Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Caring for carers: A virtual psychosocial supervision intervention to improve the quality and sustainability of mental health and psychosocial support in humanitarian contexts

Introduction

Mental health and psychosocial support (MHPSS) staff in humanitarian settings have limited access to clinical supervision and are at high risk of experiencing burnout. We previously piloted an online, peer-supervision program for MHPSS professionals working with displaced Rohingya (Bangladesh) and Syrian (Turkey and Northwest Syria) communities. Pilot evaluations demonstrated that online, peer-supervision is feasible, low-cost, and acceptable to MHPSS practitioners in humanitarian settings.

Objectives

This project will determine the impact of online supervision on i) the wellbeing and burnout levels of local MHPSS practitioners, and ii) practitioner technical skills to improve beneficiary perceived service satisfaction, acceptability, and appropriateness.

Methods

MHPSS practitioners in two contexts (Bangladesh and Turkey/Northwest Syria) will participate in 90-minute group-based online supervision, fortnightly for six months. Sessions will be run on zoom and will be co-facilitated by MHPSS practitioners and in-country research assistants. A quasi-experimental multiple-baseline design will enable a quantitative comparison of practitioner and beneficiary outcomes between control periods (12-months) and the intervention. Outcomes to be assessed include the Kessler-6, Harvard Trauma Questionnaire and Copenhagen Burnout Inventory and Client Satisfaction Questionnaire-8.

Results

A total of 80 MHPSS practitioners will complete 24 monthly online assessments from May 2022. Concurrently, 1920 people receiving MHPSS services will be randomly selected for post-session interviews (24 per practitioner).

Conclusions

This study will determine the impact of an online, peer-supervision program for MHPSS practitioners in humanitarian settings. Results from the baseline assessments, pilot evaluation, and theory of change model will be presented.

Disclosure

No significant relationships.

Association between physical activity and leisure-time sedentary behavior among 140,808 adolescents aged 12 to 15 from 47 low- and middle-income countries

OBJECTIVES

Data from high-income countries (HICs) indicate that sedentary behavior is negatively associated with moderate-to-vigorous physical activity (MVPA) in young people. We examined associations between leisure-time sedentary behavior (LTSB) and MVPA in adolescents from 47 low- and middle-income countries (LMICs).

STUDY DESIGN

Cross-sectional study.

METHODS

Data from the Global school-based Student Health Survey were analyzed in 140,808 adolescents (13.8 ± 1.0 years; 49% girls). Time spent in LTSB was a composite variable assessing time spent sitting and playing computer games, watching TV, talking with friends during a typical day. The PACE + Adolescent Physical Activity Measure assessed MVPA levels. The association between ≥3 h/day of LTSB and adequate physical activity levels (every day last week 60 min MVPA) was explored with multivariable logistic regression analyses.

RESULTS

The prevalence of ≥3 h/day of LTSB and 60 min of MVPA/day last week were 26.3% (girls 26.2%; boys 26.5%) and 15.3% (girls 12.1%; boys 18.4%), respectively. LTSB of ≥3 h/day versus <3 h/day was associated with a 35% increased odds for adequate levels of MVPA in boys [OR = 1.35 (95%CI = 1.23-1.48)] and 22% in girls [1.22 (95%CI = 1.10-1.36)].

CONCLUSIONS

Our data indicate that being physically active 60 min per day every day and at moderate-to-vigorous intensity and being sedentary ≥3 h/day during leisure-time might co-exist in adolescents in some LMICs.

Burnout and compassion fatigue among Exercise Physiologists in mental healthcare

BACKGROUND

Burnout and compassion fatigue (CF) are common among mental health practitioners. Accredited Exercise Physiologists (AEPs) provide clinical services to individuals experiencing mental illness, increasing their likelihood of experiencing burnout and CF.

AIMS

To examine the prevalence of burnout and CF among AEPs working with people experiencing mental illness.

METHODS

An anonymous online cross-sectional survey of AEPs working with people experiencing mental illness was distributed via the Exercise and Sports Science Australia Mental Health Special Interest Group Facebook page between July and November 2019. In addition to demographics and caseload data, respondents completed the Professional Quality of Life scale and Oldenburg Burnout Inventory (OLBI). Results are reported using descriptive statistics.

RESULTS

Sixty-two AEPs (68%, n = 42 female) completed the survey. Most (n = 53, 86%) reported delivering services to consumers with severe mental health conditions. Less than half (n = 27, 44%) reported working in a dedicated mental health facility. Moderate levels of burnout and CF were experienced by 60% and 30% of respondents, respectively.

CONCLUSIONS

The prevalence of moderate burnout and CF symptoms in AEPs is comparable with other mental health professionals. Strategies to preserve psychological well-being such as enhancing mental health training for undergraduates and formalized supervision structures discussed.

