Associations between disturbed sleep and attenuated psychotic experiences in people at clinical high risk for psychosis

BACKGROUND

Pre-diagnostic stages of psychotic illnesses, including 'clinical high risk' (CHR), are marked by sleep disturbances. These sleep disturbances appear to represent a key aspect in the etiology and maintenance of psychotic disorders. We aimed to examine the relationship between self-reported sleep dysfunction and attenuated psychotic symptoms (APS) on a day-to-day basis.

METHODS

Seventy-six CHR young people completed the Experience Sampling Methodology (ESM) component of the European Union Gene-Environment Interaction Study, collected through PsyMate® devices, prompting sleep and symptom questionnaires 10 times daily for 6 days. Bayesian multilevel mixed linear regression analyses were performed on time-variant ESM data using the brms package in R. We investigated the day-to-day associations between sleep and psychotic experiences bidirectionally on an item level. Sleep items included sleep onset latency, fragmentation, and quality. Psychosis items assessed a range of perceptual, cognitive, and bizarre thought content common in the CHR population.

RESULTS

Two of the seven psychosis variables were unidirectionally predicted by previous night's number of awakenings: every unit increase in number of nightly awakenings predicted a 0.27 and 0.28 unit increase in feeling unreal or paranoid the next day, respectively. No other sleep variables credibly predicted next-day psychotic symptoms or vice-versa.

CONCLUSION

In this study, the relationship between sleep disturbance and APS appears specific to the item in question. However, some APS, including perceptual disturbances, had low levels of endorsement amongst this sample. Nonetheless, these results provide evidence for a unidirectional relationship between sleep and some APS in this population.

Cognitive and Social Cognitive Impairment and their Impact on Real-Life Functioning and Quality of life

Cognitive and social cognitive impairments are a central feature of schizophrenia and are known to significantly affect real-life functioning [1]. These impairments include deficits in memory, language function and executive function, as well as in processing speed and attention. In the domains of social cognition, face perception [2], voice perception, mentalizing and emotion regulation have been described to be affected. All deficits, cognitive and social-cognitive, can persist during symptomatic remission. Social cognition is a partial mediator between neurocognition and functional outcome. Recent research has demonstrated that neurocognition affects functional capacity and that social cognition affects community functioning [3]. The impact of cognition on quality of life (QOL) was shown in a large meta-analytic study, in which a moderate correlation of verbal ability and processing speed with subjective quality of life was found [4]. A network analysis showed that functional capacity and everyday life skills were the most central and highly interconnected nodes in the network. Functional capacity bridged cognition with everyday life skills, the everyday life skills node was linked to disorganization and expressive deficits [5]. Deficits in neurocognition and social cognition play a pivotal role as enduring impairment after clinical remission and as a critical rate-limiting factor in functional recovery. [1] Green et al. Schizophr Bull. 2000; 26(1): 119-136 [2] Sachs et al. Schizophr Res. 2004; 68(1):27-35 [3] Bechi et al. Psychiatry Res. 2017; 251:118-124 [4] Tolman & Kurtz Schizophr Bull. 2012; 272:419-424 [5] Galderisi et al. JAMA Psychiatry. 2018; 75(4):396-404

Predictors of Functional Outcome in Patients with Bipolar Disorder

Introduction Bipolar disorder is a severe disorder that is often accompanied by deficits in both neurocognitive (1) and psychosocial function (2). At the Department of Psychiatry and Psychotherapy of the Medical University of Vienna we performed a study to further identify potential cognitive, clinical and treatment-dependent predictors for functional impairment, symptom severity and early recurrence in bipolar patients (3). Methods Forty-three remitted bipolar patients and 40 healthy probands were assessed with a cognitive battery. In a randomized controlled trial, remitted patients were assigned to two treatment conditions as add-on to state-of-the-art pharmacotherapy: cognitive psychoeducational group therapy (CPEGT) over 14 weeks or treatment-as-usual. At 1 year after therapy, functional impairment and severity of symptoms were assessed. Results As compared to healthy probands, bipolar patients showed lower performance in executive function, sustained attention, verbal learning and verbal fluency. Both attention and CPEGT predicted occupational functioning. In our study verbal memory recall was a predictor for symptom severity. Discussion Our data suggest that bipolar patients benefit from CPEGT in the domain of occupational life. Implications for treatment strategies are discussed. Solé B, Jiménez E, Torrent C, Reinares M, Bonnin CDM, Torres I, Varo C, Grande I, Valls E, Salagre E, Sanchez-Moreno J, Martinez-Aran A, Carvalho AF, Vieta E. Int J Neuropsychopharmacol (2017) 20:670–80. Tohen M, Zarate CA Jr, Hennen J, Khalsa HM, Strakowski SM, Gebre-Medhin P, Salvatore P, Baldessarini RJ. Am J Psychiatry (2003) 160:2099–107. Sachs G, Berg A, Jagsch R, Lenz G, Erfurth A. Front Psychiatry (2020) 23;11:530026.

Disclosure

No significant relationships.

Prediction of functional outcome in bipolar disorder: Effects of cognitive remediation and cognitive psychoeducational group therapy

Introduction

In bipolar patients cognitive deficits are an important feature. Persisting neurocognitive impairment is associated with low psychosocial functioning.

Objectives

The aim of this presentation is to discuss potential cognitive, clinical and treatment-dependent predictors for functional impairment in bipolar patients.

Methods

In a first study (1) at the Medical University of Vienna 43 remitted bipolar patients and 40 healthy controls were assessed testing specifically attention, memory, verbal fluency and executive functions. In a randomized controlled trial, patients were assigned to two treatment conditions as add-on to state-of-the-art pharmacotherapy: cognitive psychoeducational group therapy over 14 weeks or treatment-as-usual. At 12 months after therapy, functional impairment and severity of symptoms were assessed. In a second, ongoing study, in-patients from a defined catchment area in Vienna (12th, 13th and 23rd district) were assessed via SCIP (Purdon S. 2005. The screen for cognitive impairment in psychiatry: Administration and psychometric properties. Edmonton, Alberta, Canada: PNL Inc.). The SCIP was performed before and after cognitive remediation. The effects of treatment on functioning were measured with the clinical Global Impression Scale (CGI).

Results

Compared to controls, bipolar patients showed lower performance in executive function, sustained attention, verbal learning and verbal fluency. Cognitive psychoeducational group therapy and attention predicted occupational functioning. In the second study, SCIP and CGI values showed improvement after treatment.

Conclusions

Our data support the idea that cognition affects outcome. Bipolar patients benefit from cognitive psychoeducational group therapy in the domain of occupational life. (1) Sachs G et al. Front. Psychiatry, 23 November 2020 | https://doi.org/10.3389/fpsyt.2020.530026

Disclosure

No significant relationships.

