Polypharmacy in psychiatry and weight gain: longitudinal study of 832 patients hospitalized for depression or schizophrenia, along with data of 3180 students from Europe, the U.S., South America, and China

Epidemiologic data indicate that overweight and obesity are on the rise worldwide. Psychiatric patients are particularly vulnerable in this respect as they have an increased prevalence of overweight and obesity, and often experience rapid, highly undesirable weight gain under psychotropic drug treatment. Current treatment strategies in psychiatry are oriented towards polypharmacy, so that the information on drug-induced weight gain from earlier monotherapy studies is of very limited validity. We have analyzed the longitudinal data of 832 inpatients with ICD-10 diagnoses of either F2 (schizophrenia; n = 282) or F3 (major depression; n = 550) with the goal of ranking treatment regimens in terms of weight gain, side effects, and response to treatment. The patient data were complemented by the data of 3180 students aged 18-22 years, with which we aimed to identify factors that enable the early detection and prevention of obesity and mental health problems. After 3 weeks of treatment, 47.7% of F2 patients and 54.9% of F3 patients showed a weight gain of 2 kg and more. Major predictive factors were "starting weight" (r = 0.115), "concurrent medications" (r = 0.176), and "increased appetite"(r = 0.275). Between 11 and 30% of the observed variance in weight gain could be explained by these factors, complemented by sex and age. The comparison between monotherapy (n = 409) and polypharmacy (n = 399) revealed significant drawbacks for polypharmacy: higher weight gain (p = 0.0005), more severe side effects (p = 0.0011), and lower response rates (F2: p = 0.0008); F3: p = 0.0101). The data of 3180 students made it clear that overweight and obesity often begin early in life among those affected, and are interconnected with personality traits, while increasing the risk of developing psychosomatic disturbances, mental health problems, or somatic illnesses. Although the available data did not readily lead to a comprehensive, clinically applicable model of unwanted weight gain, our results have nevertheless demonstrated that there are ways to successfully counteract such weight gain at early stages of treatment.

Analysis of genetic diversity in patients with major psychiatric disorders versus healthy controls: A molecular-genetic study of 1698 subjects genotyped for 100 candidate genes (549 SNPs)

BACKGROUND

This study analyzed the extent to which irregularities in genetic diversity separate psychiatric patients from healthy controls.

METHODS

Genetic diversity was quantified through multidimensional "gene vectors" assembled from 4 to 8 polymorphic SNPs located within each of 100 candidate genes. The number of different genotypic patterns observed per gene was called the gene's "diversity index".

RESULTS

The diversity indices were found to be only weakly correlated with their constituent number of SNPs (20.5 % explained variance), thus suggesting that genetic diversity is an intrinsic gene property that has evolved over the course of evolution. Significant deviations from "normal" diversity values were found for (1) major depression; (2) Alzheimer's disease; and (3) schizoaffective disorders. Almost one third of the genes were correlated with each other, with correlations ranging from 0.0303 to 0.7245. The central finding of this study was the discovery of "singular genes" characterized by distinctive genotypic patterns that appeared exclusively in patients but not in healthy controls. Neural Nets yielded nonlinear classifiers that correctly identified up to 90 % of patients. Overlaps between diagnostic subgroups on the genotype level suggested that (1) diagnoses-crossing vulnerabilities are likely involved in the pathogenesis of major psychiatric disorders; (2) clinically defined diagnoses may not constitute etiological entities.

CONCLUSION

Detailed analyses of the variation of genotypic patterns in genes along with the correlation between genes lead to nonlinear classifiers that enable very robust separation between psychiatric patients and healthy controls on the genotype level.

Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy

BACKGROUND

The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients.

METHODS

We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively).

RESULTS

Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER.

CONCLUSIONS

Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.