Psychiatry heal thyself: a lifestyle intervention targeting mental health staff to enhance uptake of lifestyle interventions for people prescribed antipsychotic medication

Introduction

People experiencing severe mental illness (SMI) face a shortened life expectancy of up to 20 years, primarily due to preventable cardiovascular (CV) diseases. Lifestyle interventions are effective in reducing CV risk, yet examples of service-wide interventions are lacking. Staff culture remains a barrier to the successful implementation of lifestyle interventions. The Keeping the Body in Mind (KBIM) program, established by SESLHD (Australia), aims to close the gap in life expectancy through multidisciplinary teams, including clinical nurse consultants, dieticians, exercise physiologists, and peer support workers. Prior to the KBIM rollout, an individualized lifestyle intervention called Keeping Our Staff In Mind (KoSiM) was offered to all district mental health staff.

Objective

KoSiM examined the effectiveness of a staff intervention to improve physical health, confidence, knowledge and attitudes of mental health staff.

Methods

Mental health staffs were invited to participate in an online survey and a 4-week individualized intervention including personalised health screening and lifestyle advice, with a 16-week follow-up. Outcomes assessed included: attitudes, confidence and knowledge regarding metabolic health, weight, waist circumference (WC), blood pressure, sleep, diet, physical activity and exercise capacity.

Results

Of a total of 702 staff, 204 completed the survey (29%). Among those completing the survey, 154 staff (75%) participated in the intervention. A mean decrease in waist circumference of 2 ± 2.7 cm, (P < 0.001) was achieved. Among staffs that were overweight or obese at baseline, 75% achieved a decrease in WC.

Conclusion

Improving staff culture regarding physical health interventions is an important step in integrating lifestyle interventions into routine care.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Assessing physical activity in people with mental illness: 23-country reliability and validity of the simple physical activity questionnaire (SIMPAQ)

BACKGROUND

Physical inactivity is a key contributor to the global burden of disease and disproportionately impacts the wellbeing of people experiencing mental illness. Increases in physical activity are associated with improvements in symptoms of mental illness and reduction in cardiometabolic risk. Reliable and valid clinical tools that assess physical activity would improve evaluation of intervention studies that aim to increase physical activity and reduce sedentary behaviour in people living with mental illness.

METHODS

The five-item Simple Physical Activity Questionnaire (SIMPAQ) was developed by a multidisciplinary, international working group as a clinical tool to assess physical activity and sedentary behaviour in people living with mental illness. Patients with a DSM or ICD mental illness diagnoses were recruited and completed the SIMPAQ on two occasions, one week apart. Participants wore an Actigraph accelerometer and completed brief cognitive and clinical assessments.

RESULTS

Evidence of SIMPAQ validity was assessed against accelerometer-derived measures of physical activity. Data were obtained from 1010 participants. The SIMPAQ had good test-retest reliability. Correlations for moderate-vigorous physical activity was comparable to studies conducted in general population samples. Evidence of validity for the sedentary behaviour item was poor. An alternative method to calculate sedentary behaviour had stronger evidence of validity. This alternative method is recommended for use in future studies employing the SIMPAQ.

CONCLUSIONS

The SIMPAQ is a brief measure of physical activity and sedentary behaviour that can be reliably and validly administered by health professionals.

Aromatization Is Not Required for the Facilitation of Appetitive Sexual Behaviors in Ovariectomized Rats Treated With Estradiol and Testosterone

Testosterone can be safely and effectively administered to estrogen-treated post-menopausal women experiencing hypoactive sexual desire. However, in the United States and Canada, although it is often administered off-label, testosterone co-administered with estradiol is not a federally approved treatment for sexual arousal/desire disorder, partly because its mechanism is poorly understood. One possible mechanism involves the aromatization of testosterone to estradiol. In an animal model, the administration of testosterone propionate (TP) given in combination with estradiol benzoate (EB) significantly increases sexually appetitive behaviors (i.e., solicitations and hops/darts) in ovariectomized (OVX) Long-Evans rats, compared to those treated with EB-alone. The goal of current study was to test whether blocking aromatization of testosterone to estradiol would disrupt the facilitation of sexual behaviors in OVX Long-Evans rats, and to determine group differences in Fos immunoreactivity within brain regions involved in sexual motivation and reward. Groups of sexually experienced OVX Long-Evans rats were treated with EB alone, EB+TP, or EB+TP and the aromatase inhibitor Fadrozole (EB+TP+FAD). Females treated with EB+TP+FAD displayed significantly more hops and darts, solicitations and lordosis magnitudes when compared to EB-alone females. Furthermore, TP, administered with or without FAD, induced the activation of Fos-immunoreactivity in brain areas implicated in sexual motivation and reward including the medial preoptic area, ventrolateral division of the ventromedial nucleus of the hypothalamus, the nucleus accumbens core, and the prefrontal cortex. These results suggest that aromatization may not be necessary for TP to enhance female sexual behavior and that EB+TP may act via androgenic pathways to increase the sensitivity of response to male-related cues, to induce female sexual desire.