Climate change and mental health: An overview

According to the UN Environment Programme “climate change is one of the most pervasive and threatening issues of our time”. “In many places, temperature changes and sea-level rise are already putting ecosystems under stress and affecting human well-being” (1). The presentation wants to give an overview on how climate change can affect mental health. A search was performed on PubMed for the combination of “climate change” and “mental health”. 281 publications were identified, the first being from 2007 (the only one in that year). In 2020, until Dec 22nd, 76 publications were found. The somehow prophetic 2007 publication reviews “natural disasters, climate change and mental health considerations for rural Australia” (2) and pinpoints central aspects of today’s debate, namely anxiety and depression, vulnerability and resilience. In addition to problems of rural areas (2), the impact of urbanicity (3) will be discussed as well as the role of air pollution on psychiatric disorders (4). (1) UN Environment Programme. https://www.unenvironment.org/explore-topics/climate-change/about-climate-change Dec 22nd, 2020. (2) Morissey SA, Reser JP. Aust J Rural Health. 2007 Apr;15(2):120-5. doi: 10.1111/j.1440-1584.2007.00865.x. (3) Krabbendam L et al. Psychol Med. 2020 Mar 11:1-12. doi: 10.1017/S0033291720000355. (4) Kim SY et al. Sci Total Environ. 2020 Dec 8;757:143960. doi: 10.1016/j.scitotenv.2020.143960.

Disclosure

No significant relationships.

Predicting functional outcome in bipolar patients: Effects of cognitive psychoeducational group therapy after 12 months

Introduction

Cognitive impairment is known as a core feature in bipolar patients. Persisting neurocognitive impairment has been associated with low psychosocial functioning.

Objectives

The goal of this work was to identify clinical and cognitive predictors for functional impairment, symptom severity and early recurrence in bipolar disorder, as well as to compare the neurocognitive performance of bipolar patients with that of healthy probands.

Methods

43 remitted bipolar patients and 40 healthy controls were compared using a neurocognitive battery testing specifically attention, memory, verbal fluency and executive functions. In a randomized controlled trial, the 43 remitted patients were assigned to two treatment conditions as add-on to state-of-the-art pharmacotherapy: cognitive psychoeducational group therapy over 14 weeks or treatment-as-usual. At 12 months after therapy, functional impairment and severity of symptoms were assessed.

Results

As compared to healthy probands, bipolar patients showed lower performance in executive function (perseverative errors p<0.01, categories correct p<0.001), sustained attention (total hits p<0.001), verbal learning (delayed recall p<0.001) and verbal fluency (pwords p<0.002). Cognitive psychoeducational group therapy and attention predicted occupational functioning with a hit ratio of 87.5%. Verbal memory recall was found to be a predictor for symptom severity (hit ratio 86.8%). Recurrence in the follow-up period was predicted by premorbid IQ and by years of education (hit ratio 77.8%).

Conclusions

Our data show that bipolar patients benefit from cognitive psychoeducational group therapy in the domain of occupational life. Reductions in sustained attention have an impact on occupational impairment.

Disclosure

No significant relationships.

The role of cognition in the psychopathology of schizophrenia: Assessment and treatment options

Cognitive dysfunction is a characteristic feature of patients with schizophrenia. Traditionally, the main distinction between “dementia praecox” and “manic-depressive insanity” was in fact the cognitive outcome during the course of the disease [1].

For the assessment of cognitive dysfunction both large, detailed instruments [2] and brief screening scales for quick and multiple use [3,4] are available.

Recently, the role of social cognition has been thoroughly examined showing differential effects [5].

Treatment of cognitive dysfunction in schizophrenia comprises adherence to a therapy with atypical antipsychotics as well as specific treatment programs for cognitive [6] and social cognitive [7,8] dysfunction.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Editorial: control of acid secretion

Linked Content

This article is linked to Sunwoo et al paper. To view this article visit https://doi.org/10.1111/apt.14818.

From (Psycho) Pathology to Diagnosis: Psychiatry Nosology Beyond Dichotomy

As in all medical disciplines, diagnosis in clinical psychiatry should be reached in a step-wise approach: after assessing the chief complaint of the patient, a careful examination of the psychopathology follows e.g. by using the AMDP system [1] to preliminarily conclude the process with a syndromal classification [2]. This syndromal classification is of great importance as it guides the initiation of therapy in daily life practice. After gaining additional information (e.g. investigation in the course of the disease, brain imaging, thorough assessment of cognitive function, exclusion of organic causes) a final diagnosis is possible. Unfortunately, a premature jumping to diagnosis is not uncommon (with the potential consequence of incorrect therapies).

In addition to these difficulties, recent neurobiological research has shown that nosologic assignments through conventional diagnostic classifications are far less specific than assumed, revealing a large overlap between diagnostic categories [3,4], e.g. between Schizophrenia and affective disorders. Consequences of this finding are discussed both for the construction of future classification systems and for therapy.

Disclosure of interest

The authors declare that they have no competing interest.

The effects of integrated treatment with atypical antipsychotics and social cognition training on functional outcome

Social cognition is impaired in patients with schizophrenia [1]. This impairment is one of the core features of the illness and has a clear impact on functional outcome.

While conventional antipsychotics might have a worsening effect on social cognition, e.g. on amygdala attenuation in fMRI studies on facial recognition [2], atypical antipsychotics might not show this effect [3].

Social cognitive training [4] – such as the training of affect recognition [5] – is a promising approach in the treatment of schizophrenia.

Holistic strategies including both treatment with atypical antipsychotics and social cognitive training can improve functional outcome in patients with schizophrenia [6].

Disclosure of interest

The author has not supplied his declaration of competing interest.

Polypharmacy and bipolar disorder: what's personality got to do with it?

The majority of patients treated for bipolar disorder receive multiple psychotropic medications concurrently (polypharmacy), despite a lack of empirical evidence for any combination of three or more medications. Some patients benefit from the skillful management of a complex medication regimen, but iterative additions to a treatment regimen often do not lead to clinical improvement, are expensive, and can confound assessment of the underlying mood disorder. Given these potential problems of polypharmacy, this paper reviews the evidence supporting the use of multiple medications and seeks to identify patient personality traits that may put patients at a greater risk for ineffective complex chronic care. Patients with bipolar disorder (n = 89), ages 18 and older, were assessed on the Montgomery Asberg Depression Rating Scale (MADRS), Young Mania Rating Scale (YMRS), and the NEO Five Factor Inventory (NEO-FFI), and completed a treatment history questionnaire to report psychotropic medication use. We found that patients with lower scores on openness had significantly more current psychotropic medications than patients with higher scores on openness (3.7 ± 1.9 vs. 2.8 ± 1.8, p < 0.05). Patients with the highest lifetime medication use had significantly lower extraversion (21.8 ± 8.9 vs. 25.4 ± 7.6, p < 0.05) and lower conscientiousness (21.9 ± 8.2 vs. 27.9 ± 8.2, p < 0.01) than those reporting lower lifetime medication use. Low levels of openness, extraversion, and conscientiousness may be associated with increased psychotropic medication use. Investigating the role of individual differences, such as patient personality traits, in moderating effective polypharmacy warrants future research.

