Low lung function in Bipolar Disorder and Schizophrenia: a hidden risk

Introduction: People with serious mental illness (SMI), such as schizophrenia and bipolar disorder, have a higher risk of premature morbidity and mortality. In the general population, impaired lung function is associated with increased morbidity and mortality. We compared lung function between people with and without serious mental illnesses using a cross-sectional study in 9 community mental health units. Methods: Subjects aged 40-70 years with a diagnosis of schizophrenia or bipolar disorder were recruited consecutively. The controls had no psychiatric diagnosis and were not receiving any psychotropics. Spirometry was performed by a trained nurse. We used the 2021 American Thoracic Society/European Respiratory Society standards for the interpretation of the spirometry results. Results: We studied 287 subjects. People with SMI (n = 169) had lower spirometry values than those without a psychiatric diagnosis (n = 118). An abnormal spirometry pattern (36.1% vs 16.9%, p < 0.001), possible restriction or non-specific (Preserved Ratio Impaired Spirometry [PRISm]) pattern (17.8% vs 7.6%, p = 0.014), and pattern of airflow obstruction or possible mixed disorder (18.3% vs 9.3%, p = 0.033) were more frequent in people with SMI. Multivariate analyses showed that the PRISm pattern was associated with abdominal circumference (odds ratio [OR] 1.05, 95%CI 1.03-1.08) and that the pattern of airflow obstruction or possible mixed disorder was associated with smoking behavior (OR 5.15, 95%CI 2.06-15.7). Conclusion: People with SMI have impaired lung function, with up to one-third of them showing an abnormal spirometry pattern. This suggests that regular monitoring of lung function and addressing modifiable risk factors, such as tobacco use and obesity, in this population is of paramount importance.

Portal hypertension increases the risk of hepatic decompensation after 90Yttrium radioembolization in patients with hepatocellular carcinoma: a cohort study

Background

Transarterial radioembolization (TARE) is increasingly used in patients with hepatocellular carcinoma (HCC). This treatment can induce or impair portal hypertension, leading to hepatic decompensation. TARE also promotes changes in liver and spleen volumes that may modify therapeutic decisions and outcomes after therapy.

Objectives

We aimed to investigate the impact of TARE on the incidence of decompensation events and its predictive factors.

Design

In all, 63 consecutive patients treated with TARE between February 2012 and December 2018 were retrospectively included.

Methods

We assessed clinical (including Barcelona Clinic Liver Cancer stage, portal hypertension assessment, and liver decompensation), laboratory parameters, and liver and spleen volumes before and 6 and 12 weeks after treatment. A multivariate analysis was performed.

Results

In total, 18 out of 63 (28.6%) patients had liver decompensation (ascites, variceal bleeding, jaundice, or encephalopathy) within the first 3 months after therapy, not associated with tumor progression. Clinically significant portal hypertension (CSPH) and bilobar treatment independently predicted the development of liver decompensation after TARE. A significant volume increase in the non-treated hemi-liver was observed only in patients with unilobar treatment (median volume increase of 20.2% in patients with right lobe TARE; p = 0.007), especially in those without CSPH. Spleen volume also increased after TARE (median volume increase of 16.1%; p = 0.0001) and was associated with worsening liver function scores and decreased platelet count.

Conclusion

Bilobar TARE and CSPH may be associated with an increased risk of liver decompensation in patients with intermediate or advanced HCC. A careful assessment considering these variables before therapy may optimize candidate selection and improve treatment planning.

