"In the tube" following sternotomy: A quasi-experimental study

BACKGROUND

Traditionally, physical movement has been limited for cardiac surgery patients, up to 12-weeks post-operatively. Patients are asked to use "standard sternal precautions," restricting their arm movement, and thereby limiting stress on the healing sternum.

AIM

To compare return to function, pain/discomfort, wound healing, use of pain medication and antibiotics, and post-operative length of hospital stay in cardiac surgery patients having median sternotomy who used standard sternal precautions or Keep Your Move in the Tube movement protocols post-operatively.

METHODS

A quasi-experimental design was used (100 standard sternal precautions and 100 Keep Your Move in the Tube patients). Patients were followed in person or by telephone over a period of 12-weeks postoperatively. Outcomes were measured at day 7, as well as weeks 4, 8, and 12 weeks.

RESULTS

The majority of participants (77% in each group) were male and had coronary artery bypass graft surgery (66% standard sternal precautions and 72% Keep Your Move in the Tube). Univariate analysis revealed the standard sternal precautions group had lesser ability to return to functional activities than the Keep Your Move in the Tube group (p<0.0001) over time. This difference was minimized however, by week 12. Multivariate analysis revealed that increasing age, body mass index, and female sex were associated with greater functional impairment over time, but no difference between standard sternal precautions and Keep Your Move in the Tube groups.

CONCLUSIONS

Keep Your Move in the Tube, a novel patient-oriented movement protocol, has potential for cardiac surgery patients to be more confident and comfortable in their recovery.

Core-valence double photoionization of the CS(2) molecule

Double photoionization spectra of the CS(2) molecule have been recorded using the TOF-PEPECO technique in combination with synchrotron radiation at the photon energies hν=220, 230, 240, 243, and 362.7 eV. The spectra were recorded in the S 2p and C 1s inner-shell ionization regions and reflect dicationic states formed out of one inner-shell vacancy and one vacancy in the valence region. MCSCF calculations were performed to model the energies of the dicationic states. The spectra associated with a S 2p vacancy are well structured and have been interpreted in some detail by comparison to conventional S 2p and valence photoelectron spectra. The lowest inner-shell-valence dicationic state is observed at the vertical double ionization energy 188.45 eV and is associated with a (2p(3/2))(-1)(2π(g))(-1) double vacancy. The spectrum connected to the C 1s vacancy shows a distinct line at 310.8 eV, accompanied by additional broad features at higher double ionization energies. This line is associated with a (C 1s)(-1)(2π(g))(-1) double vacancy.

A lossless negative dielectric constant from quantum dot exciton polaritons

Prospects for a lossless negative dielectric constant material for optical devices are studied. Simulations show that with sufficient gain, a mixture of two semiconductor quantum dots (QDs) can produce an effective dielectric constant that is lossless and negative. This permits, in concept, arbitrarily small scaling of the optical mode volume, a major goal in the field of nanophotonics. The proposed implementation of a lossless negative dielectric constant material based on colloidal QDs opens a tractable path.

Many-photon dynamics of photobleaching

A detailed dynamical theory of photobleaching by periodical sequences of laser pulses is presented. The theory is used for interpretation of recent experiments with pyrylium salts. Our simulations are based on first-principles simulations of photoabsorption cross-sections and on empirical rate constants. Two competitive channels of photobleaching, namely, photobleaching from the lowest excited singlet and triplet states and from higher excited states, are found to explain different intensity dependences of the photobleaching rates in different samples. The process includes two-photon excitation from the ground state to the first or second excited singlet states and one-photon excitation from the first singlet or triplet states to higher excited states. The fluorescence follows double-exponential dynamics with two characteristic times. The first and the shorter one is the equilibrium settling time between the ground and the lowest triplet states. The second characteristic time, the time of photobleaching, is responsible for the long-term dynamics. The effective rate of photobleaching from the first excited singlet and lowest triplet states depends differently on the irradiance in comparison with the photobleaching in higher states. The first channel is characterized by a quadratic intensity dependence in contrast to the second channel that shows a cubic dependence. The competition between these photobleaching channels is very sensitive to the rate constants as well as to the repetition rate, the pulse duration, and the peak intensity. The double-exponential decay of the fluorescence is explained by the spatial inhomogeneity of the light beam. The findings in this work are discussed in terms of the possibility of using many-photon-induced photobleaching for new three-dimensional read-write devices.