Experimental verification of dynamic soaring in albatrosses

Dynamic soaring is a small-scale flight manoeuvre which is the basis for the extreme flight performance of albatrosses and other large seabirds to travel huge distances in sustained non-flapping flight. As experimental data with sufficient resolution of th ese small-scale movements are not available, knowledge is lacking about dynamic soaring and the physical mechanism of the energy gain of the bird from the wind. With new in-house developments of GPS logging units for recording raw phase observations and of a dedicated mathematical method for postprocessing these measurements, it was possible to determine the small-scale flight manoeuvre with the required high precision. Experimental results from tracking 16 wandering albatrosses (Diomedea exulans) in the southern Indian Ocean show the characteristic pattern of dynamic soaring. This pattern consists of four flight phases comprising a windward climb, an upper curve, a leeward descent and a lower curve, which are continually repeated. It is shown that the primary energy gain from the shear wind is attained in the upper curve where the bird changes the flight direction from windward to leeward. As a result, the upper curve is the characteristic flight phase of dynamic soaring for achieving the energy gain necessary for sustained non-flapping flight.

Training of affect recognition (TAR) in schizophrenia--impact on functional outcome

Deficits in facial affect recognition as one aspect of social cognitive deficits are treatment targets to improve functional outcome in schizophrenia. According to preliminary results antipsychotics alone show little effects on affect recognition. A few randomized intervention studies have evaluated special psychosocial treatment programs on social cognition. In this study, the effects of a computer-based training of affect recognition were investigated as well as its impact on facial affect recognition and functional outcome, particularly on patients' quality of life. Forty clinically stabilized schizophrenic patients were randomized to a six-week training on affect recognition (TAR) or treatment as usual including occupational therapy (TAU) and completed pre- and post-treatment assessments of emotion recognition, cognition, quality of life and clinical symptoms. Between pre- and post treatment, the TAR group achieved significant improvements in facial affect recognition, in particular in recognizing sad faces and, in addition, in the quality of life domain social relationship. These changes were not found in the TAU group. Furthermore, the TAR training contributes to enhancing some aspects of cognitive functioning and negative symptoms. These improvements in facial affect recognition and quality of life were independent of changes in clinical symptoms and general cognitive functions. The findings support the efficacy of an affect recognition training for patients with schizophrenia and the generalization to social relationship. Further development is needed in the impact of a psychosocial intervention in other aspects of social cognition and functional outcome.

Personality and bipolar disorder: dissecting state and trait associations between mood and personality

BACKGROUND

Some personality characteristics have previously been associated with an increased risk for psychiatric disorder. Longitudinal studies are required in order to tease apart temporary (state) and enduring (trait) differences in personality among individuals with bipolar disorder (BD). This study aimed to determine whether there is a characteristic personality profile in BD, and whether associations between BD and personality are best explained by state or trait effects.

METHOD

A total of 2247 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder study completed the NEO Five-Factor Inventory administered at study entry, and at 1 and 2 years.

RESULTS

Personality in BD was characterized by high neuroticism (N) and openness (O), and low agreeableness (A), conscientiousness (C) and extraversion (E). This profile was replicated in two independent samples, and openness was found to distinguish BD from major depressive disorder. Latent growth modeling demonstrated that manic symptoms were associated with increased E and decreased A, and depressed symptoms with higher N and lower E, A, C and O. During euthymic phases, high N and low E scores predicted a future depression-prone course.

CONCLUSIONS

While there are clear state effects of mood on self-reported personality, personality variables during euthymia predict future course of illness. Personality disturbances in extraversion, neuroticism and openness may be enduring characteristics of patients with BD.

Aims and results of the NIMH systematic treatment enhancement program for bipolar disorder (STEP-BD)

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) was funded as part of a National Institute of Mental Health initiative to develop effectiveness information about treatments, illness course, and assessment strategies for severe mental disorders. STEP-BD studies were planned to be generalizable both to the research knowledge base for bipolar disorder and to clinical care of bipolar patients. Several novel methodologies were developed to aid in illness characterization, and were combined with existing scales on function, quality of life, illness burden, adherence, adverse effects, and temperament to yield a comprehensive data set. The methods integrated naturalistic treatment and randomized clinical trials, which a portion of STEP-BD participants participated. All investigators and other researchers in this multisite program were trained in a collaborative care model with the objective of retaining a high percentage of enrollees for several years. Articles from STEP-BD have yielded evidence on risk factors impacting outcomes, suicidality, functional status, recovery, relapse, and caretaker burden. The findings from these studies brought into question the widely practiced use of antidepressants in bipolar depression as well as substantiated the poorly responsive course of bipolar depression despite use of combination strategies. In particular, large studies on the characteristics and course of bipolar depression (the more pervasive pole of the illness), and the outcomes of treatments concluded that adjunctive psychosocial treatments but not adjunctive antidepressants yielded outcomes superior to those achieved with mood stabilizers alone. The majority of patients with bipolar depression concurrently had clinically significant manic symptoms. Anxiety, smoking, and early age of bipolar onset were each associated with increased illness burden. STEP-BD has established procedures that are relevant to future collaborative research programs aimed at the systematic study of the complex, intrinsically important elements of bipolar disorders.

A targeted remediation approach: The training of affect recognition (TAR)

Introduction

An increasing number of studies is focusing on general deficits in patients with schizophrenia in identifying, differentiating and recalling facial emotions which significantly impairs the patient's psychosocial functioning and quality of life.

Objectives

These impairments seem not to be affected by conventional treatment. According to preliminary results antipsychotics alone show only little effects on social cognition.

Aims

The present study investigated the efficacy of a computer based training focussing on facial affect recognition (Training of Affect recognition TAR, Wölwer et al. 2005) for the remediation of social cognitive dysfunctions.

Methods

Effects on social cognition were tested with the Vienna Emotion Recognition Task (VERT-K, Pawelak 2004). Neurocognitive performance was assessed by the Wisconsin Card Sorting Test (WCST Heaton et al. 1993). Additional assessments were tests of alertness, vigilance and working memory (TAP Zimmermann and Fimm 2002), positive and negative symptoms (PANSS Kay et al. 1987), Beck Depression Scale (BDI Beck 1964) and Quality of Life (WHOQOL-Bref WHOQOL Group 1998).

Results

In comparison to the TAU group, the TAR group achieved significant improvements in affect recognition in general as well as in recognizing sad faces (p < 0.01) (Fig.2). In addition, we found significant improvements for the TAR group in regard to vigilance and Quality of Life (p < 0.05).

Conclusions

Treatment with new antipsychotics alone leads only to limited effects on social cognition and functioning. A specific combined treatment of new antipsychotics and TAR leads to improved cognition and emotional performance with additional positive effects on functional outcome.

