Clinical utility of a personalized and long-term monitoring device for Parkinson's disease in a real clinical practice setting: An expert opinion survey on STAT-ON™

BACKGROUND

STAT-ON™ is an objective tool that registers ON-OFF fluctuations making possible to know the state of the patient at every moment of the day in normal life. Our aim was to analyze the opinion of different Parkinson's disease experts about the STAT-ON™ tool after using the device in a real clinical practice setting (RCPS).

METHODS

STAT-ON™ was provided by the Company Sense4Care to Spanish neurologists for using it in a RCPS. Each neurologist had the device for at least three months and could use it in PD patients at his/her own discretion. In February 2020, a survey with 30 questions was sent to all participants.

RESULTS

Two thirds of neurologists (53.8% females; mean age 44.9±9 years old) worked in a Movement Disorders Unit, the average experience in PD was 16±6.9 years, and 40.7% of them had previously used other devices. A total of 119 evaluations were performed in 114 patients (range 2-9 by neurologist; mean 4.5±2.3). STAT-ON™ was considered "quite" to "very useful" by 74% of the neurologists with an overall opinion of 6.9±1.7 (0, worst; 10, best). STAT-ON™ was considered better than diaries by 70.3% of neurologists and a useful tool for the identification of patients with advanced PD by 81.5%. Proper identification of freezing of gait episodes and falls were frequent limitations reported.

CONCLUSION

STAT-ON™ could be a useful device for using in PD patients in clinical practice.

Clinical utility of a personalized and long-term monitoring device for Parkinson's disease in a real clinical practice setting: An expert opinion survey on STAT-ON™

BACKGROUND

STAT-ON™ is an objective tool that registers ON-OFF fluctuations making possible to know the state of the patient at every moment of the day in normal life. Our aim was to analyze the opinion of different Parkinson's disease experts about the STAT-ON™ tool after using the device in a real clinical practice setting (RCPS).

METHODS

STAT-ON™ was provided by the Company Sense4Care to Spanish neurologists for using it in a RCPS. Each neurologist had the device for at least three months and could use it in PD patients at his/her own discretion. In February 2020, a survey with 30 questions was sent to all participants.

RESULTS

Two thirds of neurologists (53.8% females; mean age 44.9±9 years old) worked in a Movement Disorders Unit, the average experience in PD was 16±6.9 years, and 40.7% of them had previously used other devices. A total of 119 evaluations were performed in 114 patients (range 2-9 by neurologist; mean 4.5±2.3). STAT-ON™ was considered "quite" to "very useful" by 74% of the neurologists with an overall opinion of 6.9±1.7 (0, worst; 10, best). STAT-ON™ was considered better than diaries by 70.3% of neurologists and a useful tool for the identification of patients with advanced PD by 81.5%. Proper identification of freezing of gait episodes and falls were frequent limitations reported.

CONCLUSION

STAT-ON™ could be a useful device for using in PD patients in clinical practice.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Laparoscopic Roux-en-Y gastric bypass in the treatment of obesity: evidence based update through randomized clinical trials and meta-analyses

Bariatric surgery was introduced in 1953, but during the last 20 years its popularity has increased after the development of significant Romaevidenced based breakthroughs in the field. Currently, approximately 150 long-term randomized clinical trials and 40 meta-analyses support and give credibility to the surgical approaches for the treatment of obesity and its related metabolic disturbances. Bariatric surgery has demonstrated improved outcomes compared to medical treatment, conduct therapy, and endoscopic procedures. Roux-en-Y gastrojejunostomy (RYGB) and Sleeve gastrectomy (SG) are the surgical procedures most frequently performed, due to their satisfactory results and security profile. There is sufficient evidence in medical literature to perform these procedures when indicated; however, there are still several controversies regarding technical aspects that need to be further explored.

Perinatal mortality associated with congenital defects of the central nervous system in Colombia, 2005-2014

In Colombia, congenital anomalies are the second leading cause of death in children aged less than 1 year, and central nervous system (CNS) anomalies are the second most common cause within this group. The aim of the study is to determine the frequency of perinatal mortality attributable to CNS anomalies in Colombia between 2005 and 2014. Using data from the Integral Information System of Social Protection (SISPRO), we determined the perinatal mortality rate associated with CNS anomalies; we also determined frequency of mortality according to age, type of abnormality, year of presentation, and georeferencing. A total of 4706 deaths were recorded to be primarily caused by CNS anomalies (anencephaly and hydrocephalus) in departments and prominent urban centers. The perinatal mortality rate associated with CNS defects has remained relatively constant over the past several years. Major referral centers in the country registered the highest mortality rates. The impact of CNS defects increased with the decrease in infant mortality rates and other health issues. Reinforcement of primary and secondary prevention strategies is warranted for reducing its incidence.

Long-Term Safety of In Utero Exposure to Anti-TNFα Drugs for the Treatment of Inflammatory Bowel Disease: Results from the Multicenter European TEDDY Study

OBJECTIVES

The long-term safety of exposure to anti-tumor necrosis factor (anti-TNFα) drugs during pregnancy has received little attention. We aimed to compare the relative risk of severe infections in children of mothers with inflammatory bowel disease (IBD) who were exposed to anti-TNFα drugs in utero with that of children who were not exposed to the drugs.

METHODS

Retrospective multicenter cohort study. Exposed cohort: children from mothers with IBD receiving anti-TNFα medication (with or without thiopurines) at any time during pregnancy or during the 3 months before conception. Non-exposed cohort: children from mothers with IBD not treated with anti-TNFα agents or thiopurines at any time during pregnancy or the 3 months before conception. The cumulative incidence of severe infections after birth was estimated using Kaplan-Meier curves, which were compared using the log-rank test. Cox-regression analysis was performed to identify potential predictive factors for severe infections in the offspring.

