Non-binary gender, vulnerable populations and mental health during the COVID-19 pandemic: Data from the COVID-19 MEntal health inTernational for the general population (COMET-G) study

BACKGROUND

The COVID-19 pandemic has brought significant mental health challenges, particularly for vulnerable populations, including non-binary gender individuals. The COMET international study aimed to investigate specific risk factors for clinical depression or distress during the pandemic, also in these special populations.

METHODS

Chi-square tests were used for initial screening to select only those variables which would show an initial significance. Risk Ratios (RR) were calculated, and a Multiple Backward Stepwise Linear Regression Analysis (MBSLRA) was followed with those variables given significant results at screening and with the presence of distress or depression or the lack of both of them.

RESULTS

The most important risk factors for depression were female (RR = 1.59-5.49) and non-binary gender (RR = 1.56-7.41), unemployment (RR = 1.41-6.57), not working during lockdowns (RR = 1.43-5.79), bad general health (RR = 2.74-9.98), chronic somatic disorder (RR = 1.22-5.57), history of mental disorders (depression RR = 2.31-9.47; suicide attempt RR = 2.33-9.75; psychosis RR = 2.14-10.08; Bipolar disorder RR = 2.75-12.86), smoking status (RR = 1.15-5.31) and substance use (RR = 1.77-8.01). The risk factors for distress or depression that survived MBSLRA were younger age, being widowed, living alone, bad general health, being a carer, chronic somatic disorder, not working during lockdowns, being single, self-reported history of depression, bipolar disorder, self-harm, suicide attempts and of other mental disorders, smoking, alcohol, and substance use.

CONCLUSIONS

Targeted preventive interventions are crucial to safeguard the mental health of vulnerable groups, emphasizing the importance of diverse samples in future research.

LIMITATIONS

Online data collection may have resulted in the underrepresentation of certain population groups.

Somatic multicomorbidity and disability in patients with psychiatric disorders in comparison to the general population: a quasi-epidemiological investigation in 54,826 subjects from 40 countries (COMET-G study)

BACKGROUND

The prevalence of medical illnesses is high among patients with psychiatric disorders. The current study aimed to investigate multi-comorbidity in patients with psychiatric disorders in comparison to the general population. Secondary aims were to investigate factors associated with metabolic syndrome and treatment appropriateness of mental disorders.

METHODS

The sample included 54,826 subjects (64.73% females; 34.15% males; 1.11% nonbinary gender) from 40 countries (COMET-G study). The analysis was based on the registration of previous history that could serve as a fair approximation for the lifetime prevalence of various medical conditions.

RESULTS

About 24.5% reported a history of somatic and 26.14% of mental disorders. Mental disorders were by far the most prevalent group of medical conditions. Comorbidity of any somatic with any mental disorder was reported by 8.21%. One-third to almost two-thirds of somatic patients were also suffering from a mental disorder depending on the severity and multicomorbidity. Bipolar and psychotic patients and to a lesser extent depressives, manifested an earlier (15-20 years) manifestation of somatic multicomorbidity, severe disability, and probably earlier death. The overwhelming majority of patients with mental disorders were not receiving treatment or were being treated in a way that was not recommended. Antipsychotics and antidepressants were not related to the development of metabolic syndrome.

CONCLUSIONS

The finding that one-third to almost two-thirds of somatic patients also suffered from a mental disorder strongly suggests that psychiatry is the field with the most trans-specialty and interdisciplinary value and application points to the importance of teaching psychiatry and mental health in medical schools and also to the need for more technocratically oriented training of psychiatric residents.

Update on the use and management of lithium in neuropsychiatry

Lithium is an alkaline metal, used for more than 60 years in psychiatry, and currently considered the gold standard in the treatment of bipolar disorder (BD). According to recent evidence, this active ingredient is useful for the treatment of a wide spectrum of clinical varieties of affective disorders. In addition, it is estimated that lithium reduces the risk of suicide and suicidal behavior in people with mood disorders. On the other hand, some novel studies have shown that the cation has a potential efficacy for the treatment of other neuropsychiatric processes, such as the likelihood of reducing the risk of dementia and slowing down the development of neurodegenerative diseases. Despite the enormous evidence in favor of the use of lithium, it is known that, in Argentina, medications containing it are prescribed less than expected. In view of all this, the Asociación Argentina de Psiquiatría Biológica (Argentine Association of Biological Psychiatry) (AAPB or AABP) convened a group of experts to review the available scientific literature and prepare an updated document on the management and use of lithium in neuropsychiatry. In addition to the use of the ion in daily clinical practice, the scope of this review includes other contents that have been considered of interest for the psychiatrist, such as certain pharmacological and pharmacogenetic aspects, possible clinical predictors of response to treatment with lithium, management of ion during perinatal period, management of lithium in child and adolescent population, management of adverse effects linked to cation and interactions with drugs and other substances.

Third Argentine Consensus statement on management Bipolar Disorders. Section3: Bipolar Disorder in the context of special situations

This document constitutes the third and last part of the Third Argentine Consensus on the Management of Bipolar Disorders carried out by the Argentine Association of Biological Psychiatry (AAPB). Continuing with the initial objective, this section of the Consensus on the Management of Bipolar Disorders is focused on the management of bipolar disorders in special populations. This section constitutes a comprehensive review and expert consideration of the scientific evidence on: a) the management of bipolar disorders in treatment-resistant patients; b) the management of bipolar disorder in childhood and adolescence; c) the management of bipolar disorders in women during their perinatal period and, d) the management of bipolar disorders in older adults.

Latin American consensus recommendations for the management and treatment of patients with treatment-resistant depression (TRD)

Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD, and available treatment pathways for the management of TRD vary across the Latin American region, highlighting the need for a uniform definition and treatment principles to optimize the management of TRD in Latin America.

METHODS

Following a thematic literature review and pre-meeting survey, a Latin America expert panel comprising 14 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA appropriateness method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management.

RESULTS

The expert panel agreed that 'treatment-resistant depression' (TRD) is defined as 'failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode'. A stepwise treatment approach should be employed for the management of TRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Nonpharmacological treatments, such as electroconvulsive therapy, are also appropriate options for patients with TRD.

CONCLUSION

These consensus recommendations on the operational definition of TRD and approved treatments for its management can be adapted to local contexts in the Latin American countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with TRD.

Results of the COVID-19 mental health international for the health professionals (COMET-HP) study: depression, suicidal tendencies and conspiracism

INTRODUCTION

The current study aimed to investigate the rates of anxiety, clinical depression, and suicidality and their changes in health professionals during the COVID-19 outbreak.