Low-dose administration of bleomycin leads to early alterations in lung mechanics

NEW FINDINGS

What is the central question of this study? When do alterations in pulmonary mechanics occur following chronic low-dose administration of bleomycin? What is the main finding and its importance? Remarkably, we report changes in lung mechanics as early as day 7 that corresponded to parameters determined from single-frequency forced oscillation manoeuvres and pressure-volume loops. These changes preceded substantial histological changes or changes in gene expression levels. These findings are significant to refine drug discovery in idiopathic pulmonary fibrosis, where preclinical studies using lung function parameters would enhance the translational potential of drug candidates where lung function readouts are routinely performed in the clinic.

ABSTRACT

Idiopathic pulmonary fibrosis (IPF) is the most widespread form of interstitial lung disease and, currently, there are only limited treatment options available. In preclinical animal models of lung fibrosis, the effectiveness of experimental therapeutics is often deemed successful via reductions in collagen deposition and expression of profibrotic genes in the lung. However, in clinical studies, improvements in lung function are primarily used to gauge the success of therapeutics directed towards IPF. Therefore, we examined whether changes in respiratory system mechanics in the early stages of an experimental model of lung fibrosis can be used to refine drug discovery approaches for IPF. C57BL/6J mice were administered bleomycin (BLM) or a vehicle control i.p. twice a week for 4 weeks. At 7, 14, 21, 28 and 33 days into the BLM treatment regimen, indices of respiratory system mechanics and pressure-volume relationships were measured. Concomitant with these measurements, histological and gene analyses relevant to lung fibrosis were performed. Alterations in respiratory system mechanics and pressure-volume relationships were observed as early as 7 days after the start of BLM administration. Changes in respiratory system mechanics preceded the appearance of histological and molecular indices of lung fibrosis. Administration of BLM leads to early changes in respiratory system mechanics that coincide with the appearance of representative histological and molecular indices of lung fibrosis. Consequently, these data suggest that dampening the early changes in respiratory system mechanics might be used to assess the effectiveness of experimental therapeutics in preclinical animal models of lung fibrosis.

Treating depression with physical activity in adolescents and young adults: a systematic review and meta-analysis of randomised controlled trials

We aimed to establish the treatment effect of physical activity for depression in young people through meta-analysis. Four databases were searched to September 2016 for randomised controlled trials of physical activity interventions for adolescents and young adults, 12-25 years, experiencing a diagnosis or threshold symptoms of depression. Random-effects meta-analysis was used to estimate the standardised mean difference (SMD) between physical activity and control conditions. Subgroup analysis and meta-regression investigated potential treatment effect modifiers. Acceptability was estimated using dropout. Trials were assessed against risk of bias domains and overall quality of evidence was assessed using GRADE criteria. Seventeen trials were eligible and 16 provided data from 771 participants showing a large effect of physical activity on depression symptoms compared to controls (SMD = -0.82, 95% CI = -1.02 to -0.61, p < 0.05, I2 = 38%). The effect remained robust in trials with clinical samples (k = 5, SMD = -0.72, 95% CI = -1.15 to -0.30), and in trials using attention/activity placebo controls (k = 7, SMD = -0.82, 95% CI = -1.05 to -0.59). Dropout was 11% across physical activity arms and equivalent in controls (k = 12, RD = -0.01, 95% CI = -0.04 to 0.03, p = 0.70). However, the quality of RCT-level evidence contributing to the primary analysis was downgraded two levels to LOW (trial-level risk of bias, suspected publication bias), suggesting uncertainty in the size of effect and caution in its interpretation. While physical activity appears to be a promising and acceptable intervention for adolescents and young adults experiencing depression, robust clinical effectiveness trials that minimise risk of bias are required to increase confidence in the current finding. The specific intervention characteristics required to improve depression remain unclear, however best candidates given current evidence may include, but are not limited to, supervised, aerobic-based activity of moderate-to-vigorous intensity, engaged in multiple times per week over eight or more weeks. Further research is needed. (Registration: PROSPERO-CRD 42015024388).

