Derotational distal femoral osteotomy corrects excessive femoral anteversion in patients with patellofemoral instability: A systematic review

PURPOSE

Patellofemoral instability (PFI) is a common condition that can be caused from multiple factors, including lower limb rotational malalignments. Determining precise criteria for performing corrective torsional osteotomy can be a daunting task due to the lack of consensus on normal and excessive values and the limited evidence-based data in the postoperative results. The purpose was to assess the clinical, functional and imaging outcomes following derotational distal femoral osteotomy (DDFO) in patients with PFI and/or anterior knee pain (AKP) associated with lower limb rotational malalignments.

METHODS

Searches were conducted on PubMed, EMBASE and Web of Science databases up to October 2023. Studies reporting outcomes after DDFO in patients with PFI and/or AKP were eligible for the systematic review. The primary outcome was imaging metrics, especially femoral anteversion. Secondary outcomes included the patient-reported outcome measures (PROMs) (clinical and functional). Quantitative synthesis involved the use of weighted averages to calculate pre- to postoperative mean differences (MD) and compare them against the minimal clinically important difference (MCID).

RESULTS

Ten studies (309 knees) were included with a mean follow-up of 36.1 ± 11.7 months. Imaging outcomes consistently indicated the correction of femoral anteversion (MD = -19.4 degrees, 95% confidence interval: -20.1 to -18.7) following DDFO. PROMs showed significant improvements in most studies, exceeding the MCID. Patient satisfaction with the DDFO was high (93.3%).

CONCLUSIONS

The DDFO was an effective treatment option for correcting excessive femoral anteversion in patients with PFI associated with clinically relevant functional and clinical improvement and a high satisfaction rate.

LEVEL OF EVIDENCE

Level IV, systematic review of level II-IV studies.

Derotational high tibial osteotomy in cases of anterior knee pain and/or patellofemoral instability: a systematic review

IMPORTANCE

Derotational high tibial osteotomy (HTO) is a surgical intervention for correcting rotational malalignments in the lower limb, which may contribute to anterior knee pain (AKP) and/or patellofemoral instability (PFI). This surgical technique is not yet widely implemented and requires a systematic evaluation of its outcomes.

AIM

To assess the effectiveness of derotational HTO in correcting rotational malalignments of the lower limb in patients with AKP and/or PFI through radiological, clinical, and patient-reported outcome measures.

EVIDENCE REVIEW

Searches were conducted in the PubMed, Embase, and Web of Science databases up to March 3, 2023, to identify studies utilizing derotational HTO in patients with AKP and/or PFI. The primary outcome measures of interest were measurements of lower limb angular correction. Other radiological, clinical, and patient-reported outcome measures were also analyzed. The risk of bias was judged with the RoBANS tool.

FINDINGS

A total of 8 studies were included, comprising 215 patients (27.0 ​± ​3.9 years) and 245 knees. The most reported angle was tibial torsion (k ​= ​6 studies, n ​= ​173 knees), with a mean difference between postoperative and preoperative values (postsurgical correction) ranging from -37.8° to -10.8°. Patient-reported outcome measures showed significant improvements in the postoperative moment, exceeding the minimal clinically important difference in almost all cases, and with high patient satisfaction (93.6%).

CONCLUSIONS AND RELEVANCE

Derotational HTO allows the correction of rotational malalignments of the lower limb (tibial torsion) and promotes patient satisfaction.

LEVEL OF EVIDENCE

Level IV.

Adrenal Gland Incidentaloma: A Rare Case of Extranodal B-cell Lymphoma

The prevalence of adrenal incidentalomas (i.e., incidental findings) has grown in recent years with the evolution of imaging methods. Adrenal masses can be benign or malignant. Malignant ones are less frequent, but the detection of primary adrenal neoplasms is even less frequent, especially in the case of a diffuse large B-cell lymphoma (DLBCL). This case concerns a 68-year-old man who presented to the emergency department due to fatigue and anorexia. Given his blood test results on admission, he underwent a computed tomography (CT) with angiography that identified a mass in the left adrenal gland with displacement of the ipsilateral kidney. Left tumorectomy, adrenalectomy, and nephrectomy were performed, and the mass corresponded to a nongerminal center-type DLBCL. This case highlights the importance of prompt diagnosis and surgical and pharmacologic treatment of DLBCL.

From Prevention to Care: Unveiling a Parasitic Leiomyoma Within a Gigantic Abdominal Mass

Leiomyomas are non-cancerous tumors emerging from the smooth muscle cells and fibroblasts of the myometrium. They are the most common pelvic tumors in females and are usually asymptomatic. Parasitic leiomyomas have been defined as unusual variants of pedunculated leiomyomas. When symptomatic, leiomyomas can cause abnormal uterine bleeding, pelvic pain/pressure, and reproductive effects, such as infertility or adverse pregnancy outcomes. Treatment varies depending on age, symptoms, and the preference to preserve fertility. In this article, we describe the case of a 58-year-old woman who presented for a scheduled cervical cancer screening in primary healthcare. Upon objective examination, the patient exhibited a distended and tense abdomen, along with edema in the lower limbs. These symptoms were associated with fatigue and weight gain over the last few months. Subsequent investigation led to an exploratory laparotomy which revealed a massive abdominal mass, measuring approximately 45 cm in diameter and weighing 35 kg. The findings were suggestive of a parasitic leiomyoma.

An HIV-1/HIV-2 Chimeric Envelope Glycoprotein Generates Binding and Neutralising Antibodies against HIV-1 and HIV-2 Isolates

The development of immunogens that elicit broadly reactive neutralising antibodies (bNAbs) is the highest priority for an HIV vaccine. We have shown that a prime-boost vaccination strategy with vaccinia virus expressing the envelope glycoprotein gp120 of HIV-2 and a polypeptide comprising the envelope regions C2, V3 and C3 elicits bNAbs against HIV-2. We hypothesised that a chimeric envelope gp120 containing the C2, V3 and C3 regions of HIV-2 and the remaining parts of HIV-1 would elicit a neutralising response against HIV-1 and HIV-2. This chimeric envelope was synthesised and expressed in vaccinia virus. Balb/c mice primed with the recombinant vaccinia virus and boosted with an HIV-2 C2V3C3 polypeptide or monomeric gp120 from a CRF01_AG HIV-1 isolate produced antibodies that neutralised >60% (serum dilution 1:40) of a primary HIV-2 isolate. Four out of nine mice also produced antibodies that neutralised at least one HIV-1 isolate. Neutralising epitope specificity was assessed using a panel of HIV-1 TRO.11 pseudoviruses with key neutralising epitopes disrupted by alanine substitution (N160A in V2; N278A in the CD4 binding site region; N332A in the high mannose patch). The neutralisation of the mutant pseudoviruses was reduced or abolished in one mouse, suggesting that neutralising antibodies target the three major neutralising epitopes in the HIV-1 envelope gp120. These results provide proof of concept for chimeric HIV-1/HIV-2 envelope glycoproteins as vaccine immunogens that can direct the antibody response against neutralising epitopes in the HIV-1 and HIV-2 surface glycoproteins.

