[Anticholinergic scales: Use in psychiatry and update of the anticholinergic impregnation scale]

Anticholinergic properties are well known to prescribers, notably in mental health, as a therapeutic strategy for i.e. extrapyramidal syndrome but also as a source of numerous adverse side effects. Herein, we propose a narrative literature review describing: (i) cholinergic pharmacology and anticholinergic properties; (ii) the importance of anticholinergic therapeutic properties in psychiatry; (iii) the existing anticholinergic drug scales and their usage limitations in Psychiatry and; last (iv) an update to the anticholinergic drug impregnation scale, designed for the French psychiatry practice. The anticholinergic side effects can appear both in the peripheral level (dry mouth, constipation, etc.) and in the central level (especially as cognitive deficits). Many of the so called « anticholinergic » drugs are in fact entirely or mostly antimuscarinic and act essentially as parasympathetic system antagonists. Overall, anticholinergic/antimuscarinic side effects are usually attributed to psychotropic medications: to certain antipsychotics, notably classical neuroleptics such as phenothiazine and also to tricyclic antidepressants. In practice, the impact of anticholinergic toxicity treatments is often highlighted due to their excessively prolonged use in patients on antipsychotics. Interestingly, these antipsychotic treatments are better known for their anticholinergic side effects, especially cognitive ones, with an early onset specially in elder patients and/or in the case of polymedication. In order to evaluate anticholinergic side effects, metrics known as anticholinergic burden scales were created in the last few decades. Nowadays, 13 different scales are documented and accepted by the international academic community, but only three of them are commonly used: the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB). All of them are based on a similar principle, consisting of grading treatments individually, and they are normally scored from 0 - no presence of side effects - to 3 - anticholinergic effects considered to be strong or very strong. Using these scales enables the calculation of the so-called "anticholinergic burden", which corresponds to the cumulative effect of using multiple medications with anticholinergic properties simultaneously. The application of anticholinergic scales to patients with psychiatric disorders has revealed that schizophrenic patients seem to be especially sensitive to anticholinergic cognitive side effects, while elder and depressed patients were more likely to show symptoms of dementia when exposed to higher anticholinergic burden. Unfortunately, these tools appear to have a low parallel reliability, and so they might induce large differences when assessing side effects predictability. In addition, the capacity of these scales to predict central adverse effects is limited due to the fact they poorly or do not differentiate, the ability of treatments to cross the blood-brain barrier. Finally, one last limitation on the validity of these scales is prescription posology is not accounted for side effects considered to be dose dependent. Recently, the MARANTE (Muscarinic Acetylcholine Receptor ANTagonist Exposure) scale has incorporated an anticholinergic burden weighting by posology. Nevertheless, this new model can be criticized, due to the limited number of medications included and due to testing a limited number of potency ranges and dosages for each treatment. Herein, we propose an update to the Anticholinergic Impregnation Scale, developed specifically for the French Psychiatry practice. The scale validation was based on an evaluation of the prescriptions correcting anticholinergic peripheral side effects (constipation, xerostomia and xeropthalmia). This indirect evaluation allowed us to show patients with an anticholinergic impregnation score higher than 5 received significantly more treatments for constipation and xerostomia. This strategy bypasses the bias of a cognitive evaluation in patients with severe mental health disorders. Moreover, the relevance of a tool developed specifically for French psychiatry is justified by the fact that some highly prescribed treatments for mental illness in France (cyamemazine and tropatemine) are strong anticholinergics, and also by the fact they are rarely included in the existing anticholinergic scales. This update of the original scale, published in 2017, includes information whether prescribed drugs cross the blood-brain barrier and thus makes possible a more accurate assessment when evaluating anticholinergic central side effects. Finally, the anticholinergic impregnation scale will soon be integrated into a prescription help software, which is currently being developed to take into consideration dose dependent adverse effects.

Geographical differences in survival of dogs with non-Hodgkin lymphoma treated with a CHOP based chemotherapy protocol

BACKGROUND

In humans geographical differences in the incidence and presentation of various cancers have been reported. However, much of this information has not been collected in veterinary oncology.

AIM

The purpose of this study was to determine if a geographic difference in progression free survival exists for dogs with lymphoma treated within the US.

MATERIALS AND METHODS

Medical records of 775 cases of canine lymphoma from 3 US regions (west, south and north), treated with CHOP chemotherapy, were retrospectively evaluated. Cases were collected from referral institutions and were required to have received at least one doxorubicin treatment and have follow up information regarding time to progression.