Resource use and costs associated with patients treated for depression in primary care

We investigated medical resource consumption, productivity loss and costs associated with patients treated with antidepressants for depression in primary care in Sweden. Patients on treatment for depression were followed naturalistically for six-months, and data on patients' characteristics, daily activity and resource-use were collected. The total cost per patient was estimated at euro 5,500 (95%CI euro 5,000-6,100) over six months in 2005 prices. Direct costs were estimated at euro 1,900 (euro 1,700-2,200), 35% of total costs, and indirect costs at euro 3,600 (euro 3,100-4,100), 65% of total costs. The cost for antidepressants represented only 4% of the total costs. We conclude that the burden of depression is high, both to the individual as well as to wider society, and there seems to be a particular need for therapies that have the potential to improve productivity in depressed patients.

Proton Transfer Mediated by the Vibronic Coupling in Oxygen Core Ionized States of Glyoxalmonoxime Studied by Infrared−X-ray Pump−Probe Spectroscopy

The theory of IR-X-ray pump-probe spectroscopy beyond the Born-Oppenheimer approximation is developed and applied to the study of the dynamics of intramolecular proton transfer in glyoxalmonoxime leading to the formation of the tautomer 2-nitrosoethenol. Due to the IR pump pulses the molecule gains sufficient energy to promote a proton to a weakly bound well. A femtosecond X-ray pulse snapshots the wave packet route and, hence, the dynamics of the proton transfer. The glyoxalmonoxime molecule contains two chemically nonequivalent oxygen atoms that possess distinct roles in the hydrogen bond, a hydrogen donor and an acceptor. Core ionizations of these form two intersecting core-ionized states, the vibronic coupling between which along the OH stretching mode partially delocalizes the core hole, resulting in a hopping of the core hole from one site to another. This, in turn, affects the dynamics of the proton transfer in the core-ionized state. The quantum dynamical simulations of X-ray photoelectron spectra of glyoxalmonoxime driven by strong IR pulses demonstrate the general applicability of the technique for studies of intramolecular proton transfer in systems with vibronic coupling.

The mission is remission: health economic consequences of achieving full remission with antidepressant treatment for depression

The aim of the present study was to determine the magnitude of the impact of treating depression to full remission on cost and health-related quality of life. In a naturalistic longitudinal survey recordings of resource use and quality of life were carried out among depressed patients treated with antidepressant therapy in 56 Swedish primary care clinics. We found that a total of 52% of the patients achieved full remission during the study period. Remitting patients had, on average, three outpatient visits less than non-remitting patients (p < 0.01), 22 fewer sick leave days (p = 0.01), which translated into a significantly lower total cost (Euro 2700) compared with non-remitting patients (p < 0.01). Health-related quality-of-life scores improved by 40% for remitting patients when compared with non-remitting ones (p < 0.01). We conclude that remission has a substantial health economic impact on patients treated for depression, which further strengthens the importance of aiming for full remission in the treatment of depression.

Nonadiabatic effects in resonant inelastic x-ray scattering

We have studied the spectral features of resonant inelastic x-ray scattering of condensed ethylene with vibrational selectivity both experimentally and theoretically. Purely vibrational spectral loss features and coupled electronic and vibrational losses are observed. The one-step theory for resonant soft x-ray scattering is applied, taking multiple vibrational modes and vibronic coupling into account. Our investigation of ethylene underlines that the assignment of spectral features observed in resonant inelastic x-ray scattering of polyatomic systems requires an explicit description of the coupled electronic and vibrational loss features.

Interplay of One- and Two-Step Channels in Electrovibrational Two-Photon Absorption

We present a theory of two-photon absorption that addresses the formation of spectral shapes taking the vibrational degrees of freedom into account. The theory is used to rationalize the observed differences between the spectral shapes of one- and two-photon absorption. We find that the main cause of these differences is that the two-step and coherent two-photon spectral bands are different even considering a single final state. Our formalism is applied to the N101 molecule (p-nitro-p'-diphenylamine stilbene), which was recently studied experimentally. Simulations show that the two-step two-photon electrovibrational absorption results in a blue shift of the absorption spectrum in agreement with the measurements.