A unified model of ketamine's dissociative and psychedelic properties

Ketamine is an N-methyl-d-aspartate antagonist which is increasingly being researched and used as a treatment for depression. In low doses, it can cause a transitory modification in consciousness which was classically labelled as 'dissociation'. However, ketamine is also commonly classified as an atypical psychedelic and it has been recently reported that ego dissolution experiences during ketamine administration are associated with greater antidepressant response. Neuroimaging studies have highlighted several similarities between the effects of ketamine and those of serotonergic psychedelics in the brain; however, no unified account has been proposed for ketamine's multi-level effects - from molecular to network and psychological levels. Here, we propose that the fast, albeit transient, antidepressant effects observed after ketamine infusions are mainly driven by its acute modulation of reward circuits and sub-acute increase in neuroplasticity, while its dissociative and psychedelic properties are driven by dose- and context-dependent disruption of large-scale functional networks. Computationally, as nodes of the salience network (SN) represent high-level priors about the body ('minimal' self) and nodes of the default-mode network (DMN) represent the highest-level priors about narrative self-experience ('biographical' self), we propose that transitory SN desegregation and disintegration accounts for ketamine's 'dissociative' state, while transitory DMN desegregation and disintegration accounts for ketamine's 'psychedelic' state. In psychedelic-assisted psychotherapy, a relaxation of the highest-level beliefs with psychotherapeutic support may allow a revision of pathological self-representation models, for which neuroplasticity plays a permissive role. Our account provides a multi-level rationale for using the psychedelic properties of ketamine to increase its long-term benefits.

High Instantaneous Inhibitory Potential of Bictegravir and the New Spiro-β-Lactam BSS-730A for HIV-2 Isolates from RAL-Naïve and RAL-Failing Patients

Integrase inhibitors (INIs) are an important class of drugs for treating HIV-2 infection, given the limited number of drugs active against this virus. While the clinical efficacy of raltegravir and dolutegravir is well established, the clinical efficacy of bictegravir for treating HIV-2 infected patients has not been determined. Little information is available regarding the activity of bictegravir against HIV-2 isolates from patients failing raltegravir-based therapy. In this study, we examined the phenotypic and matched genotypic susceptibility of HIV-2 primary isolates from raltegravir-naïve and raltegravir-failing patients to raltegravir, dolutegravir, and bictegravir, and to the new spiro-β-lactam BSS-730A. The instantaneous inhibitory potential (IIP) was calculated to help predict the clinical activity of bictegravir and BSS-730A. Isolates from raltegravir-naïve patients were highly sensitive to all INIs and BSS-730A. Combined integrase mutations E92A and Q148K conferred high-level resistance to raltegravir, and E92Q and T97A conferred resistance to raltegravir and dolutegravir. The antiviral activity of bictegravir and BSS-730A was not affected by these mutations. BSS-730A displayed strong antiviral synergism with raltegravir. Mean IIP values at Cmax were similar for all INIs and were not significantly affected by resistance mutations. IIP values were significantly higher for BSS-730A than for INIs. The high IIP values of bictegravir and BSS-730A for raltegravir-naïve and raltegravir-resistant HIV-2 isolates highlight their potential value for treating HIV-2 infection. Overall, the results are consistent with the high clinical efficacy of raltegravir and dolutegravir for HIV-2 infection and suggest a promising clinical profile for bictegravir and BSS-730A.

What can we say about the impact of teleconsultations on preventing psychiatric inpatient treatment during COVID-19 pandemic?

Introduction

Telepsychiatry was proved effective and satisfactory in settings like the emergency department and mental health services, but its use is historically restricted. Although there are several studies about telepsychiatry pros and cons, more is needed to know about its effect on patient’s follow-up and its influence on inpatient treatment rates, specifically during COVID-19 pandemic.

Objectives

The aim is to look for an eventual change on psychiatric inpatient admissions, during COVID-19 pandemic, when psychiatric patients are in follow-up through teleconsultation.

Methods

We compared the number of hospitalizations for 3 different 6 months periods of time: the 2^nd semester of 2019 with no teleconsultations, March-August 2020 only with teleconsultations (except some few 1^st consultations) and the 1^st semester of 2021 with face-to-face and teleconsultations. A one-way repeated measures ANOVA was conducted on a 1050 patients sample.

Results

The statists showed that the type of approach in consultations didn’t lead to statistically significant differences in hospitalizations (F test-statistic = 0.33086, p = 0.718345).

Conclusions

There is a plethora of advantages about telepsychiatry and it was already shown to be as effective as in-person contact. Some articles show an association of telepsychiatry with a decrease in hospitalization rates, but mostly display similar clinical outcomes. In this study, the authors found that the results follow the latter tendency, although we must consider the COVID-19 pandemic as a possible decompensation and worsening clinical factor. More studies on this matter are important to better understand the potential benefits (and risks) of this treatment setting.

Disclosure

No significant relationships.

A non-coding RNA balancing act: miR-346-induced DNA damage is limited by the long non-coding RNA NORAD in prostate cancer

BACKGROUND

miR-346 was identified as an activator of Androgen Receptor (AR) signalling that associates with DNA damage response (DDR)-linked transcripts in prostate cancer (PC). We sought to delineate the impact of miR-346 on DNA damage, and its potential as a therapeutic agent.

METHODS

RNA-IP, RNA-seq, RNA-ISH, DNA fibre assays, in vivo xenograft studies and bioinformatics approaches were used alongside a novel method for amplification-free, single nucleotide-resolution genome-wide mapping of DNA breaks (INDUCE-seq).

RESULTS

miR-346 induces rapid and extensive DNA damage in PC cells - the first report of microRNA-induced DNA damage. Mechanistically, this is achieved through transcriptional hyperactivation, R-loop formation and replication stress, leading to checkpoint activation and cell cycle arrest. miR-346 also interacts with genome-protective lncRNA NORAD to disrupt its interaction with PUM2, leading to PUM2 stabilisation and its increased turnover of DNA damage response (DDR) transcripts. Confirming clinical relevance, NORAD expression and activity strongly correlate with poor PC clinical outcomes and increased DDR in biopsy RNA-seq studies. In contrast, miR-346 is associated with improved PC survival. INDUCE-seq reveals that miR-346-induced DSBs occur preferentially at binding sites of the most highly-transcriptionally active transcription factors in PC cells, including c-Myc, FOXA1, HOXB13, NKX3.1, and importantly, AR, resulting in target transcript downregulation. Further, RNA-seq reveals widespread miR-346 and shNORAD dysregulation of DNA damage, replication and cell cycle processes. NORAD drives target-directed miR decay (TDMD) of miR-346 as a novel genome protection mechanism: NORAD silencing increases mature miR-346 levels by several thousand-fold, and WT but not TDMD-mutant NORAD rescues miR-346-induced DNA damage. Importantly, miR-346 sensitises PC cells to DNA-damaging drugs including PARP inhibitor and chemotherapy, and induces tumour regression as a monotherapy in vivo, indicating that targeting miR-346:NORAD balance is a valid therapeutic strategy.