MATERIALS AND METHODS

The data came from the larger COMET-G study. The study sample includes 12,792 health professionals from 40 countries (62.40% women aged 39.76 ± 11.70; 36.81% men aged 35.91 ± 11.00 and 0.78% non-binary gender aged 35.15 ± 13.03). Distress and clinical depression were identified with the use of a previously developed cut-off and algorithm, respectively.

STATISTICAL ANALYSIS

Descriptive statistics were calculated. Chi-square tests, multiple forward stepwise linear regression analyses, and Factorial Analysis of Variance (ANOVA) tested relations among variables.

RESULTS

Clinical depression was detected in 13.16% with male doctors and 'non-binary genders' having the lowest rates (7.89 and 5.88% respectively) and 'non-binary gender' nurses and administrative staff had the highest (37.50%); distress was present in 15.19%. A significant percentage reported a deterioration in mental state, family dynamics, and everyday lifestyle. Persons with a history of mental disorders had higher rates of current depression (24.64% vs. 9.62%; p < 0.0001). Suicidal tendencies were at least doubled in terms of RASS scores. Approximately one-third of participants were accepting (at least to a moderate degree) a non-bizarre conspiracy. The highest Relative Risk (RR) to develop clinical depression was associated with a history of Bipolar disorder (RR = 4.23).

CONCLUSIONS

The current study reported findings in health care professionals similar in magnitude and quality to those reported earlier in the general population although rates of clinical depression, suicidal tendencies, and adherence to conspiracy theories were much lower. However, the general model of factors interplay seems to be the same and this could be of practical utility since many of these factors are modifiable.

Third Argentine Consensus statement on management Bipolar Disorders. Section 2 B

This document constitutes the second section B of the Third Argentine Consensus on the Management of Bipolar Disorders, focused on synthesizing the most updated evidence on therapeutic approaches for adult patients. The scope of this section is to provide therapeutic recommendations for managing bipolar disorders in adults, (i) acute mania (ii) bipolar depression (iii) mixed stated (iv) suicidality and (vi) psychological interventions. In addition, the current manuscript outlines the assessment and management of side effects of pharmacotherapeutic treatments.

Third Argentine Consensus statement on management Bipolar Disorders. Section 2 A: Comprehensive treatment of the bipolar disorders in adults

This document constitutes the second section A of the Third Argentine Consensus on the Management of Bipolar Disorders, focused on synthesizing the most updated evidence on therapeutic approaches for adult patients. The aim of this section (2A) is to provide therapeutic recommendations for managing bipolar disorders in adults. In addition, the scope of this current manuscript outlines recommendations on the use of treatment guidelines, levels of evidence available to support these recommendations, general considerations for the treatment of bipolar disorders, the so-called pseudoresistance and adherence to treatment, general considerations on psychological therapies, as well as long term treatment of bipolar disorders.

Third Argentine Consensus statement on management Bipolar Disorders. Section 2 A: Comprehensive treatment of the bipolar disorders in adults

This document constitutes the second section A of the Third Argentine Consensus on the Management of Bipolar Disorders, focused on synthesizing the most updated evidence on therapeutic approaches for adult patients. The aim of this section (2A) is to provide therapeutic recommendations for managing bipolar disorders in adults. In addition, the scope of this current manuscript outlines recommendations on the use of treatment guidelines, levels of evidence available to support these recommendations, general considerations for the treatment of bipolar disorders, the so-called pseudoresistance and adherence to treatment, general considerations on psychological therapies, as well as long term treatment of bipolar disorders.

Saline bladder infusion vs standard catheter removal in patients with acute urinary retention related to benign prostatic hyperplasia: The BLAPERF Study

PURPOSE

Bladder infusion, which involves filling the bladder with saline prior to catheter removal, has been associated with reduced time-to-discharge and increased success rates in trials without catheter (TWOCs) in perioperative setting. The objective of this study was to evaluate the applicability of this protocol in patients with acute urinary retention (AUR) related to benign prostatic hyperplasia (BPH).

METHODS

We conducted a retrospective single-center study comparing bladder infusion with at least 150mL of warm saline vs. standard catheter removal during TWOC in patients with BPH-related AUR between January and December 2021. The primary outcome was time to discharge. Secondary outcomes included: TWOC success, and early recurrence of urinary retention defined as recurrence within three months of successful TWOC.

RESULTS

A total of 75 men were included: 35 in the bladder infusion protocol and 40 in the standard protocol. Baseline characteristics were well balanced between groups. Overall, 35 patients (46.7%) had a successful TWOC without statistically significant difference between groups (P=0.10). Bladder infusion protocol was associated with a shorter median time to discharge (200 vs. 240min, P=0.003). However, patients in the bladder infusion group were associated with a higher risk of early recurrence of urinary retention (30% vs. 0%, P=0.02).

CONCLUSION

In patients with BPH-related AUR, the saline bladder infusion method reduced time-to-discharge with similar TWOC success rates. Larger studies are needed to properly analyze the risk of early recurrence of urinary retention before any clinical application.

LEVEL OF EVIDENCE

III.

Third Argentine Consensus statement on management Bipolar Disorders. Section1: introduction and general concepts

The Third Argentine Consensus on the management of bipolar disorders (TB) is an initiative of the Argentine Association of Biological Psychiatry (AAPB). As a reference document, this consensus pursues two main objectives: on the one hand, to summarize and systematize the best available evidence on the comprehensive management of this pathology; on the other, to provide a useful, up-to-date instrument for psychiatrists, multidisciplinary teams dedicated to mental health, and government agencies. During a period of approximately six months of work -that is, from May to October 2022- a committee of experts made up of 18 professionals and representatives of the three most important Psychiatry and Mental Health associations in Argentina (that is, the AAPB, the Argentine Association of Psychiatrists, AAP, and the Association of Argentine Psychiatrists, APSA) have focused on updating the information regarding TB. Finally, this document was prepared as a result of an exhaustive review of the bibliography published to date, which was strategically divided into three parts: the first deals with the generalities of TB; the second deals with the comprehensive treatment of the pathology; finally, the third analyzes TB in the context of special situations.

The effect of different degrees of lockdown and self-identified gender on anxiety, depression and suicidality during the COVID-19 pandemic: Data from the international COMET-G study

INTRODUCTION

During the COVID-19 pandemic various degrees of lockdown were applied by countries around the world. It is considered that such measures have an adverse effect on mental health but the relationship of measure intensity with the mental health effect has not been thoroughly studied. Here we report data from the larger COMET-G study pertaining to this question.