Guidelines on radioiodine therapy for differentiated thyroid carcinoma

Aim: For the examination of the impact on clinical practice of the guidelines for differentiated thyroid carcinoma (DTC), treatment data from the ongoing Multicenter Study Differentiated Thyroid Carcinoma (MSDS) were analyzed. Patients, methods: Patients were randomized to adjuvant external beam radiotherapy (RTx) or no RTx in addition to standard therapy in TNM stages pT4 pN0/1/x M0/x (UICC, 5th ed. 1997). All patients were to receive the same treatment regimen consisting of thyroidectomy, ablative radioiodine therapy (RIT), and a diagnostic 131I whole-body scintigraphy (WBS) 3-4 months after RIT. Results: Of 339 eligible patients enrolled between January 2000 and March 2004, 273 could be analyzed. Guideline recommendations by the German Society for Nuclear Medicine from 1999 and 1992 were complied with within 28% and 82% with regard to the interval between surgery and RIT (4 vs. 4–6 weeks), in 33% and 84% with regard to 131I activity for RIT (1-3 vs. 1-4 GBq; ± 10%), and in 16% and 60% with regard to 131I activity for WBS (15319-300 vs. 15319-400 MBq; ± 10%). Conclusions: The 1999 guideline revision appears to have had little impact on clinical practice. Further follow-up will reveal if guideline compliance had an effect on outcomes.

Central ghrelin receptor stimulation modulates sex motivation in male rats in a site dependent manner

Ghrelin, a hormone produced primarily by the stomach, has been associated with motivational processes that include reward-seeking behaviors. In male laboratory mice, elevation of ghrelin levels enhances some aspects of sexual motivation and behavior, whereas in other experiments with male mice, rats, and other species, ghrelin treatment or food deprivation decreases sexual motivation and/or behavior. The present tested the hypothesis that stimulation of ghrelin receptors in different brain regions have opposite effects on male sexual motivation and behavior. To do this we examined appetitive and consummatory sex behaviors of male rats with a truncated ghrelin receptor (FHH-GHSR^m1/Mcwi), and that of their WT (FHH) littermates. We also examined the effects of ghrelin or the ghrelin antagonist D-Lys-GHRP6 delivered into the VTA or the MPOA on appetitive and consummatory sex behaviors in male Long Evans rats. Results demonstrate that rats with a truncated ghrelin receptor, or rats that are food deprived, show deficits in anticipatory sex. Furthermore, although ghrelin does not further stimulate sex anticipation in rats when infused into the VTA, intra-VTA infusions of D-Lys-GHRP6 into the VTA further decreases in sex anticipation in food deprived rats. In contrast, ghrelin delivery into the mPOA decreased sex anticipation compared to saline or D-Lys-GHRP6 infused rats. Overall, these data suggest that ghrelin receptor signalling is important for full expression of appetitive sex behaviors. Within the VTA, ghrelin may act to enhance sex motivation, while acting on the mPOA to decrease sex motivation and promote foraging.

The effects of vitamin and mineral supplementation on symptoms of schizophrenia: a systematic review and meta-analysis

BACKGROUND

When used as an adjunctive with antipsychotics, certain vitamins and minerals may be effective for improving symptomatic outcomes of schizophrenia, by restoring nutritional deficits, reducing oxidative stress, or modulating neurological pathways.

METHOD

We conducted a systematic review of all randomized controlled trials (RCTs) reporting effects of vitamin and/or mineral supplements on psychiatric symptoms in people with schizophrenia. Random-effects meta-analyses were used to calculate the standardized mean difference between nutrient and placebo treatments.

RESULTS

An electronic database search in July 2016 identified 18 eligible RCTs, with outcome data for 832 patients. Pooled effects showed that vitamin B supplementation (including B6, B8 and B12) reduced psychiatric symptoms significantly more than control conditions [g = 0.508, 95% confidence interval (CI) 0.01-1.01, p = 0.047, I 2 = 72.3%]. Similar effects were observed among vitamin B RCTs which used intention-to-treat analyses (g = 0.734, 95% CI 0.00-1.49, p = 0.051). However, no effects of B vitamins were observed in individual domains of positive and negative symptoms (both p > 0.1). Meta-regression analyses showed that shorter illness duration was associated with greater vitamin B effectiveness (p = 0.001). There were no overall effects from antioxidant vitamins, inositol or dietary minerals on psychiatric symptoms.

CONCLUSIONS

There is preliminary evidence that certain vitamin and mineral supplements may reduce psychiatric symptoms in some people with schizophrenia. Further research is needed to examine how the benefits of supplementation relate to nutrient deficits and the impact upon underlying neurobiological pathways, in order to establish optimal nutrient formulations for improving clinical outcomes in this population. Future studies should also explore the effects of combining beneficial nutrients within multi-nutrient formulas.

Physical activity and depression: a large cross-sectional, population-based study across 36 low- and middle-income countries

OBJECTIVE

Physical activity (PA) is good for health, yet several small-scale studies have suggested that depression is associated with low PA. A paucity of nationally representative studies investigating this relationship exists, particularly in low- and middle-income countries (LMICs). This study explored the global association of PA with depression and its mediating factors.