RESULTS

Significant differences in sex (p = 0.05), weight (p = 0.049), stage (p < 0.001), immunophenotype (p = <0.001), and number of doxorubicin doses (p = 0.001) were seen between regions. Upon univariate analysis, progression free survival (PFS) differed by region (p = 0.006), stage (p = 0.009), sub-stage (p = 0.0005), and immunophenotype (p = 0.001). A multivariable Cox regression model showed that dogs in the western region had a significantly shorter PFS when compared to the south and east.

CONCLUSION

PFS was significantly affected by stage, sub-stage and phenotype.

Validation of a Multiplexed Gene Signature Assay for Diagnosis of Canine Cancers from Formalin-Fixed Paraffin-Embedded Tissues

Background

Use of molecular‐based diagnostics for companion animals is impeded by availability of technology platforms, tissue acquisition requirements, and species‐specific reagents.

Hypothesis/Objectives

To validate a quantitative nuclease protection assay (qNPA) to simultaneously measure RNA expression of multiple genes in archived formalin‐fixed paraffin‐embedded (FFPE) tumors from dogs.

Animals

All tumor biopsy samples were collected retrospectively from surgical biopsies and in the care of veterinarians.

Methods

Retrospective case series. A qNPA 96‐well ArrayPlate was built using 30 canine‐specific genes, 5 housekeeping genes, positive and negative controls with qualified gene‐specific oligonucleotides. Pearson's correlation, coefficient of variation (CV), and multivariate analysis were used to determine analytical performance using 40 FFPE dog tumors. Once validated, 70 FFPE dog tumors were analyzed for differences in gene expression using hierarchical clustering and analysis of variance of log transformed data. Immunohistochemistry (IHC) was performed to correlate gene expression and protein expression in a subset of tumors.

Results

The assay was linear with decreasing sample input (R² = 0.978), reproducible within and between 96‐well plates (r = 0.988 and 0.95, respectively) and between different laboratories (CV = 0.96). Hierarchical cluster analysis showed grouping of tumors by histogenesis and oncogenes. Significant differences were found between BCl2, E2F transcription factor 1, MDM2, COX‐2, MET proto‐oncogene receptor kinase, and other biologically relevant gene expression in tumor subtypes. Immunohistochemistry confirmed protein expression.

Conclusions and Clinical Implications

Because this technology works reliably on FFPE specimens, it can help expedite the broad introduction of multiplexed genomic information for improved diagnostics and discovery of new targets for therapies in veterinary oncology.

Recurrence rates and clinical outcome for dogs with grade II mast cell tumours with a low AgNOR count and Ki67 index treated with surgery alone

Grade II mast cell tumours (MCT) are tumours with variable biologic behaviour. Multiple factors have been associated with outcome, including proliferation markers. The purpose of this study was to determine if extent of surgical excision affects recurrence rate in dogs with grade II MCT with low proliferation activity, determined by Ki67 and argyrophilic nucleolar organising regions (AgNOR). Eighty-six dogs with cutaneous MCT were evaluated. All dogs had surgical excision of their MCT with a low Ki67 index and combined AgNORxKi67 (Ag67) values. Twenty-three (27%) dogs developed local or distant recurrence during the median follow-up time. Of these dogs, six (7%) had local recurrence, one had complete and five had incomplete histologic margins. This difference in recurrence rates between dogs with complete and incomplete histologic margins was not significant. On the basis of this study, ancillary therapy may not be necessary for patients with incompletely excised grade II MCT with low proliferation activity.

Unaltered instrumental learning and attenuated body-weight gain in rats during non-rotating simulated shiftwork

Exposure to shiftwork has been associated with multiple health disorders and cognitive impairments in humans. We tested if we could replicate metabolic and cognitive consequences of shiftwork, as reported in humans, in a rat model comparable to 5 wks of non-rotating night shifts. The following hypotheses were addressed: (i) shiftwork enhances body-weight gain, which would indicate metabolic effects; and (ii) shiftwork negatively affects learning of a simple goal-directed behavior, i.e., the association of lever pressing with food reward (instrumental learning), which would indicate cognitive effects. We used a novel method of forced locomotion to model work during the animals' normal resting period. We first show that Wistar rats, indeed, are active throughout a shiftwork protocol. In contrast with previous findings, the shiftwork protocol attenuated the normal weight gain to 76 ± 8 g in 5 wks as compared to 123 ± 15 g in the control group. The discrepancy with previous work may be explained by the concurrent observation that with our shiftwork protocol rats did not adjust their between-work circadian activity pattern. They maintained a normal level of activity during the "off-work" periods. In the control experiment, rats were kept active during the dark period, normally dominated by activity. This demonstrated that forced activity, per se, did not affect body-weight gain (mean ± SEM: 85 ± 11 g over 5 wks as compared to 84 ± 11 g in the control group). Rats were trained on an instrumental learning paradigm during the fifth week of the protocol. All groups showed equivalent increases in lever pressing from the first (3.8 ± .7) to the sixth (21.3 ± 2.4) session, and needed a similar amount of sessions (5.1 ± .3) to reach a learning criterion (≥ 27 out of 30 lever presses). These results suggest that while on prolonged non-rotating shiftwork, not fully reversing the circadian rhythm might actually be beneficial to prevent body-weight gain and cognitive impairments.