Early nivolumab addition to regorafenib in patients with hepatocellular carcinoma progressing under first-line therapy (GOING trial), interim analysis and safety profile

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Background: Regorafenib (Rego) improves survival in patients with hepatocellular carcinoma (HCC) (RESORCE trial) while nivolumab (Nivo) is also safe and active in terms of radiologic response (15-20% objective response) in second-line. The GOING trial (NCT04170556) is an investigator-initiated phase I/IIa study assessing the safety of Rego plus Nivo in HCC patients who progress and tolerate sorafenib (Cohort A) or who discontinue atezolizumab plus bevacizumab (Cohort B). Methods: Patients from cohort A receive Rego as monotherapy for the first 2 cycles (starting dose 160 mg/day, 3 weeks on/1 week off and adjusted for adverse events [AEs]) and Nivo is added at day 1 of cycle 3 (the first 10 patients at 3 mg/kg; since they did not present serious-AE (SAE), the final dose is 240 mg every two weeks). Treatment continues until unacceptable AEs, symptomatic tumor progression, patient decision or death. Safety is measured by the rate of AEs, rate of treatment related-AEs (Tr-AE), rate of AEs leading to treatment discontinuation and rate of death. Severity of AEs are evaluated according to CTCAE v.5.0. A futility analysis using the non-binding Lan & DeMets beta-spending functions with a boundary of p=0.814 is mandated when 32.8% of cohort A has data of tumor assessment at least at week 16 by RECIST 1.1. Results: Fifty-one patients have been enrolled in cohort A as of May 15, 2021. The first 30 (BCLC-C 73%) were considered in this safety analysis. All patients developed at least one AE, 29 (96.7%) had Tr-AEs of any grade and 10 (33.3%) had grade 3 (no grades 4 or 5 have been reported). Ten (33.3%) patients had a Rego-related AE, 4 (13.3%) Nivo-related, and 4 (13.3%) Tr-AE grade 3 of special interest. The table describes the profile Tr-AE occurring in > 10% of patients. Only 4 (13.3%) patients developed Tr-SAE, 3 (10 %) Rego-related and 3 (10 %) Nivo-related. Four patients discontinued the study due to physician decision, 2 for progression, and 2 for AEs (one related to study treatment). One patient had surgical resection after treatment discontinuation and a complete necrosis was observed at pathology. Conclusions: The sequential combination of Rego-Nivo has a manageable safety profile. Less than one third of the patients developed grade 3/4 Tr-AE and there was no treatment-related death. Futility analysis allowed to continuing recruitment. Clinical trial information: NCT04170556. [Table: see text]

Chronic obstructive pulmonary disease in severe mental illness: A timely diagnosis to advance the process of quitting smoking

Background

This study has two main objectives: to describe the prevalence of undetected chronic obstructive pulmonary disease (COPD) in a clinical sample of smokers with severe mental illness (SMI), and to assess the value of the Tobacco Intensive Motivational Estimated Risk tool, which informs smokers of their respiratory risk and uses brief text messages to reinforce intervention.

Method

A multicenter, randomized, open-label, and active-controlled clinical trial, with a 12-month follow-up. Outpatients with schizophrenia (SZ) and bipolar disorder were randomized either to the experimental group—studied by spirometry and informed of their calculated lung age and degree of obstruction (if any)—or to the active control group, who followed the 5 A’s intervention.

Results

The study sample consisted of 160 patients (71.9% SZ), 78.1% of whom completed the 12-month follow-up. Of the patients who completed the spirometry test, 23.9% showed evidence of COPD (77.8% in moderate or severe stages). TIMER was associated with a significant reduction in tobacco use at week 12 and in the long term, 21.9% of patients reduced consumption and 14.6% at least halved it. At week 48, six patients (7.3%) allocated to the experimental group achieved the seven-day smoking abstinence confirmed by CO (primary outcome in terms of efficacy), compared to three (3.8%) in the control group.

Conclusion

In this clinical pilot trial, one in four outpatients with an SMI who smoked had undiagnosed COPD. An intensive intervention tool favors the early detection of COPD and maintains its efficacy to quit smoking, compared with the standard 5 A’s intervention.