Probing Weak Molecular Orbital Interactions in Non-Conjugated Diene Molecules by Means of Near-Edge X-ray Absorption Spectroscopy

Carbon and oxygen near-edge X-ray absorption fine structure (NEXAFS) spectra of 1,4-cyclohexadiene, p-benzoquinone, norbornadiene, norbornadienone, and cis-cis-[4,4,2]propella-3,8-diene-11,12-dione were calculated by means of Hartree-Fock and hybrid density functional theory using the static-exchange (STEX) approximation. The NEXAFS spectra are used as a probe to identify weak molecular interactions between the two non-conjugated ethylenic pi* orbitals present in these molecules. We show that the X-ray absorption spectrum of 1,4-cyclohexadiene exhibits some particular spectral structures in the discrete energy region that evidence diene through-bond orbital interaction, whereas absorption peaks are identified in the norbornadiene and norbornadienone spectra that indicate effective through-space orbital interactions. The molecular structure of the cis-cis-[4,4,2]propella-3,8-diene-11,12-dione isomer is such that the indirect through-bond or through-space diene orbital interactions are too weak to be assigned by its C1s NEXAFS spectrum.

Perception of rearing circumstances relates to course of illness in patients with therapy-refractory affective disorders

BACKGROUND

Qualitative aspects of childhood experiences are believed to have an impact on course in affective disorder. Does perception of parental rearing correlate to persistence of affective illness?

METHODS

In retrospective life charts were recorded every previous illness episode for 38 consecutive patients with treatment-refractory affective disorder. A semi-structured interview was used for collecting information about perception of parental rearing.

RESULTS

Ten patients perceived themselves as "unwanted" during childhood, and 28 as "wanted". These former were found to have a more malignant illness course, as measured by total days in illness, percent of life in illness, and illness days per episode.

LIMITATIONS

The patient sample was small and the findings require replication.

CONCLUSIONS

Perception of not having been wanted by parents during upbringing might be an important vulnerability factor in the persistence of depressive symptomatology into adult life.

The principles of infrared-x-ray pump-probe spectroscopy. Applications on proton transfer in core-ionized water dimers

In this paper we derive the basic physics underlying infrared-x-ray pump-probe spectroscopy (IR, infrared). Particular features of the spectroscopy are highlighted and discussed, such as dependence on phase of the infrared pulse, duration and delay time of the x-ray pulse, and molecular orientation. Numerical applications are carried out for the water dimer using wave packet techniques. It is shown that core ionization of the donor oxygen of the water dimer results in a drastic change of the potential with the global minimum placed in the proton transfer region. The results of the modeling indicate that IR-x-ray pump-probe spectroscopy can be used to study the dynamics of proton transfer in this core-ionized state, and that, contrary to conventional core level photoelectron spectroscopy, x-ray core-ionization driven by an IR field is a proper method to explore the proton transfer in a system like the water dimer. We observe that the trajectory of the nuclear wave packet in the ground state potential well is strongly affected by the absolute phase of the IR pulse.

Core Excitations of Biphenyl

High-resolution C(1s) near-edge X-ray absorption and X-ray photoionization spectra of the free biphenyl molecule are presented and theoretically analyzed in order to allow an assignment of the observed spectral features. Finite lifetime broadening, a high density of vibrational states, and a strong overlap of contributions from chemically different carbon atom sites only partially allow resolving the vibrational fine structure. However, the shape and width of the spectral profiles are strongly determined by both chemical shifts and vibronic effects. In particular, different from photoionization of valence levels, both types of core level spectra do not contain contributions from dihedral modes which are related to the twisting motion of the two phenyl rings. Contrary to naphthalene, C-H stretching modes are significantly enhanced in the core excitation spectra of biphenyl while the contributions from C-C stretching modes are reduced.

Core excitations of naphthalene: Vibrational structure versus chemical shifts

High-resolution x-ray photoelectron emission (XPS) and near-edge x-ray absorption fine structure (NEXAFS) spectra of naphthalene are analyzed in terms of the initial state chemical shifts and the vibrational fine structure of the excitations. Carbon atoms located at peripheral sites experience only a small chemical shift and exhibit rather similar charge-vibrational coupling, while the atoms in the bridging positions differ substantially. In the XPS spectra, C-H stretching modes provide important contributions to the overall shape of the spectrum. In contrast, the NEXAFS spectrum contains only vibrational progressions from particular C-C stretching modes. The accuracy of ab initio calculations of absolute electronic transition energies is discussed in the context of minute chemical shifts, the vibrational fine structure, and the state multiplicity.