Selective gene expression by rat gastric corpus epithelium

The gastrointestinal (GI) tract is divided into several segments that have distinct functional properties, largely absorptive. The gastric corpus is the only segment thought of as largely secretory. Microarray hybridization of the gastric corpus mucosal epithelial cells was used to compare gene expression with other segments of the columnar GI tract followed by statistical data subtraction to identify genes selectively expressed by the rat gastric corpus mucosa. This provides a means of identifying less obvious specific functions of the corpus in addition to its secretion-related genes. For example, important properties found by this GI tract comparative transcriptome reflect the energy demand of acid secretion, a role in lipid metabolism, the large variety of resident neuroendocrine cells, responses to damaging agents and transcription factors defining differentiation of its epithelium. In terms of overlap of gastric corpus genes with the rest of the GI tract, the distal small bowel appears to express many of the gastric corpus genes in contrast to proximal small and large bowel. This differential map of gene expression by the gastric corpus epithelium will allow a more detailed description of major properties of the gastric corpus and may lead to the discovery of gastric corpus cell differentiation genes and those mis-regulated in gastric carcinomas.

Cognitive function (CF) and prognostic information understanding in advanced cancer patients (ACP)

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Background: The role of advanced cancer patients' (ACP) cognitive function (CF) and its relationship to understanding of a terminal prognosis has never been formally evaluated. Methods: ACP CF was evaluated among a population of terminally-ill patients enrolling in phase I trials at our institution using a neuropsychological battery designed to assess several domains of decisional capacity: Memory (Hopkins Verbal Learning HVLT); Executive Functioning (Verbal Fluency and Trail-making A/B); Language (Boston Naming-short); Attention (Digit Span); Comprehension (Auditory Comprehension & WAIS comprehension). Semi-structured interviews of ACPs also evaluated md-pt communication regarding prognosis, and included the Hospital Anxiety and Depression Scale (HADS), BDI-II, and the FACT-COG. Results: To date, 110 ACP enrolling in phase I trials have been interviewed: median age 60 (23–83); 66% male; 88% Ca; 62% married; 71% >high school education; 52% GI dx. 59% of ACPs reported having a discussion regarding life expectancy, and 55% stated that the physician gave them a prognostic timeframe regarding the amount of time left to live. ACP who stated the physician did not provide them a timeframe had measurable deficits in CF as indicated by Z scores for HVLT immediate recall (-1.3 ± .84 v -.74 ± 1.1, p=.03); total recall (-1.9 ± 1.2 v -1.2 ±1.5, p=.02); delayed recall (-1.7 ± 1.6 v -1.1 ±1.6, p=.04); language (.26 ± 1.3 v .78 ± .68, p=.03); Trails B (-1.6 ± 2.5 v -.61 ± 2.2, p=.04) and WAIS comprehension ss scores (14 ± 2.9 v 16 ± 3.0, p=.06). These ACP tended to exhibit more depressive symptoms (12 ± 10 v 6 ± 3, p=.04) and had lower scores for perceived cognitive impairment (96 ± 25 v 105 ±16, p=.04); impact on quality of life (26 ± 7 v 28 ± 5, p=.03); and FACT-COG total (152 ± 31 v 164 ± 22, p=.05). Conclusions: ACP enrolling in phase I trials who could not recall specific prognostic information had measurable cognitive impairment as compared to those ACP who could recall such information. Our data indicate that CF may play a role in ACP communication and/or understanding of prognostic information.

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Correlates of subjective and objective burden among caregivers of patients with bipolar disorder

OBJECTIVE

We examined the relationship between mood symptoms and episodes in patients with bipolar disorder and burden reported by their primary caregivers.

METHOD

Data on subjective and objective burden reported by 500 primary caregivers for 500 patients with bipolar disorder participating in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) were collected using semistructured interviews. Patient data were collected prospectively over 1 year. The relationship between patient course and subsequent caregiver burden was examined.

RESULTS

Episodes of patient depression, but not mood elevation, were associated with greater objective and subjective caregiver burden. Burden was associated with fewer patient days well over the previous year. Patient depression was associated with caregiver burden even after controlling for days well.

CONCLUSION

Patient depression, after accounting for chronicity of symptoms, independently predicts caregiver burden. This study underscores the important impact of bipolar depression on those most closely involved with those whom it affects.

Whole-genome association study of bipolar disorder

We performed a genome-wide association scan in 1461 patients with bipolar (BP) 1 disorder, 2008 controls drawn from the Systematic Treatment Enhancement Program for Bipolar Disorder and the University College London sample collections with successful genotyping for 372,193 single nucleotide polymorphisms (SNPs). Our strongest single SNP results are found in myosin5B (MYO5B; P=1.66 x 10(-7)) and tetraspanin-8 (TSPAN8; P=6.11 x 10(-7)). Haplotype analysis further supported single SNP results highlighting MYO5B, TSPAN8 and the epidermal growth factor receptor (MYO5B; P=2.04 x 10(-8), TSPAN8; P=7.57 x 10(-7) and EGFR; P=8.36 x 10(-8)). For replication, we genotyped 304 SNPs in family-based NIMH samples (n=409 trios) and University of Edinburgh case-control samples (n=365 cases, 351 controls) that did not provide independent replication after correction for multiple testing. A comparison of our strongest associations with the genome-wide scan of 1868 patients with BP disorder and 2938 controls who completed the scan as part of the Wellcome Trust Case-Control Consortium indicates concordant signals for SNPs within the voltage-dependent calcium channel, L-type, alpha 1C subunit (CACNA1C) gene. Given the heritability of BP disorder, the lack of agreement between studies emphasizes that susceptibility alleles are likely to be modest in effect size and require even larger samples for detection.

Identification and pharmacological characterization of the prostaglandin FP receptor and FP receptor variant complexes

Background and purpose: A prostamide analogue, bimatoprost, has been shown to be effective in reducing intraocular pressure, but its precise mechanism of action remains unclear. Hence, to elucidate the molecular mechanisms of this effect of bimatoprost, we focused on pharmacologically characterizing prostaglandin FP receptor (FP) and FP receptor variant (altFP) complexes.

Experimental approach: FP receptor mRNA variants were identified by reverse transcription-polymerase chain reaction. The FP-altFP4 heterodimers were established in HEK293/EBNA cells co-expressing FP and altFP4 receptor variants. A fluorometric imaging plate reader was used to study Ca²⁺ mobilization. Upregulation of cysteine-rich angiogenic protein 61 (Cyr61) mRNA was measured by Northern blot analysis, and phosphorylation of myosin light chain (MLC) by western analysis.

Key results: Six splicing variants of FP receptor mRNA were identified in human ocular tissues. Immunoprecipitation confirmed that the FP receptor is dimerized with altFP4 receptors in HEK293/EBNA cells co-expressing FP and altFP4 receptors. In the studies of the kinetic profile for Ca²⁺ mobilization, prostaglandin F_2α (PGF_2α) elicited a rapid increase in intracellular Ca²⁺ followed by a steady state phase. In contrast, bimatoprost elicited an immediate increase in intracellular Ca²⁺ followed by a second phase. The prostamide antagonist, AGN211335, selectively and dose-dependently inhibited the bimatoprost-initiated second phase of Ca²⁺ mobilization, Cyr61 mRNA upregulation and MLC phosphorylation, but did not block the action of PGF_2α.

