Circulating myeloid-derived MMP8 in stress susceptibility and depression

Psychosocial stress has profound effects on the body, including the immune system and the brain1,2. Although a large number of pre-clinical and clinical studies have linked peripheral immune system alterations to stress-related disorders such as major depressive disorder (MDD)3, the underlying mechanisms are not well understood. Here we show that expression of a circulating myeloid cell-specific proteinase, matrix metalloproteinase 8 (MMP8), is increased in the serum of humans with MDD as well as in stress-susceptible mice following chronic social defeat stress (CSDS). In mice, we show that this increase leads to alterations in extracellular space and neurophysiological changes in the nucleus accumbens (NAc), as well as altered social behaviour. Using a combination of mass cytometry and single-cell RNA sequencing, we performed high-dimensional phenotyping of immune cells in circulation and in the brain and demonstrate that peripheral monocytes are strongly affected by stress. In stress-susceptible mice, both circulating monocytes and monocytes that traffic to the brain showed increased Mmp8 expression following chronic social defeat stress. We further demonstrate that circulating MMP8 directly infiltrates the NAc parenchyma and controls the ultrastructure of the extracellular space. Depleting MMP8 prevented stress-induced social avoidance behaviour and alterations in NAc neurophysiology and extracellular space. Collectively, these data establish a mechanism by which peripheral immune factors can affect central nervous system function and behaviour in the context of stress. Targeting specific peripheral immune cell-derived matrix metalloproteinases could constitute novel therapeutic targets for stress-related neuropsychiatric disorders.

Social stress induces autoimmune responses against the brain

Clinical studies have revealed a high comorbidity between autoimmune diseases and psychiatric disorders, including major depressive disorder (MDD). However, the mechanisms connecting autoimmunity and depression remain unclear. Here, we aim to identify the processes by which stress impacts the adaptive immune system and the implications of such responses to depression. To examine this relationship, we analyzed antibody responses and autoimmunity in the chronic social defeat stress (CSDS) model in mice, and in clinical samples from patients with MDD. We show that socially stressed mice have elevated serum antibody concentrations. We also confirm that social stress leads to the expansion of specific T and B cell populations within the cervical lymph nodes, where brain-derived antigens are preferentially delivered. Sera from stress-susceptible (SUS) mice exhibited high reactivity against brain tissue, and brain-reactive immunoglobulin G (IgG) antibody levels positively correlated with social avoidance behavior. IgG antibody concentrations in the brain were significantly higher in SUS mice than in unstressed mice, and positively correlated with social avoidance. Similarly, in humans, increased peripheral levels of brain-reactive IgG antibodies were associated with increased anhedonia. In vivo assessment of IgG antibodies showed they largely accumulate around blood vessels in the brain only in SUS mice. B cell-depleted mice exhibited stress resilience following CSDS, confirming the contribution of antibody-producing cells to social avoidance behavior. This study provides mechanistic insights connecting stress-induced autoimmune reactions against the brain and stress susceptibility. Therapeutic strategies targeting autoimmune responses might aid in the treatment of patients with MDD featuring immune abnormalities.

Ketamine for Major Depressive Disorder

Major Depressive Disorder (MDD) is a leading cause of disability worldwide. Conventional antidepressant treatment is characterised by a significant time to onset of therapeutic action (approximately 2 weeks) and fails to achieve a stable remission of symptoms in one-third of subjects with MDD. In the last 20 years the discovery of antidepressant effects of the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine as a rapid acting (within hours) and sustained (up to 7 days) antidepressant has represented a major paradigm shift in the field.The present chapter reviews the pharmacology, safety, and efficacy of ketamine as a novel therapeutic agent for MDD and specifically for subjects who did not respond to conventional antidepressant (treatment resistant depression). The impact of ketamine on suicidal ideation, the availability of brain biomarkers of ketamine treatment response and the association of ketamine and psychotherapy are considered.

Preliminary Evaluation of a Web-Based International Journal Club for Ketamine in Psychiatric Disorders: Cross-Sectional Survey Study

BACKGROUND

The use of novel rapid-acting antidepressants for psychiatric disorders is expanding. The web-based Ketamine and Related Compounds International Journal Club (KIJC) was created during the COVID-19 pandemic by UK academic psychiatrists and trainees for interested global professionals to discuss papers related to the topic of ketamine for the treatment of psychiatric disorders. The KIJC aimed to facilitate bidirectional discussions, sharing of ideas, and networking among participants.

OBJECTIVE

The aim of this study is a preliminary evaluation of the journal club's format for satisfaction and impact after the first year of running.

METHODS

A website, email, and word of mouth were used for recruitment. The journal club was held twice per month using videoconferencing software in 3 parts: a 20-minute presentation, a 15-minute chaired question and answer session, and a 25-minute informal discussion with participants' cameras on. The first 2 parts were recorded and uploaded to the website alongside links to the corresponding papers. In total, 24 speakers presented from 8 countries, typically within 2 (SD 2) months of publication. The average attendance was 51 (SD 20) audience members, and there were 63 (SD 50) views of each subsequent recording. Two anonymous web-based cross-sectional surveys were conducted from November 2021 to February 2022, one for speakers and another for audience members, separately. Various survey statements, 14 for speakers and 12 for the audience, were categorized according to satisfaction and impact, alongside obtaining participants' primary career roles and requesting optional written feedback. Responses were compared between both groups and analyzed, including an inductive thematic analysis and a summary of lessons learned.

RESULTS

A total of 30 survey responses were obtained, demonstrating overall agreement with the statements. In total, 12 (50%) out of 24 speakers and 18 (35%) out of an average of 51 (SD 20) audience members regarded the journal club's format as satisfying and impactful. The majority (26/30, 87%) of respondents identified as clinicians (9/30, 30%), researchers (9/30, 30%), and clinician-researchers (8/30, 27%). Additionally, 11 (37%) of the 30 respondents also provided optional written feedback: 3 (10%) speakers and 8 (27%) audience members. From the written feedback, 5 main themes were derived: engagement with the journal club, desire for active participation, improving the platform, positive learning experiences, and suggestions for future sessions.

CONCLUSIONS

The journal club successfully reached its intended audience and developed into a web-based community. The majority of the participants were satisfied with the format and found it impactful. Overall, the journal club appears to be a valuable tool for knowledge sharing and community building in the field of ketamine use for the treatment of psychiatric disorders. A larger sample size and additional testing methods are required to support the generalizability of the journal club's format.

A Randomized Controlled Trial of Repeated Ketamine Administration for Chronic Posttraumatic Stress Disorder

Objective

Posttraumatic stress disorder (PTSD) is a chronic and disabling disorder, for which available pharmacotherapies have limited efficacy. The authors' previous proof-of-concept randomized controlled trial of single-dose intravenous ketamine infusion in individuals with PTSD showed significant and rapid PTSD symptom reduction 24 hours postinfusion. The present study is the first randomized controlled trial to test the efficacy and safety of repeated intravenous ketamine infusions for the treatment of chronic PTSD.