MATERIAL AND METHODS

During the COVID-19 pandemic, data were gathered with an online questionnaire from 55,589 participants from 40 countries (64.85% females aged 35.80 ± 13.61; 34.05% males aged 34.90±13.29 and 1.10% other aged 31.64±13.15). Anxiety was measured with the STAI, depression with the CES-D and suicidality with the RASS. Distress and probable depression were identified with the use of a previously developed cut-off and algorithm respectively.

STATISTICAL ANALYSIS

It included the calculation of Relative Risk (RR), Factorial ANOVA and Multiple backwards stepwise linear regression analysis RESULTS: Approximately two-thirds were currently living under significant restrictions due to lockdown. For both males and females the risk to develop clinical depression correlated significantly with each and every level of increasing lockdown degree (RR 1.72 and 1.90 respectively). The combined lockdown and psychiatric history increased RR to 6.88 The overall relationship of lockdown with severity of depression, though significant was small.

CONCLUSIONS

The current study is the first which reports an almost linear relationship between lockdown degree and effect in mental health. Our findings, support previous suggestions concerning the need for a proactive targeted intervention to protect mental health more specifically in vulnerable groups.

Suicidality and Quality of Life in Treatment-Resistant Depression Patients in Latin America: Secondary Interim Analysis of the TRAL Study

BACKGROUND

A large proportion of patients with major depressive disorder (MDD) have treatment-resistant depression (TRD). The TRAL study examines the impact of TRD on suicidality and health-related quality of life (HRQoL) among MDD patients in 4 Latin American countries.

METHODS

In this multicenter, prospective, observational study, MDD patients were recruited from 33 sites in Mexico, Colombia, Brazil, and Argentina. Patients were assessed for TRD, defined as failure to respond to ≥2 antidepressant medications of adequate dose and duration. Other assessments included current disease status, Mini International Neuropsychiatric Interview (MINI), Columbia-Suicide Severity Rating Scale (C-SSRS), 5 Level EQ-5D (EQ-5D-5L), Patient Health Questionnaire-9 (PHQ-9), and Sheehan Disability Scale (SDS).

RESULTS

1,475 MDD patients were included in the analysis (mean age, 45.6 years; 78% women), and 429 met criteria for TRD. Thoughts of suicide and suicide attempts were more common among TRD patients (38.7%) compared with non-TRD patients (24.9%; P < 0.0001), according to the current disease status questionnaire. The C-SSRS showed that lifetime suicidal behavior was significantly more common among TRD patients than non-TRD patients (13.8 vs. 10.0%; P = 0.0384). Compared with non-TRD patients, TRD patients showed significantly greater adverse impacts on QoL (EQ-5D-5L), more severe depression (PHQ-9), and greater functional impairment (SDS).

CONCLUSION

TRD patients in clinical sites from Mexico, Colombia, Brazil, and Argentina were more likely to experience suicidality and negative effects on HRQoL than non-TRD patients.

Results of the COVID-19 mental health international for the general population (COMET-G) study

INTRODUCTION

There are few published empirical data on the effects of COVID-19 on mental health, and until now, there is no large international study.

MATERIAL AND METHODS

During the COVID-19 pandemic, an online questionnaire gathered data from 55,589 participants from 40 countries (64.85% females aged 35.80 ± 13.61; 34.05% males aged 34.90±13.29 and 1.10% other aged 31.64±13.15). Distress and probable depression were identified with the use of a previously developed cut-off and algorithm respectively.

STATISTICAL ANALYSIS

Descriptive statistics were calculated. Chi-square tests, multiple forward stepwise linear regression analyses and Factorial Analysis of Variance (ANOVA) tested relations among variables.

RESULTS

Probable depression was detected in 17.80% and distress in 16.71%. A significant percentage reported a deterioration in mental state, family dynamics and everyday lifestyle. Persons with a history of mental disorders had higher rates of current depression (31.82% vs. 13.07%). At least half of participants were accepting (at least to a moderate degree) a non-bizarre conspiracy. The highest Relative Risk (RR) to develop depression was associated with history of Bipolar disorder and self-harm/attempts (RR = 5.88). Suicidality was not increased in persons without a history of any mental disorder. Based on these results a model was developed.

CONCLUSIONS

The final model revealed multiple vulnerabilities and an interplay leading from simple anxiety to probable depression and suicidality through distress. This could be of practical utility since many of these factors are modifiable. Future research and interventions should specifically focus on them.

[Argentine consensus on the diagnosis and therapeutics of treatment resistant schizophrenia]

Approximately 30% of people with schizophrenia fail to respond to first-line antipsychotic treatment which impacts the burden of the disease. Treatment-resistant schizophrenia (TRS) denotes patients with failure to respond to at least two adequate trials of different antipsychotics. Clozapine is a unique drug approved for treating treatment-resistant schizophrenia, however 1/3 of patients fail to respond to clozapine. Even though different strategies have been proposed for treating clozapine-resistant schizophrenia, the evidence is very limited, unclear, and of poor quality. A formal literature search was conducted and then, panel members were asked to complete 35 questions addressing different aspects of TRS. A modified Delphi method was used to unify expert opinion and achieve consensus. The expert consensus in diagnostic and treatment of TRS is the result of experts from the main national scientific societies under the organization of the Argentine Association of Biological Psychiatric (AAPB). The consensus statement aims to guide on diagnosis and treatment.

Longitudinal follow up of serological response in children treated for Chagas disease

Background

Evaluation of therapeutic response in chronic Chagas disease is a major challenge, due to prolonged persistence of Trypanosoma cruzi-specific antibodies, lack of sensitivity of parasitological tests, and need for long-term follow-up to observe negative seroconversion of conventional serological tests (CS). The objective of this study was to evaluate F2/3-ELISA serology, a promising early biomarker of therapeutic response, and T.cruzi Polymerase chain reaction (PCR) for T. cruzi Deoxyribonucleic acid (DNA), for neonatal diagnosis and evaluation of parasitemia after treatment.

Methods

Prospective cohort study, with three-year clinical, serological and parasitological follow-up of pediatric Chagas disease patients treated with benznidazole. Serology was evaluated by Enzyme-Linked ImmunoSorbent Assay (ELISA), Indirect hemagglutination (IHA) and F2/3-ELISA; Parasitemia by microhematocrit (MH) and PCR.