Conclusion and implications: Bimatoprost lacks effects on the FP receptor but may interact with the FP-altFP receptor heterodimer to induce alterations in second messenger signalling. Hence, FP-altFP complexes may represent the underlying basis of bimatoprost pharmacology.

Adjunctive treatment of acute mania: a clinical overview

OBJECTIVE

To provide an overview of the available high quality evidence-base of studies of adjunctive pharmacologic treatment for acute mania.

METHOD

Double-blind controlled trials with adequate samples (n > 100) were identified through search of PubMed/MEDLINE and computerized abstracts from 2004-2006 meetings of the American Psychiatric Association, International Conference on Bipolar Disorder, and Collegium Internationale Neuro-Psychopharmacolium using key words mania, adjunct, and combination.

RESULTS

Placebo-controlled studies with positive results support the adjunctive use of five agents including valproate, olanzapine, risperidone, quetiapine, and haloperidol. Agents with only negative or failed placebo-controlled studies included carbamazepine, gabapentin, lamotrigine, topiramate, oxcarbazepine, and ziprasidone. We found no placebo-controlled study of many commonly used agents including lithium, aripiprazole, and clozapine. No studies explicitly excluded subjects, based on prior treatment with the monotherapy being offered and several studies limited randomization to patients with documented inadequate response to the monotherapy arm.

CONCLUSION

The available placebo-controlled randomized clinical trials support adjunctive therapy combining lithium or valproate with olanzapine, risperidone, haloperidol or quetiapine. The additional increment of antimanic efficacy of these combinations over monotherapy was similar in magnitude to that seen for the same agents as monotherapy in comparison with placebo. These additive benefits enhanced the tolerability of adverse effects sufficiently to allow a higher proportion of subjects receiving combination therapies to complete the studies than monotherapy treated patients. The available data has several shortcomings and the available studies are inadequate to conclusively determine whether combination treatment is more efficacious than monotherapy when used by subjects naive to both treatments. Nevertheless, adjunctive treatment, which combines agents with proven antimanic efficacy, offers an attractive option for patients with acute mania.

A study of informed consent (IC), age, and cognitive function (CF) among advanced cancer patients (acp) in phase I trials

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Background: Ethical concerns exist about acps’ ability to provide adequate informed consent (IC) for phase I trials. While cognitive impairment (CI) among acp is well-recognized due to multiple factors, e.g., previous effects of chemotherapy, age, psychological status, the prevalence of CI among acp in phase I trials has never been described. Methods: Acp CF was assessed using a neuropsychological battery of instruments: Hopkins Verbal Learning (HVLT); Verbal Fluency; Mini-Cognitive Assessment; Trail-making (Parts A& B); Boston Naming (short); WAIS subtests (Comprehension and Digit Span). Acp underwent semi-structured interviews to evaluate elements of IC, and completed the FACT-COG and the Hospital Anxiety and Depression Scale (HADS). Results: To date, a total of 34 acp enrolling in Phase I trials have been studied. Median age: 63y (range: 38–81y); 77% male; 77% Caucasian; 67% > HS education. Regarding IC understanding: Only 20% of responding acp correctly identified the purpose of Phase I trials; all subjects could recall risks of side effects, correctly stated they could refuse trial participation, and stated they could withdraw at anytime; 53% believed the trial was their only option. Older acp (>age 55y) were less likely to correctly describe the research purpose of the trial (29% v. 71% p=0.02). Older acp had measurable deficits in CF: Boston Naming (14±0.9 v.15±0.3, p=0.09); HVLT Total Recall (14±2 v.26±6, p<0.00) and Discrimination Index (7.5±3 v.11±1, p=0.03); Digit Span-Backwards (4±2 v.7±2, p<0.00); Trail-making B (244±64 v.188±51, p=0.04). While there were no differences in perceived CI (95±18 v.101±19, p=0.5) or impact on quality of life (25±7 v. 27±5, p=0.5), both groups had scores well below prior reported means. Older acp tended to report depressive symptoms more than younger acp (8±2 v.6±1, p=0.07). Conclusions: Our data suggest that CF may play a role in acp understanding of IC for clinical trials, especially among the elderly. Further research is needed, given ethical concerns regarding elderly acp in clinical trials of experimental agents who may have CI.

No significant financial relationships to disclose.

The continuing development of gastric acid pump inhibitors

The synthesis and action of H2-receptor antagonists changed the understanding of gastric acid secretion as well as changing medical therapy for peptic ulcer disease. It is now known that peripheral regulation of gastric acid secretion depends largely, but not entirely, on histamine release from the enterochromaffin-like cell. There is, therefore, no final common pathway for stimulation of the parietal cell. In contrast, all stimuli converge to activate the acid pump, the H+,K(+)-ATPase. Inhibition of this pump by clinically useful drugs was achieved by developing derivatives of timoprazole, pyridyl-2-methylsulfinyl benzimidazole. Two of these derivatives, omeprazole and lansoprazole, have shown superiority in acid control and therefore in therapy for peptic ulcer disease compared to the available H2-receptor antagonists.

Urea transport in bacteria: acid acclimation by gastric Helicobacter spp

Urea transporters in bacteria are relatively rare. There are three classes, the ABC transporters such as those expressed by cyanobacteria and Corynebacterium glutamicum, the Yut protein expressed by Yersinia spp and the UreI expressed by gastric Helicobacter spp. This review focuses largely on the UreI proton-gated channel that is part of the acid acclimation mechanism essential for gastric colonization by the latter. UreI is a six-transmembrane polytopic integral membrane protein, N and C termini periplasmic, and is expressed in all gastric Helicobacter spp that have been studied but also in Helicobacter hepaticus and Streptococcus salivarius. The first two are proton-gated, the latter is pH insensitive. Site-directed mutagenesis and chimeric constructs have identified histidines and dicarboxylic amino acids in the second periplasmic loop of H. pylori and the first loop of H. hepaticus UreI and the C terminus of both as involved in a hydrogen-bonding dependence of proton gating, with the membrane domain in these but not in the UreI of S. salivarius responding to the periplasmic conformational changes. UreI and urease are essential for gastric colonization and urease associates with UreI during acid exposure, facilitating activation of the UreA and UreB apoenzyme complex by Ni2+ insertion by the UreF-UreH and UreE-UreG assembly proteins. Transcriptome analysis of acid responses of H. pylori also identified a cytoplasmic and periplasmic carbonic anhydrase as responding specifically to changes in periplasmic pH and these have been shown to be essential also for acid acclimation. The finding also of upregulation of the two-component histidine kinase HP0165 and its response element HP0166, illustrates the complexity of the acid acclimation processes involved in gastric colonization by this pathogen.