Methods

Individuals with chronic PTSD (N=30) were randomly assigned (1:1) to receive six infusions of ketamine (0.5 mg/kg) or midazolam (0.045 mg/kg) (psychoactive placebo control) over 2 consecutive weeks. Clinician-rated and self-report assessments were administered 24 hours after the first infusion and at weekly visits. The primary outcome measure was change in PTSD symptom severity, as assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), from baseline to 2 weeks (after completion of all infusions). Secondary outcome measures included the Impact of Event Scale-Revised, the Montgomery-Åsberg Depression Rating Scale (MADRS), and side effect measures.

Results

The ketamine group showed a significantly greater improvement in CAPS-5 and MADRS total scores than the midazolam group from baseline to week 2. At week 2, the mean CAPS-5 total score was 11.88 points (SE=3.96) lower in the ketamine group than in the midazolam group (d=1.13, 95% CI=0.36, 1.91). Sixty-seven percent of participants in the ketamine group were treatment responders, compared with 20% in the midazolam group. Among ketamine responders, the median time to loss of response was 27.5 days following the 2-week course of infusions. Ketamine infusions were well tolerated overall, without serious adverse events.

Conclusions

This randomized controlled trial provides the first evidence of efficacy of repeated ketamine infusions in reducing symptom severity in individuals with chronic PTSD. Further studies are warranted to understand ketamine's full potential as a treatment for chronic PTSD.Reprinted from Am J Psychiatry 2021; 178:193-202, with permission from American Psychiatric Association Publishing. Copyright © 2021.

Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression

BACKGROUND

Electroconvulsive therapy (ECT) and subanesthetic intravenous ketamine are both currently used for treatment-resistant major depression, but the comparative effectiveness of the two treatments remains uncertain.

METHODS

We conducted an open-label, randomized, noninferiority trial involving patients referred to ECT clinics for treatment-resistant major depression. Patients with treatment-resistant major depression without psychosis were recruited and assigned in a 1:1 ratio to receive ketamine or ECT. During an initial 3-week treatment phase, patients received either ECT three times per week or ketamine (0.5 mg per kilogram of body weight over 40 minutes) twice per week. The primary outcome was a response to treatment (i.e., a decrease of ≥50% from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report; scores range from 0 to 27, with higher scores indicating greater depression). The noninferiority margin was -10 percentage points. Secondary outcomes included scores on memory tests and patient-reported quality of life. After the initial treatment phase, the patients who had a response were followed over a 6-month period.

RESULTS

A total of 403 patients underwent randomization at five clinical sites; 200 patients were assigned to the ketamine group and 203 to the ECT group. After 38 patients had withdrawn before initiation of the assigned treatment, ketamine was administered to 195 patients and ECT to 170 patients. A total of 55.4% of the patients in the ketamine group and 41.2% of those in the ECT group had a response (difference, 14.2 percentage points; 95% confidence interval, 3.9 to 24.2; P<0.001 for the noninferiority of ketamine to ECT). ECT appeared to be associated with a decrease in memory recall after 3 weeks of treatment (mean [±SE] decrease in the T-score for delayed recall on the Hopkins Verbal Learning Test-Revised, -0.9±1.1 in the ketamine group vs. -9.7±1.2 in the ECT group; scores range from -300 to 200, with higher scores indicating better function) with gradual recovery during follow-up. Improvement in patient-reported quality-of-life was similar in the two trial groups. ECT was associated with musculoskeletal adverse effects, whereas ketamine was associated with dissociation.

CONCLUSIONS

Ketamine was noninferior to ECT as therapy for treatment-resistant major depression without psychosis. (Funded by the Patient-Centered Outcomes Research Institute; ELEKT-D ClinicalTrials.gov number, NCT03113968.).

Peripheral immune-derived matrix metalloproteinase promotes stress susceptibility

Psychosocial stress has profound effects on the body, including the peripheral immune system and the brain1,2. Although a large number of pre-clinical and clinical studies have linked peripheral immune system alterations to stress-related disorders such as major depressive disorder (MDD)3,4,5, the underlying mechanisms are not well understood. Here we show that a peripheral myeloid cell-specific proteinase, matrix metalloproteinase 8 (MMP8), is elevated in serum of subjects with MDD as well as in stress-susceptible (SUS) mice following chronic social defeat stress (CSDS). In mice, we show that this increase leads to alterations in extracellular space and neurophysiological changes in the nucleus accumbens (NAc), thereby altering social behaviour. Using a combination of mass cytometry and single-cell RNA-sequencing, we performed high-dimensional phenotyping of immune cells in circulation and brain and demonstrate that peripheral monocytes are strongly affected by stress. Both peripheral and brain-infiltrating monocytes of SUS mice showed increased Mmp8 expression following CSDS. We further demonstrate that peripheral MMP8 directly infiltrates the NAc parenchyma to control the ultrastructure of the extracellular space. Depleting MMP8 prevented stress-induced social avoidance behaviour and alterations in NAc neurophysiology and extracellular space. Collectively, these data establish a novel mechanism by which peripheral immune factors can affect central nervous system function and behaviour in the context of stress. Targeting specific peripheral immune cell-derived matrix metalloproteinases could constitute novel therapeutic targets for stress-related neuropsychiatric disorders.

A randomized pilot study of the prophylactic effect of ketamine on laboratory-induced stress in healthy adults

Background

Stress exposure is a key risk factor for the development of major depressive disorder and posttraumatic stress disorder. Enhancing stress resilience in at-risk populations could potentially protect against stress-induced disorders. The administration of ketamine one week prior to an acute stressor prevents the development of stress-induced depressive-like behavior in rodents. This study aimed to test if the prophylactic effect of ketamine against stress also applies to humans.

Methods

We conducted a double-blind, placebo-controlled study wherein 24 healthy subjects (n = 11 males) were randomized to receive either ketamine (0.5 mg/kg) or midazolam (0.045 mg/kg) intravenously one week prior to an acute stress [Trier Social Stress Test (TSST)]. The primary endpoint was the anxious-composed subscale of the Profile of Mood States Bipolar Scale (POMS-Bi) administered immediately after the TSST. Salivary and plasma cortisol and salivary alpha amylase were also measured at 15-min intervals for 60 min following the stressor, as proxies of hypothalamic pituitary adrenal (HPA) and sympathetic-adrenal-medullary (SAM) axis activity, respectively.

Results

Compared to the midazolam group (n = 12), the ketamine group (n = 12) showed a moderate to large (Cohen's d = 0.7) reduction in levels of anxiety immediately following stress, although this was not significant (p = 0.06). There was no effect of group on change in salivary cortisol or salivary alpha amylase following stress. We conducted a secondary analysis excluding one participant who did not show an expected correlation between plasma and salivary cortisol (n = 23, ketamine n = 11). In this subgroup, we observed a significant reduction in the level of salivary alpha amylase in the ketamine group compared to midazolam (Cohen's d = 0.7, p = 0.03). No formal adjustment for multiple testing was made as this is a pilot study and all secondary analyses are considered hypothesis-generating.