RESULTS

The study population comprised 841 children, of whom 388 (46%) had been exposed to anti-TNFα agents. Median follow-up after delivery was 47 months in the exposed group and 68 months in the non-exposed group. Both univariate and multivariate analysis showed the incidence rate of severe infections to be similar in non-exposed and exposed children (1.6% vs. 2.8% per person-year, hazard ratio 1.2 (95% confidence interval 0.8-1.8)). In the multivariate analysis, preterm delivery was the only variable associated with a higher risk of severe infection (2.5% (1.5-4.3)).

CONCLUSIONS

In utero exposure to anti-TNFα drugs does not seem to be associated with increased short-term or long-term risk of severe infections in children.

Service innovations: a depersonalisation research unit progress report

Depersonalisation was described clinically over 100 years ago, yet there has been little research into this interesting but distressing psychiatric disorder. The symptom of depersonalisation can occur alone or in the context of other psychiatric and neurological illnesses and is characterised by the experience of detachment from one's senses and the outside environment, and may be present for several years without remission. Two years after the establishment of the depersonalisation research unit at the Maudsley Hospital, London, we report on current neurobiological and clinical research findings, including functional magnetic resonance imaging, psychophysiology and neuroendocrinology and progress regarding the development of effective treatments.

Oxidative stress prediction: A preliminary approach using a response surface based technique

A response surface was built to predict the lipid peroxidation level, generated in an iron-ascorbate in vitro model, of any organ, which is correlated with the oxidative stress injury in biological membranes. Oxidative stress studies are numerous, usually performed on laboratory animals. However, ethical concerns require validated methods to reduce the use of laboratory animals. The response surface described here is a validated method to replace animals. Tissue samples of rabbit liver, kidney, heart, skeletal muscle and brain were oxidized with different concentrations of FeCl₃ (0.1 to 8mM) and ascorbate (0.1mM), during different periods of time (0 to 90min) at 37°C. Experimental data obtained, with lipid content and antioxidant activity of each organ, allowed constructing a multidimensional surface capable of predicting, by interpolation, the lipid peroxidation level of any organ defined by its antioxidant activity and fat content, when exposed to different oxidant conditions. To check the predictive potential of the technique, two more experiments were carried out. First, in vitro oxidation data from lung tissue were collected. Second, the antioxidant capacity of kidney homogenates was modified by adding melatonin. Then, the response surface generated could predict lipid peroxidation levels produced in these new situations. The potential of this technique could be reinforced using collaborative databases to reduce the number of animals in experimental procedures.

Transfer of innovation on allergic rhinitis and asthma multimorbidity in the elderly (MACVIA-ARIA) - EIP on AHA Twinning Reference Site (GARD research demonstration project)

The overarching goals of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) are to enable European citizens to lead healthy, active and independent lives whilst ageing. The EIP on AHA includes 74 Reference Sites. The aim of this study was to transfer innovation from an app developed by the MACVIA-France EIP on AHA reference site (Allergy Diary) to other reference sites. The phenotypic characteristics of rhinitis and asthma multimorbidity in adults and the elderly will be compared using validated information and communication technology (ICT) tools (i.e. the Allergy Diary and CARAT: Control of Allergic Rhinitis and Asthma Test) in 22 Reference Sites or regions across Europe. This will improve the understanding, assessment of burden, diagnosis and management of rhinitis in the elderly by comparison with an adult population. Specific objectives will be: (i) to assess the percentage of adults and elderly who are able to use the Allergy Diary, (ii) to study the phenotypic characteristics and treatment over a 1-year period of rhinitis and asthma multimorbidity at baseline (cross-sectional study) and (iii) to follow-up using visual analogue scale (VAS). This part of the study may provide some insight into the differences between the elderly and adults in terms of response to treatment and practice. Finally (iv) work productivity will be examined in adults.

Imported malaria in children in Madrid, Spain, 2007-2013

BACKGROUND

The majority of malaria cases diagnosed in Europe in the last few years have occurred in people living in non-endemic areas travelling back to their home country to visit friends and relatives (VFRs). Children account for 15-20% of imported malaria, with known higher risk of severe disease.

MATERIAL AND METHODS

A retrospective multicentre study was conducted in 24 hospitals in Madrid (Spain) including patients under 16 years diagnosed with malaria (2007-2013).

RESULTS

A total of 149 episodes in 147 children were reported. Plasmodium falciparum was the species most commonly isolated. Twenty-five patients developed severe malaria and there was one death related to malaria. VFR accounted for 45.8% of our children. Only 17 VFRs had received prophylaxis, and 4 of them taken appropriately. They presented more frequently with fever (98% vs. 69%), a longer time with fever (55 vs. 26%), delay in diagnosis of more than three days (62 vs. 37%), and more thrombocytopenia (65 vs. 33%) than non-VFRs, and with significant differences (p<0.05).

CONCLUSIONS

VFRs represent a large proportion of imported malaria cases in our study. They seldom took adequate prophylaxis, and delayed the visit to the physician, increasing the length of fever and subsequent delaying in diagnosis. Appropriate preventive measures, such as education and pre-travel advices should be taken in this population.

Predicting muscle fatigue: a response surface approximation based on proper generalized decomposition technique

A novel technique is proposed to predict force reduction in skeletal muscle due to fatigue under the influence of electrical stimulus parameters and muscle physiological characteristics. Twelve New Zealand white rabbits were divided in four groups ([Formula: see text]) to obtain the active force evolution of in vitro Extensor Digitorum Longus muscles for an hour of repeated contractions under different electrical stimulation patterns. Left and right muscles were tested, and a total of 24 samples were used to construct a response surface based in the proper generalized decomposition. After the response surface development, one additional rabbit was used to check the predictive potential of the technique. This multidimensional surface takes into account not only the decay of the maximum repeated peak force, but also the shape evolution of each contraction, muscle weight, electrical input signal and stimulation protocol. This new approach of the fatigue simulation challenge allows to predict, inside the multispace surface generated, the muscle response considering other stimulation patterns, different tissue weight, etc.