Results

A cohort of 107 pediatric patients treated with benznidazole was enrolled in the study. ELISA and IHA were initially reactive in 100% of patients, F2/3-ELISA serology was reactive in 80% (86/107) and 91% (97/107) had detectable parasitemia. Seventy-six (71%) patients completed at least 36 months of serological follow up after treatment. Although a similar decreasing linear trend was observed for all serological tests, F2/3-ELISA presented earlier, age dependent, negative seroconversion compared to CS. All patients reaching undetectable CS titers had previously seroreverted by F2/3-ELISA. All patients with persistently decreasing antibody titers had negative PCRs throughout the follow up period. No new cardiological lesions were observed during the 3 years follow-up period.

Conclusions

The data reported here, using CS, F2/3 ELISA and PCR provide support for the efficacy of benznidazole in congenital Chagas diseases. These results provide support for scaling up of screening, diagnosis and access to benznidazole treatment.

Trial registration

ClinicalTrials.gov 0028/04 in the Research Council, Secretary of Health Buenos Aires city Goberment.

Evaluation of therapeutic response in chronic Chagas disease is a major challenge, particularly in the early post-treatment phase, due to prolonged persistence of Trypanosoma cruzi-specific antibodies and lack of sensitivity of available parasitological tests. The main limitation in evaluating Chagas disease treatment response stems from the need for long-term follow-up to observe negative seroconversion of conventional serological tests. New biomarkers of cure are needed. We evaluated F2/3-ELISA, a promising early serological marker of therapeutic response, and T.cruzi PCR for T.cruzi DNA, for neonatal diagnosis and evaluation of parasitemia after treatment. F2/3-ELISA and PCR proved to be excellent early markers of treatment response that correlate with ELISA and IHA but can identify treatment response or failure at much earlier timepoints. This information can help design future paediatric clinical trials in Chagas disease.

Can the Positive and Negative Syndrome scale (PANSS) differentiate treatment-resistant from non-treatment-resistant schizophrenia? A factor analytic investigation based on data from the Pattern cohort study

Treatment-Resistant Schizophrenia (TRS) and Non-Treatment-Resistant Schizophrenia (NTRS) may represent different subtypes of schizophrenia. However, few studies have investigated their PANSS symptom dimensions by Exploratory (EFA) or Confirmatory (CFA). Data from the present study are derived from 1429 patients of the Pattern study. TRS was defined by the use of clozapine in the previous year whereas NTRS by the use of non-clozapine antipsychotics ("by proxy"). Factors were chosen based on the Kaiser criterion and considered valid when loadings were greater than or equal to 0.5. The fit to the data was evaluated by CFA in comparison with well-established PANSS models, using fit indexes. The EFA yielded similar five-factor model in both groups: Negative, Positive, Anxiety/Depression, Cognitive and Excited. CFA showed a satisfactory, but not perfect, fit to the data, as compared with the previous PANSS factor analytic models. Despite the limitations regarding the 'by proxy' definition of TRS, the results of the present study show that there are no differences in the factorial structure of PANSS in patients with TRS and NTRS.

Correlation of Health-Related Quality of Life in Clinically Stable Outpatients with Schizophrenia

BACKGROUND

Generic health-related quality of life (HRQoL) scales are increasingly being used to assess the effects of new treatments in schizophrenia. The objective of this study is to better understand the usefulness of generic and condition specific HRQoL scales in schizophrenia by analyzing their correlates.

METHODS

Data formed part of the Pattern study, an international observational study among 1379 outpatients with schizophrenia. Patients were evaluated with the Mini International Neuropsychiatric Inventory, the Clinical Global Impression-Schizophrenia (CGI-SCH) Scale and the Positive and Negative Syndrome Scale (PANSS) and reported their HRQoL using the Schizophrenia Quality of Life Scale (SQLS), the Short Form-36 (SF-36), and the EuroQol-5 Dimension (EQ-5D). The two summary values of the SF-36 (the Mental Component Score and the Physical Component Score, SF-36 MCS and SF-36 PCS) were calculated.

RESULTS

Higher PANSS positive dimension ratings were associated with worse HRQoL for the SQLS, EQ-5D VAS, SF-36 MCS, and SF-36 PCS. Higher PANSS negative dimension ratings were associated with worse HRQoL for the EQ-5D VAS, SF-36 MCS, and SF-36 PCS, but not for the SQLS or the EQ-5D tariff. PANSS depression ratings were associated with lower HRQoL in all the scales. There was a high correlation between the HRQoL scales. However, in patients with more severe cognitive/disorganized PANSS symptoms, the SQLS score was relatively higher than the EQ-5D tariff and SF-36 PCS scores.

CONCLUSION

This study has shown substantial agreement between three HRQoL scales, being either generic or condition specific. This supports the use of generic HRQoL measures in schizophrenia.

CLINICALTRIALSGOV IDENTIFIER

NCT01634542 (July 6, 2012, retrospectively registered).

Understanding the course of persistent symptoms in schizophrenia: Longitudinal findings from the pattern study

The Pattern study was conducted to provide longitudinal observational data for individual patients with persistent symptoms of schizophrenia. Pattern is an international, multicenter, non-interventional, prospective cohort study of schizophrenia outpatients who were not considered to be in recovery. In the longitudinal phase reported herein, patients were assessed over 1 year using different clinical rating scales. Patient management followed routine local clinical practice. Primary outcome was disease state, defined by the Positive and Negative Syndrome Scale (PANSS), Negative Symptom Factor Score (NSFS), Positive Symptom Factor Score (PSFS), and Personal and Social Performance (PSP) Scale. In total, 1344 protocol-compliant patients (70.9% male) were included. Patients showed a high stability in disease state between consecutive study visits. Persistent negative persistent symptoms and symptomatic remission were the most prevalent and stable disease states. Patients in relapse generally transitioned to negative persistent symptoms or to symptomatic remission. PANSS, PSP, and quality of life ratings remained relatively stable. Relapses occurred in 10% of patients; probability of relapse was associated with younger age, extra-pyramidal symptoms, and more antipsychotic medications. Despite treatment, schizophrenia symptoms tend to remain stable over time, without overall improvement. One of the greatest challenges in schizophrenia is attainment of full symptom remission.

Oral health in Alzheimer's disease: a multicenter case-control study

OBJECTIVES

The aim of this case-control study was to carry out an oral health assessment on a group of Alzheimer's patients and to establish a hypothesis regarding the implication of the characteristics of the disease and the treatment of oral health.