METHOD

Participants from 36 LMICs from the World Health Survey were included. Multivariable logistic regression analyses were undertaken exploring the relationship between PA and depression.

RESULTS

Across 178 867 people (mean ± SD age = 36.2 ± 13.5 years; 49.9% male), the prevalence of depression and the prevalence of low PA were 6.6% and 16.8% respectively. The prevalence of low PA was significantly higher among those with depression vs. no depression (26.0% vs. 15.8%, P < 0.0001). In the adjusted model, depression was associated with higher odds for low PA (OR = 1.42; 95% CI = 1.24-1.63). Mediation analyses demonstrated that low PA among people with depression was explained by mobility limitations (40.3%), pain and discomfort (35.8%), disruptions in sleep and energy (25.2%), cognition (19.4%) and vision (10.9%).

CONCLUSION

Individuals with depression engage in lower levels of PA in LMICs. Future longitudinal research is warranted to better understand the relationships observed.

Choosing Usability Research Methods

This paper describes why and how human factors practitioners should employ a combination of research methods for user data collection, rather than relying on only one or two such as heuristic evaluation and laboratory testing. The paper presents three case studies of multiple-method usability research projects: alternating usability testing with ethnographic interviews in a longitudinal study of a clinical information system; two parallel usability research efforts for a small company with a limited budget; and contextual inquiries followed by group interviews of experts, then by usability testing. The authors believe that combining research methods is more likely to increase the strategic penetration of human factors within organizations.

Motivating factors and barriers towards exercise in severe mental illness: a systematic review and meta-analysis

Exercise can improve clinical outcomes in people with severe mental illness (SMI). However, this population typically engages in low levels of physical activity with poor adherence to exercise interventions. Understanding the motivating factors and barriers towards exercise for people with SMI would help to maximize exercise participation. A search of major electronic databases was conducted from inception until May 2016. Quantitative studies providing proportional data on the motivating factors and/or barriers towards exercise among patients with SMI were eligible. Random-effects meta-analyses were undertaken to calculate proportional data and 95% confidence intervals (CI) for motivating factors and barriers toward exercise. From 1468 studies, 12 independent studies of 6431 psychiatric patients were eligible for inclusion. Meta-analyses showed that 91% of people with SMI endorsed 'improving health' as a reason for exercise (N = 6, n = 790, 95% CI 80-94). Among specific aspects of health and well-being, the most common motivations were 'losing weight' (83% of patients), 'improving mood' (81%) and 'reducing stress' (78%). However, low mood and stress were also identified as the most prevalent barriers towards exercise (61% of patients), followed by 'lack of support' (50%). Many of the desirable outcomes of exercise for people with SMI, such as mood improvement, stress reduction and increased energy, are inversely related to the barriers of depression, stress and fatigue which frequently restrict their participation in exercise. Providing patients with professional support to identify and achieve their exercise goals may enable them to overcome psychological barriers, and maintain motivation towards regular physical activity.

Validating faecal glucocorticoid metabolite analysis in the Virunga mountain gorilla using a natural biological stressor

The continued degradation of primate habitat worldwide is forcing many primate populations into small protected forest islands surrounded by high-density human populations. One well-studied example is the critically endangered mountain gorilla (Gorilla beringei beringei). Decades of monitoring and research on Rwanda's mountain gorillas offer a unique opportunity to use non-invasive endocrine analysis to address pressing questions about the conservation of this endangered population. The aims of our study were as follows: (i) to validate field and laboratory methods for assessing stress through faecal glucocorticoid metabolite (FGM) analysis using inter-social unit interactions as a natural stressor; (ii) to determine the excretion lag times between interactions and detectable stress response in faeces; and (iii) to determine whether there are circadian patterns of FGM excretion. We collected ~6000 faecal samples from 127 known gorillas in 10 habituated groups, monitored by the Dian Fossey Gorilla Fund's Karisoke Research Center over 21 months in 2011 and 2012. Extracted FGMs were measured using a cortisol enzyme immunoassay (R4866; C. J. Munro). Results revealed cause-effect relationships between inter-unit interactions and increased FGMs (relative to individual pre-event samples) between 20 and 140 h after interactions, with the peak most often occurring on day 3. There was no evidence of circadian patterns in FGM concentrations, as previously shown in many species with long gut passage times. However, baseline FGM concentrations were lower in adult males than in adult females, and variation was associated with the collection month, indicating possible seasonal variation. This study provides a biologically validated, field-friendly faecal hormone metabolite extraction and laboratory enzyme immunoassay analysis method for non-invasive monitoring of adrenocortical activity in Virunga mountain gorillas. The methods are useful for future evaluation of a variety of environmental and human-induced potential stressors in this critically endangered population.

