Psychotropic drug treatment, clinical characteristics and cognitive processing speed in patients with schizophrenia: results from the ELAN study

INTRODUCTION

Psychotropic drug combinations (PDC) are common in the treatment of patients with schizophrenia but there is little research regarding the effects of PDC on cognition.

OBJECTIVE

The aim of this study was to analyse the effects of antipsychotic monotherapy and various types of PDC on cognitive processing speed (CPS).

METHODS

ELAN is a 24-month multi-site prospective observational controlled trial following up 374 patients with schizophrenia under routine treatment conditions following discharge from inpatient treatment. The propensity score method, multinomial logistic regression analyses and mixed effects regression models were used.

RESULTS

CPS correlated significantly with PANSS and GAF scores and improved over time in the monotherapy group. Negative effects of some PDC (antipsychotics + tranquilizers/antipsychotics+at least 2 other psychopharmacological subclasses, sedative/anticholinergic drugs/high adjusted antipsychotic dose) lost significance after controlling for clinical characteristics.

DISCUSSION

Indications for PDC should be examined with care although, in the present study, effects on cognition were small.

Pollen limitation and inbreeding depression in an 'old rare' bumblebee-pollinated grassland herb

Habitat fragmentation and reduction of population size have been found to negatively affect plant reproduction in 'new rare' species that were formerly common. This has been attributed primarily to effects of increased inbreeding but also to pollen limitation. In contrast, little is known about the reproduction of 'old rare' species that are naturally restricted to small and isolated habitats and thus may have developed strategies to cope with long-term isolation and small population size. Here we study the effects of pollen source and quantity on reproduction of the 'old rare' bumblebee-pollinated herb, Astragalus exscapus. In two populations of this species, we tested for pollen autodeposition, inbreeding depression and outbreeding depression. Caged plants were left unpollinated or were pollinated with pollen from the same plant, from the same population or from a distant population (50 km). Additionally, we tested for pollen limitation by pollen supplementation in four populations of different size and density. In the absence of pollinators, plants did not produce seed whereas self-pollinated plants did. This indicates a self-compatible breeding system dependent on insect pollination. Both self-pollination and, in one of the two populations, cross-pollination with pollen from plants from the distant population resulted in a lower number of seeds per flower than cross-pollination with pollen from plants from the resident population, indicating inbreeding and outbreeding depression. Pollen addition enhanced fruit set and number of seeds per flower in three of the four populations, indicating pollen limitation. The degree of pollen limitation was lowest in the smallest but densest population. Our results suggest that, similar to 'new rare' plant species, also 'old rare' species may be at risk of inbreeding depression and pollen limitation.

Risk evaluation in cutaneous melanoma patients undergoing lymph node dissection: impact of POSSUM

INTRODUCTION

When lymphatic metastasis occurs, surgery is the primary treatment modality in melanoma patients. Depending on the tumour stage, patients receive a completion lymph node dissection (CLND) when a positive sentinel node is detected. Patients with clinically evident disease of the regional lymph nodes are recommended to undergo a therapeutic lymph node dissection (TLND). The aim of this study was to assess the morbidity of CLND and TLND and to evaluate the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) for preoperative risk adjustment of postoperative morbidity.

METHODS

The hospital files of 143 patients who underwent CLND and TLND for malignant melanoma were analysed. The POSSUM score was used to predict morbidity rates after surgery for the total patient group as well as separated for CLND and TLND patients.

RESULTS

The overall complication rate was 28.0% and the mortality rate was 0%. The morbidity rate predicted by POSSUM was 32.9%, the mortality 8.3%. Morbidity in patients undergoing CLND was significantly higher with regard to overall wound complications compared with patients with TLND. In these subgroups, POSSUM failed to predict the rates precisely.

CONCLUSIONS

The POSSUM score predicted the morbidity of the total patient group accurately but failed to predict the rates in the TLND and CLND subgroups. Patients receiving CLND showed the highest morbidity rates. Preoperative sentinel lymph node biopsy therefore has more influence on postoperative morbidity than the physiological parameters represented in the POSSUM physiological score.

