Impact of Chemotherapy Stock-Out on Standard Therapy Delivery Among Cancer Patients in Botswana

Background: Cancer drug shortages represent a complex global issue with potentially adverse survival outcomes. Up to 98% of oncologists and pharmacists surveyed in North America reported at least 1 drug shortage in the prior year and 66% reported at least one patient who had clinical care impacted by the shortage. In low- and middle-income countries (LMICs), these shortages are even more frequent. No studies to our knowledge have evaluated the impact of chemotherapy stock-out on receipt of standard cancer therapy in LMICs. Aim: Quantify the association between the duration of chemotherapy stock-out and the risk of having a suboptimal therapy delivery event, compared with standard delivery of therapy among cancer patients in Botswana. Methods: Prevalent cohort study of patients with cervical, breast, prostate, esophagus, Kaposi sarcoma, head and neck cancers, lung, uterine, ovarian and colorectal cancers who received any systemic therapy between 01/01/16-12/31/16 at Princess Marina Hospital, Botswana. Primary exposure was stock-out duration per cycle interval calculated by generating a code for the six different patterns for chemotherapy stock-out, using stock data at the Central Medical Stores. Primary outcome was suboptimal therapy delivery defined as a dose reduction, dose delay or switch in intended therapy. We measured statistical associations using two sample t-test and mixed effects univariate and multivariate logistic regression models. Results: 378 patients were identified who met diagnostic criteria and received systemic chemotherapy in 2016. Of these, 293 received commonly prescribed standard regimens who contributed 1452 cycle intervals and were included in our analysis. Majority of the patients (48%) had breast cancer. The mean duration of stock-out for receipt of standard therapy without events was 3.2 days (95% CI: 2.8-3.7) compared with 7.8 days for patients who had a suboptimal therapy delivery event (95% CI: 6.6-9) ( P < 0.0001). Male sex, age < 65 and HIV-positive status were also significantly associated with an increased risk of experiencing dose reduction, change in therapy or switch in therapy. Adjusting for these factors in a mixed effects logistic regression, each week of stock-out was independently associated with an 80% increased risk of having a suboptimal therapy delivery event (OR=1.8 (95% CI: 1.6-2.0, P < 0.0001)). Conclusion: Chemotherapy stock-out is independently associated with an 80% increased risk of a patient experiencing dose reduction, change in therapy or delay in therapy. The risk increases with longer duration of stock out. Given prior data showing that these events lead to worse survival outcomes, our further analysis is focusing on quantifying risk of stock-out on survival outcomes in this population. to determine whether interventions promoting standard therapy delivery are warranted to optimize survival outcomes.

Association or lack of association between tetracycline class antibiotics used for acne vulgaris and lupus erythematosus

BACKGROUND

Previous studies have associated tetracyclines and, perhaps more specifically, minocycline use for the treatment of acne with onset of drug-induced lupus erythematosus (LE).

OBJECTIVES

To determine the frequency of LE among those with acne who used antibiotics from the tetracycline class of antibiotics.

METHODS

A retrospective cohort study of individuals aged 15-35 years with acne within the practices of the general practice physicians in the U.K. who participate in The Health Information Network (THIN). Our outcome measure was physician reports of LE.

RESULTS

We identified 97 694 subjects with acne who were followed for about 520 000 person-years. They were on average about 22 years old and 57.5% were female. Minocycline exposure was noted in 24.8% of our subjects, doxycycline exposure in 15.6%, other tetracyclines in 42.3%, and 17.3% had not received a tetracycline antibiotic. The overall hazard ratio for the association of minocycline to LE was 2.64 (95% confidence interval 1.51-4.66) and when adjusted for age and gender was 3.11 (1.77-5.48). Those affected were often treated for LE. No association was noted for doxycycline and the other tetracyclines.

CONCLUSIONS

The use of minocycline and not the other tetracyclines is associated with LE. LE as reported in THIN often required systemic therapy. Overall, the event is uncommon but the risk and benefit of minocycline therapy must be carefully considered.

Rolipram: a specific phosphodiesterase 4 inhibitor with potential antipsychotic activity

Currently available antipsychotic medications work primarily by antagonizing D2 dopamine receptors, thus raising intracellular cAMP levels. We hypothesized that intracellular stimulation of cAMP levels in the CNS would have similar effects to treatment with antipsychotic medication. To test this hypothesis, we studied the effect of an acute treatment of rolipram, an inhibitor of type 4 phosphodiesterases that degrade cAMP, on acoustic startle and prepulse inhibition (PPI) of the acoustic startle response in C57BL/6J mice known to exhibit poor PPI. PPI is disrupted in schizophrenia patients, and the ability of a drug to increase PPI in mice is predictive of antipsychotic efficacy. We show here that acute treatment with rolipram significantly increases PPI at doses that do not alter the acoustic startle response (lowest effective dose 0.66 mg/kg). In addition, rolipram (0.66 mg/kg) blocks the disruptive effects of amphetamine (10 mg/kg) on PPI. At a slightly higher dose (1.0 mg/kg), rolipram also induces catalepsy. Thus, phosphodiesterase-4 (PDE4) inhibition has many of the same behavioral effects as traditional antipsychotic medications. In contrast to traditional antipsychotics, these effects are achieved through alteration of an intracellular second messenger system rather than antagonism of neurotransmitter receptors. Given previous reports showing rolipram improves cognition, we conclude that PDE4 represents an important novel target for further antipsychotic drug development.

Medical conditions associated with venous leg ulcers

BACKGROUND

In patients who have a venous leg ulcer, very little is known about the frequency of their concomitant medical conditions.