MATERIALS AND METHODS

A total of 70 Alzheimer's patients, residents at the Alzheimer Center Reina Sofia Foundation (Madrid, Spain) and at the Alzheimer State Reference Center (Salamanca, Spain), and 36 controls (companions/acquaintances), were studied by oral examination and saliva sampling. The oral health indices DMFT/DMFS, CPI, the prosthetic condition, oral hygiene, saliva volume, and pH, as well as the specific microbiological parameters governing the risk of developing caries were assessed.

RESULTS

Alzheimer's patients exhibited, as compared to the control group, (1) fewer teeth (10.9 ± 10.5 vs 23.7 ± 6.5), (2) fewer obturations (2.2 ± 3.4 vs 6.6 ± 5.6), (3) fewer periodontally healthy sextants (0.1 ± 0.4 vs 1.4 ± 2.2), (4) worse oral hygiene (43.1 vs 72.2% brushed), (5) greater use of removable prostheses (47.8 vs 8.4%), (6) higher incidence of candida infection (11.8 vs 0.0%) and cheilitis (15.9 vs 0.0%), (7) lower salivary flow (0.6 ± 0.6 vs 1.1 ± 0.6), and (8) lower buffering capacity (46 vs 80%).

CONCLUSIONS

After taking into account the influence of age, Alzheimer's patients had worse oral health (caries and periodontal disease), more mucosal lesions (cheilitis and candidiasis), and worse saliva quantity and quality.

CLINICAL RELEVANCE

Clinicians should be aware of the implications of Alzheimer's disease in oral health, in order to stablish the effective preventive measures and the optimal treatment plan.

Effectiveness of agomelatine on anhedonia in depressed patients: an outpatient, open-label, real-world study

OBJECTIVE

The aim of this real-world study was to evaluate the effect of agomelatine on anhedonia as primary endpoint in outpatients under treatment of major depressive episodes.

METHODS

The study was an open-label, multicenter, 8-week phase IV trial. Two hundred fifty-seven (257) patients were recruited, and 143 patients were included in the analysis. Agomelatine was administered orally as a 25-mg tablet. The dose could be increased to 50 mg after 2 weeks of treatment.

RESULTS

An improvement in the severity of anhedonia (Snaith-Hamilton Pleasure Scale total score) was observed from 8.5 points at baseline to 4.1 at week 8, statistically significant (p < 0.05) from the first week. Significant decreases in scores on the severity of depression (Quick Inventory of Depressive Symptomatology 16-item Self-Report [QIDS-SR-16]), anxiety (Generalized Anxiety Disorder 7-item scale), and in overall clinical status (CGI) were also found over 8 weeks, independently from the presence of a first or recurrence episode. Response (QIDS-SR-16 score ≥ 50% of baseline) at week 8 was observed in 65.7% of the patients, while 49.6% of the patients achieved remission (QIDS-SR-16 score ≤ 5).

CONCLUSION

Agomelatine was shown to be effective on anhedonia, depression, and anxiety in subjects with major depression. The pragmatic design of the study reflects real-world clinical practice providing interesting insights into routine care management.

Understanding the impact of persistent symptoms in schizophrenia: Cross-sectional findings from the Pattern study

BACKGROUND

The high societal burden of schizophrenia is largely caused by the persistence of symptoms and accompanying functional impairment. To date, no studies have specifically assessed the course of persistent symptoms or the individual contributions of positive and negative symptoms to patient functioning. The cross-sectional analysis of the Pattern study provides an international perspective of the burden of schizophrenia.

METHODS

Clinically stable outpatients from 140 study centers across eight countries (Argentina, Brazil, Canada, France, Germany, Italy, Spain and the United Kingdom) were assessed using clinical rating scales: Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression-Schizophrenia (CGI-SCH) Scale and the Personal and Social Performance (PSP) Scale. Additional measures included patient-reported outcomes, patient socio-demographic variables, living situation, employment and resource use.

RESULTS

Overall, 1379 patients were assessed and analyzed and had similar sociodemographic characteristics across countries, with 61.6% having persistent positive and/or negative symptoms. Positive and negative symptoms had been persistent for a mean of 9.6 and 8.9 years (SD: 8.8 and 9.6), respectively. Approximately 86% of patients had a functional disability classified as greater than mild. Patients with a higher PANSS Negative Symptom Factor Score were more likely to have a poorer level of functioning.

CONCLUSIONS

This analysis examines individual contributions of persistent positive and negative symptoms on patient functioning in different countries. A high prevalence of patients with persistent symptoms and functional impairment was a consistent finding across countries. Longitudinal observations are necessary to assess how to improve persistent symptoms of schizophrenia and overall patient functioning.

Analysis of Xanthomonas oryzae pv. oryzicola population in Mali and Burkina Faso reveals a high level of genetic and pathogenic diversity

Bacterial leaf streak (BLS) caused by Xanthomonas oryzae pv. oryzicola was first reported in Africa in the 1980s. Recently, a substantial reemergence of this disease was observed in West Africa. Samples were collected at various sites in five and three different rice-growing regions of Burkina Faso and Mali, respectively. Sixty-seven X. oryzae pv. oryzicola strains were isolated from cultivated and wild rice varieties and from weeds showing BLS symptoms. X. oryzae pv. oryzicola strains were evaluated for virulence on rice and showed high variation in lesion length on a susceptible cultivar. X. oryzae pv. oryzicola strains were further characterized by multilocus sequence analysis (MLSA) using six housekeeping genes. Inferred dendrograms clearly indicated different groups among X. oryzae pv. oryzicola strains. Restriction fragment length polymorphism analysis using the transcriptional activator like effector avrXa7 as probe resulted in the identification of 18 haplotypes. Polymerase chain reaction-based analyses of two conserved type III effector (T3E) genes (xopAJ and xopW) differentiated the strains into distinct groups, with xopAJ not detected in most African X. oryzae pv. oryzicola strains. XopAJ functionality was confirmed by leaf infiltration on 'Kitaake' rice Rxo1 lines. Sequence analysis of xopW revealed four groups among X. oryzae pv. oryzicola strains. Distribution of 43 T3E genes shows variation in a subset of X. oryzae pv. oryzicola strains. Together, our results show that African X. oryzae pv. oryzicola strains are diverse and rapidly evolving, with a group endemic to Africa and another one that may have evolved from an Asian strain.