Mycophenolate as maintenance therapy for lupus nephritis with impaired renal function

BACKGROUND

Mycophenolate (MF) is effective as a maintenance therapy after induction therapy in patients with lupus nephritis (LN). However, little is known about its role in patients with impaired renal function. The purpose of this study was to evaluate the efficacy and safety of MF as a maintenance therapy for LN and its association with renal function.

METHODS

Data were obtained for 56 Spanish patients who were receiving MF as a maintenance therapy for LN. Patients were classified into two groups according to renal function at the initiation of MF treatment: group 1 [estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m(2)] and group 2 (eGFR <60 ml/min/1.73 m(2)). The primary endpoints of the study were the rates of renal relapse and responses, and their relationship with baseline renal function. Secondary outcomes were the appearance of side effects during treatment.

RESULTS

At initiation of MF treatment, the only differences between the groups were for age, hemoglobin levels, anti-DNA antibody titer, proteinuria, and renal function. In group 1 (n = 38), the eGFR was 98 ± 34 ml/min/1.73 m(2) and in group 2 (n = 18) the eGFR was 43 ± 14 ml/min/1.73 m(2). Only 3 cases had an eGFR <30 ml/min/1.73 m(2). No significant differences were observed in the rate of relapse at 6 months (group 1: 20%; group 2: 23%) or at 12 months (group 1: 25%; group 2: 17%). Response rates were also similar in both groups. Side effects were unremarkable.

CONCLUSIONS

MF is effective and safe as a maintenance therapy for LN both in patients with normal renal function and in those with renal impairment.

Long-term biomonitoring of breast cancer patients under adjuvant chemotherapy: the comet assay as a possible predictive factor

Most chemotherapy treatments induce DNA damage in the exposed patients. Using the comet assay and peripheral blood mononuclear cells (PBMC), we have quantified this induced DNA damage and studied its relationship with GSTM1 and GSTT1 polymorphisms, and clinical parameters. For this purpose, 29 Caucasian women, breast cancer patients under CMF or CEF adjuvant chemotherapy were included in the study. The clinical parameters considered were (i) therapies side effects, like haematological and biochemical toxicities, (ii) prognostic and predictive factors, like hormonal receptor expression, tumour differentiation degree, sickness stage, and nodal status, and (iii) the effectiveness of the chemotherapy measured as five years relapse probability. The results were also related to the confounding factor age. Comet assay results indicate that 13 patients were characterised by absence of induced DNA strand breaks, and 16 patients presented induced DNA strand breaks along the treatment. Relationships between comet variables and clinical parameters, found with principal component analysis, correlations, one-way ANOVA and multivariate logistic regression analyses revealed that: (1) baseline levels of DNA damage are related to GSTM1 genotype and to hormonal receptor expression; (2) GSTM1 genotype also influences comet results after chemotherapy, as it does the AST level; (3) the tail moment values of the cycle 6.1 and the sickness stage might predict cancer relapse at five years: for the Stage, OR = 13.8 (IIB versus I+IIA), 95% CI 0.80-238.97, and for 6.1 cycle TM, OR = 1.3, 95%, CI 0.97-1.79, with a potential model (10* Stage (I-IIA = 0, IIB = 1) + 6.1 cycle), that has a good predictive capacity, with an area under ROC curve of 0.872 (CI 0.62-1.00). To our knowledge, this is the first time such a predictive value is found for the comet assay. Nevertheless, before the comet assay could be used as a tool for oncologists, this relationship should be confirmed in more patients, and problems of standardisation and data interpretation should be solved.

Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: a multicenter study

BACKGROUND

Despite medical therapy, 30% of patients with ulcerative colitis (UC) need to undergo surgery. Around 50% of patients with proctocolectomy with ileal pouch-anal anastomosis (IPAA) develop complications of the pouch. Clinical evidence for the use of infliximab (IFX) in refractory pouchitis is limited. The aim of this study was to report efficacy of IFX in these patients.

METHODS

A retrospective, multicenter study was designed. Patients older than 18 years with chronic refractory pouchitis treated with IFX (5 mg/kg) were included. Short-term IFX efficacy was evaluated at week 8 and mid-term efficacy at weeks 26 and 52. Complete response was defined as cessation of diarrhea and urgency and partial response as marked clinical improvement but persisting symptoms. The modified Pouchitis Disease Activity Index (mPDAI) without endoscopy was calculated when available.

RESULTS

Thirty-three consecutive UC patients with chronic refractory pouchitis were included (18 male, mean age 45 years, range 21-67). At week 8, 21% patients achieved complete response and 63% showed partial clinical response. At weeks 26 and 52, 33% and 27% achieved complete response and 33% and 18% showed partial clinical response, respectively. Thirteen patients (39%) withdrew treatment (four for lack of efficacy, four for loss of response and five for adverse events). None of the potential factors analyzed had an influence on response to IFX.

CONCLUSIONS

IFX was effective in the short- and mid-term in patients with chronic refractory pouchitis. However, medication had to be discontinued in a high number of patients.

Risk factors for encephalitis from West Nile Virus: a matched case-control study using hospitalized controls

We conducted a case-control study to determine risk factors for developing encephalitis among West Nile virus cases when compared with age-, gender and race/ethnicity-matched hospitalized controls. In the multivariable conditional logistic regression analysis, we identified the following independent risk factors associated with being an encephalitis case: hypertension (OR 4.0; P = 0.005), immunosuppressing conditions (OR 5.6; P = 0.001) and cardiovascular disease (OR = 28.3; P < 0.001). Individuals with these comorbidities should be targeted for education on protecting themselves from mosquito exposures.

