Does the intensity of dissociation predict antidepressant effects 24 hours after infusion of racemic ketamine and esketamine in treatment-resistant depression? A secondary analysis from a randomized controlled trial

BACKGROUND

Ketamine and esketamine have both shown significant antidepressant effects in treatment-resistant depression (TRD), and conflicting evidence suggests that induced dissociation by these drugs can be a clinical predictor of esketamine/ketamine's efficacy.

METHODS

This study is a secondary analysis from a bi-center, randomized, controlled trial. Participants were randomly assigned 1:1 to receive an IV infusion of esketamine (.25 mg/kg) or racemic ketamine (.50 mg/kg) over 40 minutes. Dissociative symptoms were assessed using the Clinician-Administered Dissociative State Scale (CADSS) 40 minutes following the beginning of the infusion. The variation in depression scores was measured with the Montgomery-Asberg Depression Rating Scale (MADRS), which was administered before the intervention as a baseline measure and 24 hrs, 72 hrs, and 7 days following infusion.

RESULTS

Sixty-one patients were included in the analysis. Examining CADSS scores of 15 or below, for every 1-point increment in the CADSS score, there was a mean change of -0.5 (SD = 0.25; p-value 0.04) of predicted MADRS score from baseline to 24 hrs. The results for 72 hrs and 7 days following infusion were not significant. Limitations: This study was not designed to assess the relationship between ketamine or esketamine-induced dissociation and antidepressant effects as the main outcome, therefore confounding variables for this relationship were not controlled.

CONCLUSION

We suggest a positive relationship between dissociation intensity, measured by CADSS, and antidepressant effect 24 hours after ketamine and esketamine infusion for a CADSS score of up to 15 points.

Comparative study of esketamine and racemic ketamine in treatment-resistant depression: Protocol for a non-inferiority clinical trial

INTRODUCTION

The use of ketamine as an option in the treatment of depressive disorder is growing rapidly, supported by numerous clinical trials attesting its efficacy and safety. Esketamine, the S (+) enantiomer of ketamine, is the most widely used form in the anesthetic environment in some countries, and new studies have shown that it may also be effective in depression and with better tolerability. However, no study so far has directly compared esketamine with racemic ketamine. Here we propose a protocol of a clinical trial to evaluate esketamine as a noninferior medication when compared to ketamine in the treatment of patients with treatment-resistant depression.

METHODS/DESIGN

This study protocol is for a randomized, controlled, double-blind noninferiority clinical trial. Subjects will be 18 years or older, with major depression characterized as treatment-resistant. Participants will receive a single infusion of either esketamine (0.25 mg/kg) or ketamine (0.5 mg/kg) over 40 minutes. The primary outcome will be the difference in remission rates between the 2 treatment arms at 24 and 72 hours after drug infusion. Secondary outcomes will include other timepoints, measurements of cognition, dissociation, and blood biomarkers.

DISCUSSION

A head-to-head study is the best way to evaluate whether the esketamine is in fact comparable to the racemic ketamine in terms of both efficacy and safety, and, if positive, it would be an initial step to increase the access to that type of treatment worldwide.

ETHICS AND DISSEMINATION

The study was approved by the local Institutional Review Board (University Hospital Professor Edgard Santos-Federal University of Bahia-Number: 46657415.0.0000.0049). Subjects will only participate after voluntarily agreeing and signing the Informed Consent Form. The study findings will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION

This trial has been registered in the Japan Primary Registries Network (JPRN): UMIN000032355, which is affiliated with the World Health Organization.

Phenology and frugivory by birds on Miconia ligustroides (MELASTOMATACEAE) in a fragment of cerrado, southeastern Brazil

We identified the avian assembly that consumes Miconia ligustroides (Melastomataceae) fruit and described its phenophases in a fragment of cerrado vegetation located in southeastern Brazil. The fruiting period occurred between March and June, a period of food shortage. In 2005 and 2008, we registered eighteen bird species consuming fruits, during 156 hours of observations. Species of the families Thraupidae and Tyrannidae were the most representative in the number of visits and fruit consumption. Short visits (less than three minutes) and low incidence of defecation apparently indicate that seeds may be released far from the parent-plant, suggesting dispersal efficiency by the studied assembly. Owing to its characteristics, we believe Miconia ligustroides may be useful in the restoration of degraded areas.