Frequency of HLA-A, -B and -DRB1 specificities and haplotypic associations in the population of Castilla y León (northwest-central Spain)

The frequencies of human leukocyte antigen (HLA) class I and class II specificities and haplotypic associations were determined in 1940 unrelated donors from Castilla y León and compared with other Iberian, Mediterranean and European populations. Specificities were determined using polymerase chain reaction reverse sequence-specific oligonucleotide or polymerase chain reaction sequence-specific primer techniques. In the analysis, 19, 29 and 13 specificities were found for HLA-A, -B and -DRB1, respectively, with HLA-A*02 (26%), -A*01 (11%), -B*44 (16%), -B*35 (10%), -DRB1*07 (16%) and -DRB1*13 (14%) showing the highest frequencies. In addition, 10 common HLA-A-B-DRB1 haplotypic associations were observed, A*01-B*08-DRB1*03 (3%) and A*29-B*44-DRB1*07 (3%) being the most frequent ones. These findings indicate that the population of Castilla y León is genetically equidistant from the Portuguese and other Spanish populations and shares a common origin with other Iberian populations, in which European, Mediterranean and North African genetic components are present; this is in agreement with the historical and genetic background of the population. These data contribute to a better understanding of the genetic structure of the Iberian Peninsula and provide a healthy control population from our region that should be useful for the study of disease associations.

Design and synthesis of Hsp90 inhibitors: exploring the SAR of Sansalvamide A derivatives

Utilizing the structure-activity relationship we have developed during the synthesis of the first two generations and mechanism of action studies that point to the interaction of these molecules with the key oncogenic protein Hsp90, we report here the design of 32 new Sansalvamide A derivatives and their synthesis. Our new structures, designed from previously reported potent compounds, were tested for cytotoxicity on the HCT116 colon cancer cell line, and their binding to the biological target was analyzed using computational studies involving blind docking of derivatives using Autodock. Further, we show new evidence that our molecules bind directly to Hsp90 and modulate Hsp90's binding with client proteins. Finally, we demonstrate that we have integrated good ADME properties into a new derivative.

A blended learning experience for teaching microbiology

OBJECTIVES

To create a virtual laboratory system in which experimental science students could learn required skills and competencies while overcoming such challenges as time limitations, high cost of resources, and lack of feedback often encountered in a traditional laboratory setting.

DESIGN

A blended learning experience that combines traditional practices and e-learning was implemented to teach microbiological methods to pharmacy students. Virtual laboratory modules were used to acquire nonmanual skills such as visual and mental skills for data reading, calculations, interpretation of the results, deployment of an analytical protocol, and reporting results.

ASSESSMENT

Learning achievement was evaluated by questions about microbiology case-based problems. Students' perceptions were obtained by assessment questionnaire.

CONCLUSION

By combining different learning scenarios, the acquisition of the necessary but otherwise unreachable competences was achieved. Students achieved similar grades in the modules whose initiation was in the virtual laboratory to the grades they achieved with the modules whose complete or partial initiation took place in the laboratory. The knowledge acquired was satisfactory and the participants valued the experience.

Simplification of the Mitsunobu Reaction. Di-p-chlorobenzyl Azodicarboxylate: A New Azodicarboxylate

Di-p-chlorobenzyl azodicarboxylate (DCAD) is introduced as a novel, stable, solid alternative to DEAD and DIAD for a variety of Mitsunobu couplings. DCAD/Ph(3)P-mediated reactions in CH(2)Cl(2) generate a readily separable hydrazine byproduct. [reaction: see text]

Synthesis and cytotoxicity of novel sansalvamide A derivatives

Described are the syntheses of 14 derivatives of the natural product Sansalvamide A, where two are more active against HCT 116 colon cancer cell lines than the natural product. These derivatives were synthesized using a combinatorial-type strategy that permits elucidation of the amino acid role in the cytotoxicity, and they lay the groundwork for development of new anticancer agents. [structure: see text]

Synthesis of Sansalvamide A derivatives and their cytotoxicity in the MSS colon cancer cell line HT-29

We report the synthesis of thirty-six Sansalvamide A derivatives, and their biological activity against colon cancer HT-29 cell line, a microsatellite stable (MSS) colon cancer cell-line. The thirty-six compounds can be divided into three subsets, where the first subset of compounds contains L-amino acids, the second subset contains D-amino acids, and the third subset contains both D- and L-amino acids. Five compounds exhibited excellent inhibitory activity (>75% inhibition). The structure-activity relationship (SAR) of the compounds established that a single D-amino acid in position 2 or 3 gave up to a 10-fold improved cytotoxicity over Sansalvamide A peptide. This work highlights the importance of residues 2 and 3 and the role of D-amino acids in the extraordinary SAR for this compound class.

A novel synthetic adjuvant effectively enhances the immunogenicity of the influenza vaccine

Influenza vaccination is a key intervention to reduce morbidity and mortality provoked by this disease. To date, the challenge of improving its efficacy remains unmet. The immunogenic synthetic peptide GK1 from Taenia crassiceps cysticerci was tested herein in its capacity as adjuvant, co-administered with the inactivated anti-influenza vaccine before and after challenge with influenza virus in both young and aged mice. Co-administration of GK1 with the influenza vaccine increased levels of anti-influenza antibodies in aged mice before and after infection, reduced the local inflammation that accompanied influenza vaccination itself and favored virus clearance after infection in both young and aged mice.

Etanidazole in pH-sensitive liposomes: design, characterization and in vitro/in vivo anti-Trypanosoma cruzi activity

In this work, the hydrophilic, low molecular weight and trypanocidal drug etanidazole (ETZ) was loaded in pH-sensitive liposomes (L-ETZ). Liposomes were made of dioleoyl-phosphatidylethanolamine: cholesteryl hemisuccinate (DOPE:CHEMS, 6:4, mol:mol), of 380 nm size at 14% ETZ/total lipid (w/w) ratio. To follow their uptake and intracellular fate by fluorescence microscopy, pH-sensitive liposomes were loaded with the fluorophore/quencher pair HPTS/DPX. A fast and massive delivery of the liposomal aqueous content into the cytosol of murine J774 macrophages was observed. L-ETZ vesicles were phagocytosed by both uninfected and Trypanosoma cruzi-infected macrophages. A 72% of anti-amastigote activity (AA) was demonstrated on L-ETZ-treated J774 cells, whereas the same dose of free ETZ rendered 0% AA. Endovenous administration of L-ETZ at 14 microg/mouse dose provoked significant decrease in parasitemia levels of T. cruzi-infected mice. Conversely, inoculation of a 180-fold higher dose of free ETZ failed in reducing the number of bloodstream trypomastigotes. Hence, these results point to develop systems, such as L-ETZ, designed for selective delivery of drugs to the cytoplasm of phagocytic cells, thus enhancing the efficacy of molecules considered poorly active.