Non-selective beta-blockers impair global circulatory homeostasis and renal function in cirrhotic patients with refractory ascites

BACKGROUND & AIMS

The safety of non-selective β-blockers (NSBBs) has been questioned in refractory ascites (RA). We studied the effects of NSBBs on cardiac systolic function, systemic hemodynamics, and renal perfusion pressure (RPP) and function in patients with diuretic-responsive ascites (DRA) and RA.

METHODS

We performed a prospective pre-post repeated-measures study in cirrhotic patients, 18 with DRA and 20 with RA on NSBBs for variceal bleeding prophylaxis. Systolic function (by ejection intraventricular pressure difference [EIVPD]), hepatic venous pressure gradient (HVPG), cardiopulmonary pressures, RPP, and sympathetic activation were measured at baseline and after 4 weeks of propranolol.

RESULTS

EIVPD was elevated at baseline (RA 4.5 [2.8-5.7] and DRA 4.2 [3.1-5.7] mmHg; normal 2.4-3.6 mmHg) and directly related to the severity of vasodilation and sympathetic activation. NSBBs led to similar reductions in heart rate and HVPG in both groups. NSBBs reduced EIPVD in RA but not in DRA (-20% vs. -2%, p <0.01). In RA, the NSBB-induced reduction in EIPVD correlated with the severity of vasodilation and with higher plasma nitric oxide, norepinephrine and IL-6 (r >0.40, all p <0.05). NSBBs reduced RPP in both groups, but impaired renal function only in patients with RA. Reduced EIPVD correlated with decreases in RPP and estimated glomerular filtration rate (r >0.40, all p <0.01). After NSBB treatment, RPP dropped below the threshold of renal flow autoregulation in 11 of the 20 (55%) patients with RA, including the 4 fulfilling the criteria for HRS-AKI.

CONCLUSION

Renal perfusion and function depend critically on systolic function and sympathetic hyperactivation in RA. NSBBs blunt the sympathetic overdrive, hamper cardiac output, lower RPP below the critical threshold and impair renal function. β-blockade should be used cautiously or even avoided in patients with RA.

LAY SUMMARY

We have identified the mechanisms by which non-selective beta-blockers could impair survival in patients with refractory ascites. We show that peripheral vasodilation and sympathetic activation lead to increased left ventricle systolic function in patients with cirrhosis and ascites, which acts as an adaptive mechanism to maintain renal perfusion. When ascites becomes refractory, this compensatory cardiac response to vasodilation is critically dependent on sympathetic hyperactivation and is hardly able to maintain renal perfusion. In this setting, β-blockade blunts the sympathetic overdrive of cardiac function, hampers cardiac output, lowers renal perfusion pressure below the critical threshold and impairs renal function.

Smoking cessation opportunities in severe mental illness (tobacco intensive motivational and estimate risk - TIMER-): study protocol for a randomized controlled trial

Background

There is an increased risk of premature death in people with severe mental illness (SMI). Respiratory disorders and cardiovascular disease are leading causes of increased mortality rates in these patients, and tobacco consumption remains the most preventable risk factor involved. Developing new tools to motivate patients towards cessation of smoking is a high priority. Information on the motivational value of giving the lung age and prevention opportunities is unknown in this high-risk population.

Methods/design

This article describes in detail a protocol developed to evaluate an intensive motivational tool, based on the individual risks of pulmonary damage and prevention opportunities. It is designed as a randomized, 12-month, follow-up, multicenter study. A minimum of 204 smokers will be included, aged 40 years and older, all of whom are patients diagnosed with either schizophrenia or bipolar disorder (BD). Chronic obstructive pulmonary disease (COPD) will be evaluated using spirometry, and the diagnosis will then be validated by a pneumologist and the lung age estimated. Based on this value, a motivational message about prevention will be issued for the intervention group, which will be reinforced by individualized text messages over a period of 3 months.

The efficacy of the method and the pulmonary damage variables will be evaluated: smoking cessation at the end of follow-up will be confirmed by cooximetry, and the COPD diagnosis and the severity of the staging for disease will be assessed.