Preventing weight gain and increased waist circumference during the first two years after antipsychotic initiation in youth with first-episode psychosis

Background

We recently demonstrated that weight gain could be prevented in young people experiencing a first-episode of psychosis commencing treatment with antipsychotics. A 12-week, intensive lifestyle and life skills intervention – the Keeping the Body in Mind program, – was delivered by dedicated nursing, dietetic and exercise physiology clinicians, for new referrals with < one month of antipsychotic exposure. (Curtis et al., Early intervention in psychiatry, in press). At the conclusion of the intervention the 16 young people participating in the program experienced a mean weight gain of 1.8 kilograms, and a mean increase in waist circumference of 0.1 centimeters. The participants were followed up for two years after initial referral.

Methods

During the two-year follow-up, participants had continuing access to an in house gym and weekly cooking groups, but without the same intensity of follow-up. Two year follow-up data were obtained from 11 participants form the original cohort.

Results

Mean weight gain at two-year follow-up was 0.90 (SD 8.7) kilograms, and this difference was not statistically significant [t (10) = 0.3, NS]. Waist circumference decreased by 0.7 (SD 7.7) centimeters, which was not t statistically significant [t (10) = 0.3, NS]. Nine of the participants (82%) did not experience clinically significant weight gain two years after initiation of antipsychotic medication.

Conclusion

This two-year follow-up data demonstrated that it is feasible to prevent weight gain in youth with first-episode psychosis over the first two years of treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Group structure predicts variation in proximity relationships between male-female and male-infant pairs of mountain gorillas (Gorilla beringei beringei)

Relationships between conspecifics are influenced by both ecological factors and the social organization they live in. Systematic variation of both--consistent with predictions derived from socioecology models--is well documented, but there is considerable variation within species and populations that is poorly understood. The mountain gorilla (Gorilla beringei) is unusual because, despite possessing morphology associated with male contest competition (e.g., extreme sexual dimorphism), they are regularly observed in both single-male and multimale groups. Both male-female and male-infant bonds are strong because males provide protection against infanticide and/or predation. Risk of these threats varies with social structure, which may influence the strength of social relationships among group members (including females and offspring, if females with lower infant mortality risk are less protective of infants). Here, we investigate the relationship between group structure and the strength of proximity relationships between males and females, males and infants, and females and offspring. Data come from 10 social groups containing 1-7 adult males, monitored by the Dian Fossey Gorilla Fund's Karisoke Research Center in Volcanoes National Park, Rwanda. After controlling for group size and infant age, association strength was similar for male-female pairs across group types with both dominant and nondominant males, but male-infant relationships were strongest in single-male groups where paternity certainty was high and animals had fewer social partners to choose from. The male:female and male:infant ratios better predicted both male-female and male-infant associations than the absolute number of males, females, or infants did. The fewer the number of males per female or infant, the more both pair types associated. Dominant males in groups containing fewer males had higher eigenvector centrality (a measure of importance in a social network) than dominant males in groups with more males. Results indicate that nondominant males are an important influence on relationships between dominant males and females/infants despite their peripheral social positions, and that relationships between males and infants must be considered an important foundation of gorilla social structure.

Vaginocervical stimulation attenuates the sensitization of appetitive sexual behaviors by estradiol benzoate in the ovariectomized rat

The acute administration of estradiol benzoate (EB) to the ovariectomized (OVX) rat induces low levels of lordosis while sexually appetitive behaviors (e.g., hops, darts, solicitations) are absent, yet the repeated administration of EB results in a behavioral sensitization in which lordosis is potentiated and sexually appetitive behaviors are induced. We have shown that repeated copulation attenuates the sensitization of appetitive sexual behaviors. Here, we assessed which component of male stimulation during copulation is involved in the attenuation. On 8 occasions, sexually experienced OVX Long-Evans rats were treated with 10μgEB and 48h later assigned to one of six groups that differed in their experience on intermediates tests (2-7). One was given repeated access to a male (EB/Male), and another was placed in the copulation chamber alone (EB/Alone) on intermediate tests. Three groups were given one of three somatosensory stimuli by the experimenter: manual flank stimulation (FLS), clitoral stimulation (CLS), or vaginocervical stimulation (VCS). Finally, the control group was left undisturbed in the animal care facility (ACF). Sexual behaviors were measured on Tests 1 and 8. VCS received from the experimenter (VCS) or from the male during copulation (EB/Male) attenuated the magnitude of the sensitization of appetitive sexual behaviors compared with those that were not brought to the testing rooms (ACF), and the effect was most pronounced on sexual solicitations. These results suggest that VCS received during penile intromission inhibits the sensitization of sexually appetitive behaviors by repeated administration of EB. As such, repeated administration of EB may oppose those mechanisms that induce estrous termination, perhaps by sensitizing inhibitory processes within the ventromedial hypothalamus that typically prevent the display of sexual behaviors (i.e., by facilitating disinhibition).