A randomized trial investigating the efficacy and safety of water soluble micellar paclitaxel (Paccal Vet) for treatment of nonresectable grade 2 or 3 mast cell tumors in dogs

BACKGROUND

Effective treatments for dogs with advanced stage mast cell tumors (MCT) remain a pressing need. A micellar formulation of paclitaxel (paclitaxel [micellar]) has shown promise in early-phase studies.

HYPOTHESIS/OBJECTIVES

The objective was to demonstrate greater activity for paclitaxel (micellar) compared with lomustine. The null hypothesis was μ(p) = μ(L) (ie, proportion of responders for the paclitaxel [micellar] and lomustine groups, respectively).

ANIMALS

Two hundred and fifty-two dogs with advanced stage nonresectable grade 2 or 3 MCT.

METHODS

Prospective multicenter randomized double-blind positive-controlled clinical trial. The primary endpoint was confirmed overall response rate (CORR) at 14 weeks. A secondary endpoint, biologic observed response rate (BORR), also was calculated. Safety was assessed by the characterization and grading of adverse events (AE).

RESULTS

Overall CORR (7% versus 1%; P = .048) and BORR (23% versus 10%; P = .012) were greater for paclitaxel (micellar) compared with lomustine. Paclitaxel (micellar)-treated dogs were 6.5 times more likely to have a confirmed response and 3.1 times more likely to experience a biologic observed response. The majority of AE with paclitaxel (micellar) were transient and clinically manageable. Twenty-seven dogs (33%) receiving lomustine were discontinued because of hepatopathy compared with 3 dogs (2%) receiving paclitaxel (micellar) (P < .0001; odds ratio 26.7).

CONCLUSIONS AND CLINICAL IMPORTANCE

Paclitaxel (micellar)'s activity and safety profile are superior to lomustine. The addition of an active and novel taxane to the veterinary armamentarium could fill a substantial need and, as its mechanism of action and AE profile do not overlap with currently available TKI, its availability could lead to effective combination protocols.

Development of the mizes anorectic cognitions questionnaire-revised: psychometric properties and factor structure in a large sample of eating disorder patients

OBJECTIVE

This project was designed to develop and test the psychometric properties and factor structure of a revision of the Mizes Anorectic Cognitions questionnaire (MAC). The goals of the revision were to improve the reliability and discriminant validity of the Weight and Approval subscale and to equalize the length of the three subscales. Also, the study compared the original MAC and the MAC-R in terms of their psychometric properties.

METHOD

Twenty-four new items were developed for potential inclusion in the MAC-R, in addition to the original 33 items of the MAC. These items were administered to 205 eating disorder patients from five eating disorder clinics or programs, including inpatient, outpatient, and residential treatment settings that served diverse patient populations. Additionally, other measures of eating disorder constructs were administered to assess construct validity.

RESULTS

Factor analysis of the large pool of items and item reduction resulted in the final 24-item MAC-R, each subscale being eight items in length. Results showed that the MAC-R highly correlated with the MAC and other eating disorder questionnaires. Reliability of the MAC-R was improved over that of the MAC. Two subscales of the MAC-R discriminated among diagnostic groups, whereas the original MAC did not, indicating improved sensitivity of the revised scale.

DISCUSSION

The MAC-R appears to be an improvement over the original MAC. It provides useful information on the cognitions of eating-disordered patients and merits further investigation into its psychometric properties.