OBJECTIVES

To evaluate the frequency that other medical conditions are associated with a new venous leg ulcer.

METHODS

We studied a 10% random sample of elderly patients registered in the General Practice Research Database between 1988 and 1996. We describe the frequency of medical conditions using simple percentages. In order to assess the associations between medical conditions and the onset of a venous leg ulcer, we used logistic regression models.

RESULTS

Several medical conditions occur commonly in patients who develop venous leg ulcers, including anaemia, angina, asthma, cellulitis of the lower extremity, depression, diabetes, limb oedema, hypertension, osteoarthritis, pneumonia and urinary tract infection. After statistical adjustment many medical conditions were significantly associated with those who had recent onset of a venous leg ulcer, including asthma, cellulitis of the lower extremity, congestive heart failure, diabetes, deep venous thrombosis, lower limb oedema, osteoarthritis, peripheral vascular arterial disease of the lower extremity, rheumatoid arthritis, history of hip surgery, and history of venous surgery/ligation. Unexpectedly, some illnesses were inversely associated with those that had recent onset of a venous leg ulcer, including angina, cerebral vascular accident, depression, malignancy, myocardial infarction, pneumonia and urinary tract infection.

CONCLUSIONS

Physicians caring for individuals with venous leg ulcers need to be aware that it is likely that these individuals may have one of the comorbid illnesses listed above.

The risk of malignancy associated with psoriasis

OBJECTIVE

To measure the incidence of cancer in patients with psoriasis, stratified by the severity of their disease.

DESIGN

A cohort study.

SETTING

Administrative claims records obtained from Medicaid programs in 3 US states.

PARTICIPANTS

All individuals in the claims database who qualified for 1 of the 5 following groups: severe psoriasis as defined by treatment with systemic medication, less severe psoriasis, severe eczema, history of organ transplantation, and hypertension.

MAIN OUTCOME MEASURE

A diagnosis of cancer.

RESULTS

Individuals with severe psoriasis were more likely to develop a malignancy than those with hypertension (risk ratio, 1.78; 95% confidence interval [CI], 1.32-2.40). The risk of malignancy in the severe psoriasis group approaches that in patients with organ transplants (risk ratio, 2.12; 95% CI, 1.80-2.50). Most of these cancers were nonmelanoma skin cancers and lymphoproliferative malignancies. Those with less severe psoriasis were only slightly more likely to develop a new malignancy than those with hypertension (risk ratio, 1.13; 95% CI, 1.03-1.25).

CONCLUSIONS

Patients with psoriasis are at an increased risk of developing a malignancy compared with patients with hypertension. The increased risk is greatest for those with severe disease (ie, patients with psoriasis treated with systemic agents) and minimal (if an increased risk at all) for those with less severe disease compared with those in the hypertension group. The increased risk is mainly for lymphoproliferative cancers and nonmelanoma skin cancers.

Association of fear auras with mood and anxiety disorders after temporal lobectomy

PURPOSE

Epilepsy has been associated with increased occurrence of behavioral disorders. Auras reflect abnormal stimulation of brain areas in close proximity to regions from which clinical seizures originate. The purpose of our study was to investigate whether fear auras are associated with a higher rate of mood and anxiety disorders before and 1 year after temporal lobectomy.

METHODS

Twenty-two patients with fear auras were compared with matched groups with other auras and no auras. Neurologic and neuropsychological evaluations before, 1-2 months after, and 1 year after temporal lobectomy were reviewed for mood and anxiety disorders and psychotropic medication treatment. A logistic regression model examined effects of patient group and psychiatric status on postoperative psychiatric status.

RESULTS

The majority of patients in the three groups experienced mood and anxiety disorders before surgery. Mood and anxiety disorders declined in the control, but not in the fear aura group after surgery. Presence of auras at 1 year after surgery was not related to psychiatric outcome. Postoperative mood and anxiety disorders were more common in patients with persistence of seizures and in those in the fear group who were seizure free. The minority of patients in all groups underwent psychotropic treatment before surgery, but the majority with fear auras underwent treatment after surgery.

CONCLUSIONS

Postoperative mood and anxiety disorders were more common in fear aura patients after temporal lobectomy, in particular, if seizure free. Possible mechanisms include the role of the amygdala in fear conditioning, the concepts of forced normalization, and kindling.

Comparison of the standard and structured interview guide for the Hamilton Depression Rating Scale in depressed geriatric inpatients

The interrater reliability of the standard Hamilton Depression Rating Scale (Ham-D) and a structured interview guide for the Ham-D (the SIGH-D) were compared in a sample of 20 elderly inpatients with major depression. Each patient was independently interviewed by four raters; two used the standard 24-item Ham-D, and the other two used a 24-item modified version of the Structured Interview Guide for the Ham-D. Systematic counterbalancing of raters and scales and a stringent evaluation schedule were used to counter position effects, spontaneous symptom change, or diurnal variation. The modified SIGH-D produced uniformly higher item- and summary-scale reliabilities than the unstructured Ham-D.

Age-related volumetric changes of brain gray and white matter in healthy infants and children

To date there is little information about brain development during infancy and childhood, although several quantitative studies have shown volume changes in adult brains. We performed three-dimensional magnetic resonance imaging (3D-MRI) in 28 healthy children aged 1 month to 10 years. We examined the volumes of whole brain and frontal and temporal lobes with an advanced method for segmenting images into gray matter (GM), white matter (WM) and cerebrospinal fluid (CSF) compartments. Growth spurts of whole brain and frontal and temporal lobes could be seen during the first 2 years after birth. During this period the frontal lobes grew more rapidly than the temporal lobes, the right--left asymmetry was more noticeable in the temporal lobes than in the frontal lobes and the increase in GM was larger than that in WM in the temporal lobes. Subsequently, WM volume increased at a higher rate than GM volume throughout childhood. Quantitative information on normal brain development may play a pivotal role in clarifying brain neurodevelopmental abnormalities.

