[Reversible posterior encephalopathy syndrome and cardiomyopathy after bevacizumab therapy]

INTRODUCTION

Bevacizumab is an antibody directed against VEGF-A. It is approved for the treatment of many cancer diseases. Its side effects are currently not well known by physicians.

CASE REPORT

A 70-year-old female with metastatic colonic adenocarcinoma was admitted in the intensive care unit because of a coma, four days after having received a combined monthly chemotherapy containing bevacizumab, oxaliplatine, 5 fluorouracil, and folinic acid for the fourth time. On clinical examination, she presented with lower limbs spasticity and hypertension. Etiologic investigations, including cerebral tomodensitometry, cerebrospinal fluid examination, psychotropic drugs urinary testing, and electroencephalogram, were negative. Consciousness improved without any other treatment than nicardipine and urapidil, but the patient was initially confused. Cerebral magnetic resonance imaging showed changes suggestive of posterior reversible encephalopathy syndrome, but also involving frontal lobes. There were additional biological and echocardiographic changes suggestive of cardiac involvement. The patient recovered completely of both cardiac and neurologic manifestations 10 days later.

CONCLUSION

Physicians should be aware of cardiovascular adverse effects of bevacizumab. High blood pressure must be treated to avoid more severe complications. When a posterior reversible encephalopathy syndrome occurs, cardiac involvement should be investigated.

The role of age in the development of Schneiderian symptoms in patients with a first psychotic episode

OBJECTIVE

The likelihood of developing psychotic symptoms greatly increases after puberty. In acute psychotic disorders, first rank symptoms (FRS) are prevalent and considered useful for the diagnostic process. The aim of this study was to test for a linear association between age and the probability of occurrence of FRS in patients with a first psychotic episode (FPE).

METHOD

A total of 112 patients, consecutively admitted with an FPE, were included at baseline and evaluated yearly over a 3-year period using SCID-I and a checklist of 11 items of FRS.

RESULTS

FRS were documented for 65.2% patients at baseline. There was a dose-response relationship in the association between age and FRS. There was no interaction with sex or with final diagnostic category.

CONCLUSION

Variation in the expression of the core positive symptoms of psychosis is subject to the influence of underlying age-dependent maturational processes both in terms of occurrence and level of severity.

Psychoeducation and cognitive-behavioral therapy in bipolar disorder: an update

OBJECTIVE

To review the available literature on psychoeducation and cognitive-behavioral therapy (CBT) in bipolar disorder (BD) and to give an integral view of these therapies.

METHOD

Studies were identified through Medline searches in English language publications between 1971 and 2003. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice.

RESULTS

A number of studies demonstrate that psychoeducation enhances adherence to treatment, and one finds that it improves outcome in BD. Other studies find that CBT diminishes depressive symptoms and improves quality of life in BD. Occasionally some adverse effects may occur with psychotherapy and, although they are sporadic, should not be overlooked.

CONCLUSION

When combined with pharmacological treatment, psychoeducation helps to improve adherence. Training in the identification of early manic symptoms helps to improve outcomes and decreases the number of manic relapses in BD.

Principal components of mania

OBJECTIVE

An alternative to the categorical classification of psychiatric diseases is the dimensional study of the signs and symptoms of psychiatric syndromes. To date, there have been few reports about the dimensions of mania, and the existence of a depressive dimension in mania remains controversial. The aim of this study was to investigate the dimensions of manic disorder by using classical scales to study the signs and symptoms of affective disorders.

METHODS

One-hundred and three consecutively admitted inpatients who met DSM IV criteria for bipolar disorder, manic or mixed were rated with the Young Mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS-21). A principal components factor analysis of the HDRS-21 and the YMRS was carried out.

RESULTS

Factor analysis showed five independent and clinically interpretable factors corresponding to depression, dysphoria, hedonism, psychosis and activation. The distribution of factor scores on the depressive factor was bimodal, whereas it was unimodal on the dysphoric, hedonism and activation factors. Finally, the psychosis factor was not normally distributed.