Conclusions

Ketamine was associated with a numeric reduction in TSST-induced anxiety, equivalent to a medium-to-large effect size. However, this did not reach statistical significance . In a subset of subjects, ketamine appeared to blunt SAM reactivity following an acute stressor. Future studies with larger sample size are required to further investigate the pro-resilient effect of ketamine.

Exaggerated amygdala response to threat and association with immune hyperactivity in depression

BACKGROUND

Depression is characterized by altered neurobiological responses to threat and inflammation may be involved in the development and maintenance of symptoms. However, the mechanistic pathways underlying the relationship between the neural underpinnings of threat, inflammation and depressive symptoms remain unknown.

METHODS

Twenty participants with major depressive disorder (MDD) and 17 healthy controls (HCs) completed this study. Peripheral blood mononuclear cells (PBMCs) were collected and stimulated ex vivo with lipopolysaccharide (LPS). We then measured a broad array of secreted proteins and performed principal component analysis to compute an aggregated immune reactivity score. Subjects completed a well-validated emotional face processing task during functional magnetic resonance imaging (fMRI). Amygdala activation was measured during perception of threat for the main contrast of interest: fear > happy face. Participants completed the Mood and Anxiety Symptom Questionnaire (MASQ) and the Perceived Stress Scale (PSS). Correlation analyses between amygdala activation, the aggregate immune score, and symptom were computed across groups. A mediation analysis was also performed across groups to further explore the relationship between these three variables.

RESULTS

In line with our hypotheses and with prior work, the MDD group showed greater amygdala activation in response to threat compared to the HC group [t35 = -2.038, p = 0.049]. Internal consistency of amygdala activation to threat was found to be moderate. Response to an ex vivo immune challenge was greater in MDD than HC based on the computed immune reactivity score (PC1; t35 = 2.674, p = 0.011). Amygdala activation was positively correlated with the immune score (r = 0.331, p = 0.045). Moreover, higher amygdala activation was associated with greater anxious arousal measured by the MASQ (r = 0.390, p = 0.017). Exploring the role of stress, we found that higher perceived stress was positively associated with both inflammatory response (r = 0.367, p = 0.026) and amygdala response to threat (r = 0.325, p = 0.050). Mediation analyses showed that perceived stress predicted anxious arousal, but neither inflammation nor amygdala activation fully accounted for the effect of perceived stress on anxious arousal.

CONCLUSION

These data highlight the potential importance of threat circuitry hyperactivation in MDD, consistent with prior reports. We found that higher levels of inflammatory biomarkers were associated with higher amygdala activation, which in turn was associated with anxious arousal. Future research utilizing larger sample sizes are needed to replicate these preliminary results.

The Potential of KCNQ Potassium Channel Openers as Novel Antidepressants

Major depressive disorder (MDD) is a leading cause of disability worldwide and less than one-third of patients with MDD achieve stable remission of symptoms, despite currently available treatments. Although MDD represents a serious health problem, a complete understanding of the neurobiological mechanisms underlying this condition continues to be elusive. Accumulating evidence from preclinical and animal studies provides support for the antidepressant potential of modulators of KCNQ voltage-gated potassium (K⁺) channels. KCNQ K⁺ channels, through regulation of neuronal excitability and activity, contribute to neurophysiological mechanisms underlying stress resilience, and represent potential targets of drug discovery for depression. The present article focuses on the pharmacology and efficacy of KCNQ2/3 K⁺ channel openers as novel therapeutic agents for depressive disorders from initial studies conducted on animal models showing depressive-like behaviors to recent work in humans that examines the potential for KCNQ2/3 channel modulators as novel antidepressants. Data from preclinical work suggest that KCNQ-type K⁺ channels are an active mediator of stress resilience and KCNQ2/3 K⁺ channel openers show antidepressant efficacy. Similarly, evidence from clinical trials conducted in patients with MDD using the KCNQ2/3 channel opener ezogabine (retigabine) showed significant improvements in depressive symptoms and anhedonia. Overall, KCNQ channel openers appear a promising target for the development of novel therapeutics for the treatment of psychiatric disorders and specifically for MDD.

Whole blood transcriptional signatures associated with rapid antidepressant response to ketamine in patients with treatment resistant depression

Ketamine has rapid and sustained antidepressant effects in patients with treatment-resistant depression (TRD). However, the underlying mechanisms of action are not well understood. There is increasing evidence that TRD is associated with a pro-inflammatory state and that ketamine may inhibit inflammatory processes. We thus investigated whole blood transcriptional profiles related to TRD and gene expression changes associated with treatment response to ketamine. Whole blood was collected at baseline (21 healthy controls [HC], 26 patients with TRD) and then again in patients with TRD 24 hours following a single intravenous infusion of ketamine (0.5 mg/kg). We performed RNA-sequencing and analyzed (a) baseline transcriptional profiles between patients with TRD and HC, (b) responders vs. non-responders before ketamine treatment, and (c) gene expression signatures associated with clinical improvement. At baseline, patients with TRD compared to HC showed a gene expression signature indicative of interferon signaling pathway activation. Prior to ketamine administration, the metabotropic glutamate receptor gene GRM2 and the ionotropic glutamate receptor gene GRIN2D were upregulated in responders compared to non-responders. Response to ketamine was associated with a distinct transcriptional signature, however, we did not observe gene expression changes indicative of an anti-inflammatory effect. Future studies are needed to determine the role of the peripheral immune system in the antidepressant effect of ketamine.

Ketamine as a prophylactic resilience-enhancing agent

Stress exposure is one of the greatest risk factors for psychiatric illnesses, including major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Enhancing stress resilience could potentially protect against the development of stress-induced psychiatric disorders, yet no resilience-enhancing pharmaceuticals have been developed to date. This review serves to consider the existing evidence for a potential pro-resilience effect of ketamine in rodents as well as the preliminary evidence of ketamine as a prophylactic treatment for postpartum depression (PPD) in humans. Several animal studies have demonstrated that ketamine administered 1 week prior to a stressor (e.g., chronic social defeat and learned helplessness) may protect against depressive-like behavior. A similar protective effect has been demonstrated against PTSD-like behavior following Contextual Fear Conditioning (CFC). Recent work has sought to explore if the administration of ketamine prevented the development of postpartum depression (PPD) in humans. Researchers administered ketamine immediately following caesarian-section and found a significantly reduced prevalence of PPD in the ketamine-treated groups compared to the control groups. Utilizing ketamine as a resilience-enhancing treatment may have unique applications, including leading to a deeper understanding of the neurobiological mechanism underlying resilience. Future trials aiming to translate and replicate these findings with humans are warranted.

Treatment-resistant depression: therapeutic options when first-line treatments fail

The Cochrane review by Davies et al aimed to address the lack of clarity on the risks and benefits of switching and augmentation strategies in the pharmacological treatment of treatment-resistant depression in adults who did not respond (or partially responded) to at least 4 weeks of antidepressant treatment at a recommended dose. This commentary assesses their review and their conclusion that augmenting the current antidepressant with mianserin or with an antipsychotic improves depressive symptoms over the short-term (8 to 12 weeks). Their results need to be treated with caution owing to the small body of evidence and individual comparisons supported by one, two or three studies, the limited evidence on long-term effects and the significant gaps in the literature (e.g. a lack of studies assessing dose increases).