Doppler effect in resonant photoemission from SF6: correlation between Doppler profile and Auger emission anisotropy

Fragmentation of the SF6 molecule upon F 1s excitation has been studied by resonant photoemission. The F atomiclike Auger line exhibits the characteristic Doppler profile that depends on the direction of the photoelectron momentum relative to the polarization vector of the radiation as well as on the photon energy. The measured Doppler profiles are analyzed by the model simulation that takes account of the anisotropy of the Auger emission in the molecular frame. The Auger anisotropy extracted from the data decreases with an increase in the F-SF5 internuclear distance.

Molecular structure of alcohol-water mixtures

We use x-ray emission spectroscopy to elucidate the molecular structure of liquid methanol, water, and methanol-water solutions. We find that molecules in the pure liquid methanol predominantly persist as hydrogen-bonded chains and rings with six and/or eight molecules of equal abundance. For water-methanol solutions we find evidence of incomplete mixing at the microscopic level. Our results provide a new explanation for a smaller entropy increase in the solution due to water molecules bridging methanol chains to form rings.

X-ray emission spectroscopy of hydrogen bonding and electronic structure of liquid water

We use x-ray emission spectroscopy to examine the influence of the intermolecular interaction on the local electronic structure of liquid water. By comparing x-ray emission spectra of the water molecule and liquid water, we find a strong involvement of the a(1)-symmetry valence-orbital in the hydrogen bonding. The local electronic structure of water molecules, where one hydrogen bond is broken at the hydrogen site, is separately determined. Our results provide an illustration of the important potential of x-ray emission spectroscopy for elucidating basic features of liquids.

Interference quenching of nu(")=1 vibrational line in resonant photoemission of N2: a possibility to obtain geometrical information on the core-excited state

An interference quenching of the nu(")=1 vibrational line in the resonant Auger decay of N 1s-->pi(*) core-excited N2 is observed and analyzed. The intensity ratio between the nu(")=1 and nu(")=0 vibrational levels of the X2Sigma(+)(g) final state shows a surprising nonmonotonous variation as a function of frequency detuning, going through a minimum with a complete suppression of nu(")=1. We have developed a simple model which shows a linear relation between the value of the detuning frequency for this minimum and the equilibrium bond distance R(0)(c) of the core-excited state. A new way is thus established of determining the equilibrium bond distance for the core-excited state with a precision deltaR(0)(c)<10(-3) A.

Tau and Abeta42 in cerebrospinal fluid from healthy adults 21-93 years of age: establishment of reference values

BACKGROUND

Tau protein and the 42-amino acid form of beta-amyloid (Abeta42) measured in cerebrospinal fluid (CSF) have been proposed as potential biochemical diagnostic markers for Alzheimer disease. For the introduction of these assays in clinical practice, adequate reference values are of importance.

METHODS

CSF samples were obtained from 231 neurologically and psychiatrically healthy individuals, 21-93 years of age, all with a MiniMental State examination score of 28 or above. Standardized ELISAs were used to measure tau and Abeta42 in CSF. Following IFCC recommendations, we used a rank-based method; the 0.90 and 0.10 fractiles were estimated to establish reference values for CSF-tau and CSF-Abeta42, respectively. Putative confounding factors, such as the influence of the passage of proteins from peripheral blood to CSF, influence of dysfunction of the blood-brain barrier, and freezing and thawing of CSF, were investigated.

RESULTS

A correlation with age was found for CSF-tau (r = 0.60; P <0.001). Therefore, separate reference values for different age groups were established for CSF-tau: <300 ng/L in the group 21-50 years of age, <450 ng/L in the group 51-70 years of age, and <500 ng/L in the group 71-93 years of age. CSF-Abeta42 did not correlate with age (r = -0.045), and the reference value was set to >500 ng/L. No correlation was found between blood-brain barrier function and CSF-tau or CSF-Abeta42.

CONCLUSIONS

These reference values can be applied when using CSF-tau and CSF-Abeta42 in clinical practice.

Subjective lack of social support and presence of dependent stressful life events characterize patients suffering from major depression compared with healthy volunteers

The aim of this study was to characterize and compare patients with major depression and healthy volunteers concerning stressful negative life events, social support and social network occurring during a 12-month period. Forty outpatients who fulfilled DSM-IV criteria for major depression and 19 healthy volunteers were included in the study. The results showed no significant differences between the patients and the volunteers concerning the number of independent life events, perceived sufficient persons in the network, the number of family members, having a partner, and perceiving family members as offering the best support. Thus, there were differences in the number of both dependent stressful life events, especially increased arguments with partner and family members, and life events including personal illness. The patient group had experienced a greater number of these events compared with the volunteer group. Comparisons between the two groups revealed differences concerning social support and social network. Fewer patients, especially women, felt they had sufficient social support, had fewer persons in the network, less contact with persons in the network, and fewer confidants compared with the volunteers.