Promotion of cardiorespiratory fitness in schizophrenia: a clinical overview and meta-analysis

OBJECTIVE

Cardiorespiratory fitness (CRF) is a major modifiable risk factor for cardiovascular disease (CVD). We conducted a clinical overview to highlight the reduced CRF expressed as maximal oxygen uptake (VO2max) (or predicted) or peak oxygen uptake (VO2 peak) in people with schizophrenia compared to the general population. We also aimed to identify correlates of and clinical strategies to improve CRF.

METHOD

We systematically searched major electronic databases from inception until November 2014. A meta-analysis calculating the standardised mean difference (SMD) was employed.

RESULTS

CRF was significantly reduced in people with schizophrenia (n = 154) with a SMD of -0.96 (95% CI -1.29 to -0.64) (N = 5) compared to controls (n = 182). Negative symptoms, increased body mass index and female gender were negatively associated with CRF. Promoting physical activity may improve CRF in people with schizophrenia by up to 4-4.5 ml/kg/min following a 6-8 weeks programme (N = 4, n = 98).

CONCLUSION

People with schizophrenia have a large and significantly reduced CRF. Given the overwhelming evidence for physical activity as the cornerstone of preventing and managing CVD in the general population, incorporating such interventions in the treatment of people with schizophrenia is justified and urgently required. We present clear practical strategies of how this can be achieved within clinical settings.

Exercise augmentation compared with usual care for post-traumatic stress disorder: a randomized controlled trial

OBJECTIVE

To investigate the impact of a 12-week exercise programme in addition to usual care for post-traumatic stress disorder (PTSD).

METHOD

An assessor-blinded randomized controlled trial was conducted among 81 participants with a DSM-IV-TR diagnosis of primary PTSD. Participants were recruited after admission to an in-patient programme at a private hospital. Participants were randomized to receive either usual care (n=42), or exercise in addition to usual care (n=39). The exercise intervention involved three, 30-min resistance-training sessions/week and a pedometer-based walking programme. Usual care involved psychotherapy, pharmaceutical interventions, and group therapy. Primary outcome was PTSD symptoms assessed via the PTSD checklist-civilian version (PCL-C). Secondary outcomes included symptoms of depression, anthropometry, physical activity, mobility, strength, and sleep quality.

RESULTS

Participants had a mean (SD) age of 47.8 years (12.1), 84% male. PTSD symptoms in the intervention group significantly reduced compared with the usual care group (mean difference=-5.4, 95% CI -10.5 to -0.3, P=0.04, n=58). There were significant between-group differences at follow-up for depressive symptoms, waist circumference, sleep quality, and sedentary time.

CONCLUSION

This study provides the first evidence that an exercise intervention is associated with reduced PTSD and depressive symptoms, reduced waist circumference, and improved sleep quality.

The prevalence of pain in bipolar disorder: a systematic review and large-scale meta-analysis

OBJECTIVE

To conduct a meta-analysis investigating the prevalence of pain in people with bipolar disorder (BD).

METHOD

A systematic review and random effects meta-analysis searching major electronic databases from inception till 01/2014 in accordance with the PRISMA statement. We included articles reporting quantitative data on the prevalence of pain in people with BD with or without a healthy control group. Two independent authors conducted searches, extracted data, and completed methodological quality assessment.

RESULTS

Twenty two cross-sectional studies were included, representing 12,375,644 individuals (BD n=171,352, n controls=12,204,292). The prevalence of pain in people with BD was 28.9% (95% CI=16.4-43.4%, BD n=171,352). The relative risk (RR) of pain in BD compared to controls was 2.14 (95% CI=1.67-2.75%, n=12,342,577). The prevalence of migraine was 14.2% (95% CI=10.6-18.3%, BD n=127,905), and the RR was 3.30 (95% CI=2.27-4.80%, n=6,732,220).About 23.7% (95% CI=13.1-36.3%, n=106,214) of people with BD experienced chronic pain. Age, percentage of males, methodological quality, and method of BD classification did not explain the observed heterogeneity.

CONCLUSION

People with BD experience significantly increased levels of pain (particularly chronic pain and migraine). The assessment and treatment of pain should form an integral part of the management of BD.

Vascular pathology in the extracranial vertebral arteries in patients with acute ischemic stroke

Introduction

Vascular pathology in the extracranial vertebral arteries remains among the possible causes in cryptogenic stroke. However, the diagnosis is challenged by the great variety in the anatomy of the vertebral arteries, clinical symptoms and difficulties in the radiological assessments. The aim of this study was to assess the prevalence of CT angiography (CTA)-detected pathological findings in the extracranial vertebral arteries in an acute stroke population and secondly to determine the frequency of posterior pathology as probable cause in patients with otherwise cryptogenic stroke.

