once acute psychotic symptomatology is not prominent. A multi-dimensional approach to the assessment of insight is necessary, as different dimensions are influenced by different factors.

[Attention deficit/hyperactivity disorder: burden of the disease according to subtypes in recently diagnosed children]

INTRODUCTION

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with deterioration of several dimensions of quality of life (QoL) and with the development of comorbid psychiatric disorders. The objective of the present study is to evaluate the burden of illness of ADHD subtypes in untreated newly diagnosed children in Spain.

METHODS

We recruited 124 children (80 combined, 25 inattentive and 19 hyperactive-impulsive subtype) aged 6-12 years with untreated newly diagnosed Diagnostic and Statistical Manual of Mental Disorders, 4th edition DSM-IV) ADHD. We collected socio-demographic, clinical (Attention-Deficit/Hyperactivity Disorder Rating Scale ADHD-RS], Conner's Parent Rating Scale-Revised: Short Form [CPRS:R-S], Clinical Global Impression-Severity [CGI-S], Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version [K-SADS-PL], intelligence Quotient [IQ]), Quality of Life (QoL), Child Health Questionnaire-Parent Form 50 CHQ-PF50), academic performance and health care resources utilization data. We investigated the correlations between ADHD symptom severity and QoL, academic performance and time from onset of symptoms to diagnosis.

RESULTS

QoL of children with combined-type ADHD was rated as significantly worse in patients with predominance of hyperactivity/impulsivity for most of the domains. Inattentive-type children also had worse ratings than patients with hyperactivity/impulsivity predominance in most of the domains. The ADHD Index of Conner's Parent Rating Scale-Revised: Short Form (CPRS-R:S) was significantly lower in hyperactive/impulsive patients. We found no differences across subtypes in IQ, academic performance and health care resources utilization. Higher ADHD symptom severity was associated to poor QoL.

CONCLUSIONS

Combined and inattentive subtypes are associated with greater disorder severity, more comorbid psychiatric disorders, and worse QoL than the subtype with hyperactivity/impulsivity predominance.

Regional cerebral blood flow SPECT study, at rest and during Wisconsin Card Sorting Test (WCST) performance, in schizophrenia naive patients or treated with atypical neuroleptics

INTRODUCTION

To corroborate the hypothesis of hypofrontality in schizophrenia and to study the relationship between positive/negative symptoms (measured by the positive and negative syndrome scale [PANSS]) and regional cortical blood flow (rCBF), both at rest and during the Wisconsin Card Sorting Test (WCST) performance (activation).

METHODS

We compared a control group (n = 18) to a group of patients with schizophrenia (n = 21) in terms of rCBF, measured by single photon emission computed tomography (SPECT).

RESULTS

We found significantly higher left-frontal- CBF (during the WCST performance and at rest) and right-frontal-CBF (only at rest) in control subjects. Only the control group showed a right-frontal-CBF increase during activation. Only the patients group showed a significant right-occipital-CBF increase during the activation. We observed a positive significant correlation between the PANSS-P score and the left- frontal index at rest. Some negative symptoms such as difficulty in abstract thinking (N5) and lack of spontaneity and flow of conversation (N6) are associated to low frontal blood flow at rest. Affective blunting (N1) is associated to low left-frontal blood flow during activation.

CONCLUSIONS

Our data support the hypothesis of hypofrontality, at rest and during activation, which means the incapacity of schizophrenic patients to increase the frontal CBF while performing the WCST (activation). Schizophrenia positive symptoms are associated to high left-frontal blood flow.

[Atomoxetine safety and efficacy in children with attention deficit/hyperactivity disorder (ADHD): initial phase of 10-week treatment in a relapse prevention study with a Spanish sample]

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) appears to be associated to problems with regulation of cortical dopaminergic/noradrenergic function. The purpose of this work is to present efficacy and safety data from 10-week open label treatment with atomoxetine, a highly selective norepinephrine reuptake inhibitor, in a Spanish sample of children and adolescents with ADHD participating in a double-blinded, placebo-controlled, multinational study on relapse prevention.

PATIENTS AND METHODS

Sub-analysis of data in 36 children and adolescents aged 6 to 15 years, with diagnosis of ADHD (DSM-IV) included in Spain, receiving open-label treatment with atomoxetine for 10 weeks and assessed using ADHD-RS, CGI-ADHD-S, CPRS-R:S, CTRS-R:S y CHQ-PF50.

RESULTS

After 10 weeks of treatment with atomoxetine, statistically significant reductions in ADHD-RS, CGI-ADHD-S, CPRS-R:S and CTRS-R:S scores were obtained in both subtypes; 87.5 % of inattentive patients and 82.14 % of patients with combined subtype were responders. No recurrences were observed. No serious adverse event-driven discontinuations occurred, and no statistically significant changes in blood pressure, but a mild increase in heart rate (p < 0.0001) were observed.

CONCLUSIONS

In general, atomoxetine was well tolerated and effective in the open phase in Spanish patients, both for inattentive and combined subtypes. Atomoxetine appears as a non-stimulant therapeutic alternative for the treatment of ADHD.

Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: an open retrospective study

BACKGROUND

This study evaluated divalproex response in sex offenders with a bipolar disorder.

METHODS

We reviewed the records of all sex offenders who participated in a residential rehabilitative program who received divalproex for treatment of a bipolar disorder. Patients' mood symptoms and, when present, comorbid paraphilic symptoms, were retrospectively assessed using the CGI severity scale.

RESULTS

Sex offenders displayed significant improvement in manic symptoms with divalproex treatment. However, there was no significant improvement in paraphilic symptoms in the subset of patients admitting to these symptoms.

CONCLUSION

Divalproex may be effective for manic symptoms in sex offenders with a bipolar disorder. However, for bipolar sex offenders with comorbid paraphilias, the drug may not be effective for paraphilic symptoms.

LIMITATIONS

This study was limited by its retrospective, open-label design, lack of systematic means of assessing manic and paraphilic symptoms, and small sample size.

CLINICAL RELEVANCE

Divalproex may be a helpful adjunct in the treatment of the subset of sex offenders who have a bipolar disorder.

Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections

OBJECTIVE

To investigate the reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections.

METHOD

The 1986 version of the KSADS was modified and expanded to include onset and offset of each symptom for both current and lifetime episodes, expanded prepubertal mania and rapid cycling sections, and categories for attention-deficit/hyperactivity disorder and other DSM-IV diagnoses. To optimize diagnostic research, skip-outs were minimized. Subjects participated in the ongoing "Phenomenology and Course of Pediatric Bipolar Disorder" study. Mothers and children were interviewed separately by research nurses who were blind to diagnostic group status. In addition, ratings of off-site child psychiatrists, made from the narrative documentation given for each WASH-U-KSADS item, were compared with research nurse ratings. This work was performed between 1995 and 2000.

RESULTS

There was 100% interrater reliability, five consecutive times, as both interviewer and observer after 10 to 15 trials. The kappa values of comparisons between research nurse and off-site blind best-estimate ratings of mania and rapid cycling sections were excellent (0.74-1.00). High 6-month stability for mania diagnoses (85.7%) and for individual mania items and validity against parental and teacher reports were previously reported.

CONCLUSIONS

The WASH-U-KSADS mania and rapid cycling sections have acceptable reliability.