A prospective, observational study of the safety and effectiveness of intramuscular psychotropic treatment in acutely agitated patients with schizophrenia and bipolar mania

This naturalistic, observational pan-European study assessed the safety and early effectiveness of intramuscular (IM) psychotropic treatments in patients with acute agitation suffering from schizophrenia or bipolar mania. One thousand nine hundred and forty of 1945 patients completed the 24-hour observation period after initial IM treatment. Patients from 12 European countries were included (mean age 39 years; 58% male, 66% schizophrenia). IM treatment was at the physician's discretion. The primary objective was to describe the acute tolerability of IM psychotropic therapies in clinical practice, with particular emphasis on EPS. At baseline, 68% of the patients received IM monotherapy, with IM olanzapine most commonly prescribed (36%). During the first 24hours, 190 (9.8%) patients experienced EPS. The occurrence of EPS was statistically significantly lower in patients treated with IM olanzapine compared to those treated with other IM psychotropic medications (mainly typical antipsychotics and benzodiazepines): acute dystonia: 1.1%, 95% CI 0.5–2.3 and 2.9%, CI 2.0–4.0; akathisia: 2.3%, CI 1.3–3.7 and 5.5%, CI 4.3–6.9; Parkinsonism: 2.9%, CI 1.8–4.4 and 7.8%, CI 6.4–9.4, respectively. Anticholinergic treatment was given to 12% IM olanzapine versus 31% non-olanzapine treated patients. Acute agitation after 24hours was reduced by 1.68 (95% CI 1.46–1.91) points on the Clinical Global Impression of Severity (CGI-S) in IM olanzapine patients and 1.51 (95% CI 1.30–1.73) points in non-olanzapine patients. Additional psychotropic medication was required for 90% of the patients during the first 24hours of treatment. Results provide naturalistic evidence for low EPS rates and improvement of agitation with IM psychotropic medications during acute states of patients suffering from acute mania or schizophrenia.

Diagnostic relevance of IgE sensitization profiles to eight recombinant Phleum pratense molecules

BACKGROUND

Grass pollen-related seasonal allergic rhinoconjunctivitis (SARg) is clinically heterogeneous in severity, comorbidities, and response to treatment. The component-resolved diagnostics disclosed also a high heterogeneity at molecular level. Our study aimed at analyzing the characteristics of the IgE sensitization to Phleum pratense molecules and investigating the diagnostic relevance of such molecules in childhood.

METHODS

We examined 1120 children (age 4-18 years) with SARg. Standardized questionnaires on atopy were acquired through informatics platform (AllergyCARD™). Skin prick tests were performed with pollen extracts. Serum IgE to airborne allergens and eight P. pratense molecules (rPhl p 1, rPhl p 2, rPhl p 4, rPhl p 5b, rPhl p 6, rPhl p 7, rPhl p 11, rPhl p 12) were tested by ImmunoCAP FEIA.

RESULTS

The analysis of IgE responses against eight P. pratense molecules showed 87 profiles. According to the number of molecules recognized by IgE, the more complex profiles were characterized by higher serum total IgE, higher grass-specific serum IgE, and higher number and degree of sensitization to pollens. The most frequent IgE sensitization profile was the monomolecular Phl p 1. Sensitization to Phl p 7 was a reliable biomarker of asthma, whereas Phl p 12 of oral allergy syndrome. Sensitization to Phl p 7 was associated with a higher severity of SARg, and complex profiles were associated with longer disease duration.

CONCLUSIONS

In a large pediatric population, the complexity of IgE sensitization profiles against P. pratense molecules is related to high atopic features although useless for predicting the clinical severity. The detection of serum IgE to Phl p 1, Phl p 7, and Phl p 12 can be used as clinical biomarkers of SARg and comorbidities. Further studies in different areas are required to test the impact of different IgE molecular profiles on AIT response.

Selection and Assessment of Laboratory Tests for the Evaluation of Liver Functional Impairment

A large number of biochemical tests is at present available for the evaluation of the different aspects of the liver function. As a consequence, the requirement of laboratory investigations is generally increasing in clinical practice. However, the usefulness of such a tendency in liver investigation is questionable: the doubt concerns both the diagnostic efficacy of new individual tests and the opportunity of a progressive increase in tests requirement.

This paper deals with the problem of selecting liver tests on the basis of their information content with respect to different aspects of liver function. The study was performed on 288 normal and pathological subjects. Two different methods were used: a classical statistical feature selection method, and a method based on the probability theory developed in the framework of the fuzzy sets theory. The ranking of the tests was based on the estimated misclassification rate.

The results obtained appear quite relevant from a practical point of view: no effective improvement in liver functional assessment is reached by using more than 3 or 4 selected tests among the many available for each of the functional aspects considered.