[Anti-F2/3 antibodies as cure marker in children with congenital Trypanosoma cruzi infection]

The F2/3 antigenic fraction isolated from Trypanosoma cruzi trypomastigotes contains epitopes recognised by antibodies which are representative of active infection. The kinetics of disappearance of conventional serology (CS) and anti-F2/3 antibodies were compared in 21 patients with congenital Chagas disease after receiving benznidazole treatment. Patients were divided into 2 groups: (A) Age < 8 months at diagnosis; (B) Age > 9 months at diagnosis. Group A presented negative outcome for CS at 6.6 mo. (CI95 3.4-9.8 mo.) and for anti-F2/3 at 4 mo. (CI95 0.9-7.1 mo.), p = 0.18. Group B exhibited non-reactive CS at 63.1 mo. (CI95 42.1-84.2 mo.) whereas anti-F2/3 antibody determination became negative at 21.9 mo. (CI95 5.7-38.1 mo.), p = 0.0025. In patients belonging to group A, antibodies were undetectable by both CS and anti-F2/3 ELISA soon after receiving chemotherapy. In infants included into group B, a negative result for anti-F2/3 antibody detection significantly anticipated the disappearance of CS reactivity. Consequently, an anti-F2/3 antibody assay becoming negative should be considered as an early marker for assessment of cure, particularly in those patients with prolonged time of infection.

Role of macrophage inflammatory protein-1alpha (MIP-1alpha) in macrophage homing in the spleen and heart pathology during experimental infection with Trypanosoma cruzi

We investigated in vivo the effect of macrophage inflammatory protein-1alpha (MIP-1alpha) inhibition upon the cellular recruitment into tissue damage sites and spleen histology in mice acutely infected with Trypanosoma cruzi. Histopathological studies of spleen sections revealed a 68% decrease in macrophage/monocyte infiltration as a result of MIP-1alpha neutralisation. Moreover, a reduction in the number of plasma cells and immunoblasts was observed. However, antibody (Ab)-mediated blocking of MIP-1alpha failed to modify tissue parasite levels. Examination of myocardial sections showed an increase in inflammatory lesions in mice treated with anti-MIP-1alpha Ab. There was also an increasing trend in the number of amastigote nests in the myocardium of anti-MIP-1alpha-treated mice compared with controls. Administration of anti-MIP-1alpha Ab failed to affect either the extent of inflammatory infiltrates or the parasite count in liver and skeletal muscle. To the best of our knowledge, these data are the first in vivo demonstration that Cz.sbnd;C chemokine MIP-1alpha is involved in cellular recruitment during acute infection with T. cruzi, indicating that MIP-1alpha influences macrophage/monocyte influx into target organs.

A defect in the regional deposition of adipose tissue (partial lipodystrophy) is encoded by a gene at chromosome 1q

Partial lipodystrophy (PLD), also known as "Dunnigan-Kobberling syndrome," is transmitted as a highly penetrant autosomal dominant disorder that is characterized by a dramatic absence of adipose tissue in the limbs and trunk, more evident in females than in males. In contrast, fat is retained on the face, in retro-orbital space, and at periserous sites. Associated metabolic abnormalities, including insulin resistance, hyperinsulinemia, and dyslipidemia, are referred to as "metabolic syndrome X" (Reaven 1988). Despite the intense interest in the genetic determinants underlying fat deposition, the genes involved in the lipodystrophic syndromes have not been identified. We ascertained two multigeneration families, with a combined total of 18 individuals with PLD, and performed a genomewide search. We obtained conclusive evidence for linkage of the PLD locus to microsatellite markers on chromosome 1q21 (D1S498, maximum LOD score 6.89 at recombination fraction .00), with no evidence of heterogeneity. Haplotype and multipoint analysis support the location of the PLD locus within a 21.2-cM chromosomal region that is flanked by the markers D1S2881 and D1S484. These data represent an important step in the effort to isolate and characterize the PLD gene. The identification of the gene will have important implications for the understanding of both developmental and metabolic aspects of the adipocyte and may prove useful as a single-gene model for the common metabolic disorder known as "syndrome X."

HTLV type I and HTLV type II infection among Indians and natives from Argentina

Endemic foci for HTLV-II infection have been identified in several Amerindian populations. To determine HTLV-I and/or HTLV-II infection among Amerindians living in Argentina we studied 454 sera or plasmas from Indians and natives from different areas of our country. All samples were tested by the particle agglutination technique, and positive reactions were confirmed by the immunofluorescence assay (IFA). IFA titration was used to differentiate HTLV-I and HTLV-II antibodies. Twenty-three of 222 samples (10.4%) were found positive among the Tobas Indians; 22 samples were typed as HTLV-II and 1 as HTLV-I. Antibodies for HTLV-I were found in the serum and CSF of three natives from Salta with a TSP diagnosis. No positive samples were found among 96 Mapuche Indians and 133 natives from San Luis. Our results indicate that HTLV-II is endemic among the Tobas Indians. In this study, infection by these retroviruses in Argentinian Amerindians seems to have a marked geographic distribution.

Evaluación del método de ELISA para detección de antígenos y complejos inmunes circulantes de Trypanosoma cruzi a través de un estudio de campo en una zona endémica de Argentina

En una zona endémica de la República Argentina se llevó a cabo un ensayo de campo de la prueba inmunoenzimática ELISA para la detección de antígenos (cAg) y complejos inmunes circulantes (CIC) en sueros de pacientes chagásicos crónicos. Del total de 215 muestras de sangre analizadas, 51 fueron positivas para ELISA-CIC y 45 lo fueron para ELISA-cAg. De los 74 (34,32% de la población) sujetos considerados infectados con dos reacciones serológicas positivas, 49 (66,21%) presentaron CIC en suero, en tanto que en 43 (58,11%) de ellos se encontró cAg por ELISA. Solo en 2 casos serológicamente no reactivos, se detectaron inespecíficamente CIC y cAg. Dentro del grupo considerado no infectado, se observó reactividad inespecífica de bajo título por una de las pruebas serológicas en 16 (11,35%) de 141 individuos. Estos sueros arrojaron resultados consistentemente negativos por ELISA-CIC y cAg demostrando la utilidad de estos métodos de diagnóstico antigénico en casos de serología conflictiva. La determinación de fracciones antigénicas circulantes por ELISA en individuos chagásicos crónicos permite evidenciar la infección por T. cruzi de manera más directa que midiendo la respuesta inmune humoral en el huésped, presentando además mayor sensibilidad que el diagnóstico parasitológico clásico