Aggression in the general Swedish population, measured with a new self-rating inventory: The Aggression Questionnaire--revised Swedish version (AQ-RSV)

The aim of the present study was to develop a Swedish self-rating instrument for clinical aggression research based on the American Aggression Questionnaire (AQ), which measures physical aggression, verbal aggression, anger, and hostility. To test this adapted Aggression Questionnaire--revised Swedish version (AQ-RSV), it was mailed to 781 randomly selected individuals, aged 20-40 year. A total of 497 (64%) evaluable AQ-RSV inventories were obtained and analyzed statistically. Drop-out analysis showed that non-responders were most often male and significantly older than responders. Among the responders, AQ-RSV showed significant sex differences in all aggression subscales except Hostility. Aggression was found to vary with age, geographical region, and size of home community. The AQ and the AQ-RSV were comparable in correlations between the four aggression subscales and in alpha coefficients, which indicated considerable internal consistency. Development of the aggression-measuring instrument for Swedish conditions is important not only to study subtraits of aggression but to enable analyses of their relationships to neurobiological and psychiatric variables.

Sertraline versus paroxetine in major depression: clinical outcome after six months of continuous therapy

reuptake inhibitors (SSRIs) during continuation therapy. This investigation reports the differential effect of 6 months of treatment with sertraline versus paroxetine for symptoms of depression, quality of life, and personality outcomes. Outpatients with unipolar major depression (DSM-III-R) were randomly assigned to receive 24 weeks of double-blind treatment with flexible doses of paroxetine (20-40 mg) or sertraline (50-150 mg). Assessments included the Montgomery-Asberg Depression Rating Scale (MADRS), the Clinical Global Impression Scale, the Battelle Quality of Life Questionnaire, and the Structured Clinical Interview for DSM-III-R Personality Disorders screen questionnaire. One hundred seventy-six patients (mean age, 43 years; 64% female; baseline MADRS, 30.3) were treated with sertraline and 177 patients (mean age, 42 years; 71% female; MADRS, 30.7) with paroxetine. Antidepressant efficacy during continuation therapy was sustained, with only 2% of patients receiving sertraline and 9% of patients receiving paroxetine suffering a relapse. Continuation therapy resulted in a substantial conversion of responders during short-term treatment to full remission: remitter rates increased from 52% to 80% for sertraline and from 57% to 74% for paroxetine. The improvements in quality of life were related to a reduced depression score. SSRI treatment had significant beneficial effects on both categorical and dimensional measures of personality. A logistic regression analysis identified early response (25% reduction in MADRS scores at week 2) as the most important predictor of treatment response, whereas high severity, chronicity, and poor baseline quality of life had no effect. Both treatments were well-tolerated, with sertraline having a somewhat lower side effect profile. Sertraline and paroxetine demonstrated comparable efficacy during short-term and continuation therapy. Treatment was associated with significant improvement in quality of life and with reductions in axis II personality psychopathology.

No evident neuronal damage after electroconvulsive therapy

Electroconvulsive therapy (ECT) is regarded as one of the most effective treatments for major depressive disorder but has also been associated with cognitive deficits possibly reflecting brain damage. The aim of this study was therefore to evaluate whether ECT induces cerebral damage as reflected by different biochemical measures. The concentrations in the cerebrospinal fluid (CSF) of three established markers of neuronal/glial degeneration, tau protein (tau), neurofilament (NFL) and S-100 beta protein, were determined in nine patients who fulfilled DSM-IV criteria for major depression. CSF samples were collected before and after a course of six ECT sessions. The CSF/serum (S) albumin ratio reflecting potential blood-brain barrier (BBB) dysfunction was also determined at these time points. The treatment was clinically successful with a significant decline of depressive symptoms in all patients as assessed by the Montgomery-Asberg Rating Scale for Depression. Several patients had signs of BBB dysfunction and/or neuronal damage before the start of treatment. Levels of CSF-tau, CSF-NFL and CSF-S-100 beta levels were not significantly changed by ECT. Also the CSF/S albumin ratio was found to be unchanged after the course of ECT. In conclusion, no biochemical evidence of neuronal/glial damage or BBB dysfunction could be demonstrated following a therapeutic course of ECT.