CONCLUSIONS

A balancing act between miR-346 and NORAD regulates DNA damage and repair in PC. miR-346 may be particularly effective as a therapeutic in the context of decreased NORAD observed in advanced PC, and in transcriptionally-hyperactive cancer cells.

Prevalence of the Most Frequent Neuropsychiatric Diagnoses in Hospitalized SARS-CoV-2 Patients Evaluated by Liaison Psychiatry: Cross-Sectional Study

INTRODUCTION

The SARS-CoV-2 infection has been associated with the acute onset of mental and behavioural symptoms and psychiatric disorders. The aim of this study was to assess the prevalence of the different neuropsychiatric diagnoses in hospitalized patients with SARS-CoV-2 infection assessed by Liaison Psychiatry.

MATERIAL AND METHODS

We performed a cross-sectional study in a hospital near Lisbon, Portugal. We reviewed the electronic health records from all inpatients with a positive SARS-CoV-2 RT-PCR test that were assessed by the Liaison Psychiatry Unit (LPU) between February and December 2020. We reviewed relevant sociodemographic and clinical data, including 15 neuropsychiatric symptoms. The prevalence of psychiatric disorders was our main outcome. We also explored differences between two groups: patients with delirium (delirium group) and patients without delirium (no delirium group).

RESULTS

We included 46 cases [Age: median = 67 years; interquartile range (IQR) = 24)], with 60.9% male individuals. Delirium was the most frequent diagnosis in our sample (43.5%), followed by major depressive disorder (21.7%). Patients with delirium were more likely to suffer from COVID-19 symptoms (delirium: 19/20, 95%; no delirium: 14/26, 53.8%; p = 0.02), and to have a longer time interval between a positive SARS-CoV-2 RT-PCR test and an evaluation by the LPU (delirium: median = 16.5 days, IQR = 16; no delirium: median = 8 days, IQR = 16.3; p = 0.045). Agitation (52.2%) and cognitive symptoms (47.8%) were the most reported neuropsychiatric symptoms.

CONCLUSION

We found a high prevalence of delirium in our sample. This finding is in line with recent literature concerning hospitalized COVID-19 patients The higher frequency of COVID-19 symptoms found in the delirium group suggests a possible association between symptomatic SARS-CoV-2 infection and delirium onset.

Fucoid Macroalgae Have Distinct Physiological Mechanisms to Face Emersion and Submersion Periods in Their Southern Limit of Distribution

During high tide, macroalgae are submersed, facing adequate environmental conditions, however, at low tide, these species can be exposed to high UV radiation and desiccation, leading to an overproduction of reactive oxygen species, causing oxidative stress. Since intertidal organisms present differential sensitivity to abiotic fluctuations, this study aimed to evaluate the physiological responses [photosynthetic pigments, hydrogen peroxide (H₂O₂), lipid peroxidation (LP), and thiols and proline] of three macroalgae, from different intertidal levels, towards tidal regimes. Samples of Pelvetia canaliculata, Ascophyllum nodosum, and Fucus serratus were collected from beaches located on the southern limit of distribution in periods of potential stress (Summer and Spring), under low and high tide. The photosynthetic pigments of P. canaliculata and F. serratus were generally higher during low tide, and the oxidative damage evidenced by H₂O₂ and LP increased in the Summer, while A. nodosum showed greater oxidative damage in the Spring. While thiol content did not change, proline levels were species- and tidal-specific among sampling dates. P. canaliculata presented higher resilience to unfavorable conditions, while F. serratus was the most sensitive species. The physiological responses analyzed were species-specific, pointing to the high susceptibility of low intertidal organisms to expected extreme climatic events.

Potentially inappropriate medicines use in older adults

Background

With the increase of the average life expectancy, and the increase in chronic diseases, consequently also increases the consumption of medicines. Polymedication leads to an increase in drug-related problems, particularly in the elderly. Prescription of medications potentially inappropriate, which can have a harmful impact on the quality of life of the elderly. The aims are identifying and classify potentially inappropriate medication according to the recent criteria of Beers.

Methods

We conducted an observational study in the nursing home. The sample consisted of 45 seniors of 65 years of age or older, take at least two different mediations at the same time. The data collection was made to a questionnaire with sociodemographic characteristics and clinical profile.

Results

The female sex predominates with 32 people (71.1%), with a very high average age (86.02 years ± 7.6). In the 45 respondents it appears that they take a minimum of 4 drugs (2.2%) and a maximum of 16 (4.4%), with an average of 9.7 daily drugs per individual. The most prescribed drugs are for the nervous and the cardiovascular system, and 34 drugs were considered potentially inappropriate medication use in older adults, 23 drugs of which were recommended to be avoided and the rest were recommended to be used with caution and dose reduction.

Conclusions

It is necessary more personalised criterion for prescription and dispensation of medication to elderly people. It is necessary to develop habits and practices that create higher prudence when prescribing medication and its rational use.

Relationship between anxiety, depression and health perception in patients with multimorbidity versus patients without multimorbidity

Background

Multimorbidity is a public health problem. It affects more than one third of Portuguese citizens and has a negative impact on health, both physical and psychological, and quality of life of patients. This study aims to understand the relationship between anxiety, depression and health perception in patients with multimorbidity versus patients without, and to understand the possible influence of sociodemographic factors on this relationship.

Methods

Cross-sectional study with a convenience sample of 176 patients interviewed by telephone using a survey that included sociodemographic variables, a list of 23 diseases to determine the presence of multimorbidity and the HADS and SF-12 scales. Subsequently, descriptive and inferential statistical analysis of the data was performed to perceive if socio-demographic factors influence multimorbidity. A value of P < 0.05 was determined as statistically significant.

Results

The sample (n = 176) had an average age of 51.33 years, 51.1% were multi-morbid. A statistically significant difference was found between the two groups only in the perception of physical health (P < 0.001). Age (P < 0.001) and multi-morbidity (P = 0.004) were identified as significant independent predictors of physical health perception, with the regression model explaining about 43% of the variability in physical health perception of study participants.