Detailing the effects of polypharmacy in psychiatry: longitudinal study of 320 patients hospitalized for depression or schizophrenia

Current treatment standards in psychiatry are oriented towards polypharmacy, that is, patients receive combinations of several antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, antihistamines, and anticholinergics, along with other somatic treatments. In tandem with the beneficial effects of psychopharmacological drug treatment, patients experience significant adverse reactions which appear to have become more frequent and more severe with the rise of ubiquitous polypharmacy. In this study, we aimed to assess today's acute inpatient treatment of depressive and schizophrenic disorders with focus on therapeutic strategies, medications, adverse side effects, time course of recovery, and efficacy of treatments. Of particular interest was the weighing of the benefits and drawbacks of polypharmacy regimens. We recruited a total of 320 patients hospitalized at three residential mental health treatment centers with a diagnosis of either schizophrenic (ICD-10: "F2x.x"; n = 94; "F2 patients") or depressive disorders (ICD-10: "F3x.x"; n = 226; "F3 patients"). The study protocol included (1) assessment of previous history by means of the SADS Syndrome Check List SSCL-16 (lifetime version); (2) repeated measurements over 5 weeks assessing the time course of improvement by the Hamilton Depression Scale HAM-D and the Positive and Negative Syndrome Scale PANSS, along with medications and adverse side effects through the Medication and Side Effects Inventory MEDIS; and (3) the collection of blood samples from which DNA and serum were extracted. Polypharmacy was by far the most common treatment regimen (85%) in this study. On average, patients received 4.50 ± 2.68 medications, consisting of 3.30 ± 1.84 psychotropic drugs, plus 0.79 ± 1.13 medications that alleviate adverse side effects, plus 0.41 ± 0.89 other somatic medications. The treating psychiatrists appeared to be the main determining factor in this context, while «previous history» and «severity at baseline» played a minor role, if at all. Adverse drug reactions were found to be an inherent component of polypharmacy and tended to have a 2-3 times higher incidence compared to monotherapy. Severe adverse reactions could not be attributed to a particular drug or drug combination. Rather, the empirical data suggested that severe side effects can be triggered by virtually all combinations of drugs, provided patients have a respective vulnerability. In terms of efficacy, there were no advantages of polypharmacy over monotherapy. The results of this study underlined the fact that polypharmacy regimens are not equally suited for every patient. Specifically, such regimens appeared to have a negative impact on treatment outcome and to obfuscate the "natural" time course of recovery through a multitude of interfering factors. Evidence clearly speaks against starting just every therapeutic intervention in psychiatry with a combination of psychopharmaceuticals. We think that it is time for psychiatry to reconsider its treatment strategies, which are far too one-sidedly fixated on psychopharmacology and pay far too little attention to alternative approaches, especially in mild cases where psychotherapy without concurrent medication should still be an option. Also, regular exercises and sports can definitely be an effective therapeutic means in a considerable number of cases. General practitioners (GPs) are particularly in demand here.

Multiple Esophageal Leiomyoma Presenting with Clinical Dysphagia from Mechanical Obstruction and Motility Disorder

Esophageal leiomyoma is uncommon. However, this tumor is the most common subepithelial tumor affecting the esophagus, comprising approximately two-thirds of benign esophageal tumors. Leiomyomas of the esophagus rarely cause symptoms when they are single and <5 cm. The mainstay of treatment is esophagectomy for symptomatic patients. A 68-year-old male patient presented with progressive dysphagia for 4 months. The degree of dysphagia and chest discomfort was more severe on solid rather than liquid diet. The CT scan of the chest showed multiple well-defined, submucosal nodules, up to 1.9 cm in diameter located at the middle esophagus. The barium swallow study illustrated multiple, well-defined, smooth, semilunar filling defects along the mid to distal esophagus. Meanwhile, esophagogastroduodenoscopy revealed 8 smooth subepithelial masses. Moreover, the radial EUS showed multiple hypoechoic masses arising from the 4th layer, with some of the tumors connected to others as a horseshoe-like shape causing narrowed lumen. Last, high-resolution esophageal manometry revealed ineffective esophageal motility. We report a rare case of numerous esophageal leiomyomas which caused dysphagia as a result of both mechanical obstruction and hypomotility disorder. The histopathology confirmed the diagnosis of esophageal leiomyoma. Symptoms improved significantly after lifestyle modifications and adherence to dietary advice on the part of the patient.