Neuroimaging correlates and predictors of response to repeated-dose intravenous ketamine in PTSD: preliminary evidence

Promising initial data indicate that the glutamate N-methyl-D-aspartate (NMDA) receptor antagonist ketamine may be beneficial in post-traumatic stress disorder (PTSD). Here, we explore the neural correlates of ketamine-related changes in PTSD symptoms, using a rich battery of functional imaging data (two emotion-processing tasks and one task-free scan), collected from a subset of participants of a randomized clinical trial of repeated-dose intravenous ketamine vs midazolam (total N = 21). In a pre-registered analysis, we tested whether changes in an a priori set of imaging measures from a target neural circuit were predictive of improvement in PTSD symptoms, using leave-one-out cross-validated elastic-net regression models (regions of interest in the target circuit consisted of the dorsal and rostral anterior cingulate cortex, ventromedial prefrontal cortex, anterior hippocampus, anterior insula, and amygdala). Improvements in PTSD severity were associated with increased functional connectivity between the ventromedial prefrontal cortex (vmPFC) and amygdala during emotional face-viewing (change score retained in model with minimum predictive error in left-out subjects, standardized regression coefficient [β] = 2.90). This effect was stronger in participants who received ketamine compared to midazolam (interaction β = 0.86), and persisted following inclusion of concomitant change in depressive symptoms in the analysis model (β = 0.69). Improvement following ketamine was also predicted by decreased dorsal anterior cingulate activity during emotional conflict regulation, and increased task-free connectivity between the vmPFC and anterior insula (βs = -2.82, 0.60). Exploratory follow-up analysis via dynamic causal modelling revealed that whilst improvement in PTSD symptoms following either drug was associated with decreased excitatory modulation of amygdala→vmPFC connectivity during emotional face-viewing, increased top-down inhibition of the amygdala by the vmPFC was only observed in participants who improved under ketamine. Individuals with low prefrontal inhibition of amygdala responses to faces at baseline also showed greater improvements following ketamine treatment. These preliminary findings suggest that, specifically under ketamine, improvements in PTSD symptoms are accompanied by normalization of hypofrontal control over amygdala responses to social signals of threat.

Peripheral immune cell reactivity and neural response to reward in patients with depression and anhedonia

Increased levels of peripheral cytokines have been previously associated with depression in preclinical and clinical research. Although the precise nature of peripheral immune dysfunction in depression remains unclear, evidence from animal studies points towards a dysregulated response of peripheral leukocytes as a risk factor for stress susceptibility. This study examined dynamic release of inflammatory blood factors from peripheral blood mononuclear cells (PBMC) in depressed patients and associations with neural and behavioral measures of reward processing. Thirty unmedicated patients meeting criteria for unipolar depressive disorder and 21 healthy control volunteers were enrolled. PBMCs were isolated from whole blood and stimulated ex vivo with lipopolysaccharide (LPS). Olink multiplex assay was used to analyze a large panel of inflammatory proteins. Participants completed functional magnetic resonance imaging with an incentive flanker task to probe neural responses to reward anticipation, as well as clinical measures of anhedonia and pleasure including the Temporal Experience of Pleasure Scale (TEPS) and the Snaith-Hamilton Pleasure Scale (SHAPS). LPS stimulation revealed larger increases in immune factors in depressed compared to healthy subjects using an aggregate immune score (t₄₉= 2.83, p = 0.007). Higher peripheral immune score was associated with reduced neural responses to reward anticipation within the ventral striatum (VS) (r = -0.39, p = 0.01), and with reduced anticipation of pleasure as measured with the TEPS anticipatory sub-score (r = -0.318, p = 0.023). Our study provides new evidence suggesting that dynamic hyper-reactivity of peripheral leukocytes in depressed patients is associated with blunted activation of the brain reward system and lower subjective anticipation of pleasure.

POS1315 USEFULNESS OF SYNOVIAL BIOPSY IN THE DIFFERENTIAL DIAGNOSIS AND AS POSSIBLE PREDICTOR OF RESPONSE TO TREATMENT IN JUVENILE IDIOPATHIC ARTHRITIS

Background:

While synovial biopsy is an invasive procedure and is not required for the diagnosis of juvenile idiopathic arthritis (JIA), it may be useful in doubtful cases.

Objectives:

Aims of the study were i.to verify the role of synovial biopsy in the differential diagnosis of JIA and ii. to review the pathology slides in order to evaluate possible associations of a histologic pattern with response to treatment.

Methods:

We reviewed data from medical records of patients under the age of 18 years who underwent a synovial biopsy requested by our Pediatric Rheumatology Unit over the last 10 years. We collected information on demographic, clinical, laboratory, radiological, histopathological characteristics, as well as treatment response (in particular, remission at the last visit and number of examination, number of biologic drugs used). Among variables in the histologic score, number of layers in the synovial lining and inflammatory infiltrate (0-5) were compared to clinical status at last visit. Potential differences in variables between responders and non responders were assessed by unpaired t-test or non-parametric Mann-Whitney test, as appropriate.

Results:

We identified 64 patients (40F, 24M) with a median age at disease onset of 9 years (range 1-15) and a median follow-up time of 161 months (range 8-1160). We recognized two groups of interest: patients with a known JIA diagnosis (28/64) and patients with unknown diagnosis (36/64) at the moment of synovial biopsy. In the group with known JIA, most underwent the procedure during orthopedic surgery, and in all cases the histology was consistent with JIA. Among the unknown diagnosis group, in 19 cases results were consistent with a chronic synovitis, while among the other 17 histology could lead to a diagnosis of other conditions in 6 cases (foreign body and villonodular synovitis n=2 each, sarcoidosis and osteochondromatosis n=1 each). In the remaining 11 the final diagnoses were varied (mostly genetic forms eg skeletal dysplasia, CACP, Thiemann disease).

Between the two groups we identified 46 patients with a definite JIA diagnosis. At the last follow-up visit 29 of them were in clinical remission, albeit on medication. The remaining 17 had a severe course of disease, with persistent activity and use of at least two biologic drugs. In 26 cases we could evaluate the correlation between status at last visit and number of layers/inflammatory infiltrate, but no statistical significant correlation was found.

Conclusion:

Despite its limited use nowadays, synovial biopsy may still be a useful tool in patients whose diagnosis is unclear. In our study, while it confirmed the suspicion in most cases, in other instances it allowed the diagnosis of rare conditions that would have been otherwise missed. No association between disease course and histological features in a small JIA cohort was found. We are currently expanding the study with a larger series.

Disclosure of Interests:

None declared

POS1308 PREDICTORS OF DISEASE PROGRESSION IN A MONOCENTRIC COHORT OF 100 PATIENTS WITH CHILDHOOD-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Childhood-onset systemic lupus erythematosus (cSLE) accounts for 10-20% of overall cases, usually presenting in early adolescence. SLE in children is characterized by a severe clinical course.