Comparison of the continuous performance test with and without working memory demands in healthy controls and patients with schizophrenia

The Penn Continuous Performance Test (PCPT), a measure of sustained visual attention developed for use in functional neuroimaging studies, was compared with a standard CPT developed by Gordon Diagnostic Systems (GDS; Vigilance subtest). The PCPT and the GDS CPT were administered with a standard neuropsychological battery to 68 healthy adults to assess reliability and construct validity. The test had adequate internal consistency, and convergent validity was established through significant correlations between measures of efficiency on the PCPT and the GDS CPT. With the exception of a significant correlation between efficiency measures on the GDS CPT and a measure of auditory sustained attention, neither version of the CPT correlated significantly with other measures in the battery. Factor analysis showed that the PCPT loaded with the GDS CPT. In 39 patients with schizophrenia and 39 matched, healthy controls, equivalent impairment was evident on the two CPT tasks. Neither version correlated significantly with symptom measurements. These results support previous conclusions that sustained visual attention in schizophrenia is a core information processing deficit, not directly related to symptomatology.

Clinical laboratory measures in relation to depression, disability, and cognitive impairment in elderly patients

To characterize the dimensions of physiological abnormalities that commonly occur in older individuals in a residential care setting and to evaluate their association with clinical measures, the authors conducted an exploratory factor analysis on clinical laboratory measures from a sample of 231 elderly residents (mean age: 86) living in a nursing home and congregate apartment facility. An eight-factor solution accounted for 70.2% of the variance in these measures; factors identified were interpreted as indices of renal function, protein/calorie/nutritional status, serum electrolytes/osmolarity, liver function, acute-phase processes, plasma lipids, acid/base status, and renal-tubular function. The nutritional factor was significantly associated with measures of disability and the presence of depression. The acute-phase processes factor was significantly associated with cognitive impairment.

Volumetric asymmetries in late-onset mood disorders: an attenuation of frontal asymmetry with depression severity

The purpose of the study was to examine global and regional volumetric asymmetries in patients with late-onset mood disorders and non-depressed control subjects. Our sample comprised 34 patients with late-onset major depression, 18 patients diagnosed with late-onset minor depression and 30 control subjects. All subjects were scanned using a 1.5 Tesla GE Scanner, and quantitative estimates of global and focal brain volumes were obtained. Control subjects and patients displayed significant right-left volumetric differences across several regions, with right-sided regions being larger than the left. In the frontal lobes, the asymmetry differed significantly in the three groups (P=0.02). It was most pronounced in the control group and decreased significantly in the minor and major depression groups. There was a significant trend (P=0.005) in the magnitude of frontal asymmetry across groups, with the frontal asymmetry decreasing with increasing severity of depression. Hemispheric and temporal asymmetries were comparable in all three groups. These data suggest that an attenuation of the 'normal' volumetric asymmetry in the frontal regions may provide a structural basis to late-onset mood disorders

Agreement between older subjects and proxy informants on history of surgery and childbirth

OBJECTIVES

To assess the agreement between proxy informants' reports of history of surgery and childbirth and older index subjects' own recall.

DESIGN

Interrater reliability study.

SETTING

An outpatient family medicine clinic and a provincial electoral district in Montreal, Canada.

PARTICIPANTS

Eighty-two subjects aged 65 years and older without cognitive impairment, identified from clinic and community settings, and each index subject's proxy respondent.

MEASUREMENTS

Identical questionnaires were administered to index subjects and proxies.

RESULTS

Proxies failed to report 39% of non-childbirth surgeries reported by index subjects, but failed to report only 10% of childbirths. Female proxies were significantly less likely than male proxies to underreport non-childbirth surgeries after controlling for age of index subject and interval since surgery. Longer interval since surgery was significantly associated with greater underreporting, whereas age of the index subject and relationship between proxy and index subject were not. Agreement between proxies and index subjects on date of surgery was much higher for childbirths than for non-childbirth surgeries.

CONCLUSIONS

Our findings suggest that proxy respondents can provide reliable information on older women's history of childbirth but that use of proxy respondents for history of non-childbirth surgeries may result in substantial underreporting.

Emotion recognition deficit in schizophrenia: association with symptomatology and cognition

BACKGROUND

Previous investigations have found impaired recognition of facial affect in schizophrenia. Controversy exists as to whether this impairment represents a specific emotion recognition deficit when compared with other face recognition control tasks. Regardless of whether the emotion processing deficit is differential, it may uniquely influence other manifestations of schizophrenia. We compared patients and healthy control subjects on computerized tasks of emotion and age recognition. Performances on emotion and age recognition tasks were correlated with cognitive functioning and with symptomatology.

METHODS

Thirty-five patients with schizophrenia and 45 healthy people underwent computerized testing for emotion and age recognition. Participants were assessed neuropsychologically, and patients were rated for positive and negative symptoms.

RESULTS

The patients with schizophrenia performed worse than control subjects on emotion and age recognition without differential deficit. In both groups, we found higher error rates for identification of emotion in female faces and for identification of sad versus happy faces. In schizophrenic patients, emotion but not age recognition correlated with severity of negative and positive symptoms. In healthy control subjects, neither task correlated with cognitive functions. In schizophrenic patients, emotion but not age recognition correlated with attention, verbal and spatial memory, and language abilities.