A reasonable compromise between diagnostic efficacy, feasibility, and costs indicates that the following groups of tests could be proposed for the functional assessment of liver diseases in clinical routine: Albumin, Pseudo-cholinesterase, and Prothrombin Time for biosynthesis and metabolism; Bilirubin, Gamma-glutamyl-transpeptidase, Bile Acids (fasting) for cholestasis; Aspartate Aminotransferase, Alanine Aminotransferase, Isocitrate-dehydrogenase, for cytolysis; Gamma-globulin, G, A and M Immunoglobulin for reactivity.

Chronic intestinal pseudo-obstruction: Progress in management?

Chronic intestinal pseudo-obstruction (CIPO) is a severe form of gastrointestinal dysmotility (often due to derangement of the innervation/smooth muscle/interstitial cells of Cajal) with recurrent episodes of intestinal subocclusion mimicking a mechanical obstruction. Because of its complexity and heterogeneity, CIPO is often misdiagnosed or remains unrecognized until advanced stages. Management is a critical aspect in CIPO patient care. So far, most prokinetic drugs have not proven efficacy in restoring intestinal propulsion, thus nutritional support, fluid/electrolyte replacement, and antibiotics are the mainstay of treatment. In this issue of the journal, Ohkubo et al showed promising data indicating that percutaneous endoscopic gastro-jejunostomy (PEG-J) can be proposed as a measure for intestinal decompression, thereby improving CIPO-associated abdominal symptoms, including pain. In addition to a concise update of clinical and diagnostic features, the present minireview tackles management options, with a major emphasis on PEG-J, for CIPO patients.

Endotypes of pollen-food syndrome in children with seasonal allergic rhinoconjunctivitis: a molecular classification

BACKGROUND

Pollen-food syndrome (PFS) is heterogeneous with regard to triggers, severity, natural history, comorbidities, and response to treatment. Our study aimed to classify different endotypes of PFS based on IgE sensitization to panallergens.

METHODS

We examined 1271 Italian children (age 4-18 years) with seasonal allergic rhinoconjunctivitis (SAR). Foods triggering PFS were acquired by questionnaire. Skin prick tests were performed with commercial pollen extracts. IgE to panallergens Phl p 12 (profilin), Bet v 1 (PR-10), and Pru p 3 (nsLTP) were tested by ImmunoCAP FEIA. An unsupervised hierarchical agglomerative clustering method was applied within PFS population.

RESULTS

PFS was observed in 300/1271 children (24%). Cluster analysis identified five PFS endotypes linked to panallergen IgE sensitization: (i) cosensitization to ≥2 panallergens ('multi-panallergen PFS'); (ii-iv) sensitization to either profilin, or nsLTP, or PR-10 ('mono-panallergen PFS'); (v) no sensitization to panallergens ('no-panallergen PFS'). These endotypes showed peculiar characteristics: (i) 'multi-panallergen PFS': severe disease with frequent allergic comorbidities and multiple offending foods; (ii) 'profilin PFS': oral allergy syndrome (OAS) triggered by Cucurbitaceae; (iii) 'LTP PFS': living in Southern Italy, OAS triggered by hazelnut and peanut; (iv) 'PR-10 PFS': OAS triggered by Rosaceae; and (v) 'no-panallergen PFS': mild disease and OAS triggered by kiwifruit.

CONCLUSIONS

In a Mediterranean country characterized by multiple pollen exposures, PFS is a complex and frequent complication of childhood SAR, with five distinct endotypes marked by peculiar profiles of IgE sensitization to panallergens. Prospective studies in cohorts of patients with PFS are now required to test whether this novel classification may be useful for diagnostic and therapeutic purposes in the clinical practice.

[A severe case of Plasmodium falciparum malaria]

Malaria infections has been an important public health problem in Europe and Western countries in the last years. The international travels and moreover immigration from Africa and Asia countries has been rapidly increasing especially in Italy. The transmission and diffusion of malaria has increased, especially over last decade, due to vector resistance to insecticides and chemoresistance of these parasites to most antimalarial drugs. The authors presents a severe case of malaria infection that was caused by Plasmodium Falciparum in a one year-old female children, born in Italy, infected during a return in the parents' country of origin, Nigeria. She was admitted because of febrile gastroenteritis for five days. Since the child was in a good state of health, normal the medical examination, blood tests and radiography of the chest. The next day, persisting the fever, the child was somnolent, pale, and was present a haemoglobin concentration of 5.1 g/dl and a thrombocytopenia, a complicated falciparum malaria was diagnosed (8% parasitaemia). Treatment was started immediately with a single oral dose of Mefloquine (25 mg/Kg). Red blood cells were transfused once. The parasitaemia dropped to 4% and 0.8% in less than 48 hours. Weekly controls for the following four weeks remained negative.