Discussion

In the context of community care, screening and early detection of lung damage could potentially be used, together with mobile technology, in order to produce a prevention message, which may provide patients with SMI with a better chance of quitting smoking.

Trial registration

ClinicalTrials.gov, ID: NCT03583203. Registered on 11 July 2018.

Trial status: recruitment.

Impact of Histological Factors of Hepatocellular Carcinoma on the Outcome of Liver Transplantation

BACKGROUND

The aim of this study was to identify predictors of overall survival (OS), disease-free survival (DFS), and recurrence in a cohort of 151 patients with hepatocellular carcinoma (HCC) and cirrhosis who were treated by liver transplantation (LT).

PATIENTS AND METHODS

A retrospective database of patients undergoing LT for radiologically diagnosed HCC at "12 de Octubre" Hospital, Madrid during 1986-2006 was analyzed.

RESULTS

The median follow-up was 67.44 months (SD = 55.7 months). Overall 1-, 3-, 5-, and 10-year survival was 87.5%, 73.7%, 64.1% and 43.4%, respectively. The 5-year OS of patients beyond the Milan criteria was 47.14%, whereas that of patients within the Milan criteria was 70.13% (P = .011). The 5-year OS of patients beyond the Milan criteria and with microvascular invasion (MVI) was 27.27%, whereas that of patients beyond the Milan criteria and without MVI criteria was 57.89% (P = .003). Multivariate analysis of prognostic factors revealed MVI and G3 to be independent and statistically significant factors affecting OS (P < .0001 and P = .045, respectively), DFS (P < .0001 and P = .004, respectively), and recurrence (P = .0002 and P = .028, respectively). Multivariate analysis of prognostic factors also revealed preoperative fine-needle aspiration (FNA) to be an independent negative statistically significant factor affecting recurrence (P = .0022). Multivariate analysis of predictive MVI factors revealed preoperative α-fetoprotein (AFP) levels >200 ng/mL to be an independent positive and statistically significant predictor of MVI (P = .0004).

CONCLUSION

MVI and G3 are independent negative factors affecting OS, DFS, and recurrence. The presence of MVI or AFP levels >200 ng/mL represent a contraindication for LT, as long as the patient is beyond the Milan criteria.

Threonines at position 174 and 235 of the angiotensinogen polypeptide chain are related to familial history of hypertension in a Spanish-Mediterranean population

This study investigates the association between the allelic distribution of two polymorphisms of the angiotensinogen (AGT) gene (T174M and M235T in the polypeptide chain) and blood pressure (BP) in a Mediterranean population in the south-west of Europe. The sample consists of 1322 participants from urban and rural areas, from the province of Albacete (218,462 inhabitants), located in the south-east of Spain. The subsample of this study, adjusted by age (over 18 years old) and sex, consists of 401 individuals. A case-control study is conducted which analyses 205 individuals from the group with the highest BP (fifth quintile) and 196 from the group with the lowest BP (first quintile). In addition, a comparative and associated analysis of these polymorphisms with BP level and family history of hypertension is carried out. The T174 allele proved to be more common in the fifth quintile group, although not statistically so. When the presence of threonine was analysed in both polymorphism positions (174 and 235), the TTTT genotype was found to be more common in the fifth quintile than in the first quintile. Moreover, the TTTT genotype was significantly more common in individuals with a family history of hypertension, indicating that it could be considered a predisposing factor to high BP in individuals from such families. In addition, the T174M-T235T genotype was more common in the first quintile group, and showed significant association (P=0.05) with the group that had no family history of hypertension.

[Can or should blood pressure be measured at pharmacy offices?]

OBJECTIVE

To evaluate concordance between blood-pressure (BP) measurements at the pharmacy office (PhO) and the nurse office (NO) in the health care centre (HCC).

DESIGN

Descriptive study.

SETTING

Community.

