Higher illness burden is associated with reduced heart rate variability in bipolar disorder

Introduction

Bipolar disorder (BD) is associated with premature death and ischemic heart disease is the main cause of excess mortality. The predictive power of heart rate variability (HRV) for mortality has been confirmed in patients with or without cardiovascular disease. While several studies have analyzed the association between HRV and BD, their results are incongruent; and none has analyzed the effect of the clinical factors characterizing illness burden on HRV.

Objectives

To assess the association between HRV and the following factors characterizing illness burden: illness duration, number and type of previous episode(s), duration of the most severe depressive or hypomanic/manic episode, severity of episodes, co-morbid psychiatric disorders, family history of BD or suicide, and duration and polarity of current episode in participants experiencing one.

Methods

We used a wearable device in 53 BD participants to assess the association between HRV using 4 measures (RMSSD, SDANN, SDNN and RR Triangular Index) and the abovementioned clinical factors characterizing illness burden. For each of the 4 HRV measures we ran 11 models, one for each burden of illness clinical factor as an independent variable.

Results

Longer illness duration, higher number of depressive episodes, and family history of suicide were negatively correlated with HRV; in the 14 participants experiencing a depressive episode, the MADRS score was negatively correlated with HRV

Conclusions

Our study analyzed the association between burden of illness and HRV in BD, while controlling for functional cardiovascular status, age, sex, BMI, education, and treatment. Our results showed that high illness burden is associated with reduced HRV.

Disclosure

No significant relationships.

Adherence to clozapine vs. other antipsychotics in schizophrenia

BACKGROUND

To date, there have been no studies evaluating adherence to clozapine with electronic adherence monitoring (EAM) such as the Medication Event Monitoring System (MEMS^® ).

METHODS

In outpatients with schizophrenia, we conducted a 3-month prospective study investigating antipsychotic adherence with EAM (eCAP^® ). Participants were treated with different oral antipsychotics, including clozapine, and blind to EAM monitoring; all were on antipsychotic monotherapy administered once daily. Outcome measures included adherence rate, missed dose, and medication gap. Adherence trajectory patterns were also analyzed for clozapine vs. other antipsychotics collectively.

RESULTS

A total of 111 patients were included in the study; 33 and 78 patients received clozapine or other antipsychotics, respectively. Adherence rates, defined as proportion of days that the subject took the medication at the prescribed time ± 3 h and proportion of subjects with ≥80% adherence, were numerically higher in patients receiving clozapine vs. other antipsychotics (72.0% vs. 65.1%, P = 0.10; 49.5% vs. 35.7%, P = 0.11, respectively). Along similar lines, some of the missed dose and medication gap outcomes were significantly better in patients receiving clozapine vs. other antipsychotics. Three adherence trajectory patterns were identified for both clozapine and other antipsychotics, with two shared by both groups (i.e., low adherence with a slight decrease over time; high and stable adherence).

CONCLUSION

Findings suggest that in patients with schizophrenia clozapine adherence is at least comparable, if not slightly better, compared with other antipsychotics.

Changes in the corpus callosum in women with late-stage bipolar disorder

OBJECTIVE

This study investigated the differences in corpus callosum (CC) volumes between women with early-stage and late-stage bipolar I (BP I) disorder using the criteria previously described in the literature.

METHOD

We compared women with early- and late-stage BP I using criteria described in the Staging Systems Task Force Report of the International Society for Bipolar Disorders. We included 20 patients with early stage and 21 patients with late-stage BP I and a group of 25 healthy controls. Patients and controls underwent structural magnetic resonance imaging. Information on the clinical features of bipolar disorder was collected using a standardized questionnaire. Anatomical volumes of five regions of CC were compared between the three groups.

RESULTS

Women with late-stage BP I disorder had reduced posterior CC volumes compared with early-stage bipolar I patients and controls (F = 6.05; P = 0.004). The difference was significant after controlling for age, comorbidity with post-traumatic stress disorder, psychotic symptoms during mood episodes, and current use of medication.