Abstract P6-05-07: Molecular Classification of Breast Cancer: Clinical Correlation and Outcome in a Venezuelan Population

Background: Gene expression analysis has defined several subtypes of breast cancer that differ in prognosis and response to therapy. Distribution of clinical, pathological features and outcome was performed among Venezuelan women diagnosed with breast cancer. The objective of this study was to evaluate clinical features and outcome. Material and Methods Of 1004 women treated at the BCTC between January 1, 2000 and April 30, 2010, 624 patients had assessable data for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER 2/neu). Molecular subtypes were defined as Luminal A (ER+, PR+, HER 2-), Luminal B (ER+, PR+, HER 2+), Basal Like (ER-, PR-, HER 2-) and HER 2/neu (ER+, PR+, HER 2+). Clinical and Pathologic features were available for all 624 patients. Follow-up (FU) for distant recurrence (D.R.) and deaths were available for 514 patients (survival and distant disease free survival). Data was compared for women younger than 50 years with those 50 and older

Results Median FU was 33 months. 268 patients (43%) were 49 years or younger and 356 were 50 years (57%) or older.

Discussion: Distribution of molecular subtypes in Venezuelan women is different than other ethnicities. This study also revealed that both age subgroups in the HER2/neu subtype had the worst outcome followed by patients under 50 in the Basal subtype.

Synergistic effect of two oxidative stress-related genes (heme oxygenase-1 and GSK3β) on the risk of Parkinson's disease

BACKGROUND

Oxidative stress is a central factor in the pathogenesis of Parkinson's disease (PD). Heme oxygenase-1 (HO-1) is an antioxidant protein expressed in response to oxidative challenge, and its expression levels are inversely correlated with glycogen synthase kinase-3beta (GSK3beta) activity. Underexpression of HO-1 in concert with an upregulation of GSK3beta would result in a less effective antioxidant response and might increase the risk of PD.

METHODS

We examined two functional polymorphism in the promoter regions of HO-1 (-413, rs2071746) and GSK3beta (-157, rs6438552) in a group of 251 Spanish patients with PD and 234 controls.

RESULTS

Subjects carrying both the HO-1 (-413, rs2071746) TT genotype and the GSK3beta (-157, rs6438552) TT genotype had a four times higher risk of developing PD than subjects without these genotypes (adjusted by age and sex OR = 4.12; 95% CI = 1.45-11.71; Bonferroni corrected P = 0.024).

CONCLUSIONS

Considering synergistic effects between polymorphisms in oxidative stress-related genes may help in determining the risk profile for PD.

Evolution of the bioavailability and other pharmacokinetic parameters of levodopa (with carbidopa) in rabbits

Levodopa pharmacokinetics show important inter- and intraindividual differences when it is administered by the oral route. As a result of fluctuating drug plasma concentrations, patients may develop motor fluctuations and dyskinesias. Therefore, it is important to perform studies on levodopa pharmacokinetics in the same individual. The aim of this study was to contribute to a better knowledge of the evolution of the pharmacokinetics of levodopa administered with carbidopa. The study involved the oral administration of 20/5 mg/kg levodopa/carbidopa to rabbits for two different time periods (7 or 14 days), due to the fact that inhibition of aromatic L-amino-acid decarboxylase by carbidopa is not immediate. After 7 days of treatment, the levodopa AUC increased by 12.6% from day 1 (range: 114.2-150.7 microg.min/ml) to day 7 (range: 131.1-166.0 microg.min/ml) and C(max) increased by 9.6% (range: 1.90-2.86 microg/ml on day 1 and 2.12-3.13 microg/ml on day 7). After 14 days of treatment, the increase in AUC was 17.0% (range: 119.6-160.1 microg.min/ml on day 1 and 142.9-172.7 microg.min/ml on day 14) and C(max) increased by 6.5% (range: 2.29-2.96 microg/ml on day 1 and 2.41-3.07 microg/ml on day 14). The values obtained for C(min) (sample obtained immediately before levodopa/carbidopa administration) in both groups increased progressively with the duration of the treatment. C(max) and AUC values were very similar after 7 or 14 days of treatment. The time needed for C(min) stabilization was slightly higher, because we found significant differences until day 11 of treatment.

Low expression of ZHX2, but not RCBTB2 or RAN, is associated with poor outcome in multiple myeloma

RAN, ZHX2 and RCBTB2 (CHC1L) expression was evaluated by quantitative real time reverse transcription polymerase chain reaction in plasma cells from 85 monoclonal gammopathies: 58 symptomatic multiple myeloma (MM) (52 untreated, six relapsed), eight smouldering MM, five monoclonal gammopathy of undetermined significance, four plasma cell leukaemias and 10 myeloid cell lines. ZHX2 was weakly expressed in high-risk/proliferative disease compared to low-risk or indolent disease. High ZHX2 expression was associated with better response and longer survival after high-dose therapy. RCBTB2 expression was weaker in hyperdiploid versus non-hyperdiploid cases while RAN was more expressed in symptomatic MM and cell lines.

Isolated adrenal metastasis: the role of laparoscopic surgery

BACKGROUND

Solitary adrenal metastases (AM) are rare and their management unclear. Surgery, especially laparoscopic adrenalectomy (LA), is debatable in the management of AM. This retrospective study analysed the feasibility and the results of LA for AM.

METHODS

From 1997 to 2003, 16 patients underwent LA for isolated AM. Completeness of resection, postoperative morbidity and follow-up (FU) were recorded.