Outcomes in Schizophrenia Outpatients Treated with Amisulpride or Olanzapine

INTRODUCTION

We compared stable patients with schizophrenia who were treated with either amisulpride or olanzapine in terms of symptomatic outcome, neurocognitive functioning, functionality, and subjective outcome.

METHODS

Sixty outpatients with chronic schizophrenia who had been treated with either amisulpride or olanzapine for at least six months were investigated.

RESULTS

The scores of positive, negative, and cognitive symptoms did not differ between the two groups, but patients treated with olanzapine had significantly lower scores on the excitement and depression/anxiety components of the PANSS. With regard to cognitive variables, patients treated with amisulpride showed significantly lower values regarding verbal fluency and significantly better verbal memory than patients treated with olanzapine. Both treatment groups were comparable with respect to functional and subjective outcome variables.

DISCUSSION

These observations add to the evidence that continuous treatment with different second-generation antipsychotics with relatively few side effects leads to comparable outcomes in patients with schizophrenia.

Prospective 12-month course of bipolar disorder in out-patients with and without comorbid anxiety disorders

BACKGROUND

The impact of anxiety disorders has not been well delineated in prospective studies of bipolar disorder.

AIMS

To examine the association between anxiety and course of bipolar disorder, as defined by mood episodes, quality of life and role functioning.

METHOD

A thousand thousand out-patients with bipolar disorder were followed prospectively for 1 year.

RESULTS

A current comorbid anxiety disorder (present in 31.9% of participants) was associated with fewer days well, a lower likelihood of timely recovery from depression, risk of earlier relapse, lower quality of life and diminished role function over I year of prospective study. The negative impact was greater with multiple anxiety disorders.

CONCLUSIONS

Anxiety disorders, including those present during relative euthymia, predicted a poorer bipolar course. The detrimental effects of anxiety were not simply a feature of mood state. Treatment studies targeting anxiety disorders will help to clarify the nature of the impact of anxiety on bipolar course.

Review article: the clinical pharmacology of proton pump inhibitors

Proton pump inhibitors inhibit the gastric H+/K+-ATPase via covalent binding to cysteine residues of the proton pump. All proton pump inhibitors must undergo acid accumulation in the parietal cell through protonation, followed by activation mediated by a second protonation at the active secretory canaliculus of the parietal cell. The relative ease with which these steps occur with different proton pump inhibitors underlies differences in their rates of activation, which in turn influence the location of covalent binding and the stability of inhibition. Slow activation is associated with binding to a cysteine residue involved in proton transport that is located deep in the membrane. However, this is inaccessible to the endogenous reducing agents responsible for restoring H+/K+-ATPase activity, favouring a longer duration of gastric acid inhibition. Pantoprazole and tenatoprazole, a novel proton pump inhibitor which has an imidazopyridine ring in place of the benzimidazole moiety found in other proton pump inhibitors, are activated more slowly than other proton pump inhibitors but their inhibition is resistant to reversal. In addition, tenatoprazole has a greatly extended plasma half-life in comparison with all other proton pump inhibitors. The chemical and pharmacological characteristics of tenatoprazole give it theoretical advantages over benzimidazole-based proton pump inhibitors that should translate into improved acid control, particularly during the night.

Edkins and a century of acid suppression

In 1905, John Edkins (1863-1940) undertook the studies of gastrin that have subsequently formed the basis for a century of investigation into the physiological basis of acid secretion and led to the elucidation of a variety of acid-suppressive pharmacological agents that have revolutionized the management of acid peptic disease. Although his name is known to few, his contributions to the physiology of gastric secretion and his study of spiral organisms in the stomach were prescient and to this day remain models of insightful and rigorous research. As a mentor, his educational impact was exemplified by the fact that he was the first to teach physiology to women in the United Kingdom. Gastrin has evolved from an initially unaccepted phenomenon, to be recognized as an important hormone and a fundamental component of regulatory biology as well as a clinically relevant biomarker of disease. Its critical role in the modulation of acid secretion has become a sine qua non and has been extended to include a broad regulatory proliferative role in the mucosa of the gastrointestinal tract. The pivotal role of gastrin in gastric physiology, biology and clinical medicine is now well accepted and reflects the fundamental contributions that Edkins made to the identification of the agent and the elucidation of its function. As a result of the delineation of the neural and hormonal regulatory mechanisms of acid secretion, the scientific basis of acid peptic disease has become apparent. The identification of histamine receptors and proton pumps has led to the discovery of novel pharmacotherapeutic agents capable of producing acid suppression of such efficacy that surgery has become virtually obsolete in the treatment of the disease process. A century after the initial observations by Edkins of gastrin, the identification of Helicobacter pylori and the ability to eradicate it, as well as the use of the proton pump inhibitor class of drugs, have revolutionized the management of gastroduodenal ulceration and gastroesophageal reflux disease. Both patients and physicians owe a great debt to Edkins, whose seminal observations regarding gastrin initiated an era of gastrointestinal scientific, clinical and pharmacological advance that has culminated in the ability to treat and cure acid peptic disease.

Safety improvement issues for mission aborts of future space transportation systems

Two-stage winged space access vehicles consisting of a carrier stage with airbreathing turbo/ram jet engines and a rocket propelled orbital stage which may significantly reduce space transport costs and have additional advantages offer a great potential for mission safety improvements. Formulating the nominal mission and abort scenarios caused by engine malfunctions as an optimal control problem allows full exploitation of safety capabilities. The shaping of the nominal mission has a significant impact on the prospective safety. For this purpose, most relevant mission aborts are considered together with the nominal mission, treating them as an optimization problem of branched trajectories where the branching point is not fixed. The applied procedure yields a safety improved nominal trajectory, showing the feasibility of the included mission aborts with minimum payload penalty. The other mission aborts can be separately treated, with the initial condition given by the state of the nominal trajectory at the time when a failure occurs. A mission abort plan is set up, covering all emergency scenarios.

Characterization of gastric mucosal membranes. IX. Fractionation and purification of K+-ATPase-containing vesicles by zonal centrifugation and free-flow electrophoresis technique

Methods are described for purification of a vesicular membrane fraction of hog gastric mucosa using differential centrifugation, density gradient separation on zonal rotors and free-flow electrophoresis. As a result a fraction is obtained enriched 40-fold in terms of K(+)-ATPase and free of any other enzyme marker other than K(+)-activated p-nitrophenyl phosphatase. The 5'-nucleotidase and basal Mg(2+)-ATPase are clearly separated from the latter enzymes. Osmotic shock, Triton X-100 treatment or K+ ionophores increased the K(+)-ATPase activity in isotonic conditions, but K(+)-p-nitrophenyl phosphatase is not affected by these treatments, nor is the ATPase activity in the presence of NH4+. The results suggest that the electrophoretic fraction contains a major population of tight vesicles, whose permeability to K+ is rate limiting for the ATPase activity but not for the p-nitrophenyl phosphatase activity. It is concluded that K+ site for the ATPase is internal whereas the K+ site for the p-nitrophenyl phosphatase is external, hence, the K+ site must be mobile across the membrane.