Method

The analysis was based on 657 consecutive patients with symptoms of acute stroke and a final diagnosis of ischemic stroke or transient ischemic attack. On admission, a noncontrast CT cerebrum and CTA were performed. A senior consultant neuroradiologist, blinded to clinical data, reviewed all CTA scans systematically, assessing the four segments of the extracranial vertebral arteries. First, the frequency of pathological findings including stenosis, plaques, dissection, kinked artery and coiling was assessed. Subsequently, we explored the extent of the pathological findings that were the most plausible causes of stroke, namely either a possible dissection or a kinked artery.

Results

Findings in the extracranial vertebral arteries included significant stenosis (0.8%), atherosclerotic plaque types (3.8%), possible dissections (2.6%), kinked arteries (2.6%) and coiling (32.0%). Eighteen patients (2.8%) with pathological findings had an unknown cause of stroke, likely posterior symptoms and no clinical stroke symptoms from the anterior circuit. Of these, 3 cases were kinked arteries (0.5%) and 15 cases (2.3%) were possible dissections.

Conclusion

We found that in approximately 3% of the study population, the most plausible cause of the cryptogenic strokes was due to a pathological finding in the posterior extracranial vertebral arteries, being either a possible dissection or a kinked artery. In general, posterior vascular pathology is not uncommon, and CTA is a useful modality in the detection of changes based on characteristics and locations of findings in the extracranial vertebral arteries. Ultrasound examination can be a useful supplementary tool in deciding the consequence of vascular findings on CTA.

Male-immature relationships in multi-male groups of mountain gorillas (Gorilla beringei beringei)

We examined the pattern and possible functions of social interactions between adult males and immatures in three free-ranging, multi-male groups of mountain gorillas (Gorilla beringei beringei). Previous studies conducted during the 1970s when groups contained one to three adult males concluded that male-immature relationships were likely to be a form of low-cost paternal investment [Stewart, Mountain gorillas: three decades of research at Karisoke. Cambridge, UK: Cambridge University Press, 2001]. We evaluated whether this hypothesis still held in groups containing six to nine adult males, or if male-immature relationships might serve other functions (e.g. mating effort, kin selection, or alliance building). Overall, we found that immatures spent the most time near, and interacted most with, the alpha silverback. These behaviors peaked during the period when infants were still quite vulnerable but increasing their independence from their mothers. Such findings suggest that parenting effort remains the primary function of male-immature relationships; however, there is some evidence for the mating effort hypothesis as well.

Guidelines on radioiodine therapy for differentiated thyroid carcinoma: impact on clinical practice

AIM

For the examination of the impact on clinical practice of the guidelines for differentiated thyroid carcinoma (DTC), treatment data from the ongoing Multicenter Study Differentiated Thyroid Carcinoma (MSDS) were analyzed.

PATIENTS, METHODS

Patients were randomized to adjuvant external beam radiotherapy (RTx) or no RTx in addition to standard therapy in TNM stages pT4 pN0/1/x M0/x (UICC, 5th ed. 1997). All patients were to receive the same treatment regimen consisting of thyroidectomy, ablative radioiodine therapy (RIT), and a diagnostic 131I whole-body scintigraphy (WBS) 3-4 months after RIT.

RESULTS

Of 339 eligible patients enrolled between January 2000 and March 2004, 273 could be analyzed. Guideline recommendations by the German Society for Nuclear Medicine from 1999 and 1992 were complied with within 28% and 82% with regard to the interval between surgery and RIT (4 vs. 4-6 weeks), in 33% and 84% with regard to 131I activity for RIT (1-3 vs. 1-4 GBq; +/- 10%), and in 16% and 60% with regard to 131I activity for WBS (100-300 vs. 100-400 MBq; +/- 10%).

CONCLUSIONS

The 1999 guideline revision appears to have had little impact on clinical practice. Further follow-up will reveal if guideline compliance had an effect on outcomes.

Grundlagen und klinischer Nutzen von PET-CT

Medicine today imposes high demands on diagnosing disease. Techniques should be preferably noninvasive, identify the disease at an early stage, and be quick and accurate. Frequently, these demands can only be met by employing various diagnostic modalities. Consequently, the integration of two imaging modalities, such as the combination of PET and CT, increases the quality of coregistration and facilitates a timely diagnosis. However, complex imaging procedures require a judicious choice of the areas of application. If, for example, both PET and CT are indicated then a combined PET/CT exam results in improved diagnosis, whereby the actual benefit will depend upon the clinical problem. Typically we expect an advantage of 10% with PET/CT compared to separate examinations with CT and PET. In addition, PET/CT allows for new indications and applications, which cannot be performed satisfactorily with independent examinations and retrospective image alignment. One example is the application of PET/CT in radiation therapy planning.