RESULTS

There were 10 synchronous AM and 6 metachronous AM. Primary tumours included lung cancer (n = 9), melanoma (n = 3), mesothelioma (n = 1), rhabdomyosarcoma (n = 1), colonic adenocarcinoma (n = 1) and renal cell carcinoma (n = 1). Five patients required conversion to an open procedure. Minor complications occurred in three patients. Pathology confirmed the diagnosis of AM. Mean tumour size was 60 (range: 15-110) mm. Nine patients (56%) had complete resections, 3 had positive margins and 4 had incomplete macroscopic resections. Mean observed FU was 25 (range: 1-68) months. Median overall calculated survival was 23 months. Overall 5-year survival was 33% (Kaplan-Meyer). At the end of study, 8 patients were alive with a mean FU of 35 months (3 without evidence of disease). No patient presented with local relapse or port-site metastasis. We did not identify any predictive factors. All patients with incomplete macroscopic resection died within 24 months.

CONCLUSIONS

LA can achieve an acceptable 5-year survival, comparable to open surgery but with better postoperative comfort. It should be considered for AM with the intention of complete resection. It offers the patient the possibility of tumour resection with the benefit of a laparoscopic approach.

Endoscopic lateral approach thyroid lobectomy: safe evolution from endoscopic parathyroidectomy

INTRODUCTION

Endoscopic thyroid surgery has been shown to be feasible. Most minimal access procedures have been performed via a midline approach. Based on our experience of more than 500 endoscopic parathyroidectomies via a lateral approach we have used the same method for thyroid lobectomy.

METHODS

We present our experience of endoscopic thyroid lobectomy via a lateral approach (ETLA) and review of the results over a 1-year period (2004). Inclusion criteria for ETLA were (1) solitary nodule with atypical/suspicious fine-needle biopsy (FNB) or solitary toxic nodule; (2) lesions with a diameter of < 3 cm. Patients with a history of previous neck surgery or radiation exposure were excluded. All patients underwent postoperative vocal cord checks and plasma calcium evaluation.

RESULTS

A total of 742 thyroid procedures were performed during 2004. Among them, 38 patients (5.1%) underwent ETLA. Indications for surgery were suspicious FNB results (36 patients) and a toxic nodule (2 patients). Mean nodule size was 19.2 mm. Mean +/- SD operating time was 102 +/- 27 minutes. All recurrent laryngeal nerves were identified (including one that was nonrecurrent). Of the 38 patients, the superior parathyroid gland was identified in 36 and the inferior parathyroid gland in 33. There were two conversions due to difficulty with the dissection. Two operations were converted because malignancy was diagnosed on frozen section examination. Two patients underwent a delayed completion thyroidectomy when definitive histology necessitated it. There were no permanent operative complications, and all patients were discharged on the first postoperative day.

CONCLUSIONS

ETLA offers excellent intraoperative visualization of the vital structures and is a safe alternative to conventional thyroid lobectomy in selected cases.

Phase II study with the combination of gemcitabine and DTIC in patients with advanced soft tissue sarcomas

PURPOSE

Based on the promising results of a Phase I study with a combination of gemcitabine and DTIC performed in advanced soft tissue sarcoma (ASTS) patients, and due to the limited efficacy of second or third line therapies in those patients, we designed a Phase II study to determine the activity of this new regimen.

METHODS

Patients with ASTS, measurable disease, pretreated with chemotherapy, received gemcitabine 1,800 mg/m2 infused over 180 min followed by DTIC 500 mg/m2 (one cycle), every 2 weeks. The pharmacokinetics (PK) of gemcitabine and 2',2'-difluorodeoxyuridine (dFdU), and the accumulation of gemcitabine triphosphate (dFdCTP) by peripheral blood mononuclear cells were studied. The influence of the sequence of administration on those parameters was examined to exclude potential drug interactions.

RESULTS

Twenty-six patients received a total of 158 cycles (mean four cycles, range 1-18). Grade 3-4 anemia (23% of patients), granulocytopenia (46%) or thrombocytopenia (12%), and grade 3 increase in AST (18%), ALT (21%), or gamma-glutamyl-transferase (9%) were noted. Response rate in 23 patients was 4% (95% CI: 0-24%), and in 8 of 11 patients stable disease lasted > 6 months. Progression-free rate (PFR) at 3 and 6 months was, respectively, 48 and 28%, and median overall survival 37 weeks. Pooled data from the Phase I and Phase II studies showed clinical benefit in patients with leiomyosarcomas (LMS) (57%) and malignant fibrous histiocytomas (MFH) (33%). The sequence of administration did not influence PK of gemcitabine or dFdU. There was a trend (P = 0.11) toward a lower accumulation of dFdCTP when DTIC preceded gemcitabine.

CONCLUSIONS

Although the remission rate was low, PFR figures indicate that this regimen has activity in patients with ASTS. It should be compared with DTIC, or other gemcitabine-containing combinations, in patients with LMS or MFH, to determine whether this combination offers advantages in PFR or in overall activity.