Bird communities in two fragments of Cerrado in Itirapina, Brazil

The Cerrado domain is a mosaic of vegetation types at the local scale, and this environmental heterogeneity leads to high regional bird diversity. Therefore, we aimed to survey quantitative and qualitatively the bird fauna of two fragments of Cerrado and to compare them with an adjacent protected area (Estação Ecológica de Itirapina), in order to assess the heterogeneity of bird diversity in the region. The present study was conducted during 12 months from October 2006 to September 2007 in the municipality of Itirapina, Southeastern Brazil. Altogether we recorded 210 bird species. Fifty-six of them had never been detected in Estação Ecológica de Itirapina, and eleven species are new records for the whole Itirapina region. The list also includes six species that are endangered in Sao Paulo State and five endemic species of the Cerrado domain. Most species were recorded in less than 50% of the visits and exhibited low relative abundance. Primarily insectivorous species were the most common, followed by omnivores. Frugivorous birds were poorly represented. Carnivores were more abundant than usually observed in fragments. The similarity among fragments was higher than between fragments and the protected area. Considering the vegetation heterogeneity in the Cerrado domain, our results reinforce the importance of conserving fragments in order to sample this diversity.

Efeito do tempo de condicionamento da superfície cerâmica sobre a resistência adesiva entre uma cerâmica de fluorapatita e um cimento resinoso

O objetivo deste estudo foi avaliar a resistência de união entre uma cerâmica sintética de fluorapatita e leucita livre de feldspato e um cimento resinoso dual, variando o tempo de condicionamento ácido da superfície da cerâmica. Foram confeccionados 16 blocos de cerâmica (IPS d. SIGN- Ivoclar-Vivadent) que foram divididos aleatoriamente em 2 grupos (n=8), conforme o tempo de condicionamento ácido da superfície cerâmica: G1 - condicionamento durante 30 segundos com ácido fluorídrico 10%, seguido da aplicação do agente silano (Primer ceramic, 3M/Espe); G2: condicionamento com ácido fluorídrico 10% durante 2 minutos, seguido da aplicação do silano (Primer ceramic, 3M/Espe). Os blocos de cerâmica foram unidos a blocos de resina composta, recém confeccionados, (Fill Magic, Vigodent) com o cimento resinoso Rely X (3M/Espe) sob uma carga de 750g. Os conjuntos foram armazenados em água por 24h e seccionados em dois eixos, x e y, obtendo-se corpos-de-prova (CP) com área de aproximadamente 0,7 mm2. Os CP foram submetidos ao ensaio de microtração a uma velocidade de 0,5 mm/min. Os resultados foram submetidos a duas análises estatísticas utilizando todos os CP, incluindo os com valores zero (G1 = 12,99 ± 6,7 MPa e G2 = 14,97 ± 3,7 MPa) e excluindo os com valores zero (G1 = 20,19 ± 3,8 MPa e G2 = 22,31 ± 2,8 MPa). Não foi observada diferença estatística entre os grupos em nenhuma das análises (p>0,05).

Bird richness and composition in a Cerrado fragment in the State of São Paulo

Bird species richness is an important measure for monitoring biodiversity changes. We analysed avifauna richness and composition in a 472 ha protected cerrado fragment and surroundings at Fazenda Canchim (RL-CPPSE), São Carlos, in the State of São Paulo (SP). We carried out 95.1 hours of observation (22 visits) at irregular intervals from May 2004 to December 2006. Qualitative surveys were done walking through tracks inside the fragment and on the roads at its edge. We recorded 160 species, six of which were endemic to Cerrado domain, 22 migratory, seven threatened within the State of São Paulo, and two globally threatened. We found 28 species in the cerradão, 110 in the cerrado sensu stricto, 13 in the gallery forest, 26 in the reservoir border, 26 in pasturelands and sugar cane monoculture and 55 in an anthropic area. Most of the species had low frequency of occurrence in all vegetation forms. Insectivores were the major trophic category (46.9%), which is typical in tropical regions, and it is also related to resource availability. Omnivores followed with 19.4%, granivores with 8.8% and frugivores with 7.5%. We conclude that, despite its size and conservation status, our study area has a remarkable bird community and must be considered as a priority conservation area to preserve bird species in Sao Paulo State.