Objectives:

This study describes the evolution of clinical manifestations of cSLE, with the aims of i) identifying biomarkers predictive of disease progression and ii) assessing the effects of treatment on disease course.

Methods:

Laboratory and clinical data of cSLE patients followed in our Paediatric Rheumatology Unit were retrospectively collected at diagnosis and during follow-up. Continuous data were expressed as median (interquartile range [IQR]) and categorical data as percentages. The association between categorical variables was assessed by chi-squared test, the correlation between variables was tested by Pearson’s test. Univariate linear regression analyses were performed to investigate the relationship between the rate of new disease manifestations at follow-up and candidate predictors. Statistical analysis was performed using GraphPadPrism v6. P values <0.05 were regarded statistically significant.

Results:

One-hundred patients (89% of female gender) with cSLE were included in this study, with a median age at disease onset of 13 years (10.5-15). Clinical details are presented in Table 1. Complement levels were reduced in 71 patients (C3 in 62 and C4 in 65). At a median follow-up of 118 months (57-239), the disease progressed in 93 patients, with a median of two new manifestations per patient (1-3). No correlation emerged between the number of new disease manifestations and both age at diagnosis and disease duration. Among serological biomarkers, a reduction in complement fractions at diagnosis emerged as the only predictor of new clinical manifestations due to cSLE (p=0.013 for low C3 and p=0.0004 for low C4). Among the several different pharmacological tools, hydroxychloroquine (HCQ, p=0.021, 95% confidence interval (CI) 0.0084-0.1007), azathioprine (AZA, p=0.0217, 95%CI 0.013-0.1703) and cyclophosphamide (CTX, p=0.0305, 95%CI 0.013-0.170) were identified as protective.

At follow-up, patients most commonly developed new haematological and cutaneous involvements, which were diagnosed in 43 and 11 patients, respectively. A trend towards statistical significance emerged for low C4 levels to predict new haematological involvement at follow-up (p=0.064, chi-squared: 3.42). Differently, positivity for antibodies against dsDNA emerged as the only predictor of the onset of cutaneous manifestations during follow-up (p=0.022, chi-squared: 7.62). Low C3 levels approached statistical significance in the prediction of skin involvement (p=0.058, chi-squared 5.68).

Conclusion:

According to the data from our monocentric cohort of 100 patients, complement and anti-dsDNA antibodies are the most accurate tools to predict disease progression in cSLE. HCQ, AZA and CTX reduce the rate of disease progression.

Table 1.

Clinical manifestations, laboratory features and treatment details of recruited patients at diagnosis.

Number of patientsSkin manifestations44Haematological involvement51Lupus nephritis16Musculoskeletal involvement72Serositis14Neuropsychiatric involvement6Anti-nuclear antibodies90Anti-Ro antibodies11Anti-Sm antibodies13Anti-dsDNA antibodies67Anti-phospholipid antibodies29Hydroxychloroquine89Azathioprine40Cyclophosphosphamide29Micophenolate mofetil13Cyclosporine15Rituximab1Belimumab2Steroids91

Disclosure of Interests:

None declared

POS1307 ULTRASOUND-DETECTED TENOSYNOVITIS IN ANKLES WITH CLINICALLY ACTIVE DISEASE OF CHILDREN WITH NEW-ONSET JUVENILE IDIOPATHIC ARTHRITIS DOES NOT AFFECT THE CHANCE TO ACHIEVE DISEASE REMISSION

Background:

The ankle is one of the most commonly affected sites in juvenile idiopathic arthritis (JIA). This region has a complex anatomical structure owing to the presence of multiple joint recesses and surrounding tendons. While the prognostic value of ultrasound (US)-detected arthritis has been investigated in recent studies, the role of tenosynovitis in JIA remains still unexplored.

Objectives:

To investigate: 1) US features of ankle involvement in JIA at disease onset; 2) the predictive value of US-detected tenosynovitis in ankles with clinically active disease of children with new-onset JIA.

Methods:

The clinical charts of all consecutive patients with new-onset JIA between May 2018 and January 2020 at study centres (Policlinico and G.Pini Hospitals of Milan) and with clinically active ankle disease among the joints affected were reviewed retrospectively. Data on ankle US assessment were retrieved and patients were then stratified as follows: 1) patients with detection on US of isolated arthritis in at least one of the joint recesses of the ankle region; 2) patients with detection on US of tenosynovitis in at least one of the tendon compartments of the ankle irrespective of the presence of concomitant arthritis. For each of these two categories, estimation of patients who were able to achieve clinical disease remission at 12 months since disease onset was evaluated.

Results:

Twenty-seven new-onset JIA patients were found to have clinical involvement of the ankle among the joints affected. Nine of them (33.3%) showed on US isolated arthritis of the ankle, whereas US-detected tenosynovitis was found in 18 (66.7%) patients. The amount of patients who were able to achieve disease remission at 12-months was the same (66.7%) for both patients with and without US-detected tenosynovitis in the ankle (12/18 and 6/9 patients, respectively). In patients with US-detected tenosynovitis and clinical disease remission at 12 months, the lateral tendon compartment (LTC) was the tendon site more frequently affected by pathology (75.0%). Patients with US-detected tenosynovitis that did not achieve clinical disease remission at follow-up had the highest frequency of tendon pathology on US in the medial tendon compartment (MTC) (83.3%). The anterior tendon compartment was the less frequently affected tendon compartment of the ankle in all patients (33.3% in both patients with and without clinical remission of disease at the 12-months follow-up visit).

Conclusion:

US-detected tenosynovitis of the ankle is a common finding in patients with new-onset JIA with clinically ankle disease activity and is more frequent than the detection on US of isolated arthritis. The MTC and LTC are the tendon compartments more commonly affected on US. The detection on US of tenosynovitis at disease onset in ankles with clinical disease activity did not seem to affect the change to achieve the overall clinical disease remission compared to patients without tendon pathology but with joint disease in the ankle region.

Disclosure of Interests:

None declared

Impact of the KCNQ2/3 Channel Opener Ezogabine on Reward Circuit Activity and Clinical Symptoms in Depression: Results From a Randomized Controlled Trial

OBJECTIVE

Preclinical studies point to the KCNQ2/3 potassium channel as a novel target for the treatment of depression and anhedonia, a reduced ability to experience pleasure. The authors conducted the first randomized placebo-controlled trial testing the effect of the KCNQ2/3 positive modulator ezogabine on reward circuit activity and clinical outcomes in patients with depression.

METHODS

Depressed individuals (N=45) with elevated levels of anhedonia were assigned to a 5-week treatment period with ezogabine (900 mg/day; N=21) or placebo (N=24). Participants underwent functional MRI during a reward flanker task at baseline and following treatment. Clinical measures of depression and anhedonia were collected at weekly visits. The primary endpoint was the change from baseline to week 5 in ventral striatum activation during reward anticipation. Secondary endpoints included depression and anhedonia severity as measured using the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Snaith-Hamilton Pleasure Scale (SHAPS), respectively.