Observation of a continuum-continuum interference hole in ultrafast dissociating core-excited molecules

The femtosecond dissociation of HCl after core excitation has been studied through the resonant Auger decay. The spectra contain contributions from decay occurring at both "molecular" and "atomic" internuclear distances. We have observed a new interference mechanism in these spectra: An atomic spectral line develops into a negative spectral contribution, a "hole," when detuning the excitation energy from the maximum of the Cl2p(-1)sigma(*) resonance. Resonant x-ray scattering theory quantitatively explains this behavior as due to a novel destructive continuum-continuum interference between molecular and atomic contributions to the Auger decay.

Reduced brain norepinephrine and dopamine release in treatment-refractory depressive illness: evidence in support of the catecholamine hypothesis of mood disorders

BACKGROUND

The etiology of depressive illness has been linked with brain monoaminergic neuronal dysfunction, yet the development of sensitive markers of endogenous depression has proven difficult.

METHODS

Using catheters placed in an internal jugular vein, we estimated the release of brain monoamine neurotransmitters in 19 healthy volunteers and in 9 patients with nonbipolar depressive illness refractory to medication at rest and following intravenous desipramine hydrochloride. Venoarterial plasma concentration gradients were used to quantify the amount of neurotransmitters stemming from the brain. Cerebral oxidative metabolism was assessed concurrently from measurements of oxygen and carbon dioxide gas exchange via the process of regional indirect calorimetry.

RESULTS

The brains of these patients exhibited reduced venoarterial norepinephrine (4.0 +/- 2.7 nmol/L vs 0.7 +/- 1.3 nmol/L) and homovanillic acid concentration gradients (8.3 +/- 7.8 nmol/L vs 3.1 +/- 1.9 nmol/L), and used an energy source other than glucose. Internal jugular 5-hydroxyindoleacetic acid concentration gradients were not reduced in the patients with depressive illness. While both the reduction in norepinephrine turnover and the defect in cerebral metabolism were normalized following pharmacological blockade of the norepinephrine transporter with desipramine, paradoxically it was the brain's turnover of dopamine that bore a significant relation to the patients' clinical status (r(s) = 0.79, P =.02). The positive nature of this relationship remains difficult to reconcile.

CONCLUSIONS

In accordance with the monoamine hypothesis, a deficit in brain norepinephrine and dopamine exists in patients with depressive illness. Moreover, the brains of these patients use an energy source other than glucose, a situation that is normalized following the acute pharmacological blockade of the norepinephrine transporter with the tricyclic antidepressant, desipramine.

Doppler splitting of In-flight auger decay of dissociating oxygen molecules: the localization of delocalized core holes

By exploiting the core-excitation-induced dissociation of O2, we find that the Auger emission exhibits a Doppler-like energy shift. We show this to be a manifestation of localization of the core hole and propose that the problem of core-hole localization versus delocalization in core-hole spectroscopies may be resolved by considering the nature of the measurement.

[When insight on disease is halting. I. Clinical assessment of impaired insight--current research summarized]

This review explores the definition, assessment and possible restoration of impaired insight in psychosis. Hypotheses concerning the neuropsychological correlates of insight impairment are discussed. The distinction between impaired insight in psychosis and impaired awareness and psychological denial in other medical conditions is emphasised.

[When disease insight is halting. II. The neurobiological underpinnings]

This review examines the neurobiological underpinnings of impaired insight and awareness in psychosis. Crucial mainly dopaminergic pathways are discussed in relation to delusions and hallucinations. Thirty percent of psychotic patients with impaired insight will not respond to traditional neuroleptic drug treatment, and the possibility that multifocal brain etiology might underlie such cases is discussed. It is suggested that severe cases of thought process disorder in psychosis may result from such multifocal processes.

Oral d-fenfluramine test in treatment-refractory depression. Plasma prolactin response compared in patients with and without suicide attempts and in a healthy reference group

BACKGROUND

Fenfluramine (d-FEN) has been used as a serotonin challenge agent to assess central serotonin availability. Blunted serum prolactin (PRL) response to d-FEN has been reported in depressed patients, in suicide-prone patients, and in patients with aggression and personality disorders. We have analyzed suicidality in relation to central serotonergic events by comparing the PRL response to d-FEN in chronically depressed patients with and without suicide attempts and in healthy volunteers.