Pathways and roadblocks in muscarinic receptor-mediated growth regulation

In some cell systems muscarinic receptor stimulation can induce proliferation or transformation. This phenomenon is subtype-specific (only m1 and m3 receptors are effective) and cell type dependent. In 1321N1 astrocytoma cells activation of m3 receptors stimulates phospholipase C, but does not induce DNA synthesis. In contrast the thrombin receptor, which also couples to phospholipase C, is strongly mitogenic and induces AP-1-dependent gene expression. Various experimental findings indicate that this discrepancy is not due to muscarinic receptor desensitization or blockade of growth stimulatory pathways. Muscarinic receptor number may be limiting, in particular for receptor coupling to the pertussis toxin-insensitive G-protein G12. This G-protein is required for thrombin-induced mitogenesis in 1321N1 cells and may couple selectively to the thrombin versus muscarinic receptor. In cardiomyocytes hypertrophic cell growth is induced by heterologously expressed m1 or m3 receptors but not by the endogenous m2 receptors. Studies using chimeric receptors confirm that induction of hypertrophy requires signalling through phospholipase C, but indicate that additional signals are needed to induce the morphological features of this response. We suggest that small G-proteins of the Rho subfamily, in addition to G12, mediate growth responses to G-protein-coupled receptors.

Nonhematopoietic hepatic neoplasms in cats: 21 cases (1983-1988)

Nonhematopoietic hepatic neoplasms (n = 25) were diagnosed in 21 cats during a 5.5-year period. Thirteen of the neoplasms were benign bile duct adenomas and 12 were malignant, 6 of which were bile duct adenocarcinomas. All cats were greater than or equal to 10 years old, and 14 were male. Main clinical signs were anorexia and lethargy, and 15 of 21 cats had hepatomegaly. All 21 cats were feline leukemia virus-test negative. Although there was a trend toward high activities of serum alanine transaminase and aspartate transaminase, neither clinical signs nor enzyme activity were specific for diagnosis of hepatic neoplasia in the cats of this study.

Effect of counting errors on immunoassay precision

Using mathematical analysis and computer simulation, we studied the effect of gamma scintillation counting error on two radioimmunoassays (RIAs) and an immunoradiometric assay (IRMA). To analyze the propagation of the counting errors into the estimation of analyte concentration, we empirically derived parameters for logit-log data-reduction models for assays of digoxin and triiodothyronine (RIAs) and ferritin (IRMA). The component of the analytical error attributable to counting variability, when expressed as a CV of the analyte concentration, decreased approximately linearly with the inverse of the square root of the maximum counts bound. Larger counting-error CVs were found at lower concentrations for both RIAs and the IRMA. Substantially smaller CVs for overall assay were found when the maximum counts bound progressively increased from 500 to 10,000 counts, but further increases in maximum bound counts resulted in little decrease in overall assay CV except when very low concentrations of analyte were being measured. Therefore, RIA and IRMA systems based in duplicate determinations having at least 10,000 maximum counts bound should have adequate precision, except possibly at very low concentrations.

Effect of counting errors on immunoassay precision

Using mathematical analysis and computer simulation, we studied the effect of gamma scintillation counting error on two radioimmunoassays (RIAs) and an immunoradiometric assay (IRMA). To analyze the propagation of the counting errors into the estimation of analyte concentration, we empirically derived parameters for logit-log data-reduction models for assays of digoxin and triiodothyronine (RIAs) and ferritin (IRMA). The component of the analytical error attributable to counting variability, when expressed as a CV of the analyte concentration, decreased approximately linearly with the inverse of the square root of the maximum counts bound. Larger counting-error CVs were found at lower concentrations for both RIAs and the IRMA. Substantially smaller CVs for overall assay were found when the maximum counts bound progressively increased from 500 to 10,000 counts, but further increases in maximum bound counts resulted in little decrease in overall assay CV except when very low concentrations of analyte were being measured. Therefore, RIA and IRMA systems based in duplicate determinations having at least 10,000 maximum counts bound should have adequate precision, except possibly at very low concentrations.

Merogony and gametogony of Eimeria mccordocki (Protozoa-Eimeriidae) in the mule deer, Odocoileus h. hemionus

Eimeria mccordocki and E. madisonensis oocysts were isolated from feces of 21 of 40 captive mule deer in Fort Collins, Colorado. The two species were separated from each other by infecting one mule deer fawn, and the life cycle of E. mccordocki was studied for the first time. Four to six-weeks-old mule deer fawns were inoculated orally with E. mccordocki and killed 9, 13 and 15 days after infection. Asexual and sexual stages of life cycle developed in the ileum of mule deer, only in the surface epithelial cells of the villi. The asexual stages consisted of two generations of meronts.