Conclusions

Although this study presented some disparities with other studies, it concluded that patients with multimorbidity have a worse perception of their physical health, independently from the sociodemographic variables that were studied, except for age. The absence of a consistent definition of multimorbidity was the main limitation of the study.

Childhood trauma and mental disorders: Exploring the relationship between trauma, immunity and psychosis

Introduction

A relationship between childhood trauma, psychotic experiences, and psychosis is well established, although causality is not yet ascertained. There are several hypotheses linking trauma and psychosis, regarding genetic vulnerability and/or other environmental factors, possibly also mediated by psychological mechanisms. Long-term modifications to the transcriptome are likely mediated by epigenetic mechanisms. There is also growing evidence supporting an association between childhood trauma and adulthood dysregulation of the immune system, which could help clarify the relationship between trauma and mental disorders, namely psychosis.

Objectives

Review evidence regarding the relationship of childhood trauma, immune system and psychosis.

Methods

Literature review using Medline database.

Results

The prevalence and severity of childhood trauma is characterized by both biological alterations and increased risk of experiencing symptoms of psychosis. Childhood trauma, namely through its effects on IL6 levels, may be a risk factor for schizophrenia in general. Some studies point to a direct relationship between childhood trauma, immunity and psychosis when examined along a continuum from non-clinical controls to psychotic disorders such as schizophrenia.

Conclusions

For better understanding this association, these findings must be replicated in larger cohorts. If the impact of childhood trauma on immune function in adulthood does indeed contribute to psychopathology, an improved understanding of this relationship may lead to new and possibly more specific treatment options. Other clinical implications of these findings include increased emphasis in establishing more comprehensive screening of early trauma in patients with psychotic symptoms, as well as the importance of screen and follow children who report traumatic events for emergence of psychotic symptoms.

To what extent do sexual hormones influence bipolar disorder?

Introduction

It is known that female reproductive events and hormonal treatments can impact the course of bipolar disorder (BD) in women, some of whom are more vulnerable to the development of mood instability under periods of hormonal fluctuation. The mechanisms involved are, however, largely unknown. The aim of this work is to review the impact of sexual hormones on the course of BD, regarding a clinical case.

Objectives

To explore the role of sexual hormones in BD.

Methods

Literature review using Medline database.

Results

This is a case of a 36-year-old woman with type 1 BD who develops a manic episode after starting oral contraception (OC). This episode remitted with suspension of the pill. Estrogen and progesterone are involved in various aspects of brain function, such as brain development, synaptic plasticity, and modulation of neurotransmitter systems. Studies indicate that there is a relationship between ovarian hormones and intracellular signaling systems involved in the pathophysiology of BD. However, research on OC use in patients with mood disorders is limited. Recent studies state that OC aren’t associated with a worse clinical course and don’t negatively influence BD, while other studies show there is a subgroup of bipolar women that improve with hormonal stability, while others get worse.

Conclusions

Further studies are needed to determine possible relationships between sexual hormones and BD, and it is essential to identify patients vulnerable to these risks by measuring baseline hormone levels, assessing hormone sensitivity through a history of mood changes during menstrual cycle and a history of previous mental health problems.

Disclosure

No significant relationships.

Use of botulinum toxin type a in psychiatry - new perspectives and future potential

Introduction

For almost three decades, botulinum toxin type A (BT-A) has been used for medical purposes. Evidence of the potential use of BT-A is emerging for psychiatric disorders, like unipolar and bipolar depression, borderline personality disorder (BPD), late dyskinesia, amongst others. This may represent a new role of BT-A treatment and could expand the therapeutic arsenal in psychiatry.

Objectives

The goal is to review current evidence regarding BT-A and psychiatry disorders.

Methods

Literature review of BT-A use in psychiatric conditions using Medline database.

Results

There’s evidence supporting the use of BT-A in resistant unipolar depression, with studies showing an 8 and 4 times higher response and remission rates comparing with placebo. Beneficial effects were also found in bipolar depression. Preliminary data suggest that BT-A therapy may also be effective in the treatment of mental disorders characterized by an excess of negative emotions, such as BPD. The underlying mechanism might be the “facial feedback hypothesis”. Hyperhidrosis is a common comorbidity in social anxiety disorder and may itself give rise to depressive or anxiety symptoms. BT-A has proved to be a safe and effective treatment for hyperhidrosis. BT-A can also be safely used for dystonia secondary to the use of psychiatric medication, when there’s an inadequate response to anticholinergic medication. Also, BT-A injections in the salivary glands have been investigated for treating clozapine-induced sialorrhea and studies reported successful reduction in hypersalivation.

Conclusions

Although more studies are needed to evaluate the potential of BT-A in psychiatry, there is growing evidence of its potential use for some psychiatric conditions.

Inaugural seizure in a patient submitted to electroconvulsive therapy and anti-psychotic treatment: Who’s the culprit?

Introduction

Electroconvulsive Therapy (ECT) is one of the most effective treatments for Depressive Disorder. Although its safety and tolerability have been throughout the years, it still holds common mild and rarely persistent side effects.

Objectives

The aim is to review some of the most recent data on the connection between inaugural seizures in psychiatric patients being submitted to ECT for treatment of Major Depressive Disorder, while also discussing the possible contribution of the concomitant use of clozapine and clomipramine.

Methods

The authors present a case report of an episode of an inaugural seizure in a patient submitted to ECT, with concomitant use of clozapine and clomipramine. A search on Pubmed and Clinicalkey was performed, from which the relevant publications were selected and reviewed.

Results

The authors present a 62 year old woman who developed an inaugural generalized tonic-clonic seizure after being submitted to ECT for treatment of Recurrent Major Depressive Disorder (RMDD), while also carrying out clozapine and clomipramine dosage reduction, with the purpose of discontinuation. The patient had no history of previous seizures, nor were there relevant findings in the patient’s neurological examination, blood work, brain CT or EEG.

Conclusions

There is a plethora of possible factors involved in the development of an inaugural seizure. Although, the risk of spontaneous seizure during ECT is low, it may be increased by the concomitant use of drugs which can lower the seizure threshold. In most cases, when ECT was resumed after removal of such triggers, there were no further complications.

Therapeutic interventions for PTSD – current evidence on the the role of psychedelics

Introduction

Post-traumatic stress disorder (PTSD) is often a chronic condition, despite the existence of evidence-based treatment options. Psychotherapy is the designated first line treatment for PTSD, although high rates of psychiatric and medical comorbidity are observed among patients who have undergone treatment. The psychoactive properties of psychedelics may be of particular interest within a substance-assisted psychotherapy approach, offering new treatment opportunities for this debilitating disorder.

Objectives

Review current evidence, therapeutic context, and possible mechanisms of action of different types of psychedelics in the treatment of PTSD.