METHODS

In 56 inpatients (10 patients with and 46 without suicide attempts) with at least 2 years of treatment-refractory depression (TRD) (DSM-IV) and a reference group of 30 healthy adults, the PRL response after an oral dose of 30 mg d-FEN was followed for 5 h.

RESULTS

Controlling for group differences in age, sex, and weight, the PRL response to d-FEN did not differ significantly between the three groups. Far from confirming the hypothesis of a blunted PRL response in depressed patients, our results suggest: (1) that duration and treatment resistance of depression may affect the PRL secretion, and (2) that TRD and major depression may differ in biological relationship to suicidal behavior.

LIMITATIONS

The findings require corroboration in larger and more closely matched study populations. The fenfluramine concentration was not analyzed in blood.

CONCLUSIONS

PRL responses to d-FEN challenge did not differ between TRD patients with and without suicidality and the healthy reference group. Chronicity/treatment refractoriness per se may be related to a serotonergic mechanism.

Efficacy and tolerability of mirtazapine versus citalopram: a double-blind, randomized study in patients with major depressive disorder. Nordic Antidepressant Study Group

We aimed to compare the antidepressant and anxiolytic effects, tolerability and effects on quality of life of mirtazapine and citalopram in a randomized, double-blind, multicentre, 8-week study. Patients with a Major Depressive Episode (DSM-IV) and a baseline score of > or = 22 on the Montgomery-Asberg Depression Rating Scale (MADRS) were randomized to 8 weeks treatment with either mirtazapine (n = 137, 15-60 mg/day) or citalopram (n = 133, 20-60 mg/day). Efficacy was evaluated by the MADRS, Hamilton Anxiety Scale (HAM-A), Clinical Global Impression scales (CGI), the Leeds Sleep Evaluation Questionnaire (LSEQ) and Quality of Life Enjoyment and Satisfaction Questionnaire (QLESQ). The efficacy analyses were performed on the Intent-To-Treat Group using the Last Observation Carried Forward method. Vital signs and laboratory variables are measured and adverse events recorded at each weekly visit. The magnitude of reduction from baseline in group mean MADRS scores was large in both groups, reaching after 8 weeks of treatment mean scores of 9.1 in the mirtazapine group and 8.9 in the citalopram group. Both treatments also resulted in a substantial improvement in anxiety symptoms, sleep disturbances and quality of life, and high percentage of responders. However, at day 14, statistically significantly larger magnitudes of change favouring mirtazapine were present in the group mean MADRS, HAM-A and CGI-Severity of illness and Quality of life scores. A difference of 2.3 points on MADRS favouring mirtazapine is considered indicative for a clinically relevant superiority between two proven antidepressants. Mirtazapine treatment was also related to faster improvement of sleep, quality of sleep and improved alertness following awakening, as shown by statistically significant differences on the self-rating LSEQ at various time points. There were no differences between two treatment groups on self-rating QLSEQ. Both drugs were well tolerated, with a low number of patients in either group prematurely terminating the study due to adverse events (mirtazapine: 3.6%, citalopram, 3.0%). Sweating and nausea were statistically significantly more frequent in the citalopram group and increased appetite and complaints of weight increase in the mirtazapine group. There were no clinically relevant changes in laboratory parameters and vital sign variables with either treatment, except for clinically relevant increase in body weight, occurring more frequently in mirtazapine patients. In this study, mirtazapine and citalopram were equally effective in reducing symptoms of depression and anxiety, and well tolerated. However, mirtazapine was significantly more effective than citalopram after 2 weeks of treatment on the MADRS, HAM-A and CGI Severity of illness and Quality of life scales. This finding, consistently present at all major efficacy variables, suggests potentially faster onset of efficacy of mirtazapine over citalopram.

The influence of prolactin response to d-fenfluramine on executive functioning in major depression

BACKGROUND

The main purpose of this study was to assess the influence of serotonergic activity, as measured by prolactin response to d-fenfluramine, on executive functioning in major depression.

METHODS

Forty-one persons between 22 and 71 years of age who met the DSM-IV criteria for major depressive episode were administered the Wisconsin Card Sorting Test (WCST) in computerized format, and d-fenfluramine was administered orally. Postfenfluramine blood samples for ascertaining plasma prolactin levels were obtained.