RESULTS

The study did not meet its primary neuroimaging endpoint. Participants in the ezogabine group showed a numerical increase in ventral striatum response to reward anticipation following treatment compared with participants in the placebo group from baseline to week 5. Compared with placebo, ezogabine was associated with a significantly larger improvement in MADRS and SHAPS scores and other clinical endpoints. Ezogabine was well tolerated, and no serious adverse events occurred.

CONCLUSIONS

The study did not meet its primary neuroimaging endpoint, although the effect of treatment was significant on several secondary clinical endpoints. In aggregate, the findings may suggest that future studies of the KCNQ2/3 channel as a novel treatment target for depression and anhedonia are warranted.

A Randomized Controlled Trial of Repeated Ketamine Administration for Chronic Posttraumatic Stress Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a chronic and disabling disorder, for which available pharmacotherapies have limited efficacy. The authors' previous proof-of-concept randomized controlled trial of single-dose intravenous ketamine infusion in individuals with PTSD showed significant and rapid PTSD symptom reduction 24 hours postinfusion. The present study is the first randomized controlled trial to test the efficacy and safety of repeated intravenous ketamine infusions for the treatment of chronic PTSD.

METHODS

Individuals with chronic PTSD (N=30) were randomly assigned (1:1) to receive six infusions of ketamine (0.5 mg/kg) or midazolam (0.045 mg/kg) (psychoactive placebo control) over 2 consecutive weeks. Clinician-rated and self-report assessments were administered 24 hours after the first infusion and at weekly visits. The primary outcome measure was change in PTSD symptom severity, as assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), from baseline to 2 weeks (after completion of all infusions). Secondary outcome measures included the Impact of Event Scale-Revised, the Montgomery-Åsberg Depression Rating Scale (MADRS), and side effect measures.

RESULTS

The ketamine group showed a significantly greater improvement in CAPS-5 and MADRS total scores than the midazolam group from baseline to week 2. At week 2, the mean CAPS-5 total score was 11.88 points (SE=3.96) lower in the ketamine group than in the midazolam group (d=1.13, 95% CI=0.36, 1.91). Sixty-seven percent of participants in the ketamine group were treatment responders, compared with 20% in the midazolam group. Among ketamine responders, the median time to loss of response was 27.5 days following the 2-week course of infusions. Ketamine infusions were well tolerated overall, without serious adverse events.

CONCLUSIONS

This randomized controlled trial provides the first evidence of efficacy of repeated ketamine infusions in reducing symptom severity in individuals with chronic PTSD. Further studies are warranted to understand ketamine's full potential as a treatment for chronic PTSD.

THU0454 SOMATIC SYMPTOMS IN FIBROMYALGIA AND THEIR CORRELATION WITH DRUG TREATMENT

Background:

Drug treatment in fibromyalgia (FM) is often disappointingly ineffective, and there are currently very few data to support therapeutic choices towards a personalized medicine approach.

Objectives:

To evaluate the prevalence of selected somatic symptoms in FM, and to study their relationship with drug treatments.

Methods:

The study population consisted of 526 patients (471 F 55 M, mean age 47.31±11.33 yrs) affected by FM not associated with other rheumatic diseases. All patients were required to compile a questionnaire reporting the presence of 42 somatic symptoms -as suggested (1) – in the last 7 days. Drug usage was assessed by interview.

Results:

On average, patients reported the presence of 17.04±6.68 symptoms (range 4-35), with ample variations in the prevalence of different symptoms (Fig. 1), ranging from over 95% (fatigue and muscle pain) to less than 10 %, seizures being reported by only 2 patients (0.4%). 31.1% of patients were not taking any drug for their FM. The most frequently used drugs were analgesics (ANA, 41.7%) followed by benzodiazepines (BD, 29.1%), SSRIs (16%), gabapentinoids (GABA, 14,4%), and NSRI (14.3%) (Fig. 2). Different drugs were associated with a different spectrum of somatic symptoms: as compared to non users, BD users reported a significantly higher (p< 0.05 by chi-square test) prevalence of irritable bowel (65.4% vs 52.3%), fatigue (98.7% vs 94.9%), thinking difficulties (78.4% vs 68.5%), muscle weakness (94.1% vs 81.7%), abdominal pain (55.6% vs 43.9%), insomnia (73.9% vs 56.6%), depression (63.4 % vs 37.2%), constipation (60.1% vs 42.9%), pain in upper abdomen (50.3% vs 40.2%), nausea (53.6% vs 38.3%), nervousness (71.9% vs 61.5%), chest pain (49.0 vs 37.75), blurred vision (65.4% vs 53.6%), dry mouth (72.5% vs 52.3%), itching (56.2% vs 44.5%), vomiting (13.7% vs 7.8%), taste change (22.2% vs 12.7%), dry eyes (55.6% vs 41.0%), breath shortness (56.9% vs 47.7%), appetite loss (33.3% vs 19.7%), painful urination (15.0% vs 8.4%), and bladder spasms (18.3% vs 8.6%). NRSI users reported a significantly higher prevalence of thinking difficulties, constipation, blurred vision, dry mouth, wheezing, dry eyes, easy bruising. Among GABA users, there was a higher prevalence of thinking difficulties, numbness, insomnia, constipation, nausea, dry mouth, dry eyes, appetite loss, sun sensitivity, easy bruising, and bladder spasms. In no cases a higher prevalence of symptoms was recorded in drug non users vs users.

Conclusion:

The usage of different drugs in FM is associated with different somatic symptoms. The higher prevalence of symptoms in drug users as compared to non users raises serious questions concerning the opportunity or the appropriateness of drug selection in FM.

References:

[1]Wolfe F., et al. Arthritis Care Res (Hoboken). 2010 May;62(5):600-10

Disclosure of Interests: :

None declared

Effects of the KCNQ channel opener ezogabine on functional connectivity of the ventral striatum and clinical symptoms in patients with major depressive disorder

Major depressive disorder (MDD) is a leading cause of disability worldwide, yet current treatment strategies remain limited in their mechanistic diversity. Recent evidence has highlighted a promising novel pharmaceutical target-the KCNQ-type potassium channel-for the treatment of depressive disorders, which may exert a therapeutic effect via functional changes within the brain reward system, including the ventral striatum. The current study assessed the effects of the KCNQ channel opener ezogabine (also known as retigabine) on reward circuitry and clinical symptoms in patients with MDD. Eighteen medication-free individuals with MDD currently in a major depressive episode were enrolled in an open-label study and received ezogabine up to 900 mg/day orally over the course of 10 weeks. Resting-state functional magnetic resonance imaging data were collected at baseline and posttreatment to examine brain reward circuitry. Reward learning was measured using a computerized probabilistic reward task. After treatment with ezogabine, subjects exhibited a significant reduction of depressive symptoms (Montgomery-Asberg Depression Rating Scale score change: -13.7 ± 9.7, p < 0.001, d = 2.08) and anhedonic symptoms (Snaith-Hamilton Pleasure Scale score change: -6.1 ± 5.3, p < 0.001, d = 1.00), which remained significant even after controlling for overall depression severity. Improvement in depression was associated with decreased functional connectivity between the ventral caudate and clusters within the mid-cingulate cortex and posterior cingulate cortex (n = 14, voxel-wise p < 0.005). In addition, a subgroup of patients tested with a probabilistic reward task (n = 9) showed increased reward learning following treatment. These findings highlight the KCNQ-type potassium channel as a promising target for future drug discovery efforts in mood disorders.