Phase I/II trial of doxorubicin and fixed dose-rate infusion gemcitabine in advanced soft tissue sarcomas: a GEIS study

The aim of the study was to determine the dose-limiting toxicity and maximum tolerated dose of a first-line combination of doxorubicin and gemcitabine in adult patients with advanced soft tissue sarcomas and to explore its activity and toxicity, and the presence of possible interactions between these agents. Patients with measurable disease were initially treated with doxorubicin 60 mg m⁻² by i.v. bolus on day 1 followed by gemcitabine at 800 mg m⁻² over 80 min on days 1 and 8, every 21 days. Concentrations of gemcitabine and 2′,2′-difluorodeoxyuridine in plasma, and gemcitabine triphosphate levels in peripheral blood mononuclear cells were determined during 8 h after the start of gemcitabine infusion. Myelosuppression and stomatitis were limiting toxicities, and the initial dose level was applied for the Phase II trial, where grade 3–4 granulocytopenia occurred in 70% of patients, grade 3 stomatitis in 46% and febrile neutropenia in 20%. Objective activity in 36 patients was 22% (95% CI: 9–35%), and a 50% remission rate was noted in leiomyosarcomas. Administration of doxorubicin preceding gemcitabine significantly reduced the synthesis of gemcitabine triphosphate. Clinical activity, similar to that of single-agent doxorubicin, and the toxicity encountered do not justify further studies with this schedule of administration.

[Cross-cultural adaptation and validation of the Cambridge Depersonalisation Scale]

INTRODUCTION

The Cambridge Depersonalisation Scale (CDS) is a self-rating questionnaire constructed to capture the frequency and duration of depersonalization symptoms over the last six months. The instrument has proved to be valid and reliable and can be useful in both clinical and neurobiological research.

METHODS

This paper presents the Spanish adaptation and validation of the CDS. The study was carried out in two stages. First, we developed the Spanish version of the CDS by means of a cross-cultural adaptation methodology. Second, the CDS was tried on a sample of 130 subjects: 77 patients meeting DSM-IV-TR criteria for schizophrenia, 35 with depression disorders and 18 with anxiety disorders. Scores were compared against clinical diagnoses (gold standard). Furthermore, all the subjects of the study were administered the following: Dissociation Experiences Scale (DES), Positive and Negative Syndrome Scale (PANSS), Beck's Depression Inventory (BDI), and the Hamilton Anxiety Rating Scale (HARS).

RESULTS

38 patients (29.2 %) had depersonalization symptoms. The scale showed high internal consistency (Cronbach's alpha > 0.9 and split-half reliability > 0.8) and a test-retest reliability of 0.391. Convergent validity was 0.65 (p < 0.001) and discriminant validity was 0.308 (p < 0.05). The area under the ROC curve was 0.94. A cut-off of 71 appears to be most useful (sensitivity and specificity were 76.3 % and 89.1 %, respectively).

CONCLUSION

The Spanish version of the CDS has good reliability and validity, similar to the original instrument.

Analysis of drug resistance-associated mutations in treatment-naïve individuals infected with different genetic forms of HIV-1 circulating in countries of the former Soviet Union

There are few data on drug resistance-associated mutations in the former Soviet Union since, studies have usually been focused on the env or gag genes for subtype information. This study examines the prevalence and patterns of resistance-associated mutations to reverse transcriptase and protease inhibitors (RTI, PRI) in 278 HIV-1-infected treatment-naïve subjects from countries of Eastern Europe, and defines characteristic polymorphisms of RT and PR sequences in HIV-1 subtype A viruses. Blood samples were collected between 1997 and 2004. Plasma RNA was used for PR-RT amplification by reverse transcription coupled with nested PCR and sequencing. Phylogenetic analysis was done with neighbor-joining trees and bootscanning. Analysis of drug resistance mutations, with Stanford University HIV Drug Resistance Database's algorithm, resulted in an overall prevalence of 12.9% resistance to RTI and 3.9% to PRI. The most frequent substitutions in the RT region were at positions 62 and 236. V77I substitution in PR was found in 47.8% of samples. Polymorphisms in subtype A sequences were identified. This is the first study reporting the prevalence and patterns of both PRI and RTI resistance-associated mutations in naïve HIV-1 infected patients from the former Soviet Union. These data underline the importance of genotypic resistance testing of chronically HIV-1-infected patients before initiating treatment, in order to select the most suitable drug regimen.

[Abrikossoff tumor of the proximal esophagus misdiagnosed as a thyroid nodule]

The diagnosis of thyroid nodules is straightforward and rarely mistaken. We present a case of a paraesophageal granular cell tumor, discovered incidentally during surgery for what it was diagnosed as a suspicious thyroid nodule by ultrasound and FNA. Complete resection was achieved without disruption of the esophageal mucosa. A terminal branch of the recurrent laryngeal nerve had to be resected en bloc with the tumor. Morphological and immunohistochemical diagnosis was established postoperatively. A review of the literature is presented.

Natural resistance-associated mutations to Enfuvirtide (T20) and polymorphisms in the gp41 region of different HIV-1 genetic forms from T20 naive patients

BACKGROUND

The natural occurrence of primary resistance mutations in reverse transcriptase (RT) and protease (PR) genes of HIV-1 isolates from untreated patients has been reported and it may have important implications for the response to drug treatment. It is predictable that the same occurs in the HR1 region of gp41 sequence from patients who have never received T20 therapy, and in this regard it would be important to know not only the mutation frequencies at HR1 region but also the natural polymorphisms at resistance-associated positions present in the absence of this drug.

OBJECTIVES

The objectives of this study are to investigate the existence of natural resistance-associated mutations to T20 in HR1 gp41 region corresponding to different HIV-1 genetic forms from T20 naive patients and to determine their prevalence.

STUDY DESIGN

Two hundred HIV-1 gp41 sequences were included: subtype B: 164 (81.3%); subtype A: 15 (8.2%); subtype G: 10 (4.6%); subtype F: 6 (3.5%); subtype C: 3 (1.8%); subtype K: 1 (0.6%); and subtype D: 1 (0.6%). We analyzed the resistance-associated mutations previously described: Q32H/R, G36D/S, I37V, V38A/M, Q39R/H, Q40H, N42T/D/Q/H, N43D/S/K/Q, L44M, L45M, R46M and V69I.