CONCLUSION

The posterior CC was significantly decreased in volume in women with late-stage bipolar disorder. These findings suggest that CC may be an anatomical target of neuroprogression in the course of bipolar disorder in women.

Foscarnet-induced penile ulceration

Foscarnet is used to treat herpes viruses, including drug-resistant cytomegalovirus (CMV) and herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2). There are some reports of intravenous foscarnet-induced penile and vulvar ulceration. The authors report a case of the development of severe penile ulcers after the initiation of intravenous foscarnet therapy.

Linear IgA bullous disease in a patient with Crohn's disease

Linear IgA bullous disease is a rare autoimmune subepidermal blistering disease characterized by linear deposition of IgA along the basement membrane zone. We report a clinical case of a rare association of Linear IgA bullous disease and Crohn's disease. Parallel clinical improvement of both cutaneous and intestinal disease was observed with dapsone treatment.

Hypomania Induced by Atypical Antipsychotics among Schizophrenic Patients: Report of Three Cases

Induction of mania or hypomania related to the use of atypical antipsychotics among patients with no history of mood disorders has been previously reported. We reported the cases of three schizophrenic patients with no previous history of mood disorders (including no history of mania or hypomania episodes) who developed hypomania associated to the use of atypical antipsychotics.

Trait impulsivity in patients with mood disorders

BACKGROUND

Impulsivity is a key component of the manic behavior of bipolar disorder and is reported to occur in bipolar patients as a stable characteristic, i.e. a trait. Nevertheless, impulsivity has not been widely studied in depressed bipolar patients. We assessed impulsivity in depressed and euthymic bipolar and unipolar patients and healthy controls. We hypothesized that bipolar subjects would have higher levels of trait impulsivity than the comparison groups.

METHODS

Twenty-four depressed bipolar, 24 depressed unipolar, 12 euthymic bipolar, and 10 euthymic unipolar patients, as well as 51 healthy subjects were evaluated with the Barratt Impulsiveness Scale (BIS). Analysis of covariance with age and sex as covariates was used to compare mean group differences.

RESULTS

Depressed bipolar, euthymic bipolar, and depressed unipolar patients did not differ, and showed greater impulsivity than healthy controls on all of the BIS scales. Euthymic unipolar patients scored higher than healthy controls only on motor impulsivity.

LIMITATIONS

Higher number of past substance abusers in the bipolar groups, and no control for anxiety and personality disorders, as well as small sample sizes, limit the reach of this study.

CONCLUSIONS

This study replicates prior findings of stable trait impulsivity in bipolar disorder patients, and extends them, confirming that this trait can be demonstrated in depressed patients, as well as manic and euthymic ones. Trait impulsivity may be the result of repeated mood episodes or be present prior to their onset, either way it would influence the clinical presentation of bipolar disorder.

Impulsivity and bipolar disorder

Impulsivity is frequently associated with bipolar disorder (BD) during manic episodes, but may also be present in euthymic bipolar patients. Aggression is an impulsivity-related behavior also found during manic episodes. The objective of this review is to further clarify the relationship between impulsivity and BD. A search in Medline and Psycinfo databases, combined with a manual search of selected references, was conducted to identify available literature on BD and impulsivity-related features. Although few studies have directly measured impulsivity in BD, available findings suggest that impulsivity is not only state-related, but also a trait component of BD, which could represent a core feature of the illness. Further research exploring the neurobiology of the impulsivity/BD relationship may contribute to elucidate the pathophysiology and to improve the diagnosis and treatment of this severe illness.