Methods

Literature review using Medline database.

Results

3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy appears to be a potentially safe, effective, and durable treatment for individuals with treatment-refractory PTSD. Based on a small number of studies, ketamine administration appears to result in temporary symptom relief and may, in combination with psychotherapy, lead to lasting reductions in PTSD symptoms. Although these have not yet been investigated in controlled studies, it is known that psilocybin and LSD induce psychoactive effects that could as well contribute to the psychotherapeutic treatment of PTSD.

Conclusions

The use of psychedelic compounds within a substance-assisted psychotherapy framework offers a novel method for pharmacotherapy-psychotherapy integration, although there is still much to learn from both a clinical and neurobiological perspective. It is necessary to generate more data regarding the safety and efficacy of psychedelics, in addition to research on cost-effectiveness, its use in mental health care infrastructure and also regarding the training of specialized therapists.

Treating addiction with psychedelics - are we waking up?

Introduction

Classic psychedelics have been administered in sacramental contexts since ancient times. They were of prominent interest within psychiatry and neuroscience in the 1950s to 1960s, but the association between classic psychedelics and the emerging counterculture put an end to their research. Modern research with classic psychedelics has reinitiated interest in the treatment of both cancer-related distress and addiction, with really promising results.

Objectives

We aim to provide a review about history and new insights regarding research with psychedelics specially as treatment of addictive disorders.

Methods

A framing analysis of articles, searched on Pubmed (articles between 2010-2020) with the key words: “ psychedelics”, “psilocybin”, “substance use disorder”, “addiction”.

Results

Classic psychedelics are 5HT2AR agonists such as LSD, mescaline, and psilocybin. They were shown to occasion mystical experiences, which are experiences reported throughout different cultures and religions involving a strong sense of unity. These experiences are scientifically important because they appear to cause abrupt and sustained changes in behavior and perception, that can be very useful in the substance use disorder field. From this analysis is possible to understand that the use of psychadelics in the treatment of some addictions is currently at an early stage of research. However, they show interesting results with no clinically significant adverse events when risk individuals are excluded.

Conclusions

In comparison to psychedelic research about cancer-related psychological distress, studies with addictions are less developed, but if they continue to suggest safety and efficacy, may be the use of psilocybin for the treatment of specific addiction can happen in a close future.

The forbidden fruit – the thin line between belief, religion, and severe psychopathology: A case report

Introduction

Religious obsessions constitute an interesting component of the phenomenology of obsessive-compulsive disorder(OCD). Scrupulosity can be phenomenologically similar to other OCD subtypes but the ultimate feared consequence is religious or moral in nature.

Objectives

To develop a reflexion about religion, belief and its interaction with psychopathology, focusing on a clinical case.

Methods

Review of the clinical case and literature.

Results

37-year-old female patient with 4 prior psychiatric admissions. Stable until May 2020. After a brief online relationship patient develops subsequent guilt, anxiety and obsessive images with religious/sexual content. Abruptly, on the day of admission to the ER, the patient eats garlic in penitence and self-flagellate. At inpatient-unit she presented in mutism and total oral refusal, needing nasogastric tube for feeding and medication administration. She was medicated with diazepam and olanzapine, being added fluoxetine later on. In later interviews, a primordial idea based on the prevailing religious beliefs was found: “sex before marriage is a mortal sin”. This itself generated doubt “have I been forgiven” with compulsions of verification/purification (eg. repeated confession) and punishment, and this doubt almost reached a delirious character during the acute episode. Partial egodistonia, lived with suffering although with some continuity with her beliefs. At discharge patient showed insight for the unrealism of this dyad, though the primary idea remained immovable.

Conclusions

Although the pharmacological approach managed to control the most disturbing symptoms presented by the patient, it’s worthwhile to review and to reflect on this report in a wider perspective, within in the light of the relevance to the clinical practice.

Disclosure

No significant relationships.

Influenza and schizophrenia: How can we shed a light in the new virus from an old association?

Introduction

COVID-19 raises serious concerns regarding its unknown consequences for health, including psychiatric long term outcomes. Historically, influenza virus has been responsible for pandemics associated with schizophrenia. Epidemiological studies showed increased risk for schizophrenia in children of mothers exposed to the 1957 influenza A2 pandemic. Controversy remains concerning the mechanisms of pathogenesis underlying this risk.

Objectives

We aim to review the evidence for the association between influenza infection and schizophrenia risk, the possible pathogenic mechanisms underlying and correlate these findings with the schizophrenia hypothesis of neurodevelopment.

Methods

We reviewed literature regarding evidence from epidemiological, translational animal models and serological studies using medline database.

Results

The biological mechanisms likely to be relevant account to the effects of infection-induced maternal immune activation, microglial activation, infection-induced neuronal autoimmunity, molecular mimicry of the influenza virus, neuronal surface autoantibodies and psychosis with potential infectious antecedents. Influenza infection may fit into the theory of the neurodevelopment of schizophrenia as a factor that alters the normal maturation processes of the brain (possible second or third hit).

Conclusions

Influenza infection has multiple pathogenic pathways in both pre and post natal processes that might increase the risk of schizophrenia or psychosis. The existing evidence regarding the relationship between influenza virus and psychosis might help us draw similar long-term concerns of COVID-19.

Disclosure

No significant relationships.

Bleuler’s a or autism spectrum disorder in adults?

Introduction

Nowadays we know that autism spectrum disorders (ASD) and Schizophrenic spectrum (SS) are different types of disorders in their etiology, symptoms and prognosis, but the clinical distinction is often difficult to make due to comorbidity and similar symptoms.

Objectives

With this project, the authors intend to explore the differential diagnosis between ASD and SS specially when we talk about critical ages of onset.

Methods

An analysis of articles searched on Pubmed (articles between 2010-2020) with the key words “adult autism”, “childhood onset schizophrenia”, “childhood psychosis”.

Results

Early-onset schizophrenia (EOS) is defined as occurring before age 18 years. The condition share key diagnostic symptoms with adult-onset schizophrenia (AOS) but his prognoses and comorbidities differ. Autism spectrum disorder (ASD) is a common neurodevelopmental disorder characterized by difficulties since early childhood across reciprocal social communication and restricted interests and behaviors. ASD is a lifelong neurodevelopmental disorder, however there is a lack of answers and research for adults with ASD. There are shared aspects of odd thinking, rigid behaviors and impaired socialization in schizophrenia and ASD and COS seems to have a strong relationship with ASD, being comorbid in up to 50% of cases.

Conclusions

Usually the evaluation of the developmental history of the person, prodrome and onset, its course and the presence of positive symptoms of schizophrenia is enough to help us find a diagnosis. Unfortunately, in some ages the conclusion is not so easy to find. However is essential to determine whether the clinical manifestations belong to the autistic spectrum, the schizophrenic or result from comorbidity.