[Erik Essen-Möller and the roots of multiaxial classification in psychiatry]

Against the background of the preparation of ICD-11 and DSM-V, the historical roots of a multiaxial diagnostic assessment in psychiatry are reviewed. The principles of such an approach are traced back to the Swedish psychiatrist Erik Essen-Möller who had proposed a distinction between aetiological and descriptive aspects in the classification of mental disorders. Furthermore, he suggested to break down the descriptive classification into the cross-sectional psychopathological picture and the clinical course. Nowadays, a multiaxial assessment is used in diagnostic systems such as DSM-IV. However, these current concepts differ considerably from Essen-Möller's suggestions. A return to the original approach of multiaxial diagnostic assessment comprising the axes "syndromes", "course types" and "aetiology" would be in line with current neurobiological findings and may provide a bridge between the traditional categorical diagnostic approach and dimensional models.

A systematic review of duloxetine and venlafaxine in major depression, including unpublished data

OBJECTIVE

To determine the short-term antidepressant efficacy and tolerability of duloxetine and venlafaxine vs. each other, placebo, selective serotonin reuptake inhibitors (SSRIs), and tri- and tetracyclic antidepressants (TCAs) in adults with major depression.

METHOD

Meta-analysis of randomised controlled trials identified through bibliographical databases and other sources, including unpublished manufacturer reports.

RESULTS

Fifty-four studies including venlafaxine arms (n = 12,816), 14 including duloxetine arms (n = 4,528), and two direct comparisons (n = 836) were analysed. Twenty-three studies were previously unpublished. In the meta-analysis, both duloxetine and venlafaxine showed superior efficacy (higher remission and response rates) and inferior tolerability (higher discontinuation rates due to adverse events) to placebo. Venlafaxine had superior efficacy in response rates but inferior tolerability to SSRIs (OR = 1.20, 95% CI 1.07-1.35 and 1.38, 95% CI 1.15-1.66, respectively), and no differences in efficacy and tolerability to TCAs. Duloxetine did not show any advantages over other antidepressants and was less well tolerated than SSRIs and venlafaxine (OR = 1.53, 95% CI 1.10-2.13 and OR 1.79, 95% CI 1.16-2.78, respectively).

CONCLUSION

Rather than being a first-line option, venlafaxine appears to be a valid alternative in patients who do not tolerate or respond to SSRIs or TCAs. Duloxetine does not seem to be indicated as a first-line treatment.

[Neuropathological research on organs of patients of the "Heil- und pflegeanstalt" (state hospital) Günzburg]

BACKGROUND

The two Kaiser Wilhelm-Institutes (KWI) in Berlin (1914, new building 1931) and in Munich (1917, new building 1926-28), specialized on pathologic anatomical as well as psychiatric genetic research, were set up before times of National Socialism.

METHODS

Data evaluation is based on patient documents and annual reports of the archive of today's district hospital Günzburg and on patient documents (copies) of the historical archive of today's Max-Planck Institute of Psychiatry.

RESULTS

The KWI in Munich was indirectly provided with brain material by Bavarian "Heil- und Pflegeanstalten" (state hospitals) including the state hospital Günzburg.

CONCLUSIONS

During National Socialism patients' organs were sent from the "Heil- und Pflegeanstalt" (state hospital) Günzburg to the KWI in Munich for the purpose of conducting research. Commemorating patients' fates and clarifying what happened defines a place of remembrance.

Discharge planning, an intervention study - and where to go next?

Background

Process evaluation should be an integral part of randomised controlled trials (RCTs), and this is important in examining complex interventions with a number of active ingredients.

Objective

To analyse effectiveness and effect moderators in a multi-centre RCT of needs-oriented discharge planning vs. treatment as usual (TAU) for high utilisers of mental health care.

Method

From April 2006 to July 2007, 491 adults with high utilisation of mental health care for psychotic disorders gave informed consent to participate in a multi-site RCT at five German psychiatric inpatient services. Subjects allocated to the intervention group were offered a manualised needs-led discharge planning intervention of two 45 minute sessions delivered by a trained study worker. Outcomes (service use, needs, psychopathology, depression, quality of life, direct costs) were assessed at four measurement points during 18-month follow-up. Latent class modelling was used to scrutinise differential effectiveness. Characteristics of subgroups of participants showing variable treatment response will be described.