Prefrontal hyperactivation during working memory task in untreated individuals with major depressive disorder

The prefrontal cortex, a part of the limbic-thalamic-cortical network, participates in regulation of mood, cognition and behavior and has been implicated in the pathophysiology of major depressive disorder (MDD). Many neuropsychological studies demonstrate impairment of working memory in patients with MDD. However, there are few functional neuroimaging studies of MDD patients during working memory processing, and most of the available ones included medicated patients or patients with both MDD and bipolar disorder. We used functional magnetic resonance imaging (fMRI) to measure prefrontal cortex function during working memory processing in untreated depressed patients with MDD. Fifteen untreated individuals with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition recurrent MDD (mean age+/-s.d.=34.3+/-11.5 years) and 15 healthy comparison subjects (37.7+/-12.1 years) matched for age, sex and race were studied using a GE/Elscint 2T MR system. An echo-planar MRI sequence was used to acquire 24 axial slices. The n-back task (0-back, 1-back and 2-back) was used to elicit frontal cortex activation. Data were analyzed with a multiple regression analysis using the FSL-FEAT software. MDD patients showed significantly greater left dorsolateral cortex activation during the n-back task compared to the healthy controls (P<0.01), although task performance was similar in the two groups. Furthermore, the patients showed significant anterior cingulate cortex activation during the task, but the comparison subjects did not (P<0.01). This study provides in vivo imaging evidence of abnormal frontolimbic circuit function during working memory processing in individuals with MDD.

Plasma cell cheilitis

Plasma cell cheilitis is a rare inflammatory disorder of the lip with a characteristic band-like infiltrate of plasma cells in the upper dermis. Differential diagnosis should consider allergic/irritant contact cheilitis, candidiasis, syphilis, Queyrat's erythroplasia, granulomatous cheilitis, plasmoacanthoma, plasmacytoma, squamous cell carcinoma and exfoliative or factitious cheilitis. We observed plasma cell cheilitis in a 60-year-old Caucasian female who had a partial response to topical steroids and oral griseofulvin.

Overdoses among cocaine users in Brazil

AIMS

A survey of cocaine users was undertaken to study (i) the frequency of reported drug overdoses among cocaine users; and (ii) the frequency of witnessing drug overdoses in the same population.

DESIGN AND SETTING

A cross-sectional study as part of the World Health Organization (WHO) Multi-city Study among injecting drug users (IDUs), phase II, was conducted in Santos Metropolitan Region, State of São Paulo, Brazil, in 1999.

PARTICIPANTS

Three hundred and ninety-six exclusive users of cocaine in the Santos Metropolitan Region, São Paulo State, Brazil were surveyed concerning their past experience with drug overdoses.

FINDINGS

Eighty (20%) of the cocaine users reported having experienced one or more overdoses, and 50% reported that they knew one or more other cocaine users who had died of an overdose. On multivariate analysis, being female and having spent time in jail were associated with an increased likelihood of having had one or more overdoses.

CONCLUSION

Cocaine overdoses are an important and under-recognized health problem in the Santos Metropolitan Region, and possibly in other areas of Brazil.

[Prevalence of cutaneous lesions in Freixo de Espada à Cinta]