[Evaluation of an ELISA technique for detection of antigens and circulating immune complexes of Trypanosoma cruzi by a field study in an endemic zone of Argentina]

The ELISA technique for detection of T. cruzi circulating antigens (cAg) and immune complexes (CIC) in the sera of chronic chagasic patients was field-tested in a well-known endemic area of Argentina (San Luis province). Of 215 individuals screened, 51 were positive for ELISA-CIC and 45 for ELISA-cAg. Seventy four subjects were considered por T. cruzi-infected, as they showed serologic reactivity at least by two different techniques. In this group, 49 (66.21%) were ELISA-CIC positive, whereas in 43 (58.11%) of them cAg was found by ELISA. Unspecific reactions were observed in only 2 cases with reactive serology for Chagas disease. Within the group considered as noninfected, a false-positive outcome was obtained at low dilution by one of the serologic tests in 16 (11.35%) of 141 individuals. These sera yielded consistently negative results by ELISA-CIC and cAg, showing the utility of antigen detection in situations of conflictive serology. While antibody determination merely provides an indirect proof of infection, our ELISA tests for demonstration of T. cruzi-specific antigenic fractions in the host's circulation allow a parasitologic diagnosis in chronic patients, with higher sensitivity than that exhibited by traditional methods for detection of the whole parasite.

Trypanosoma cruzi: cloning and expression of an antigen recognized by acute and chronic human chagasic sera

Here we describe the characterization of a Trypanosoma cruzi DNA sequence (clone A13) that codes for a polypeptide recognized by IgM and IgG antibodies from sera of acute and congenital chagasic patients. Antibodies to A13 antigen are also detected in the sera of chronic patients with different clinical forms of Chagas' disease, but not in sera of patients with leishmaniasis or other parasitic diseases. The antigenic determinants encoded by clone A13 are found in amastigotes and trypomastigotes of several T. cruzi strains, but not in the noninfective epimastigotes. The DNA sequence of the recombinant clone reveals one open reading frame encoding 251 amino acids without tandemly repeated sequences. Our data suggest that the A13 antigen may be useful for the development of serodiagnostic procedures.

Rapid determination of Trypanosoma cruzi urinary antigens in human chronic Chagas disease by agglutination test

Detection of Trypanosoma cruzi in man becomes particularly difficult during the chronic stage of Chagas disease because of the low parasitemia. We were able to develop a simple and straightforward method for determining the concentration of T. cruzi antigens in urine using nitrocellulose micellar suspension (Nitrocell-Mr, Polychaco Argentina) and for their subsequent detection through a "latex" type agglutination test. The latex used was an esferocell nitrocellulose suspension (Esferocell-Mr, Polychaco). Specific antigens for T. cruzi were detected in 54 of 58 urine samples from chronic chagasic patients. The antigens characterized by affinity chromatography and SDS-PAGE were glycoproteins with apparent molecular weights (and pIs) of 100 kDa (pI 5 to 5.5), 80 kDa (pI 6.0), and 50 kDa (pI 6.5 to 7.0). This method is practical and fulfills the requirement of large-scale epidemiological studies. It is also helpful in cases of conflictive serology.

Tropical spastic paraparesis in Colombia

A high-incidence focus of tropical spastic paraparesis (TSP) occurs on the South Pacific coast of Colombia. Of 55 patients studied, 52 (94.5%) had IgG antibodies to the human T-cell lymphotropic virus type I (HTLV-I) in serum and/or cerebrospinal fluid. Control groups did not show similar high positivity. Our results suggest that HTLV-I or other antigenically related retroviruses may be the cause of TSP in Colombia. Similar clinical, laboratory, and epidemiological findings have been reported in widely remote geographical regions of the world, with very similar clinical pictures of TSP in all high-incidence regions. The demonstration of IgG antibodies in serum and cerebrospinal fluid of patients with TSP in the Caribbean and Seychelles Islands, southern Japan, and the Ivory Coast indicate that the HTLV-I retrovirus could be the cause of this "tropical" myeloneuropathy.

Epidemiology of tropical spastic paraparesis in Columbia and associated HTLV-I infection

The clinical syndrome earlier designated as paraparesia espástica del Pacífico is an isolated form of tropical spastic paraparesis (TSP) that was reported in 1981 in the southern Pacific lowlands of Columbia in and near Tumaco. The clinical features are similar to those of TSP reported in Jamaica, Martinique, the Seychelles, and the Ivory Coast of Africa and resemble also those clinical features of the human T-lymphotropic virus type I (HTLV-I)-associated myelopathy described in southern Japan. Since HTLV-I infection is closely associated with TSP, we conducted a case-control study to evaluate the role of HTLV-I-associated risk factors among patients from the endemic focus in Tumaco, Colombia, and the seroprevalence rates of this virus in other geographical areas of the Pacific Colombian lowlands with and without TSP. From our seroprevalence study of antibodies to HTLV-I among TSP index patients, matched controls, household contacts (first- and second-degree relatives), and healthy controls from these areas, we found a strong association between HTLV-I and TSP. Also, there is a high seroprevalence of HTLV-I among sexual partners of patients and to a lesser extent among their offspring and other relatives some of whom had an early mean acquisition of antibodies to HTLV-I. Heterosexual promiscuity and other close interpersonal contact may play an important role in the transmission of TSP in the Pacific lowlands of Colombia.

Ventilatory muscle dysfunction in patients with bilateral idiopathic diaphragmatic paralysis: reversal by intermittent external negative pressure ventilation

Bilateral idiopathic diaphragmatic paralysis (BIDP) may result in progressive ventilatory failure. To test the hypothesis that this is in part due to dysfunction of overtaxed inspiratory muscles, we studied 3 patients with BIDP before and after 2, 5, and 18 wk of daily intermittent external surface negative pressure ventilation (ENPV). The patients were evaluated using a zero to 10 functional score (FS) that graded dyspnea, orthopnea, capacity to perform activities of daily living, and ability to work. Pleural (Ppl), abdominal (Pab), and transdiaphragmatic (Pdi) pressures were used as an index of respiratory muscle function. All patients improved their functional score (FS increased 2, 6, and 6, respectively) and their pressure generating ability (Pplmax increased -18, -37, and -46 cm H2O, respectively). Forced vital capacity and functional residual capacity increased in the 2 patients ventilated for longer than 2 wk. These results indicate that ventilatory muscle dysfunction may result from chronic increased work of the inspiratory muscles and that it may improve after periods of intermittent ENPV. This may occur as early as 2 wk after initiation of therapy.