Isolation and receptor profiling of ileal enterochromaffin cells

AIM AND METHODS

Enterochromaffin (EC) cells, interspersed throughout the gastrointestinal mucosa, provide most of the serotonin of the body and control intestinal motility, secretion and absorption. We purified EC cells from the rat ileum by a combination of elutriation and density gradient centrifugation in order to characterize the function of this important cell type.

RESULTS

Immunostaining showed that there were 84% serotonin-positive cells in the highly enriched EC fraction as compared with 12% in unfractionated cells, yielding a approximately sevenfold enrichment. Serotonin measurements in the cell suspensions indicated a seven to 14-fold enrichment. Presence of alpha- and beta-adrenoreceptor isoforms, muscarinic M3 and gama-aminobutyric acid (GABA)-A receptors was confirmed by RT-PCR and cytochemistry. Increased expression of VMAT-1 and GABA-A mRNA was also shown by quantitative TaqMan PCR using EC cell RNA. Serotonin release in isolated EC cells was stimulated by noradrenaline, and to a smaller extent, by carbachol, while GABA addition was without effect.

CONCLUSION

Our data provide a basis for a new approach to characterize receptors on this unique cell type.

[The unexpectedly difficult airway -- a plea for the oxford-non-kinking-tube]

The skill to safely manage the unexpectedly difficult airway is expected from every anaesthetist. The strategies to safely overcome this severe problem have to be adapted to the given equipment and the individual aptitude and skills of the respective colleague. The algorithms for management of the difficult airway should be as simple as possible, and one cannot assume that devices for fibre-optic intubation are available at every site. Indispensable, however, is the availability of face masks, naso- and oropharyngeal airways and laryngeal mask airways in different sizes at each induction site. This paper is especially devoted to recalling the Oxford non-kinking tube and its specific way of handling, as a lot of cases of unexpectedly difficult airway can be safely managed with this tool. Alternatives to safeguarding the difficult airway are the intubation laryngeal mask airway or the esophago-tracheal combitube. For managing the worst case, the "cannot ventilate - cannot intubate" disaster, instruments for percutaneous punction of the trachea and devices for oxygen insufflation must be readily available in every theatre.

Strategies for improving treatment of bipolar disorder: integration of measurement and management

OBJECTIVE

Bipolar disorder is a common and complex condition associated with high rates of disability and high health care costs. The aim of this article is to provide an overview of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

METHOD

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) was conceived in response to an NIMH request for proposals to study the effectiveness of treatments for Bipolar Disorder. Aspects of this program have been adapted and enriched for presentation in this paper.

RESULT

Designed for implementation in routine practice across a variety of settings, STEP-BD offers a disease management program in which standardized assessments are linked to critical decision points in clinical management pathways.

CONCLUSION

This paper describes strategies used in STEP-BD to improve the treatment of Bipolar disorder: a simple conceptual model, which integrates assessments and management, and several specialized elements, used in the STEP-BD assessment package.

Treatment emergent affective switch: a controlled study

OBJECTIVE

To study the clinical features of treatment emergent affective switch (TEAS) in comparison with spontaneous mania.

METHODS

Twelve patients with TEAS within a 12-week period (average) of starting standard antidepressant medication were compared with 12 patients with spontaneous mania.

RESULTS

Patients with TEAS were older, had longer duration of illness, more previous episodes, higher prevalence of subclinical hypothyroidism, and reported more previous episodes of mania associated with antidepressant use. TEAS was less severe, with a lower incidence of psychotic symptoms, lower Young Mania Rating Scale index score and rarely required hospitalization. The interval from intervention to response and remission was similar in both groups.

CONCLUSION

TEAS was less severe, but had similar duration when compared with spontaneous mania. These results cannot directly answer the question of whether there is a causal relationship between antidepressant use and TEAS. While it is also possible that patients with longer duration of illness and higher cycle frequencies are more likely to experience episodes, it is difficult to attribute lesser severity of TEAS episodes to these clinical factors. Our observations are consistent with the suggestion that patients with longer duration of illness and previous history of TEAS may be at a greater risk of switching to mania during the use of antidepressants.

Characteristics of non-verbal memory impairment in bipolar disorder: the role of encoding strategies

BACKGROUND

There is evidence that individuals with bipolar disorder exhibit neuropsychological impairments not only during episodes of depression or mania but also when they are euthymic. One of the most consistently reported cognitive problems in euthymic individuals with bipolar disorder is impairment in episodic memory. Learning and memory depend on individuals' ability to organize information during learning. A recent study by our group showed that verbal episodic memory impairments in euthymic patients with bipolar I disorder (BP-I) are mediated by difficulties in organizing verbal information appropriately during learning. The purpose of the present study was to determine whether memory impairments in euthymic individuals with BP-I extend to non-verbal memory and whether non-verbal memory impairments are mediated by difficulties in organizing non-verbal information during encoding.

METHOD

Study participants were 25 euthymic, remitted individuals with BP-I and 25 age, gender and education matched control participants. Participants completed the Rey-Osterrieth Complex Figure Test (RCFT), a well-established measure of non-verbal memory that enables assessment of organization during learning.

RESULTS

Compared to control participants, BP-I participants showed impaired performance on the RCFT immediate recall. They also relied less on organizational strategies during encoding. Multiple regression modeling indicated that group differences between control and BP-I participants in long-delayed free recall did not remain statistically significant when effects of lower organization were partialled out.

CONCLUSIONS

Non-verbal memory problems in individuals with bipolar disorder, while euthymic, are mediated by poor use of non-verbal organization strategies during encoding, but do not appear to reflect deficits in retention of information.

Quetiapine with lithium or divalproex for the treatment of bipolar mania: a randomized, double-blind, placebo-controlled study

OBJECTIVE

Evaluate the efficacy and tolerability of quetiapine (QTP) combined with lithium (Li) or divalproex (DVP) in the treatment of acute mania.

METHODS

Patients were randomized to 21 days of double-blind treatment with QTP plus Li/DVP, or placebo (PBO) plus Li/DVP. QTP was rapidly dosed up to a maximum of 800 mg/day; Li was dosed to 0.7-1.0 mEq/L; or DVP to 50-100 microg/mL.

RESULTS

Fifty-six of 91 (61.5%) individuals in the QTP + Li/DVP group compared with 49 of 100 (49%) taking PBO + Li/DVP completed the study. A significantly greater mean reduction in total Young Mania Rating Scale (YMRS) score was observed at end-point in patients receiving QTP + Li/DVP compared with those in the PBO + Li/DVP group (-13.76 versus -9.93; p = 0.021). The response rate (> or =50% YMRS improvement) was significantly higher in the QTP + Li/DVP group than in PBO + Li/DVP-treated patients (54.3% versus 32.6%; p = 0.005), as was the proportion of patients achieving clinical remission (YMRS < 12) (45.7% versus 25.8%; p = 0.007). Patients receiving QTP + Li/DVP also had a significantly greater improvement in Clinical Global Impressions-Bipolar (CGI-BP) Severity of Illness scores (-1.38 versus -0.78; p = 0.001). The mean last-week dose of QTP was 584 mg/day in patients meeting response criteria. Common adverse events (at least 10% and twice the rate of Li/DVP) in the QTP + Li/DVP group included somnolence, dry mouth, asthenia, and postural hypotension.