[A case of recurrent cough in bronchial carcinoid]

The carcinoid tumors of the bronchial are extremely uncommon, with an incidence of 5% of all pulmonary neoplasms. The carcinoid is the more frequent tumor of the lung in paediatric age. The symptoms most often reported were cough, recurring infection, chest pain, hemoptysis, fever, dyspnea, mild dyspnea attacks after physical effort or nervousness. The carcinoid syndrome is uncommon. Neuroendocrine tumors of the lung embrace a spectrum from low-grade typical carcinoid, intermediate-grade atypical carcinoid, and high-grade categories of large cell neuroendocrine carcinoma and small cell carcinoma. Low grade neoplasms may metastasize to adjacent nodes. Atypical carcinoids are considered low grade malignancies. Most malignant end of neuroendocrine neoplasm group is small cell carcinoma. Typical carcinoids carry an excellent prognosis and should be offered conservative lung resection, whilst atypical carcinoids which behave aggressively should be treated by radical lung resection. The authors report a case of the young patients with bronchial typical carcinoid tumor who had suffered from cough and mild dyspnea attacks after physical effort or nervousness in the last year.

[The effects of growth hormone in children with a GH deficiency: a report of 5 cases]

The authors describe 5 cases, 3 boys and 2 girls, with idiopathic growth hormone deficiency in prepubertal age, treated with human growth hormone. In four of five cases the response to treatment with GH was relevant. Only in one case (F1) the response was negative. The results of this study confirm that rhGH is a safe and effective therapy in children with GHD.

Evaluation of the diagnostic value of serum bile acid in the detection and functional assessment of liver diseases

The diagnostic usefulness of fasting total serum bile acids (SBA/F) in the detection of liver diseases and assessment of different aspects of hepatic function alteration was evaluated in 61 healthy subjects and 186 patients with liver disease. The value of SBA/F was compared with other routine tests. In 49 healthy subjects and 92 patients, serum bile acids were also measured after the im administration of Ceruletide as a cholecystokinetic agent (SBA/C). The diagnostic efficacy for the detection of disease states was better with aspartate-aminotransferase (EC 2.6.1.1) and alanine-aminotransferase (EC 2.6.1.2) than with SBA/F. When SBA/C was also determined the diagnostic efficacy was not substantially better than the SBA/F test. In the assessment of hepatocellular necrosis SBA/F showed a higher rate of misclassification errors compared to alanine-aminotransferase (mean error 45% vs 17%), whereas SBA/F gave similar results with direct bilirubin and pseudocholinesterase (EC 3.1.1.8) in the evaluation of cholestasis (mean error 40% vs 41%) and impaired biosynthesis (mean error 39% vs 40%), respectively. Serum bile acid determination did not show any significant diagnostic advantage with respect to the other routine liver tests.

A sequential protocol for the optimization of diagnostic procedures in hepatology

The aim of this paper is to present a sequential protocol to be used in clinical practice for the detection of liver diseases, based on clinical history, physical examination, and laboratory investigation. The evaluation of the protocol efficacy was carried out on a sample of 288 subjects (92 normal, and 196 affected by various liver alterations) by comparing the obtained results with reference classifications independently performed on the basis of all available subject records (including many more laboratory tests than the ones used in the protocol). A cost-benefit analysis was also carried out, based on the resident population of Regione Piemonte, comparing the protocol with two other simpler ones. Results show that the proposed protocol allows a considerable reduction of costs, showing a high estimated efficacy for clinical use.

Qualitative and quantitative evaluation of liver diseases: functional classifications

The problem of the best use of experimental data for qualitative and quantitative evaluation of liver disfunction is analysed. Only statistical procedures for classification are considered. Emphasis is placed on a complete description of the most important steps that must be performed (degree of clustering of the data, validity of the hypotheses underlying the statistical methods used, meaning and adequate use of the reference classification, reliability of the different statistical methods used, information content of the laboratory tests studied) since the omission of any of them may contribute to a misleading interpretation of the overall results or may prevent significant practical utilization. An application to BSP tests is carried out: results obtained from 350 subjects are presented and discussed. A classification related to the main functional aspects of liver impairment was chosen. Different combinations of the parameters obtained from BSP blood disappearance curve--initial disappearance rate (K1), 45 min-retention of total (RT45) and conjugated (RC45) BSP- and different mathematical algorithms are compared. Five classes (N, normal subjects; PN, paranormal subjects; H, prevalent hepatocellular damage; C, prevalent cholestatic damage; HC, heavy combined damages) can be satisfactorily discriminated with all three parameters (K1 + RT45 + RC45); however K1 + RC45 give almost the same results and represent an interesting compromise between data information content and laboratory complexity.