CONCLUSIONS

This study did not reveal a specific deficit for emotion recognition in schizophrenia; however, our findings lend support to the concept that emotion recognition is uniquely associated in schizophrenia with core symptomatology and cognitive domains.

Examination of the cognitive effects of cimetidine in normal elderly volunteers

The authors evaluated the cognitive effects of acute challenges with the H2 receptor-antagonist cimetidine in normal older volunteers. The study was a double-blind, placebo-controlled, crossover study of 12 volunteers, average age 71.25 years. Baseline assessment was followed by randomized administration of a placebo or ascending doses of cimetidine (400 mg, 800 mg, or 1,600 mg) in test sessions separated by 1 week. Cognitive performance was evaluated with a 1-hour battery of tests beginning 90 minutes after administration of a single dose of drug (or placebo). There were no significant cognitive decrements associated with cimetidine. Despite numerous case reports of cognitive toxicity, this study found no observable decrements in cognitive performance in a group of healthy elderly subjects; therefore, case reports in the literature may be reporting effects for patients with specific impairments or sensitivities.

Nutritive sucking and neurobehavioral development in preterm infants from 34 weeks PCA to term

PURPOSE

To investigate changes in nutritive sucking patterns, behavioral state, and neurobehavioral development of preterm infants from the 34 weeks postconceptional age (PCA) to term.

DESIGN

Nonexperimental descriptive correlational design was used.

METHODS

A convenience sample included 66 preterm infants with a gestational age between 24 and 34 weeks at birth. Mean gestational age was 29.7 weeks, with a mean birthweight of 1379 grams. Instruments included the Kron Nutritive Sucking Apparatus, the Anderson Behavioral State Scale (ABSS), and the Brazelton Neonatal Behavioral Assessment Scale (BNBAS). A feeding procedure was administered at 34 and 40 weeks PCA with BNBAS administered at 40 weeks PCA. Data analysis strategies included t-tests, Spearman rho correlations, Wilcoxon matched-pairs signed-ranks test, and a Random Coefficients Model.

RESULTS

There were significant differences in number of sucks (p < 0.001), intensity of sucking pressures (p < 0.001), average time between sucks (p < 0.001), and average time between bursts (p < 0.001) from 34 weeks PCA to term. With maturation, it was noted that the preterm infants were significantly more alert during the sucking protocol from 34 weeks to term (p < 0.001). Yet, infant sucking parameters at 34 weeks PCA and term were not significantly related to the BNBAS or to the infant's state.

CLINICAL IMPLICATIONS

These results demonstrate that high risk preterm infants mature significantly in their sucking behaviors and in their ability to maintain a more alert behavioral state from 34 weeks PCA to term. However, unlike full term infants--where state is positively correlated to feeding (sucking) success--the preterm infant state of alertness may not enhance sucking skills at 34 weeks PCA. These infants may be too stressed to manage both feeding and stimulation from the environment that is unavoidable when alert. However, this relationship does appear to change by 40 weeks PCA.

Atrophy and high intensity lesions: complementary neurobiological mechanisms in late-life major depression

The primary objective of our study was to examine the role of atrophy, high intensity lesions and medical comorbidity in the pathophysiology of major depressive disorder in the elderly (late-life MDD). Our sample was comprised of 51 patients with late-life MDD and 30 non-depressed controls. All subjects were scanned on 1.5 tesla magnetic resonance imaging scanner (MRI) and absolute and normalized measures of brain and lesion volumes were obtained and used for comparison between groups. Patients with MDD had significantly smaller frontal lobe volumes, together with larger whole brain lesion volumes when compared with controls (p < .05). Whole brain lesion volumes correlated significantly (r = 0.41, p = .006) with overall medical comorbidity. The odds ratio (OR) for existing MDD increases significantly with a decrease in frontal lobe volume and an increase in whole brain lesion volumes (p < .05). Our findings suggest that atrophy and high intensity lesions represent relatively independent pathways to late-life MDD. While medical disorders lead to neuropathological changes that are captured on MR imaging as high intensity signals, atrophy may represent a relatively autonomous phenomenon. These findings have broad implications for the pathophysiology of mood disorders and suggest that complementary neurobiological processes may lead to cumulative neuronal injury thereby predisposing to clinical depression.

Age of onset of depression and quantitative neuroanatomic measures: absence of specific correlates

The purpose of our study was to examine the relationship between volumetric neuroanatomic measures and age of onset of illness in subjects with late-life major depression. Our sample was composed of 51 elderly subjects with Major Depressive Disorder who were scanned using a 1.5-tesla GE magnetic resonance imaging scanner with head coil. Absolute total and focal brain volumes were obtained together with quantified estimates of high intensity lesions. The relationship of these measures to onset age was examined using a regression while adjusting for subjects' current age and total intracranial volume. There was no significant linear relationship between age of onset of the first episode and any of the neuroanatomic measures examined. These data do not support the notion that neuroanatomical contributions to depression increase with a later age of onset of illness.

Behavioral and neuroendocrine characteristics of the night-eating syndrome

CONTEXT

Investigators first described the night-eating syndrome (NES), which consists of morning anorexia, evening hyperphagia, and insomnia, in 1955, but, to our knowledge, this syndrome has never been subjected to careful clinical study.

OBJECTIVE

To characterize NES on the basis of behavioral characteristics and neuroendocrine data.