Ultra-high field MRI reveals mood-related circuit disturbances in depression: a comparison between 3-Tesla and 7-Tesla

Ultra-high field 7-Tesla (7 T) MRI has the potential to advance our understanding of neuropsychiatric disorders, including major depressive disorder (MDD). To date, few studies have quantified the advantage of resting state functional MRI (fMRI) at 7 T compared to 3-Tesla (3 T). We conducted a series of experiments that demonstrate the improvement in temporal signal-to-noise ratio (TSNR) of a multi-echo multi-band fMRI protocol with ultra-high field 7 T MRI, compared to a similar protocol using 3 T MRI in healthy controls (HC). We also directly tested the enhancement in ultra-high field 7 T fMRI signal power by examining the ventral tegmental area (VTA), a small midbrain structure that is critical to the expected neuropathology of MDD but difficult to discern with standard 3 T MRI. We demonstrate up to 300% improvement in TSNR and resting state functional connectivity coefficients provided by ultra-high field 7 T fMRI compared to 3 T, indicating enhanced power for detection of functional neural architecture. A multi-echo based acquisition protocol and signal denoising pipeline afforded greater gain in signal power compared to classic acquisition and denoising pipelines. Furthermore, ultra-high field fMRI revealed mood-related neurocircuit disturbances in patients with MDD compared to HC, which were not detectable with 3 T fMRI. Ultra-high field 7 T fMRI may provide an effective tool for studying functional neural architecture relevant to MDD and other neuropsychiatric disorders.

A Randomized Dose-Ranging Study of Neuropeptide Y in Patients with Posttraumatic Stress Disorder

BACKGROUND

Anxiety and trauma-related disorders are among the most prevalent and disabling medical conditions in the United States, and posttraumatic stress disorder in particular exacts a tremendous public health toll. We examined the tolerability and anxiolytic efficacy of neuropeptide Y administered via an intranasal route in patients with posttraumatic stress disorder.

METHODS

Twenty-six individuals were randomized in a cross-over, single ascending dose study into 1 of 5 cohorts: 1.4 mg (n=3), 2.8 mg (n=6), 4.6 mg (n=5), 6.8 mg (n=6), and 9.6 mg (n=6). Each individual was dosed with neuropeptide Y or placebo on separate treatment days 1 week apart in random order under double-blind conditions. Assessments were conducted at baseline and following a trauma script symptom provocation procedure subsequent to dosing. Occurrence of adverse events represented the primary tolerability outcome. The difference between treatment conditions on anxiety as measured by the Beck Anxiety Inventory and the State-Trait Anxiety Inventory immediately following the trauma script represented efficacy outcomes.

RESULTS

Twenty-four individuals completed both treatment days. Neuropeptide Y was well tolerated up to and including the highest dose. There was a significant interaction between treatment and dose; higher doses of neuropeptide Y were associated with a greater treatment effect, favoring neuropeptide Y over placebo on Beck Anxiety Inventory score (F1,20=4.95, P=.038). There was no significant interaction for State-Trait Anxiety Inventory score.

CONCLUSIONS

Our study suggests that a single dose of neuropeptide Y is well tolerated up to 9.6 mg and may be associated with anxiolytic effects. Future studies exploring the safety and efficacy of neuropeptide Y in stress-related disorders are warranted. The reported study is registered at: http://clinicaltrials.gov (ID: NCT01533519).

Altered peripheral immune profiles in treatment-resistant depression: response to ketamine and prediction of treatment outcome

A subset of patients with depression have elevated levels of inflammatory cytokines, and some studies demonstrate interaction between inflammatory factors and treatment outcome. However, most studies focus on only a narrow subset of factors in a patient sample. In the current study, we analyzed broad immune profiles in blood from patients with treatment-resistant depression (TRD) at baseline and following treatment with the glutamate modulator ketamine. Serum was analyzed from 26 healthy control and 33 actively depressed TRD patients free of antidepressant medication, and matched for age, sex and body mass index. All subjects provided baseline blood samples, and TRD subjects had additional blood draw at 4 and 24 h following intravenous infusion of ketamine (0.5 mg kg^-1). Samples underwent multiplex analysis of 41 cytokines, chemokines and growth factors using quantitative immunoassay technology. Our a priori hypothesis was that TRD patients would show elevations in canonical pro-inflammatory cytokines; analyses demonstrated significant elevation of the pro-inflammatory cytokine interleukin-6. Further exploratory analyses revealed significant regulation of four additional soluble factors in patients with TRD. Several cytokines showed transient changes in level after ketamine, but none correlated with treatment response. Low pretreatment levels of fibroblast growth factor 2 were associated with ketamine treatment response. In sum, we found that patients with TRD demonstrate a unique pattern of increased inflammatory mediators, chemokines and colony-stimulating factors, providing support for the immune hypothesis of TRD. These patterns suggest novel treatment targets for the subset of patients with TRD who evidence dysregulated immune functioning.

Current Status of Ketamine and Related Therapies for Mood and Anxiety Disorders

Major Depressive Disorder (MDD) is a leading cause of disability worldwide. Despite a plethora of established treatments, less than one-third of individuals with MDD achieve stable remission of symptoms. Given limited efficacy and significant lag time to onset of therapeutic action among conventional antidepressants, interest has shifted to treatments that act outside of the monoamine neurotransmitter systems (e.g., serotonin, norepinephrine, and dopamine). Preclinical and clinical research on the glutamate system has been particularly promising in this regard. Accumulating evidence shows support for a rapid antidepressant effect of ketamine - a glutamate N-methyl-d-aspartate (NMDA) receptor antagonist. The present article reviews the pharmacology, safety, and efficacy of ketamine as a novel therapeutic agent for mood and anxiety disorders. The majority of clinical trials using ketamine have been conducted in patients with treatment resistant forms of MDD; recent work has begun to examine ketamine in bipolar disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. The impact of ketamine on suicidal ideation is also discussed. The current status and prospects for the identification of human biomarkers of ketamine treatment response and hurdles to treatment development are considered. We conclude by considering modulators of the glutamate system other than ketamine currently in development as potential novel treatment strategies for mood and anxiety disorders.

Partial androgen deficiency, depression, and testosterone supplementation in aging men

The aim of this review was to summarize current knowledge on the correlation between depressive symptoms with a syndrome called partial androgen deficiency of the aging male (PADAM) and on the potential benefits of testosterone (T) treatment on mood. Despite, the causative nature of the relationship between low T levels and depression is uncertain, many hypogonadal men suffer from depression and vice versa several depressed patients are affected by hypogonadism. Supplementation with testosterone failed to show sound evidence of effectiveness in the treatment of depression. Nevertheless, testosterone supplementation has proved to be effective on some domains significant for the quality of life of aged patients with PADAM (sexual function and cognitive functions, muscular strengths).