Mental health conditions in people searching for aesthetic treatments: The importance of early detection

Introduction

It’s established that aesthetic dysfunctions can be associated with psychiatric conditions. In present times, considering the exponential growth of minimally invasive and accessible techniques, alongside with ideals of beauty present in everyday life through exposure in social media, the importance of early detection of mental illness and its impact on the respective outcome should be emphasized.

Objectives

To review evidence regarding psychiatric disorders in people searching for aesthetic treatments and their impact on the outcome.

Methods

Literature review using Medline database.

Results

Around 50% of individuals seeking aesthetic procedures fulfill the diagnostic criteria for psychiatric disorders. The prevalence of Body Dysmorphic Disorder (BDD) can vary from 5-15%, with some studies showing a prevalence of more than 50%. Patients with heightened BDD symptoms are less satisfied with the outcomes of aesthetic procedures which could result in exacerbation of said symptoms. With regards to eating disorders, evidence suggests the initial satisfaction following aesthetic procedures, when observed, is usually transitory, not leading to long-term changes in self-perception relating to body image, nor improving prognosis or quality of life. There’s also some evidence suggesting that personality disorders may be a predictor of poor satisfaction with the results of aesthetic treatments.

Conclusions

Awareness should be raised in this matter, since psychiatric conditions are more common in patients seeking aesthetic treatments and early identification can lead to a better prognosis by providing patients with the mental health treatment they need; this could also reduce the probability of dissatisfaction and subsequent aggravation of psychiatric symptoms following aesthetic interventions.

Readmissions in elderly patients with heart failure. A retrospective study

Heart failure is a major cause of morbidity and mortality worldwide. The prevalence increases with age and usually progresses, leading to repeated hospital admissions and significant symptom burden for patients. The correct management of these patients may decrease readmissions and increase quality of life. Our aim is to compare elderly patients with and without 1-year readmissions in an internal medicine ward, particularly in terms of mortality. Retrospective study, consulting patient’s clinical records, with a diagnosis of heart failure. The patients were characterized and divided in groups: with (wR) and without readmission (woR) within 1 year. Mortality was the primary outcome. Eighty-nine patients were included; 60 woR and 29 wR. There was no gender difference between groups, the wR group had older patients. The most frequent comorbidities included atrial fibrillation, hypertension and chronic renal failure stage 3 or higher. The most frequent cause of hospitalization was heart failure due to insufficient therapy or natural progression of the disease. The etiology of heart failure was mainly hypertensive and ischemic. The wR group had more patients classified as NYHA >III. In relation to the primary outcome; mortality at 12 months was higher in the group with repeated admissions. The characterization of this population allows us to highlight the causes of decompensation and to review medication in order to increase the quality of life.

Síndrome da Hiperémese dos Canabinoides: Uma Revisão Prática para Clínicos

A primeira descrição clínica da síndrome da hiperémese dos canabinoides advém de um artigo de Allen et al publicado em 2004. Desde então, várias publicações têm-se focado na sua conceptualização e abordagem clínica, embora se mantenha pouco conhecida na comunidade médica. Esta síndrome é caracterizada pela tríade de consumo crónico de canabinoides, hiperémese cíclica, e banhos ou duches quentes compulsivos como forma de alívio sintomatológico. Podem ainda ocorrer dor abdominal e outros sintomas. A sua verdadeira prevalência é desconhecida, embora se acumule evidência de que é mais frequente do que outrora julgado. Foram aventadas várias hipóteses para a sua patogénese, nomeadamente relacionadas com recetores canabinoides e vaniloides, o eixo hipotálamo-hipófise-adrenal e o sistema nervoso simpático. Em termos terapêuticos, justificam-se medidas de suporte (p.e. hidratação) na fase aguda, existindo evidência para a utilização de benzodiazepinas (nomeadamente lorazepam), haloperidol ou capsaicina tópica para alívio sintomático. A única intervenção que interrompe o quadro é a abstinência dos consumos, devendo ser feita psicoeducação e orientação adequadas do doente. O conhecimento relativo a esta patologia encontra-se em crescimento. A falta de sensibilização para a doença pode conduzir a testes de diagnóstico invasivos e dispendiosos, inúmeras idas ao serviço de urgência e manutenção do quadro clínico sem resolução sintomatológica. O presente artigo visa sistematizar as linhas de intervenção clínica e fomentar uma maior consciencialização dos profissionais de saúde sobre esta entidade, permitindo uma melhor identificação e abordagem terapêutica deste quadro.

A phase I dose-escalation study of enzalutamide in combination with the AKT inhibitor AZD5363 (capivasertib) in patients with metastatic castration-resistant prostate cancer

BACKGROUND

Activation of the PI3K/AKT/mTOR pathway through loss of phosphatase and tensin homolog (PTEN) occurs in approximately 50% of patients with metastatic castration-resistant prostate cancer (mCRPC). Recent evidence suggests that combined inhibition of the androgen receptor (AR) and AKT may be beneficial in mCRPC with PTEN loss.

PATIENTS AND METHODS

mCRPC patients who previously failed abiraterone and/or enzalutamide, received escalating doses of AZD5363 (capivasertib) starting at 320 mg twice daily (b.i.d.) given 4 days on and 3 days off, in combination with enzalutamide 160 mg daily. The co-primary endpoints were safety/tolerability and determining the maximum tolerated dose and recommended phase II dose; pharmacokinetics, antitumour activity, and exploratory biomarker analysis were also evaluated.

RESULTS

Sixteen patients were enrolled, 15 received study treatment and 13 were assessable for dose-limiting toxicities (DLTs). Patients were treated at 320, 400, and 480 mg b.i.d. dose levels of capivasertib. The recommended phase II dose identified for capivasertib was 400 mg b.i.d. with 1/6 patients experiencing a DLT (maculopapular rash) at this level. The most common grade ≥3 adverse events were hyperglycemia (26.7%) and rash (20%). Concomitant administration of enzalutamide significantly decreased plasma exposure of capivasertib, though this did not appear to impact pharmacodynamics. Three patients met the criteria for response (defined as prostate-specific antigen decline ≥50%, circulating tumour cell conversion, and/or radiological response). Responses were seen in patients with PTEN loss or activating mutations in AKT, low or absent AR-V7 expression, as well as those with an increase in phosphorylated extracellular signal-regulated kinase (pERK) in post-exposure samples.

CONCLUSIONS

The combination of capivasertib and enzalutamide is tolerable and has antitumour activity, with all responding patients harbouring aberrations in the PI3K/AKT/mTOR pathway.

CLINICAL TRIAL NUMBER

NCT02525068.