DESIGN AND SETTING

A behavioral observational study was conducted between January 1996 and June 1997 in a weight and eating disorders program at the University of Pennsylvania. A neuroendocrine study was conducted from May through August 1997 at the Clinical Research Center of the University Hospital, Tromso, Norway.

SUBJECTS

The behavioral study included 10 obese subjects who met criteria for NES and 10 matched control subjects. The neuroendocrine study included 12 night eaters and 21 control subjects. Behavioral study subjects were observed for 1 week on an outpatient basis, and neuroendocrine study subjects were observed during a 24-hour period in the hospital.

MAIN OUTCOME MEASURES

The behavioral study measured timing of energy intake, mood level, and sleep disturbances. The neuroendocrine study measured circadian levels of plasma melatonin, leptin, and cortisol.

RESULTS

In the behavioral study, compared with control subjects, night eaters had more eating episodes in the 24 hours (mean [SD], 9.3 [0.6] vs 4.2 [0.2]; P<.001) and consumed significantly more of their daily energy intake at night than did control subjects (56% vs 15%; P<.001). They averaged 3.6 (0.9) awakenings per night compared with 0.3 (0.3) by controls (P<.001). In night eaters, 52% of these awakenings were associated with food intake, with a mean intake per ingestion of 1134 (1197) kJ. None of the controls ate during their awakenings. In the neuroendocrine study, compared with control subjects, night eaters had attenuation of the nocturnal rise in plasma melatonin and leptin levels (P<.001 for both) and higher circadian levels of plasma cortisol (P = .001).

CONCLUSION

A coherent pattern of behavioral and neuroendocrine characteristics was found in subjects with NES.

Sex differences in brain gray and white matter in healthy young adults: correlations with cognitive performance

Sex-related differences in behavior are extensive, but their neuroanatomic substrate is unclear. Indirect perfusion data have suggested a higher percentage of gray matter (GM) in left hemisphere cortex and in women, but differences in volumes of the major cranial compartments have not been examined for the entire brain in association with cognitive performance. We used volumetric segmentation of dual echo (proton density and T2-weighted) magnetic resonance imaging (MRI) scans in healthy volunteers (40 men, 40 women) age 18-45. Supertentorial volume was segmented into GM, white matter (WM), and CSF. We confirmed that women have a higher percentage of GM, whereas men have a higher percentage of WM and of CSF. These differences sustained a correction for total intracranial volume. In men the slope of the relation between cranial volume and GM paralleled that for WM, whereas in women the increase in WM as a function of cranial volume was at a lower rate. In men the percentage of GM was higher in the left hemisphere, the percentage of WM was symmetric, and the percentage of CSF was higher in the right. Women showed no asymmetries. Both GM and WM volumes correlated moderately with global, verbal, and spatial performance across groups. However, the regression of cognitive performance and WM volume was significantly steeper in women. Because GM consists of the somatodendritic tissue of neurons whereas WM comprises myelinated connecting axons, the higher percentage of GM makes more tissue available for computation relative to transfer across distant regions. This could compensate for smaller intracranial space in women. Sex difference in the percentage and asymmetry of the principal cranial tissue volumes may contribute to differences in cognitive functioning.

Potential utility of electronic drug compliance monitoring in measures of adverse outcomes associated with immunosuppressive agents

Poor compliance with prescribed medications limits the effectiveness of many pharmacologic therapies and enhances their potential toxicities. Traditional methods of measuring drug-taking behavior, including direct observation, patient self-report, pill counts, and therapeutic drug level monitoring, all have well-described limitations in validity and interpretability. Electronic medication event monitoring has been used to assess compliance with therapies for hypertension, glaucoma, anemia, and epilepsy, overcoming many problems of traditional approaches. However, no published reports describe the use of electronic monitoring with immunosuppressive agents, despite their increasing use for non-life-threatening conditions and their many dose-dependent toxicities. Transplant recipients are thought to be at particular risk from noncompliance. Therefore, we undertook this study to assess the feasibility of electronically monitoring compliance with immunosuppressive drugs among renal allograft recipients. Twenty-five kidney transplant patients receiving immunosuppressive medications from a single pharmacy were enrolled. Each subject received electronic monitors with their immunosuppressive serum drug refills for cyclosporine and azathioprine. Each subject returned their monitors after the first month of this 2-month study for downloading data. The frequency distribution of interdose intervals were described. Two measures of average non-compliance were calculated for both drugs: the proportion of monitored days that had missed doses, and the proportion of missed doses. Once daily and twice daily regimens of cyclosporine were compared. Concordance in drug compliance between the two drugs was calculated for each subject and averaged over the study population. Twenty-two of 25 subjects missed one or more doses of cyclosporine or azathioprine. Seventeen (68%) subjects never missed four or more consecutive doses. Subjects were non-compliant with cyclosporine on 8.7% of monitored days, and non-compliance with azathioprine on 9.8% of monitored days. Subjects were non-compliant with 6.8% of their cyclosporine doses and 9.8% of their azathioprine doses. Patients were compliant with both drugs on 86.6% of days and were non-compliant with both drugs on 5.1% of days. Subjects were non-compliant with cyclosporine during 5% and 13.2% of monitored days for once and twice daily dosing regimens, respectively. Concordance analysis demonstrated that for 91.7% of days of monitoring, compliance information was identical for both drugs. This study demonstrated the feasibility of electronic medication event monitoring among kidney transplant patients. This methodology represents an important tool for monitoring compliance of immunosuppressive agents essential to their safe and effective use, and should be considered for use in future studies of these drugs and others with substantial dose-dependent toxicity.