Incidence or prevalence studies on cutaneous lesions in general populations are not available. The community observed by the authors (Freixo de Espada à Cinta, North-Eastern Portugal) is relatively closed. A pre-tested questionnaire for socio-demographic and clinical information was used and a physical observation was conducted in January and February 1994 by the Dermatology Team of Santo António General Hospital, Oporto. The analysis was supported by independent tests (Pearson and Fisher chi 2, Student-t, Mann-Whitney and Kruskall-Wallis). The Spearman correlation coefficient was also used. The results indicated that 51.9% of 1000 subjects analysed were in phototype III. Concerning specific pathologies, the following percentages were observed: melanocytic nevi 81.2; hemangiomas 26.5; androgenetic alopecia 20.5; deshydrotic eczema 12.7; seborrheic keratosis 11; solar keratosis 9.6; acne vulgaris 9.5; seborrheic dermatitis 6.9; superficial mycosis 6.4; other dermatitis 5.5; vascular spiders 4.4; vulgar psoriasis 1.9; vulgar warts 1.5; pediculosis and scabiosis 1.2.; herpes simplex 0.9; impetigo 0.7; tumours (neoplasias) 0.7; dysplastic nevi 0.6; urticaria 0.3. More than nine nevi were counted in 50% of the subjects observed. A difference was observed (p < 0.05) concerning the presence of nevi, mycosis, hemangiomas, non-specific dermatitis, vascular spider and solar keratosis according to sex. The females had more nevi in number than males (Mann-Whitney, p = 0.03). According to age there was a difference concerning the presence of nevi, superficial mycosis, deshydrotic eczema, seborrheic dermatitis, acne, psoriasis, tumours, hemangiomas, non-specific dermatitis, vascular spider, solar keratosis (with linear augmentation by age) and seborrheic keratosis. Nevi increased with ageing (Rs = 0.10 p < 0.001) and a greater number were observed in age groups 0-9 and 60 or more years. Acne was observed in 9.4% of the females and 9.7% of the males, 46.2% in the 15-29 year-old age group. This study indicated that the population had a mean of nine nevi. Psoriasis was similar to that mentioned in other studies: about 1% in the United States of America. Atopic dermatitis (5.5%) is below the values for the northern population (> = 15%), but above that indicated for the English and American population. Nevertheless, the values of the present study were higher than those in the latter populations, when children until seven years old were considered. The Freixo de Espada à Cinta population above 60 years had solar keratosis in 30.6%, a value three times higher than the previous decade (10.9%); reference values were not found. Contrary to the literature, an association was not established between phototype and solar keratosis. Cutaneous tumours were observed in 0.7% of the cases.

Guess what! Porokeratosis of Mibelli

A 72-year-old man had noticed, in his early forties, the appearance of well-defined papulous hyperkeratotic lesions, with increasing growth, located on both sides of his feet. After twenty-five years he consulted a dermatologist for the first time. Physical examination showed annular papules and rose-coloured plaques with atrophic centres, some of them hypopigmented, with higher and irregular borders, separated from the surrounding skin by longitudinal and well-defined furrows. The lesions presented variable sizes and shapes, some of them punctate, involving exclusively and in a bilateral form, both sides, back and sole of the feet (Figs. 1 and 2). The patient did not report any subjective symptoms. He was immunocompetent and did not remember that any relative had the same disease, nor had he been subjected to radiation treatment.

Two recent cases of tertiary syphilis

Tertiary syphilis is now a rare disease in Europe, mainly as a result of occasional antibiotherapy for concomitant infections. However early syphilis is rising in USA and Germany, and it is necessary to maintain an high level of knowledge and suspicion to achieve a diagnosis in the tertiary stage of the disease. In this report two patients with benign tertiary syphilis are described. The first one is a 55-year-old female with erythemato-violaceous annular scaling plaques on the right buttock and scapula and on both thighs, which had a negative and then a low VDRL titer. The second case is a 33-year-old mentally handicapped female with erythematous plaques, with psoriasiform scaling in the trunk and well defined crusted ulcers on the face, which also had negative VDRL. Biopsy of the skin lesions revealed plasmocytic infiltrate with endothelial swelling without granulomas and with negative silver stains in both patients. The investigation for cardiovascular and neurological involvement was negative in both patients. Diagnosis of tertiary syphilis can be difficult as clinical pictures can be misleading, similar to other granulomatous diseases, and serological titers can be low or negative. We recall the necessity of ruling out neurological and cardiac involvement in this stage of syphilis. These cases are reported as a reminder of the possibility of syphilis, so that new cases are not misdiagnosed and mistreated as other diseases.