RESULTS

The key finding was that prolactin response was positively related to four out of five selected WCST variables. Also, increasing age was associated with decreasing WCST performance. There was no interaction between prolactin response and age, indicating that the effects of prolactin response on the WCST generalized across the age range examined.

CONCLUSIONS

The overall pattern of results suggests that there may be a relationship between serotonergic activity and executive functioning in major depression.

[Non-profit networks for suicide prevention]

Survival groups and suicide clusters constitute new challenges for suicide prevention. Emergency ward and intensive care personnel and psychologists working in close co-operation with general practitioners are strategically important in such preventive endeavours. Scientists and health care personnel need to develop joint strategies for the purpose. Politicians and administrators are important target groups for information on suicide prevention. The foregoing are important findings in the first year's experience of the West Swedish Network for Suicide Prevention.

Effect of buspirone on sexual dysfunction in depressed patients treated with selective serotonin reuptake inhibitors

To evaluate the possible influence of buspirone on sexual dysfunction in depressed patients treated with a selective serotonin reuptake inhibitor (SSRI), we analyzed data from a placebo-controlled trial designed to explore the efficacy of buspirone as add-on treatment for patients not responding to an SSRI alone. At baseline, all patients met the criteria for a major depressive episode according to DSM-IV and had received citalopram or paroxetine during a minimum of 4 weeks without responding to the treatment. Buspirone (flexible dosage, 20-60 mg/day) or placebo was added to the SSRI for 4 weeks; the mean daily dose of buspirone at endpoint was 48.5 mg (SD = 1.0). Sexual dysfunction was evaluated using a structured interview. Before starting medication with buspirone or placebo, 40% (47 of 117) reported at least one kind of sexual dysfunction (decreased libido, ejaculatory dysfunction, orgasmic dysfunction). During the 4 weeks of treatment, approximately 58% of subjects treated with buspirone reported an improvement with respect to sexual function; in the placebo group, the response rate was 30%. The difference between placebo and active drug treatment was more pronounced in women than in men. The response was obvious during the first week, with no further improvement during the course of the study. It is suggested that the effect of buspirone on sexual dysfunction is a result of a reversal of SSRI-induced sexual side effects rather than of an antidepressant effect of the drug.

The experience of social support in patients suffering from treatment-refractory depression--a pilot study

The purpose of this study was (1) to ascertain to what extent a group of patients with treatment-refractory depression perceive that they have received sufficient social support, and (2) to define clinical variables that differentiate such patients from those who perceive that they have not received sufficient social support. Twenty-seven treatment-refractory patients with major depression were included in the study. The result showed that only 37% had what was judged as insufficient social support. Those with insufficient and sufficient social support had equally severe depressions, the same number of stressful life events, and the same number of persons in their social network. Patients with insufficient social support were characterized by (1) a subjective conviction that the number of persons in their network was insufficient, and (2) female gender. Emotional support was valued higher than any other kind of support.

A randomized, double-blind, placebo-controlled trial of buspirone in combination with an SSRI in patients with treatment-refractory depression

BACKGROUND

Case reports and open studies have reported beneficial therapeutic effects of adding buspirone to a selective serotonin reuptake inhibitor (SSRI) in the management of treatment-refractory depression. This is the first placebo-controlled study to evaluate the efficacy and safety of this combination.

METHOD

One hundred nineteen patients (82 women, 37 men) who fulfilled criteria for a major depressive episode according to DSM-IV and who had failed to respond to a minimum of 4 weeks (mean = 211 days) of treatment with citalopram or paroxetine were randomly assigned to 4 weeks of treatment with an SSRI plus buspirone (N = 58) or an SSRI plus placebo (N = 61). In addition, 97 patients participated in an optional open-label poststudy treatment phase with the SSRI plus buspirone for 2 weeks. The primary outcome measure was the score on the Clinical Global Impressions-Improvement (CGI-I) scale.

RESULTS

A total of 50.9% of patients in the buspirone group and 46.7% in the placebo group responded after 4 weeks of treatment. The difference in response rate was not statistically significant. No statistically significant differences were found in the frequency of adverse events. At the follow-up of the open SSRI plus buspirone treatment, 69.4% of patients had responded.

CONCLUSION

Adding buspirone to an SSRI is a safe and well-tolerated drug regimen. This study failed to demonstrate any difference in efficacy between buspirone or placebo augmentation of an SSRI. It could be argued, however, that the study was inconclusive due to the unusually high placebo response.