Subcortical MRI volumes in neuroleptic-naive and treated patients with schizophrenia

OBJECTIVE

This study examined whether subcortical volumes of the basal ganglia and thalamus in schizophrenic patients are related to neuroleptic exposure and symptom severity.

METHOD

Basal ganglia substructures and thalamic volumes were measured with magnetic resonance imaging in 96 patients with schizophrenia (50 men and 46 women) and 128 healthy comparison subjects (60 men and 68 women). Twenty-one of the patients were neuroleptic-naive; of the 75 previously treated patients, 48 had received typical neuroleptics only, and 27 had received typical and atypical neuroleptics. The relation of volume measures to treatment status, exposure to neuroleptics, and symptoms was examined.

RESULTS

The neuroleptic-naive patients did not differ from the healthy comparison subjects in subcortical volumes except for lower thalamic volume. In the neuroleptic-naive group, volumes did not correlate with severity of negative symptoms, but higher volumes in both the thalamus and the putamen were associated with more severe positive symptoms. The previously treated group showed higher volumes in the putamen and globus pallidus than the healthy comparison subjects and the neuroleptic-naive patients. In the treated group, a higher dose of a typical neuroleptic was associated with higher caudate, putamen, and thalamus volumes, whereas a higher dose of an atypical neuroleptic was associated only with higher thalamic volume. Higher subcortical volumes were mildly associated with greater severity of both negative and positive symptoms.

CONCLUSIONS

Increased subcortical volumes in treated schizophrenic patients seem to be medication-induced hypertrophy. This hypertrophy could reflect structural adaptation to receptor blockade and may moderate the effects of neuroleptic treatment.

Premorbid educational attainment in schizophrenia: association with symptoms, functioning, and neurobehavioral measures

BACKGROUND

The purpose of this study was to examine the association of educational attainment with phenomenology and neurobehavioral measures assessing brain structure and function in schizophrenia.

METHODS

One hundred sixty-two patients with schizophrenia were divided into two groups on the basis of educational attainment: > or = 13 years of education was the cutoff between the high and low groups. The two education groups were compared on symptomatology, functioning, and subsamples on neuropsychological profile, brain volume by magnetic resonance imaging, and brain metabolism by fluorodeoxyglucose positron-emission tomography.

RESULTS

The patients with more education had lower levels of psychotic symptomatology than their counterparts with less education. This was most evident for affective flattening, alogia, avolition, and bizarre behavior. The higher education group also had better ratings on premorbid adjustment, and the engagement and vocational factors of the Quality of Life Scale. Patients in the high education group also performed better on the neuropsychological battery. There were no brain volume differences or differences in brain metabolism between the two education groups.

CONCLUSIONS

Education is an important indicator of premorbid function and is related to the clinical presentation of schizophrenia.

Late-onset minor and major depression: early evidence for common neuroanatomical substrates detected by using MRI

The purpose of our study was to examine the neuroanatomical correlates of late-onset minor and major depression and to compare them with similar measures obtained from nondepressed controls. Our study groups were comprised of 18 patients with late-onset minor depression, 35 patients diagnosed with late-onset major depression, and 30 nondepressed controls. All subjects were scanned by using a 1. 5-tesla MRI scanner. Absolute whole brain volume and normalized measures of prefrontal and temporal lobe volumes were obtained and used for comparison among groups. Our findings indicate that patients with minor depression present with specific neuroanatomical abnormalities that are comparable with the major depression group but significantly different from the controls. Normalized prefrontal lobe volumes show a significant linear trend with severity of depression, with volumes decreasing with illness severity. Whole brain volumes did not differ significantly among groups. These findings have broad implications for the biology of late-life depression and suggest that there may be common neurobiological substrates that underlie all clinically significant forms of late-onset mood disturbances.

A follow-up magnetic resonance imaging study of schizophrenia. Relationship of neuroanatomical changes to clinical and neurobehavioral measures

BACKGROUND

Cross-sectional neuroanatomical studies have reported abnormalities in schizophrenia that relate to disease variables. Longitudinal neuroimaging investigations that integrate anatomical, clinical, and neurobehavioral measures may help clarify the pathogenesis of schizophrenia.

METHODS

Magnetic resonance brain imaging and neurobehavioral studies were conducted at baseline and after 30.63 +/- 12.92 months (mean +/- SD) in 40 patients with schizophrenia (23 men and 17 women) and 17 healthy controls (13 men and 4 women). The schizophrenia group included 20 first-episode and 20 previously treated subjects. Volumes of whole-brain, cerebrospinal fluid, and frontal and temporal lobes were measured. The severity of negative and positive symptoms was assessed, medications were monitored, and neurobehavioral functioning in 8 domains was evaluated.

RESULTS

Both first-episode and previously treated patients had smaller brains and frontal and temporal lobes than controls at intake. Longitudinally, reduction in frontal lobe volume was found only in patients, whereas temporal lobe reduction was also seen in controls. The association between volume reduction and symptom changes differed between patient groups, but volume reduction was associated with decline in some neurobehavioral functions in both groups. Exploratory analysis suggested that neuroleptic dose is correlated with changes in all 3 domains.

CONCLUSIONS

The existence of neuroanatomical and neurobehavioral abnormalities in patients with first-episode schizophrenia indicates that the brain dysfunction occurred before clinical presentation. However, there is also evidence of progression, in which anatomical changes may affect some clinical and neurobehavioral features of the illness in some patients.

Identification of medications that cause cognitive impairment in older people: the case of oxybutynin chloride

OBJECTIVES

To evaluate the cognitive effects of acute challenges with the antispasmodic agent oxybutynin hydrochloride in normal older volunteers and to compare these effects with those attributable to diphenhydramine, another commonly used medication with anticholinergic (muscarinic-blocking) activity.