CONCLUSIONS

Quetiapine combined with either Li or DVP has superior efficacy compared with Li or DVP monotherapy for treating patients with bipolar mania. Combination therapy was well-tolerated and most adverse events were mild, withdrawal because of adverse events being only 5% compared with 6% on Li or DVP monotherapy.

Plasma membrane delivery of the gastric H,K-ATPase: the role of beta-subunit glycosylation

The factors determining trafficking of the gastric H,K-ATPase to the apical membrane remain elusive. To identify such determinants in the gastric H,K-ATPase, fusion proteins of yellow fluorescent protein (YFP) and the gastric H,K-ATPase beta-subunit (YFP-beta) and cyan fluorescent protein (CFP) and the gastric H,K-ATPase alpha-subunit (CFP-alpha) were expressed in HEK-293 cells. Then plasma membrane delivery of wild-type CFP-alpha, wild-type YFP-beta, and YFP-beta mutants lacking one or two of the seven beta-subunit glycosylation sites was determined using confocal microscopy and surface biotinylation. Expression of the wild-type YFP-beta resulted in the plasma membrane localization of the protein, whereas the expressed CFP-alpha was retained intracellularly. When coexpressed, both CFP-alpha and YFP-beta were delivered to the plasma membrane. Removing each of the seven glycosylation sites, except the second one, from the extracellular loop of YFP-beta prevented plasma membrane delivery of the protein. Only the mutant lacking the second glycosylation site (Asn103Gln) was localized both intracellularly and on the plasma membrane. A double mutant lacking the first (Asn99Gln) and the second (Asn103Gln) glycosylation sites displayed intracellular accumulation of the protein. Therefore, six of the seven glycosylation sites in the beta-subunit are essential for the plasma membrane delivery of the beta-subunit of the gastric H,K-ATPase, whereas the second glycosylation site (Asn103), which is not conserved among the beta-subunits from different species, is not critical for plasma delivery of the protein.

13C urea breath test (UBT) in the diagnosis of Helicobacter pylori: why does it work better with acid test meals?

BACKGROUND

Acid test meals may improve the accuracy of the (13)C urea breath test (UBT). This has been attributed to changes in gastric emptying rather than to the effects of gastric pH on Helicobacter pylori urease.

AIMS

To determine whether enhancement of (13)CO(2) excretion in the UBT in H pylori infected volunteers by acidification of a test meal is due to a delay in gastric emptying.

METHODS

Urease activity in vitro was measured in intact bacteria and in bacterial homogenates. Urease activity in vivo was assessed by means of the UBT. Eleven H pylori infected subjects underwent UBTs with neutral Ensure (pH 7.0), acidified Ensure (pH 3.0), and apple juice (pH 3.0). Gastric emptying was assessed by (13)C sodium acetate breath test.

RESULTS

From pH 7 to pH 3, the in vitro urease activity of intact bacteria increased sixfold. In contrast, urease activity of bacterial homogenates was inactivated by low pH. In vivo, urease activity, as measured by the UBT 20 minutes after meal ingestion, was higher with apple juice (delta (13)CO(2)=21.1; p=0.03) and acidified Ensure (delta (13)CO(2)=25.5; p=0.01) than with neutral Ensure (delta (13)CO(2)=12.5). Gastric emptying was faster with apple juice (T(max)=36.7 (8) minutes) but not with acidified Ensure (T(max)=63.3 (5) minutes; p=0.06) than with neutral Ensure (T(max)=65.0 (3) minutes; p=0.04).

CONCLUSIONS

The higher UBT found with acidified compared with neutral test meals was independent of the emptying rates of the test meals but may have been due to medium acidity dependent activation of intra-bacterial urease in intact H pylori.

Pharmacological management of agitation in emergency settings

OBJECTIVE

To review, firstly, published studies comparing classic antipsychotics, benzodiazepines, and/or combination of both; and secondly, available data on the use of atypical antipsychotic medications in controlling agitation and aggressive behaviour seen in psychiatric patients in emergency.

METHOD

In the first review, studies comparing antipsychotics, benzodiazepines, and combination of both; and in the second review, efficacy trials of atypical antipsychotics that include an active and/or inactive comparator for the treatment of acute agitation were identified and reviewed. Data from clinical trials meeting the inclusion criteria were summarised by recording improvement rates, definition of improvement, and timing of defined improvement for individual studies.

RESULTS

In the first review, 11 trials were identified meeting the inclusion criteria, eight with a blind design. The total number of subjects was 701. These studies taken together suggest that combination treatment may be superior to the either agent alone with higher improvement rates and lower incidence of extrapyramidal side effects. In the review of atypical antipsychotic agents as acute antiagitation compounds, five studies were identified, three with a blind design. The total number of subjects was 711, of which 15% (104) was assigned to the placebo arm. This review found atypical antipsychotics to be as effective as the classic ones and more advantageous in many aspects.

CONCLUSION

Atypical antipsychotics such as risperidone, ziprasidone, and olanzapine with or without benzodiazepines should be considered first in the treatment of acute agitation. If these agents are not available the combination of a classic antipsychotic and a benzodiazepine would be a reasonable alternative. An oral treatment should always be offered first for building up an alliance with the patient and suggesting an internal rather than external locus of control.

Synthesis or rupture: duration of acid inhibition by proton pump inhibitors

Insight has been gained into the relationship between the structure of proton pump inhibitors (PPIs), their binding, and their suppression of acid secretion. PPIs accumulate in the acidic space of the secreting parietal cell, where then their active forms create disulfide bonds with key cysteines of the H(+), K(+)-ATPase. Studies in humans on the half-lives of recovery of acid secretion have found that while lansoprazole showed a half-life of less than 15 h, and both omeprazole and rabeprazole showed one of less than 30 h, for pantoprazole the half-life was approximately 46 h. This difference in duration of inhibition with PPIs may be related to variations in proton pump inhibitor dwell time. A study in rats suggests that the recovery of gastric pump activity after treatment with omeprazole, esomeprazole, lansoprazole and rabeprazole is likely due to both reversal of binding by disulfide-reducing agents and to pump synthesis. However, for pantoprazole, reversal of acid inhibition is probably due mainly to de novo pump synthesis and not loss of binding. This profile is likely related to the unique binding of pantoprazole to cysteine 822, a binding site which is buried deep within the membrane domain of the pump and may therefore be inaccessible to reducing agents. Although clinical data supporting these findings are limited, prolonged binding of pantoprazole may confer a longer duration of action in comparison with other PPIs.