A Prime-Boost Immunization Strategy with Vaccinia Virus Expressing Novel gp120 Envelope Glycoprotein from a CRF02_AG Isolate Elicits Cross-Clade Tier 2 HIV-1 Neutralizing Antibodies

Development of new immunogens eliciting broadly neutralizing antibodies (bNAbs) is a main priority for the HIV-1 vaccine field. Envelope glycoproteins from non-B-non-C HIV-1clades have not been fully explored as components of a vaccine. We produced Vaccinia viruses expressing a truncated version of gp120 (gp120t) from HIV-1 clades CRF02_AG, H, J, B, and C and examined their immunogenicity in mice and rabbits. Mice primed with the recombinant Vaccinia viruses and boosted with the homologous gp120t or C2V3C3 polypeptides developed antibodies that bind potently to homologous and heterologous envelope glycoproteins. Notably, a subset of mice immunized with the CRF02_AG-based envelope immunogens developed a cross-reactive neutralizing response against tier 2 HIV-1 Env-pseudoviruses and primary isolates. Rabbits vaccinated with the CRF02_AG-based envelope immunogens also generated potent binding antibodies, and one animal elicited antibodies that neutralized almost all (13 of 16, 81.3%) tier 2 HIV-1 isolates tested. Overall, the results suggest that the novel CRF02_AG-based envelope immunogens and prime-boost immunization strategy elicit the type of immune responses required for a preventive HIV-1 vaccine.

Circulating tumour cell increase as a biomarker of disease progression in metastatic castration-resistant prostate cancer patients with low baseline CTC counts

Background

The development of treatment response and surrogate biomarkers for advanced prostate cancer care is an unmet clinical need. Patients with baseline circulating tumour cell (BLCTCs) counts <5/7.5 mL represent a good prognosis subgroup but are non-evaluable for response assessment (decrease in CTCs). The aim of the study is to determine the value of any increase in CTCs (CTC progression) as an indicator of progression in prostate cancer patients with low pre-treatment CTCs (<5).

Patients and methods

We carried out a post hoc analysis of patients with BLCTCs < 5 treated in the COU-AA-301 (abiraterone or placebo + prednisone) and IMMC-38 (chemotherapy) trials. The association of CTC progression (increase in CTCs at 4, 8 or 12 weeks) with overall survival (OS) was evaluated in multi-variable Cox regression models. Performance of survival models with and without CTC progression was evaluated by calculating ROC curve area under the curves (AUCs) and weighted c-indices.

Results

Overall, 511 patients with CTCs < 5 (421 in COU-AA-301 and 90 in IMMC-38) were selected; 212 (41.7%) had CTC progression at 4, 8 or 12 weeks after treatment initiation. CTC progression was associated with significantly worse OS [27.1 versus 15.1 m; hazard ratio (HR) 3.4 (95% confidence interval [CI] 2.5-4.5; P < 0.001)], independent of baseline CTCs and established clinical variables. Adding CTC progression to the OS model significantly improved ROC AUC (0.77 versus 0.66; P < 0.001). Models including CTC progression had superior ROC AUC (0.77 versus 0.69; P < 0.001) and weighted c-index [0.750 versus 0.705; delta c-index: 0.045 (95% CI 0.019-0.071)] values than those including CTC conversion (increase to CTCs ≥ 5). In COU-AA-301, the impact of CTC progression was independent of treatment arm.

Conclusions

Increasing CTCs during the first 12 weeks of treatment are independently associated with worse OS from advanced prostate cancer in patients with baseline CTCs < 5 treated with abiraterone or chemotherapy and improve models with established prognostic variables. These findings must be prospectively validated.

SPOP-Mutated/CHD1-Deleted Lethal Prostate Cancer and Abiraterone Sensitivity

Purpose: CHD1 deletions and SPOP mutations frequently cooccur in prostate cancer with lower frequencies reported in castration-resistant prostate cancer (CRPC). We monitored CHD1 expression during disease progression and assessed the molecular and clinical characteristics of CHD1-deleted/SPOP-mutated metastatic CRPC (mCRPC).Experimental Design: We identified 89 patients with mCRPC who had hormone-naive and castration-resistant tumor samples available: These were analyzed for CHD1, PTEN, and ERG expression by IHC. SPOP status was determined by targeted next-generation sequencing (NGS). We studied the correlations between these biomarkers and (i) overall survival from diagnosis; (ii) overall survival from CRPC; (iii) duration of abiraterone treatment; and (iv) response to abiraterone. Relationship with outcome was analyzed using Cox regression and log-rank analyses.Results: CHD1 protein loss was detected in 11 (15%) and 13 (17%) of hormone-sensitive prostate cancer (HSPC) and CRPC biopsies, respectively. Comparison of CHD1 expression was feasible in 56 matched, same patient HSPC and CRPC biopsies. CHD1 protein status in HSPC and CRPC correlated in 55 of 56 cases (98%). We identified 22 patients with somatic SPOP mutations, with six of these mutations not reported previously in prostate cancer. SPOP mutations and/or CHD1 loss was associated with a higher response rate to abiraterone (SPOP: OR, 14.50 P = 0.001; CHD1: OR, 7.30, P = 0.08) and a longer time on abiraterone (SPOP: HR, 0.37, P = 0.002, CHD1: HR, 0.50, P = 0.06).Conclusions: SPOP-mutated mCRPCs are strongly enriched for CHD1 loss. These tumors appear highly sensitive to abiraterone treatment. Clin Cancer Res; 24(22); 5585-93. ©2018 AACR.

Using biological variables and reproductive strategy of the undulate ray Raja undulata to evaluate productivity and susceptibility to exploitation

The present work provides a detailed analysis of the reproductive strategy of the undulate ray Raja undulata in Portuguese mainland waters. The species was found mostly between 30 and 40 m deep on sandy bottoms. Egg-laying sites were observed in the north, centre and south-west regions, mainly at depths below 30 m. The peak of the reproductive season occurred from December to May. Asynchrony between reproductively active females and males appeared to occur, although most adult males were capable of reproducing throughout the year. The estimated length at 50% maturity was 86·2 cm (8·7 years) and 76·8 cm (7·6 years) total length for females and males, respectively. The maximum potential fecundity was estimated to be 69·8 follicles per female per reproductive season, which are released in 4·7 batches of 15 follicles. The life-history and demographic parameters of R. undulata are similar to those of other skate species, while the potential rate of population increase (0·49) is above the published values for other elasmobranch species. With these new findings, this study makes an important contribution to the understanding of the life history of R. undulata, and provides a first evaluation of the productivity and susceptibility of the species to exploitation.