LIMITATIONS

Patients of the sample were all medicated inpatients.

CONCLUSIONS

Mania seems to be composed of three core dimensions, i.e. hedonism, dysphoria and activation, and is frequently accompanied by a psychotic and a depressive factor. The existence of a depressive factor suggests that it is essential to evaluate depression during mania, and the distribution of the depressive factor supports the existence of two different states in mania.

Age-dependence of Schneiderian psychotic symptoms in bipolar patients

Psychotic symptoms frequently occur in bipolar disorder, especially in younger patients. However, whether the association with younger age also extends to psychotic symptoms that have traditionally been associated with schizophrenia, such as Schneiderian first-rank symptoms (FRSs), is unclear. This study examined FRSs in bipolar I patients and their relationship to age and gender. The sample comprised 103 consecutive inpatients who met DSM IV criteria for bipolar disorder, manic or mixed. FRSs were rated with the Scale for the Assessment of Positive Symptoms (SAPS). Interaction between FRSs and gender and FRSs and age was assessed using logistic regression. A high rate of FRSs in manic and mixed patients was found with a higher frequency in men (31%) than in women (14%; P=0.038). A monotonic increase in the association between FRSs and younger age was apparent (odds ratios (OR) over five levels: 1.42; 1.00-2.01). These results confirm previous findings that FRSs are not specific to schizophrenia and suggest in addition that a dimension of nuclear psychotic experiences of developmental origin extends across categorically defined psychotic disorders.

Suicide attempts in bipolar patients

BACKGROUND

Between 25% to 50% of patients with bipolar disorder make suicide attempts during their lives, but there are some controversies about factors related to suicide attempts in this group of patients. The aim of this study is to investigate the association between suicide attempts and the predictive factors previously described in the literature.

METHOD

The sample included all 169 patients with DSM-III-R bipolar I disorder identified in a delimited area (northern Spain). Sociodemographic, clinical, and family history variables measured by Research Diagnostic Criteria-Family History were analyzed. Significant variables were introduced in a logistic regression analysis to control for the effects of other variables.

RESULTS

There were 56 patients (33%) who had one or more suicide attempts. Early age at onset, history of hospital admission during depressive episodes, drug abuse, and family history were significantly associated with suicide in the univariate analyses (p < .05). A much higher proportion of patients with onset at or before 25 years of age than patients with onset after 25 years of age attempted suicide (23% vs. 10%). The age at onset was no longer significant after controlling for the other 3 variables included in the logistic regression analysis.

CONCLUSION

Suicide attempts are highly prevalent in bipolar patients and are related to drug abuse, family history of affective disorders, and severe depressive episodes. This study suggests that the risk of suicide in patients with an early age at onset could reflect other variables such as drug abuse, a history of hospital admissions for depression, or family history.

Use of olanzapine in dysphoric mania

BACKGROUND

The simultaneous presentation of both manic and depressive symptoms has long been recognized. Nevertheless, a variable prevalence of dysphoric mania has been reported. The aim of this study was to estimate the prevalence of dysphoric mania among hospitalized patients and to assess the effectiveness of olanzapine in this type of patients.

METHODS

Eighty-six patients who met DSM-IV criteria for mania were evaluated at admission with a protocol that included McElroy's criteria for dysphoric mania [Am. J. Psychiatry 149 (1992) 1633]. Treatment was administered according to clinical need, using mood stabilizers combined with antipsychotics. Sequential assessments were conducted throughout the study.

RESULTS

Forty-four patients (51.2%) fulfilled McElroy's criteria for dysphoric mania. Fourteen of these dysphoric patients were treated with olanzapine in combination with mood-stabilizers. All patients improved in manic symptoms but patients treated with olanzapine improved significantly more than those treated with other antipsychotics in depressive symptoms.