DESIGN

A double-blind, placebo-controlled cross-over study.

SETTING

Laboratory evaluations of community subjects.

PARTICIPANTS

A convenience sample of 12 volunteers, average age 69.17 years.

INTERVENTION

Baseline assessment was followed by randomized administration of a placebo, oxybutynin hydrochloride (5 and 10 mg), and diphenhydramine hydrochloride (50 mg) in test sessions separated by 1 week.

MEASUREMENTS

Evaluation of cognitive performance with a 1-hour battery of pencil and paper, interviewer-administered, and computer-administered tests beginning 90 minutes after drug (or placebo) administration.

RESULTS

Random regression analyses demonstrated that oxybutynin caused significant cognitive decrements on seven of 15 cognitive measures, and diphenhydramine caused decrements on five measures. The most sensitive measures for detecting the effects of oxybutynin hydrochloride were the Buschke Selective Reminding Test and Reaction Time.

CONCLUSIONS

These findings demonstrate that oxybutynin can cause cognitive impairment and suggest that physicians prescribing it should monitor their patients to facilitate the early recognition of those who experience drug-related cognitive deficits. More generally, the findings demonstrate that systematic research with normal volunteers can identify cognitive toxicity not recognized during the process of drug development or postmarketing surveillance.

Olfactory identification deficits in schizophrenia: correlation with duration of illness

OBJECTIVE

The authors examined the relationship between deficits in olfactory identification and duration of illness in young and elderly patients with schizophrenia.

METHOD

Olfactory identification performance of 38 patients with schizophrenia and 40 normal subjects was compared by using the University of Pennsylvania Smell Identification Test.

RESULTS

The schizophrenic patients demonstrated olfactory deficits relative to the comparison group, and the elderly schizophrenic patients displayed a greater magnitude of olfactory deficit than the younger patients. Independent of normal aging effects and cognitive deficit, patients with schizophrenia showed a strong relationship between olfactory identification scores and duration of illness, which suggests that olfactory abilities decline progressively over the course of the disorder.

CONCLUSIONS

In contrast to other neuropsychological measures that have been reported to be stable over the course of illness, olfactory identification abilities deteriorate steadily in patients with schizophrenia, even for those with relatively recent onset.

Neuroanatomical substrates of late-life minor depression. A quantitative magnetic resonance imaging study

OBJECTIVE

To examine the neuroanatomical correlates of late-life minor depression using magnetic resonance imaging.

DESIGN

Cross-sectional quantitative magnetic resonance imaging study of elderly patients with minor depression and age-matched controls.

SETTING

Patients and controls were recruited from the community through advertisements to the Section of Geriatric Psychiatry, University of Pennsylvania, Philadelphia.

PARTICIPANTS

Our sample included 18 subjects diagnosed as having minor depression using the modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, research criteria and 31 controls without depression. Patients were free of other central nervous system disease and both groups had comparable degrees of medical comorbidity.

MAIN OUTCOME MEASURES

All images were acquired on a 1.5-T scanner and absolute and normalized quantitative measures of global and focal brain and cerebrospinal fluid volumes were compared between groups.

RESULTS

Prefrontal lobe volume was significantly smaller in the group with minor depression (P = .002) compared with controls after controlling for age, sex, and age by sex interactions. More global measures of brain and cerebrospinal fluid volumes were comparable in both groups.

CONCLUSIONS

These data suggest that focal prefrontal atrophy may provide an important neuroanatomical substrate in late-life minor depression.

Lateralized changes in regional cerebral blood flow during performance of verbal and facial recognition tasks: correlations with performance and "effort"

Functional neuroimaging has been used to investigate neural substrates of mnemonic processes, and cerebral blood flow (CBF) measures have been sensitive to activation with memory tasks. Studies of memory with two-dimensional 133Xenon clearance techniques found that word and face recognition tasks produced contralateral CBF changes in mid-temporal cortical regions. This study replicated the activation paradigm, expanding to the three-dimensional resolution of positron emission tomography (PET). Word and face recognition, and a control baseline task were administered to 19 healthy right-handed volunteers (11 men, 8 women) during successive 10 min PET 15O-water measures of CBF. Quantitative CBF rates were calculated with the arterial input function and the equilibrium model. Redistributions of blood flow were compared across tasks-using both absolute and relative (region/ whole brain) CBF. Replicating the 133Xenon clearance findings, CBF was "appropriately" lateralized during task performance (left-right for words > left-right for faces) in the mid-temporal region. Contrary to predictions, the recognition tasks did not activate expected mesolimbic or prefrontal areas. The task-induced CBF changes also correlated with performance. Bilateral CBF in mid-temporal and parahippocampal gyrus regions of interest correlated with the ability to correctly identify word targets (sensitivity). Left-lateralized CBF in the amygdala and hippocampus correlated with better word sensitivity as well as specificity (ability to correctly reject foils). Complementally, right-lateralized CBF in the parahippocampal gyrus correlated with better face specificity performance. In addition, left-lateralized CBF in the amygdala and right-lateralized CBF in the parahippocampal gyrus and hippocampus correlated with "mental effort" indices (task performance relative to basal ability) for word and face memory tasks, respectively. Thus, whereas this recognition task showed the expected lateralized increase in the mid-temporal region and not in frontal and limbic areas, lateralized activation in some of these areas was associated with better performance. Exploratory analyses on other regions showed lateralized changes in one additional temporal region, the occipital-temporal, and several limbic regions.