Inflammatory processes linked to major depression and schizophrenic disorders and the effects of polypharmacy in psychiatry: evidence from a longitudinal study of 279 patients under therapy

Over the past 2 decades, polypharmacy has become the de-facto standard of acute treatment in psychiatry where patients with psychiatric disorders receive a multiple medication regimen. There is growing evidence for a potential link between major psychiatric disorders and inflammatory processes. Combining these two aspects aims at avoiding polypharmacy attempts among patients with inflammatory activation through alternative treatment strategies. In this study, we addressed the following questions: (1) to what extent can polypharmacy be explained through the factors "diagnosis", "previous history", "severity at baseline", "age", "gender", and "psychiatrist in charge"; (2) what are the differences between polypharmacy and monotherapy regarding efficacy and side effect profiles; and (3) what amount of between-patient variance is explainable by the natural antibody immunoglobulin M (IgM) within each diagnostic group. This naturalistic longitudinal study was comprised of 279 patients under therapy with a clinical diagnosis of depressive (ICD-10: "F3x.x"; n = 195) or schizophrenic disorders (ICD-10: "F2x.x"; n = 84). The study protocol included (1) assessment of previous history by the SADS Syndrome Check List SSCL-16 (lifetime version); (2) repeated measurements over 5 weeks assessing the time course of improvement by the Hamilton Depression Scale HAM-D and the Positive and Negative Syndrome Scale PANSS, along with medication and unwanted side effects through the Medication and Side Effects Inventory MEDIS; and (3) the collection of blood samples from which DNA and serum were extracted. The association between inflammatory response system and psychiatric disorders was detailed by fitting multi-layer Neural Net (NN) models to the observed data ("supervised learning"). The same approach was used to set up prediction models of side effects. Our data showed that polypharmacy was omnipresent. Yet the various polypharmacy regimens had no advantage over monotherapy: we even found slightly larger baseline score reductions under monotherapy, independent of primary diagnoses and for comparable baseline severities. Most patients experienced unwanted side effects. The close link between side effects and treatment regimen was revealed by a linear model in which the mere number of drugs explained a significant (p < 0.001) proportion of the observed variance. As to the inflammatory response system: For the F2 patients, our NN model identified a 22.5% subgroup exhibiting a significant correlation of r = 0.746 (p = 0.0004) between global schizophrenia scores and IgM levels, along with a correct prediction of response of 94.4%, thus explaining 55.7% of the observed between-patient variance. For the F3 patients, our NN model identified a 19.6% subgroup exhibiting a significant correlation of r = 0.644 (p = 0.00003) between global depression scores and IgM levels, along a correct prediction of response of 89.6%, thus explaining 41.4% of the observed between-patient variance. Polypharmacy is omnipresent in today's acute treatment of psychiatric disorders. Given the large proportion of patients with unwanted side effects and the strong correlation between side effects and the number of drugs, polypharmacy approaches are not equally suited for every patient. In terms of efficacy, there are no advantages of polypharmacy over monotherapy. Most notably, our study appears to have cleared the way for the reliable identification of a subgroup of patients for whom the inflammatory response system is a promising target of therapeutic intervention.

Can MR imaging be useful in differentiating low rectal cancer from anal cancer?

PURPOSE

To evaluate the role of pelvic MR imaging in differentiating between low rectal and anal cancers using the pathological results as the gold standard.

MATERIALS AND METHODS

In this study, retrospective analysis of 100 patients with a history of low rectal (n = 50) or anal (n = 50) cancers who underwent staging pelvic MR imaging before treatment was performed. The following parameters were analyzed: distance from the anal verge to the tumor, percentage of tumor above puborectalis muscle, tumor size, T2W signal intensity, sphincter/levator muscles invasion, organ invasion, and MRI diagnosis. Multivariable logistic regression was performed to determine factors associated with low rectal and anal cancers. Distances from the anal verge to the tumor were compared using receiver-operating characteristic (ROC) curves.