Androgen receptor expression in circulating tumour cells from castration-resistant prostate cancer patients treated with novel endocrine agents

BACKGROUND

Abiraterone and enzalutamide are novel endocrine treatments that abrogate androgen receptor (AR) signalling in castration-resistant prostate cancer (CRPC). Here, we developed a circulating tumour cells (CTCs)-based assay to evaluate AR expression in real-time in CRPC and investigated nuclear AR expression in CTCs in patients treated with enzalutamide and abiraterone.

METHODS

CTCs were captured and characterised using the CellSearch system. An automated algorithm to identify CTCs and quantify AR expression was employed. The primary aim was to evaluate the association between CTC AR expression and prior treatment with abiraterone or enzalutamide.

RESULTS

AR expression in CTCs was evaluated in 94 samples from 48 metastatic CRPC patients. We observed large intra-patient heterogeneity of AR expression in CTCs. Prior exposure to abiraterone or enzalutamide was not associated with a change in CTCs AR expression (median intensity and distribution of AR-positive classes). In support of this, we also confirmed maintained nuclear AR expression in tissue samples collected after progression on abiraterone. AR staining also identified additional AR-positive CD45-negative circulating cells that were CK-negative/weak and therefore missed using standard protocols. The number of these events correlated with traditional CTCs and was associated with worse outcome on univariate analysis.

CONCLUSIONS

We developed a non-invasive method to monitor AR nuclear expression in CTCs. Our studies confirm nuclear AR expression in CRPC patients progressing on novel endocrine treatments. Owing to the significant heterogeneity of AR expression in CTCs, studies in larger cohorts of patients are required to identify associations with outcome.

Validation and utilisation of high-coverage next-generation sequencing to deliver the pharmacological audit trail

Background:

Predictive biomarker development is a key challenge for novel cancer therapeutics. We explored the feasibility of next-generation sequencing (NGS) to validate exploratory genomic biomarkers that impact phase I trial selection.

Methods:

We prospectively enrolled 158 patients with advanced solid tumours referred for phase I clinical trials at the Royal Marsden Hospital (October 2012 to March 2013). After fresh and/or archived tumour tissue were obtained, 93 patients remained candidates for phase I trials. Results from tumour sequencing on the Illumina MiSeq were cross-validated in 27 out of 93 patients on the Ion Torrent Personal Genome Machine (IT-PGM) blinded to results. MiSeq validation with Sequenom MassARRAY OncoCarta 1.0 (Sequenom Inc., San Diego, CA, USA) was performed in a separate cohort.

Results:

We found 97% concordance of mutation calls by MiSeq and IT-PGM at a variant allele frequency ⩾13% and ⩾500 × depth coverage, and 91% concordance between MiSeq and Sequenom. Common ‘actionable' mutations involved deoxyribonucleic acid (DNA) repair (51%), RAS-RAF-MEK (35%), Wnt (26%), and PI3K-AKT-mTOR (24%) signalling. Out of 53, 29 (55%) patients participating in phase I trials were recommended based on identified actionable mutations.

Conclusions:

Targeted high-coverage NGS panels are a highly feasible single-centre technology well-suited to cross-platform validation, enrichment of trials with molecularly defined populations and hypothesis testing early in drug development.

First-in-human Phase I study of EZN-4176, a locked nucleic acid antisense oligonucleotide to exon 4 of the androgen receptor mRNA in patients with castration-resistant prostate cancer

BACKGROUND

Prostate cancer remains dependent of androgen receptor (AR) signalling, even after emergence of castration resistance. EZN-4176 is a third-generation antisense oligonucleotide that binds to the hinge region (exon 4) of AR mRNA resulting in full-length AR mRNA degradation and decreased AR protein expression. This Phase I study aimed to evaluate EZN-4176 in men with castration-resistant prostate cancer (CRPC).

METHODS

Patients with progressing CRPC were eligible; prior abiraterone and enzalutamide treatment were allowed. EZN-4176 was administered as a weekly (QW) 1-h intravenous infusion. The starting dose was 0.5 mg kg(-1) with a 4-week dose-limiting toxicity (DLT) period and a 3+3 modified Fibonacci dose escalation design. After determination of the DLT for weekly administration, an every 2 weeks schedule was initiated.

RESULTS

A total of 22 patients were treated with EZN-4176. At 10 mg kg(-1) QW, two DLTs were observed due to grade 3-4 ALT or AST elevation. No confirmed biochemical or soft tissue responses were observed. Of eight patients with <5 circulating tumour cells at baseline, a conversion to <5 was observed in three (38%) patients. The most common EZN-4176-related toxicities (all grades) were fatigue (59%), reversible abnormalities in liver function tests ALT (41%) and AST (41%) and infusion-related reactions including chills (36%) and pyrexia (14%).

CONCLUSION

Activity of EZN-4176 at the doses and schedules explored was minimal. The highest dose of 10 mg kg(-1) QW was associated with significant but reversible transaminase elevation.

A rare variant of the ulnar artery with important clinical implications: a case report

BACKGROUND

Variations in the major arteries of the upper limb are estimated to be present in up to one fifth of people, and may have significant clinical implications.

CASE PRESENTATION

During routine cadaveric dissection of a 69-year-old fresh female cadaver, a superficial brachioulnar artery with an aberrant path was found bilaterally. The superficial brachioulnar artery originated at midarm level from the brachial artery, pierced the brachial fascia immediately proximal to the elbow, crossed superficial to the muscles that originated from the medial epicondyle, and ran over the pronator teres muscle in a doubling of the antebrachial fascia. It then dipped into the forearm fascia, in the gap between the flexor carpi radialis and the palmaris longus. Subsequently, it ran deep to the palmaris longus muscle belly, and superficially to the flexor digitorum superficialis muscle, reaching the gap between the latter and the flexor carpi ulnaris muscle, where it assumed is usual position lateral to the ulnar nerve.

CONCLUSION

As far as the authors could determine, this variant of the superficial brachioulnar artery has only been described twice before in the literature. The existence of such a variant is of particular clinical significance, as these arteries are more susceptible to trauma, and can be easily confused with superficial veins during medical and surgical procedures, potentially leading to iatrogenic distal limb ischemia.

Reproductive biology of cuckoo ray Leucoraja naevus

The present study is the first to provide data on the reproductive biology of cuckoo ray Leucoraja naevus in Portuguese continental waters. No difference in size at maturity was detected between sexes, which was estimated as 56 cm total length. Spawning occurs all year round, but maximum activity was during winter months. Maximum fecundity is c. 63 eggs female(-1) year(-1). Encapsulated eggs are released in batches, nine in total with a mean number of seven extruded eggs in each batch.

[Cytomegalovirus infection in an infant with epidermolysis bullosa]

The authors report and discuss the case of an infant bearer of Epidermolysis Bullosa who was affected by acquired Cytomegalovirus infection.