Limb swelling in patients who have fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva is a rare heritable disorder of connective tissue characterized by progressive heterotopic ossification of soft tissues and by congenital malformation of the great toes. Limb swelling has also been noted, yet little is known about this complication of fibrodysplasia ossificans progressiva. To determine the prevalence of limb swelling in this condition, the authors reviewed detailed medical records on 74 patients (25 males, 49 females; age range, 1-49 years) who had a documented history of fibrodysplasia ossificans progressiva. The study population included more than 90% of all patients known to have fibrodysplasia ossificans progressiva in the United States. Acute swelling of the limbs occurred in association with flareups of the condition in nearly all cases. Acute swelling in the upper limbs was focal and nodular in contrast to acute swelling in the lower limbs, which was more diffuse. Acute swelling in the upper limbs occurred in all 74 patients whereas acute swelling in the lower limbs occurred in 47 of the 74 patients (64%). Two of the 74 patients who had acute swelling in the lower limbs (4%) had a documented episode of deep vein thrombophlebitis. Chronic swelling in the upper limbs occurred in 9 of the 74 patients (12%) and was not seen before the age of 12 years. Chronic swelling in the lower limbs occurred in 36 of the 74 patients (49%) and was not seen before the age of 9 years. The intense angiogenesis and edema seen on histopathologic evaluation of preosseous fibrodysplasia ossificans progressiva lesions may play a role in the pathogenesis of the limb swelling. The data show an age related prevalence of limb swelling in fibrodysplasia ossificans progressiva and suggest a model for understanding the complex pathways leading to limb swelling in this disorder.

MR evaluation of patients with congenital hyposmia or anosmia

OBJECTIVE

The purpose of this study was to evaluate patients with reduced or no sense of smell since birth for sites of abnormality by MR imaging.

MATERIALS AND METHODS

Twenty-five patients who reported no olfactory function since birth were evaluated by olfactory testing, sinonasal endoscopy, and MR imaging. Surface coil and head coil images of the olfactory bulbs, olfactory tracts, subfrontal cortex, and temporal lobes in contiguous 3-mm sections were obtained. Two reviewers determined unilateral olfactory bulb and tract volumes and temporal lobe volumes in two separate sessions. Qualitative grading for olfactory bulb, olfactory tract, olfactory sulcus, subfrontal region, hippocampus, and temporal lobe damage also was performed.

RESULTS

The absence of olfactory bulbs and tracts (68-84%) or the presence of hypoplasia (16-32%) was noted in all cases. Eight individuals had Kallmann's syndrome (hypogonadotropic hypogonadism with anosmia). Temporal and/or frontal lobe volume loss was noted in five individuals and was mild in all but one individual.

CONCLUSION

Congenital anosmia or hyposmia appears to be an olfactory bulb-olfactory tract phenomenon rather than a cerebral process.

Aberrant integrin expression in the endometrium of women with endometriosis

Integrins are ubiquitous cell adhesion molecules that undergo dynamic alterations during the normal menstrual cycle in the human endometrium. The alpha v beta 3 vitronectin receptor integrin is expressed in endometrium at the time of implantation, but its presence is delayed in endometrium that is assessed to be out of phase using classical histological features. To investigate the expression of this integrin in women with endometriosis, we assessed the presence of the beta 3-subunit throughout the menstrual cycle in 268 "in-phase" endometrial biopsies, using immunohistochemistry. The beta 3-subunit was expressed on endometrial epithelium after days 19-20 of the menstrual cycle. In 241 women whose biopsies were obtained after day 19, a lack of beta 3 expression was found to be closely related to the diagnosis of endometriosis (by Wilcoxon test, P = 0.02). This defect in integrin expression was associated with nulliparity, inversely related to the stage of disease, and occurred despite the presence of in-phase histological features. In a prospective double blind assessment of this integrin, we found endometrial beta 3 analysis to have a high specificity and positive predictive value as a nonsurgical diagnostic test for minimal and mild endometriosis. In conclusion, aberrant integrin expression in the native endometrium is associated with the finding of endometriosis and may identify some women with decreased cycle fecundity due to defects in uterine receptivity.

Long-term course of hospitalization for schizophrenia: Part II. Change with passage of time

This analysis examines the notion of progressive deterioration in schizophrenia, using long-term followup data on hospital episodes in defined cohorts from psychiatric case registers in Victoria, Australia; Denmark; and Salford, England. The analyses differentiate heterogeneity existing at the first hospitalization for schizophrenia, which produces a widely varying natural course, from heterogeneity that develops over time, as episodes of hospitalization occur. Episodes of hospitalization for schizophrenia tend to cluster earlier rather than later in the treatment career, suggesting a progressive amelioration rather than deterioration. When overall chronicity is adjusted, each additional episode of hospitalization lowers the risk for a further hospitalization by about 10 percent.

Long-term course of hospitalization for schizophrenia: Part I. Risk for rehospitalization

The probability of rehospitalization following the initial discharge on which a diagnosis of schizophrenia was made is described using data from psychiatric case registers in Victoria, Australia; Maryland, U.S.A.; Denmark; and Salford, England. The percentage eventually rehospitalized, after followup intervals as long as two decades, varies from about 50 to 80 percent in the four service systems. Survival curves for duration in the community without rehospitalization bend sharply in the period between 2 and 3 years following discharge in all four cohorts and are almost flat after 20 years. Early age of onset predicts higher risk for rehospitalization in multivariate proportional hazards models in each cohort. When age of onset is included as a covariate, neither gender nor marital status has consistent or statistically significant effects on risk for rehospitalization.