RESULTS

Natural resistance mutations to T20 were found at a high frequency: 10.5%, corresponding to 9.1% in subtype B and 16.7% in non-B subtype samples. Polymorphisms were more frequent in non-B and recombinant forms than in subtype B (p<0.001). Different substitutions were related to subtypes: N42S in subtypes A, B, G and C, but not in F, Q56R in subtype A from CRF02_AG, and L54M in subtype B from CRF14_BG.

CONCLUSIONS

To our knowledge this is the first study describing natural-resistance to T20 among different HIV-1 subtypes, warranting a study of the biological significance of this mutations and their clinical relevance. The detection of differences between subtypes may have an influence on the rate and patterns of resistance in patients undergoing T20 treatment.

Pneumococcal bacteremia in children: an 8-year review in two hospitals in Barcelona

In this study, 90 episodes of pneumococcal bacteremia that occurred over an 8-year period in two hospitals in Barcelona were analyzed retrospectively to determine the clinical and bacteriological characteristics of pneumococcal bacteremia, the risk factors for antibiotic resistance, the outcome, and the vaccine coverage. The mean age of the patients was 3.1 years and the male/female ratio was 1.7. The overall rates of penicillin-non-susceptible, cefotaxime-non-susceptible, and erythromycin-resistant isolates were 48.8, 24.4, and 25.5%, respectively. Antibiotic resistance was associated with children under the age of 2 years and with previous antibiotic treatment. The percentage of antibiotic resistance was higher in the nine episodes that occurred in patients with an underlying illness. The most prevalent serotypes identified were 1, 14, 6B, 18C, 5, and 19A. Serotypes 6A/B, 14, and 19A/F were isolated primarily from children under 2, whereas serotypes 1 and 5 were recovered more frequently from older children. Apparent relationships between serotypes 6A/B, 14, and 19A/F and occult bacteremia and between serotypes 1 and 5 and bacteremic pneumonia were confounded by the age variable. The proportion of bacteremic episodes preventable by all (7-valent, 9-valent, and 11-valent) of the conjugate pneumococcal vaccines was 60% in children under 2. In older children, the serotype coverage rate for the three formulations was 48, 87, and 87%, respectively. In summary, these data expand upon previous Spanish studies in which serotypes 1 and 5 were reported to be among the leading causes of severe systemic pneumococcal infections in children over 2, findings that should be taken into consideration when planning vaccine programmes.

The epidemiology of depersonalisation and derealisation. A systematic review

BACKGROUND

Symptoms of depersonalisation (DP) and derealisation (DR) are increasingly recognised in both clinical and non-clinical settings, but their importance and underlying pathophysiology is only now being addressed.

METHODS

This paper is a systematic review of the current state of knowledge about the prevalence of depersonalisation and derealisation using computerised databases and citation searches. All potential studies were examined and numerical data included. Three categories of study are reviewed: questionnaire and interview surveys of selected student and non-clinical samples; population-based community surveys using standardised diagnostic interviews; and clinical surveys of depersonalisation/derealisation symptoms occurring within inpatients with psychiatric disorders. In addition, we present newly analysed data of the prevalence of depersonalisation/derealisation from five large population-based studies.

RESULTS

Epidemiological surveys demonstrate that transient symptoms of depersonalisation/derealisation in the general population are common, with a lifetime prevalence rate of between 26 and 74% and between 31 and 66% at the time of a traumatic event. Community surveys employing standardised diagnostic interviews reveal rates of between 1.2 and 1.7 % for one month prevalence in a UK sample and a 2.4% current prevalence rate in a Canadian sample. Current prevalence rates in samples of consecutive inpatient admissions are reported between 1 and 16%, although screening measures employed may have resulted in these being an underestimate. Prevalence rates in clinical samples of specific psychiatric disorders vary between 30% of war veterans with PTSD and 60% of those with unipolar depression. There is a high prevalence within panic disorder with rates varying from 7.8 to 82.6%.

DISCUSSION

DP and DR symptoms are common in normal and psychiatric populations, but prevalence estimates are hampered by inconsistent definitions and the use of variable time-frames. Population-based surveys using diagnostic interviews yield prevalence rates of clinically significant DP/DR in the region of 1-2%. Surveys of clinical populations in which common screening and assessment instruments were used also yield consistently high prevalence rates. The use of reliable diagnostic assessments and rating scales is needed. The relationship between DP/DR and certain other psychiatric disorders (e. g. panic) suggests possible common pathophysiological or aetiological factors.

Depersonalisation disorder: a cognitive–behavioural conceptualisation

Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one's sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals under certain situational conditions to a chronic psychiatric disorder that causes considerable distress (depersonalisation disorder, DPD). Despite the relatively high rates of reporting these symptoms, little research has been conducted into psychological treatments for this disorder. We suggest that there is compelling evidence to link DPD with the anxiety disorders, particularly panic. This paper proposes that it is the catastrophic appraisal of the normally transient symptoms of DP/DR that results in the development of a chronic disorder. We suggest that if DP/DR symptoms are misinterpreted as indicative of severe mental illness or brain dysfunction, a vicious cycle of increasing anxiety and consequently increased DP/DR symptoms will result. Moreover, cognitive and behavioural responses to symptoms such as specific avoidances, 'safety behaviours' and cognitive biases serve to maintain the disorder by increasing awareness of the symptoms, heightening the perceived threat and preventing disconfirmation of the catastrophic misinterpretations. A coherent model facilitates the development of potentially effective cognitive and behavioural interventions.

Therapeutic effects of psyllium in type 2 diabetic patients

OBJECTIVE

The aim of this study was to evaluate the effects of psyllium in type 2 diabetic patients.