METHODS

36 PhO have voluntarily participated in the province of Albacete, where they have done 3 BP measures, without previous instructions and with their usual measurements devices, for 3-5 subjects, who were referred to their HCC so that they were taken another 3 BP measures in the NO with their Hg sphymomanometer and in their usual measure conditions (blind measures in relation to those taken at the PhO). These subjects were given a stamped envelope to send the BP measurements (taken at the NO), to the Official Pharmacy College.

RESULTS

The 6 BP measurements have been completed to 96 subjects with an average of 57.3 years old (women 63%). The differences between PhO and NO were > 5 mmHg in 58 subjects (60.4%) in the case of SBP and in 45 subjects (46.9%) in the case of DBP, and it was more than 15 mmHg in the 17 subjects (17.7%) with SBP and in 9 subjects (9.4%) with DBP. The difference average was 9.5 mmHg (SD, 8.4 mmHg) and 6.4 mmHg (SD, 5.3 mmHg) respectively. The use rate of digit 0 was 22% at the PhO and 46.5% at the NO. In most of PhO, measurement electronic devices have been used for the BP, but not validated for clinical use.

CONCLUSIONS

The PhO can be a good place for the hypertension screening, but the chemist must be trained in the BP correct measurement and use validated electronic devices. Standardization measurement conditions and the use of validated electronic devices must be extended to the NO.

[Home self-measurements of blood pressure and relationship with diagnosis of hypertension and target organ damage: comparative study with ambulatory monitoring]

BACKGROUND

The diagnosis of arterial of hypertension (AH) requires an accurate and precise measurement methodology. The habitual techniques overstimate the prevalence of AH and have a poor correlation with organ damage. The objective of the study is to know the associations between self-measurements of blood pressure (BP) at home and target organ damage of AH.

PATIENTS AND METHOD

Descriptive study which compare the association of different techniques of BP measurement with the diagnosis of AH and its organ damage. Sampling selection of consecutive cases; we select 64 cases of hypertensives not treated hypertensive patients, older than 18 years. We achieved 3 BP measurements with mercury sphygmomanometer in the office and 20 self-measurements in the morning in the office and 20 self-measurements in the afternon at home with a automatic validated device, Omron 705CP; the same day BP was measured with ambulatory blood pressure measurement (ABPM) of 24 h with a Takeda TM-2420 device; we achieved eye fundus study, microalbuminuria analysis and echocardiogram.

RESULTS

Mean values of office BP was higher than self-measurements at home and ABPM; these techniques had good correlations and concordance between them. The correlation of selfmeasurements at home with LVMI was higher than office BP and similar to ABPM; this correlation is independent of age, sex and body mass index. The best correlation of self-measurements at home with APBM and LVMI was with the mean values of 2nd-6th self-measurements.

CONCLUSIONS

A minimum program of self-measurements of BP at home with automatic devices has a prognostic value and relationship with organ damage of AH similar to ABPM.

Angiotensin-converting enzyme (ACE) gene polymorphisms, serum ACE activity and blood pressure in a Spanish-Mediterranean population

Angiotensin-converting enzyme (ACE) levels and ACE gene polymorphisms have been related with hypertension but with contradictory results between populations. We have investigated the association among the allelic distribution of the insertion-deletion (I/D) polymorphism of the ACE gene, identified by polymerase chain reaction (PCR), serum ACE activity determined by spectrophotometry, and the blood pressure (BP), in a Mediterranean population in the southwest of Europe. A total of 1322 randomised individuals were analysed, and a comparative study was conducted analysing 205 individuals from the group with highest BP (fifth quintyl) and 196 from the group with lowest BP (first quintyl). In addition we have studied the frequencies of alleles in separated groups of women and men. We conclude that in this population there is no association between I/D polymorphism and hypertension. However, we have found a statistically significant association between the presence of the D allele in the genotypes and an elevation of serum ACE activity.