Metabolism of benzene and phenol in macrophages in vitro and the inhibition of RNA synthesis by benzene metabolites

Benzene may affect hemopoiesis by damaging the bone marrow stroma that provides the microenvironment for hemopoiesis. A possible target of benzene toxicity in the stroma is the macrophage, which is a major source of protein factors required for the proliferation and differentiation of progenitor cells. As an initial approach towards understanding whether benzene inhibits hemopoietic factor production in bone marrow stroma, the metabolism of benzene and phenol has been studied and the effect of benzene and its metabolites on macrophage RNA synthesis has been examined. Benzene is not metabolized in macrophages but phenol, the major metabolite of benzene in bone marrow, is converted by peroxidase in the macrophage to both free metabolites and species which covalently bind to cellular macromolecules. Benzene and its metabolites inhibited RNA synthesis in a dose-dependent manner, with 50% inhibitory concentrations of 5 X 10(-3) M for benzene, 2.5 X 10(-3) M for phenol, 2.5 X 10(-5) M for hydroquinone, and 6 X 10(-6) M for p-benzoquinone; this inhibition was not attributable to loss of cell viability. Benzene, possibly by an inhibition of uridine transport into macrophages, and phenol, by its conversion to covalently binding species, inhibit RNA synthesis in macrophages and thus may inhibit the synthesis of colony stimulating factors required for hemopoiesis.

Outcome of eclectic psychotherapy in private psychological practice

The outcome of eclectic psychotherapy in a private psychological practice was examined in 69 clients. Target symptoms, life-adjustment ratings, social-adjustment ratings, and therapy expectancy were obtained before and after four months of psychotherapy from clients, therapists, and independent clinical raters. Results indicated that significant change had occurred after four months of psychotherapy for 6 of 10 categories of target complaints, in 9 of 11 areas of life adjustment and in 14 of 22 areas of social adjustment. Overall, 70 percent of clients showed improvement in their symptoms; 14 percent were unchanged and 17 percent deteriorated. The major value of the study is an exploration of psychotherapy outcome under naturalistic conditions in a growing but rarely studied treatment setting.

Experimental coccidiosis in mule deer fawns

Five mule deer fawns (Odocoileus hemionus) ranging in age from 3 to 6 weeks were given sporulated Eimeria mccordocki oocysts orally. Four of the five fawns developed coccidiosis. Initial clinical signs appeared by 8 to 9 days postinoculation and included elevated body temperature and bloody diarrhea. Dehydration and limited emaciation occurred as the disease progressed. The disease was allowed to run its course in one fawn and oocysts were passed in the feces on the 16th day following inoculation. Oocysts passage continued until the 27th day, at which time the animal appeared to be completely recovered. The remaining animals demonstrated all signs of coccidiosis and were euthanized prior to passing oocysts. Intracellular stages of E. mccordocki in these animals were confined to the last 75 to 100 cm of the ileum. The cytoplasm of each infected epithelial cell contained one to five meronts. The intestinal epithelium was inflammatory and contained many necrotic foci.

[HCG-determinations in serum and mammary cyst aspirates in women with benign breast tumors (author's transl)]

Results of HCG-determinations in human serum and cystfluid of benign mammary tumors are presented. HCG was determined gy RIA in 40 samples from 30 patients with different forms of fibro-cystic mastitis. In 60% of the cases positive results were obtained. It is still unclear, whether the demonstrated substance is native HCG, a free beta-subunit, a mixture of both or a different substance with immunologic properties similar to those of HCG.

Coccidia of coyotes in eastern Colorado

Eighty-two coyote fecal samples were collected from eastern Colorado and examined for coccidia. Sporocysts of Sarcocystis were observed in 17 of the samples and oocysts of Isospora ohioensis were observed in two samples. Ten fecal samples contained eimerian coccidia thought to be pseudoparasites of the coyote acquired while ingesting heavily infected rabbits.

Histological alterations in tryptophan-deficient rainbow trout

Tryptophan-deficient and nondeficient synthetic amino acid test diets were prepared using D, L-amino acids. The diets were fed to three groups of rainbow trout (Salmo gairdneri) for 8 weeks. Experimental control fish fed well and grew from 1.3 to 2.5 g. Deficient fish fed poorly and did not gain weight. Scoliosis was observed in the deficient fish after 1 week of feeding. Daily transitory scoliosis was noted in some fish. Histological studies of trypthophan-deficient scoliotic fish revealed hyperemia, disorganization of myomere septa, and protrusions of the fibrous matrix sheath, which invests the notochord. Abnormal deposition of calcium was noted in the kidney and the bony plates surrounding the notochord and sheath. Fish with mechanically induced scoliosis had disorganization of myomere septa, but did not have protrusions of fibrous matrix sheath, nor did they have abnormal calcium deposition in bone or kidney. Scoliotic fish returned to normal within 1 week upon replacement of tryptophan in the ration.