RESULTS

From the ROC curves, the cut-off value for the distance from the anal verge to the tumor in differentiating between low rectal and anal cancers was 2.1 cm and the area under the ROC curve was 0.90 (95% CI 0.84-0.97). Multivariate logistic regression revealed three significant factors in differentiating between low rectal and anal cancers, including T2 mixed hyper- and hyposignal intensity (OR 66.00, 95% CI 4.66-934.81), distance cut-off value (OR 34.72, 95% CI 5.73-210.27), and absence of sphincter invasion (OR 18.75, 95% CI 1.91-183.96), with sensitivity, specificity, PPV, and NPV of 98%, 88%, 89%, and 97%, respectively, and diagnostic accuracy increased from 79% (reader 1) and 82% (reader 2) to 93%.

CONCLUSION

MR imaging can be useful to differentiating between low rectal and anal cancers which benefits staging and treatment planning.

Contrast- vs. non-contrast enhanced MR data sets for characterization of perianal fistulas

PURPOSE

To evaluate the diagnostic efficacy between pre- and post-contrast MRI sequences in perianal fistulas using intra-operative findings as the gold standard.

MATERIALS AND METHODS

Retrospective analysis of 50 patients with a history of perianal fistula and MRI performed between January 2006 and January 2018 was performed. The inclusion criteria were patients who underwent MRI prior to surgery and had a detailed surgical report available. Pre- and post-contrast MR data sets were evaluated by two radiologists at two-week-intervals, assessed fistula type, internal/external opening, presence of abscess/secondary tracts, and confidence scores. The area under the curve (AUC) was used for comparison the diagnostic ability. The sensitivity and specificity were compared using the McNemar's test.

RESULTS

The confidence scores in detecting perianal fistulas were significantly higher in the post-contrast MR data set (p < 0.003). The post-contrast MR data set had similar ability to classify perianal fistulas as combined T2-DWI and isolated T2 data sets in 49/50 cases. For internal/external opening, the post-contrast MR, combined T2-DWI, and isolated T2 data sets had 100% concordance with intra-operative reports. For perianal abscess, there was no significant difference in sensitivity or AUC value between the isolated T2 or combined T2-DWI data sets and post-contrast MR data set (p > 0.05). All MR data sets correctly identified secondary tracts in all 50 cases.

CONCLUSIONS

Although contrast-enhanced MR studies can improve a radiologist's confidence, non-contrast MR studies had similar diagnostic efficacy in identifying perianal fistulas and their complications. Therefore, a non-contrast study may suffice in selected patients such as those with renal impairment.

Procedure-related tumour seeding in lung cancer with malignant pleural effusion: Radiological features and outcomes

INTRODUCTION

Pleural procedures are performed to prove the diagnosis of pleural effusion. This study was to assess the incidence and outcome of pleural procedure-related tumour seeding in lung cancer with malignant pleural effusion, and to review the characteristics of the implanted tumours on computed tomography (CT) images.

METHODS

From January 2008 to December 2010, 165 patients with the diagnosis of lung cancer with malignant pleural effusion, who underwent at least one pleural procedure and had follow-up CT, were included. Two radiologists retrospectively reviewed the presence of implanted tumours and their manifestations on CT images. The incidence of tumour seeding, the time to tumour seeding, and hazard ratios for death associated with the procedures and presence of tumour seeding were evaluated. Multivariable logistic regression analysis was used to identify variables that were independently associated with procedure-related tumour seeding.

RESULTS

The incidence of procedure-related tumour seeding was 22.4%. Conventional intercostal drainage (ICD) was the independent predictor of tumour seeding. Patients with a history of ICD rapidly developed implanted tumours (P = 0.0319). The estimated mean time of tumour seeding was 2.9 months. There was an increased risk of death with the presence of tumour seeding (HR: 3.35, 95% CI: 1.87-6.01). The majority of CT features showed ill-defined margins with heterogeneous enhancement.

CONCLUSION

Pleural procedure-related tumour seeding in lung cancer with malignant pleural effusion is common. There was a significantly increased risk of death with the presence of tumour seeding. The majority of the CT features in implanted tumours were ill-defined margins with heterogeneous enhancement.