Equinus foot classification in cerebral palsy: an agreement study between clinical and gait analysis assessment

BACKGROUND

Excessive ankle plantar flexion (equinus foot) is a common problem in cerebral palsy (CP) and several treatment options can be considered depending on the equinus type. Few attempts have been made to classify different forms of equinus foot for specific treatment.

AIM

This study is aimed at defining equinus foot types in CP patients according to the Ferrari classification, integrating clinical and instrumental assessments. The hypothesis is that clinical differentiation of equinus foot can be evidenced by recurrent anomalies identifiable through gait analysis (GA), which can make the assessment, usually based only on clinician semeiotics, more objective.

DESIGN

Clinical and instrumental assessments were performed separately by a senior CP physiatrist and a senior GA physiatrist, the latter was blind to the clinical diagnosis of equinus type.

SETTING

Outpatients

POPULATION

Twenty patients, 16 diplegics and 4 hemiplegics (mean age 11 years, SD 4 years 11 months).

METHODS

Clinical assessment by means of Modified Ashworth Scale, Gross Motor Function Measure (GMFM), Observational Gait Analysis (OGA), and measurement of lower limb muscle strength by dynamometer were used to classify the equinus type. Gait analysis assessed the kinematics and EMG of affected lower limbs.

RESULTS

Ten different equinus types were identified. Since various forms of equinus can be present in the same patient, we were able to classify a total of 61 types of equinus in 36 feet. Substantial agreement was found between Clinical and Gait Analysis equinus assignment matched in 50 out of 61 types (Index of agreement with Fleiss' Kappa 79.3 % ). In some case only Gait Analysis was able to identify the equinus type, while in others it did not confirm clinical assignment.

CONCLUSION

Gait analysis is able to distinguish different equinus types according to Ferrari classification, making the clinical decision less arbitrary.

CLINICAL REHABILITATION IMPACT

Correct objective diagnosis of equinus foot in CP patients is of paramount importance when choosing suitable rehabilitative interventions.

Role of comorbidities in a cohort of patients with COPD undergoing pulmonary rehabilitation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is often associated with other chronic diseases. These patients are often admitted to hospital based rehabilitation programmes.

OBJECTIVES

To determine the prevalence of chronic comorbidities in patients with COPD undergoing pulmonary rehabilitation and to assess their influence on outcome.

DESIGN

Observational retrospective cohort study.

SETTING

A single rehabilitation centre.

PATIENTS

2962 inpatients and outpatients with COPD (73% male, aged 71 (SD 8) years, forced expiratory volume in 1 s (FEV(1)) 49.3 (SD 14.8)% of predicted), graded 0, 1 or >/=2 according to the comorbidity categories and included in a pulmonary rehabilitation programme.

MEASUREMENTS

The authors analysed the number of self-reported comorbidities and recorded the Charlson Index. They then calculated the percentage of patients with a predefined positive response to pulmonary rehabilitation (minimum clinically important difference (MCID)), as measured by improvement in exercise tolerance (6 min walking distance test (6MWD)), dyspnoea (Medical Research Council scale) and/or health related quality of life (St George's Respiratory Questionnaire (SGRQ)).

RESULTS

51% of the patients reported at least one chronic comorbidity added to COPD. Metabolic (systemic hypertension, diabetes and/or dyslipidaemia) and heart diseases (chronic heart failure and/or coronary heart disease) were the most frequently reported comorbid combinations (61% and 24%, respectively) among the overall diseases associated with COPD. The prevalence of patients with MCID was different across the comorbidity categories and outcomes. In a multiple categorical logistic regression model, the Charlson Index (OR 0.72 (96% CI 0.54 to 0.98) and 0.51 (96% CI 0.38 to 0.68) vs 6MWD and SGRQ, respectively), metabolic diseases (OR 0.57 (96% CI 0.49 to 0.67) vs 6MWD) and heart diseases (OR 0.67 (96% CI 0.55 to 0.83) vs SGRQ) reduced the probability to improve outcomes of rehabilitation.

CONCLUSIONS

Most patients with COPD undergoing pulmonary rehabilitation have one or more comorbidities. Despite the fact that the presence of comorbidities does not preclude access to rehabilitation, the improvement in exercise tolerance and quality of life after rehabilitation may be reduced depending on the comorbidity.

Perspectives that influence action plans for chronic obstructive pulmonary disease

BACKGROUND

Prompt treatment of acute exacerbations (AEs) in chronic obstructive pulmonary disease (COPD) improves quality of life and reduces the use of health care resources. Although patient self-management through an individualized action plan (AP) can help with early initiation of therapy, its use is critically dependent on the patient recognizing the features of an exacerbation.

OBJECTIVE

To describe COPD patients' experiences with AEs, as well as health care professionals' (HCPs') attitudes toward the provision of an AP as part of self-management education.

METHODS

Thirty-two patients with moderate to severe COPD who recently experienced at least one AE, and 22 HCPs with experience in the management of COPD, were interviewed.

RESULTS

The most common symptoms and signs associated with an AE were difficulty breathing (84%), fatigue (81%), cold symptoms (59%), changes in sputum colour (53%) or amount (47%), and cough (44%). The main precipitants identified were environmental triggers (47%), infective agents (31%), excessive activities (25%), emotional factors (16%) and changes in medications (9%). Strategies for dyspnea relief included increasing medications (72%), resting (56%), avoiding exposure to environmental triggers (41%) and performing breathing exercises (31%). Patients supported the use of an AP and recommended that it be individualized for symptoms and triggers, and that it should also include strategies for addressing anxiety and depression. HCPs also supported the use of an individualized AP and recommended that it be regularly revisited, depending on the patient's disease severity.

CONCLUSIONS

Patients' experiences with AEs do not always conform to a standard medical definition. Therefore, an understanding of their experience is of value in the design of an individualized AP. HCPs support the use of an AP that emphasizes self-management of exacerbations as well as general COPD management.

Rehabilitation of COPD patients: which training modality

Non pharmacological therapy has been gaining more interest and has been evolving rapidly over the last decade as an essential part of therapy for COPD patients. Pulmonary Rehabilitation (PR), the most important non pharmacological treatment in patients with COPD, has a primary goal: to achieve the highest possible level of individual exercise tolerance, thus reducing the primary and/or secondary health care utilisation. The aim of the present review is to focus the role of exercise training in these patients as well as to address the question on which training methods are the most beneficial. We have therefore undertaken a MEDLINE-based search including the terms: pulmonary rehabilitation, exercise, lung disease/obstructive. Several strategies based on endurance or strength training are nowadays implemented during PR programmes in order to maximise the benefits for each patient. The impaired function of ambulation muscles causing breathlessness as one of the more frequent symptoms in many COPD, suggests that training the lower extremities is the most important goal to achieve during pulmonary rehabilitation of these patients. On the other hand, as muscle strength appears to be an independent contributor to survival and utilisation of health care resources, it seems largely justified also to include this further modality in the PR program of these patients. In conclusion, both modalities are effective and useful for COPD patients. However, whether resistance training should be administered to all COPD and which is the optimal length of strength training still needs to be elucidated.