LIMITATIONS

The lack of randomization is a methodological limitation of this study, so these findings should be considered as preliminary.

CONCLUSIONS

Dysphoric symptoms are common in this population of manic patients. Olanzapine in combination with mood-stabilizers may be effective in these patients. Additional controlled studies are needed to replicate these results.

[Involuntary hospitalization in the first psychotic episodes: associated factors]

INTRODUCTION

The great majority of involuntary admissions at acute hospital units are related to severe psychiatric diseases. The aim of this study is to determine which are the characteristics and associated factors in first psychotic episodes not due to medical illness.

METHOD

It had been evaluated, 61 first psychotic episodes hospitalised in a General Hospital Psychiatric Unit. It was used a protocol with the SCID, SCID-PANSS, DSM-IV criteria, unified clinical history, and PANSS, and Philips scales.

RESULTS

67.2% of the patients were committed to the hospital. Only the PANNS positive subscale was significantly associated with the involuntary admission.

CONCLUSIONS

There is a high admission rate of involuntary inpatients with first psychotic episode. The involuntary admission is highly related to psychotic positive symptoms.

First episode in bipolar disorder: misdiagnosis and psychotic symptoms

BACKGROUND

This study explores factors that can influence other psychotic diagnoses in the first episode of a DSM-III-R bipolar disorder.

METHODS

It includes all 163 bipolar in-patients and out-patients in the state of Alava, North of Spain (Basque country) from February 1994 to May 1996. Patients were divided into two non-overlapping groups: unstable diagnoses, bipolars with an initial diagnosis of schizophrenia (or other psychosis), and stable diagnoses of bipolar disorder.

RESULTS

A logistic regression analysis using marital status, age at onset and mood incongruent psychotic symptoms found that the latter was the only independent factor significantly associated with an unstable diagnosis.

Tobacco smoking and bipolar disorder

BACKGROUND

We sought to determine whether tobacco smoking is associated with bipolar disorder.

METHOD

This case-control study carried out in Alava, in the north of Spain, included patients with a DSM-III-R diagnosis of bipolar disorder type I (N = 51) and a representative sample of the normal population (N = 517). Smoking history of bipolar patients was assessed with the Fagerstrom Test for Nicotine Dependence and was verified by family members of the patients.

RESULTS

The frequencies of ever smoking and current daily smoking were, respectively, 63% (32/51) and 51% (26/51) for the bipolar patients and 45% (235/517) and 33% (169/517) for the control group (respective odds ratios [ORs] and 95% confidence intervals [CIs] were OR = 2.0, 95% CI = 1.1 to 3.8 and OR = 2.1, 95% CI = 1.2 to 4.0). The differences were significant (p = .03 and p = .042, respectively) for bipolar versus control males. Bipolar disorder (in both genders) was also significantly associated (OR = 4.4, 95% CI = 1.7 to 11.9, p = .0015) with heavy smoking (more than 1 pack per day).

CONCLUSION

Despite its small sample size, this study suggests that smoking may be more prevalent in bipolar patients than in the normal population. Since most patients started to smoke before the onset of illness, vulnerability to bipolar illness may make subjects vulnerable to become tobacco smokers.

[Smoking in a psychiatric population]

The relationship between tobacco consumption and psychiatric disorders is a widely discussed topic that is generating a considerable yet controversial bibliography, that can be approached from different points of view. The authors make a revision and critical evaluation about smoking prevalence on psychiatric population, in the different psychiatric disorders and discussing the theories implicated.

[Paraneoplastic myelopathy, probably necrotizing myelopathy: apropos of a case associated with anaplastic small cell carcinoma]

We comment a case of necrotizing myelopathy, a rare neurological paraneoplastic syndrome, that it was the first manifestation of a microcit anaplastic carcinoma. The diagnostic was made with the clinical and radiological base, after we deprive another diseases with similar clinical manifestations and the result of the Magnetic resonance image of the nervous system. We didn't obtain permise for the necropsic study.