DESIGN

The study included three phases: phase 1 (1 week), phase 2 (treatment, 14 g fibre/day, 6 weeks) and phase 3 (4 weeks). At the end of each phase a clinical evaluation was performed after the ingestion of a test breakfast of 1824.2 kJ (436 kcal). Measurements included concentrations of blood glucose, insulin, fructosamine, GHbA(1c), C-peptide and 24 h urinary glucose excretion. In addition, uric acid, cholesterol and several mineral and vitamin concentrations were also evaluated.

SETTING

The study was performed at the Department of Pharmacology, Toxicology and Nursing at the University of León (Spain).

SUBJECTS

Twenty type 2 diabetic patients (12 men and 8 women) participated in the study with a mean age of 67.4 y for men and 66 y for women. The mean body mass index of men was 28.2 kg/m(2) and that of women 25.9 kg/m(2).

RESULTS

Glucose absorption decreased significantly in the presence of psyllium (12.2%); this reduction is not associated with an important change in insulin levels (5%). GHbA(1c), C-peptide and 24 h urinary glucose excretion decreased (3.8, 14.9 and 22.5%, respectively) during the treatment with fibre (no significant differences) as well as fructosamine (10.9%, significant differences). Psyllium also reduced total and LDL cholesterol (7.7 and 9.2%, respectively, significant differences), and uric acid (10%, significant difference). Minerals and vitamins did not show important changes, except sodium that increased significantly after psyllium administration.

CONCLUSIONS

The results obtained indicate a beneficial therapeutic effect of psyllium (Plantaben) in the metabolic control of type 2 diabetics as well as in lowering the risk of coronary heart disease. We also conclude that consumption of this fibre does not adversely affect either mineral or vitamin A and E concentrations. Finally, for a greater effectiveness, psyllium treatment should be individually evaluated.

Separating depersonalisation and derealisation: the relevance of the "lesion method"

OBJECTIVES

Depersonalisation (DP) and derealisation (DR) are often met with in patients with a wide range of localisable neurological conditions. This suggests that the "lesion method" might be a valid approach to study the neurobiology of DP/DR. However, the fact that anxiety can trigger DP/DR makes it difficult to establish whether the presence of DP/DR in neurological patients is mainly determined by coexisting anxiety or by lesion location. To overcome this difficulty, we suggest the study of neurological phenomena, which although not considered as DP/DR, bear enough phenomenological resemblance with them as to warrant their use as models.

METHODS

One patient with "visual hypoemotionality" and another with "hemiasomatognosia" are described in detail together with a selective literature review.

RESULTS

Complaints of patients with visual hypoemotionality are indistinguishable from those of patients with "visual derealisation". There is also a phenomenological overlap between "asomatognosia" and the symptom of "body alienation", which is a central feature of depersonalisation.

CONCLUSIONS

Phenomenological similarities between visual hypoemotionality and DR suggest that a disruption of the process by means of which perception becomes emotionally coloured may be an underlying mechanism in both conditions. Likewise, phenomenological overlaps with asomatognosia suggest that DP might result from parietal mechanisms disrupting the experience of body ownership and agency. These findings give validity to the notion that DP and DR may have distinct neurobiological mechanisms.

Depersonalization disorder: thinking without feeling

Patients with depersonalization disorder (DP) experience a detachment from their own senses and surrounding events, as if they were outside observers. A particularly common symptom is emotional detachment from the surroundings. Using functional magnetic resonance imaging (fMRI), we compared neural responses to emotionally salient stimuli in DP patients, and in psychiatric and healthy control subjects. Six patients with DP, 10 with obsessive-compulsive disorder (OCD), and six volunteers were scanned whilst viewing standardized pictures of aversive and neutral scenes, matched for visual complexity. Pictures were then rated for emotional content. Both control groups rated aversive pictures as much more emotive, and demonstrated in response to these scenes significantly greater activation in regions important for disgust perception, the insula and occipito-temporal cortex, than DP patients (covarying for age, years of education and total extent of brain activation). In DP patients, aversive scenes activated the right ventral prefrontal cortex. The insula was activated only by neutral scenes in this group. Our findings indicate that a core phenomenon of depersonalization--absent subjective experience of emotion--is associated with reduced neural responses in emotion-sensitive regions, and increased responses in regions associated with emotion regulation.

Basal activity of the hypothalamic-pituitary-adrenal axis in patients with depersonalization disorder

Depersonalisation disorder may occur during severe anxiety or following a traumatic event, suggesting a possible role of stress hormones. This study investigated basal activity of the hypothalamic-pituitary-adrenal (HPA) axis in patients with depersonalisation disorder. Salivary cortisol levels were measured at four time points over 12 h in patients with depersonalisation disorder (N=13), major depressive disorder (MDD, N=14) and healthy controls (N=13). Beck Depression Inventory scores were significantly higher in depersonalised subjects than controls, while MDD subjects demonstrated higher scores than both groups. Basal cortisol levels of depersonalised subjects were significantly lower than those of MDD subjects but not healthy controls. These results point to reduced basal activity of the HPA axis in depersonalisation disorder. This pilot study supports the distinction between depersonalisation disorder and major depressive disorder which should be examined in a larger sample.

Visual imagery and depersonalisation

Twenty-eight people diagnosed with depersonalisation disorder (DD) were assessed using self-report measures of imagery ability in relation to a range of symptoms and in comparison with age- and sex-matched controls. It was found that symptoms of depersonalisation as well as other dissociative symptoms and depressed mood correlated with impaired ability to generate visual images. This was particularly evident with images pertaining to the self and other people as opposed to objects. A subgroup of 10 patients was tested on a neuropsychological battery of visual perception tests and found to be unimpaired compared with normal controls and patients with obsessive compulsive disorder, despite subjective impairments in imagery and high symptom scores. The findings add further weight to the distinctions made between imagery and perceptual processes.