Two recent cases of tertiary syphilis

Tertiary syphilis is now a rare disease in Europe, mainly as a result of occasional antibiotherapy for concomitant infections. However early syphilis is rising in USA and Germany, and it is necessary to maintain an high level of knowledge and suspicion to achieve a diagnosis in the tertiary stage of the disease. In this report two patients with benign tertiary syphilis are described. The first one is a 55-year-old female with erythemato-violaceous annular scaling plaques on the right buttock and scapula and on both thighs, which had a negative and then a low VDRL titer. The second case is a 33-year-old mentally handicapped female with erythematous plaques, with psoriasiform scaling in the trunk and well defined crusted ulcers on the face, which also had negative VDRL. Biopsy of the skin lesions revealed plasmocytic infiltrate with endothelial swelling without granulomas and with negative silver stains in both patients. The investigation for cardiovascular and neurological involvement was negative in both patients. Diagnosis of tertiary syphilis can be difficult as clinical pictures can be misleading, similar to other granulomatous diseases, and serological titers can be low or negative. We recall the necessity of ruling out neurological and cardiac involvement in this stage of syphilis. These cases are reported as a reminder of the possibility of syphilis, so that new cases are not misdiagnosed and mistreated as other diseases.

[Photosensitivity induced by piroxicam]

In Portugal, piroxicam is one of the most prescribed non-steroidal anti-inflammatory agents (NSAIDs) and is frequently associated to photosensitivity skin reactions, well known by all dermatologists. The authors review the physiopathology and clinical patterns of this adverse drug reaction. Importance is given to the high prevalence of thimerosal sensitisation in our country, a marker of piroxicam photosensitivity. The authors propose that piroxicam prescription should be avoided in Portugal, as this drug can be substituted by any other NSAID, without marked photosensitivity.

Lichen planus and chronic hepatitis C: exacerbation of the lichen under interferon-alpha-2a therapy

A 51-year-old man was treated for histologically proven chronic hepatitis C with 3 MU of recombinant interferon-alpha-2a three times a week. Before interferon therapy, a mild lichen planus (hypertrophic variant) had been diagnosed, which exacerbated within 6 weeks of treatment to a severe erosive oral form. Then interferon therapy was stopped because local measures did not improve oral lesions. However, the patient tolerated interferon therapy well, and the initially four-fold elevated aminotransferase levels returned to normal. Nine weeks after discontinuation of interferon therapy, nearly all the buccal mucous membrane lesions had disappeared. But 8 weeks after withdrawal of interferon, aminotransferase levels rose again to six times the normal range. Treating physicians should know that a pre-existing lichen planus would potentially exacerbate, as a side effect of interferon-alpha-2a therapy of chronic hepatitis. However, further observations are needed to decide its clinical relevance.

[Comparison between HDL and LDL cholesterol as risk factors for carotid atherosclerosis]

In order to find out whether there exists a relationship between HDL and LDL serum levels and atherosclerotic plaques in the carotid artery (CA), a prospective study was carried out involving 125 patients. They were aleatorily included, of both sexes and age between 45-75 years old. HDL and LDL serum levels were measured as well CA ultrasonographic mode B investigated. It was verified that the number of patients having atherosclerotic plaques in CA was inversely proportional to the HDL levels. We came up with the same ratio when the HDL levels were compared to the number of patients having CA stenosis. These results were statistically significant (x2 = 6.57 and x2 = 9.24 respectively; critical x2 = 5.99 to alpha = 5%). A direct ratio was also found out in the relationship between the presence of atherosclerotic plaques in the CA and the LDL serum levels (greater in patients with plaques). However no relationship between LDL levels and the occurrence or not of CA stenosis in patients having plaques was demonstrated. The results were not statistically significant (x2 = 0.97 and x2 = 0.41, respectively, critical x2 = 5.99 to alpha = 5%). The obtained results seem to be at least in part in agreement with literature findings. Statistically significative results in the comparison of HDL and LDL levels with the grade of stenosis of the CA were not found out (x2 = 11.78 and x2 = 4.03, respectively; critical x2 = 12.59 to alpha = 5%).