Results

There was improvement both in the intervention and (TAU) control group but no differential effectiveness of the discharge planning intervention. Only few variables significantly moderated effects. Effect moderators pertained to quality of delivery and intervention dose.

Conclusions

Study results could help to tailor interventions to local conditions and guide future implementation of discharge planning in routine care. Further research should focus on scrutinising study process, ensuring ecological suitability of interventions and on head-to-head comparison studies.

Schizophrenia quality indicators for integrated care - results from a feasibility study

Introduction/objectives

There is currently a variety of initiatives to improve the quality of care for schizophrenia, but there is no established core set of quality indicators in schizophrenia. In 2009, Weinmann and Becker published a set of indicators for quality monitoring of schizophrenia care. This study aims to evaluate the feasibility of these indicators.

Methods

Adult schizophrenic patients insured by the Federal Association of Local Health Insurance Funds (AOK) were recruited in two large psychiatric hospitals. Participants were evaluated using PANSS, CGI, Camberwell Assessment of Need-European Version (CAN-EU) and the Verona Service Satisfaction Scale (VSSS) at discharge and after six month. Furthermore, 18-month AOK administrative data was available for all patients included. Feasibility of structural and quality indicators described by Weinmann and Becker (2009) will be tested by applying the full set of indicators.

Results

82 patients with a mean age of 40 and an average GAF score of 44.3 were included. We were able to calculate all indicators. Outpatient data was available with a delay of over six month. Patients had on average 1.6 additional psychiatric diagnoses (S1) and a mean length of stay of 44 days (S6). 67% of the patients were satisfied with the treatment received (Q17). 25% of the patients were re-admitted to an inpatient psychiatric care within 30 days after discharge.

Conclusions

The usage of Quality Indicators seems to be feasible in routine care. However, delay in the availability of outpatient data has to be considered if these indicators are implemented.

A Multi-Centre Pragmatic Trial of Antipsychotic Drug Treatment

The ELAN study is a prospective multi centre observational trial on the effectiveness and safety of long-term antipsychotic treatment of people with schizophrenia or schizoaffective disorders with quetiapine in comparison to olanzapine and risperidone under real world treatment conditions.

374 adult persons with schizophrenia or schizoaffective disorder prescribed antipsychotic maintenance therapy with quetiapine, olanzapine or risperidone were included at discharge from inpatient treatment. Psychotropic regimen, psychopathological symptoms, general and cognitive functioning, negative side-effects and quality of life were assessed before discharge and at 6, 12, 18 and 24 month follow-up assessments. Intention-to-treat analyses and crossover analyses were conducted by mixed-effects regression models including random linear time effects and time x treatment effects, controlling for baseline differences and additional psychotropic medication and using propensity scores to control for selection bias.

As indicated by significant linear time effects the patients improved with regard to psychopathological symptoms, general functioning, subjective quality of life and cognitive processing speed. No change of extrapyramidal motor side-effects, body mass index or waist circumference was obtained. The lack of any significant time x treatment interaction effects indicated no differences in the safety or effectiveness between the three antipsychotics. Nevertheless, the average hospital admission rate of patients receiving olanzapine was lower in comparison to patients receiving quetiapine or risperidone.

Biliary atresia: lessons learned from the voluntary German registry

INTRODUCTION

Aim of the study was to carry out a 5-year survey of German patients with biliary atresia (BA) and to launch a discussion regarding the feasibility of voluntary registries in unregulated healthcare systems.

METHODS

A retrospective analysis of German BA patients born between 2001 and 2005, based on data collected from the voluntary European Biliary Atresia Registry (EBAR), was carried out and supplemented by data from all BA patients who underwent liver transplantation at the only 4 pediatric transplantation centers (pLTx) in Germany which are so far not registered at EBAR. Survival rates were calculated using Kaplan-Meier analysis and compared by Cox regression to determine the predictive value of age at surgery and the influence of the center size (fewer or more than 5 patients/study period) on overall survival and survival with native liver.

RESULTS

A critical review of the 148 German EBAR charts revealed that 11 patients (7.4%) had no biliary atresia. The remaining 137 patients from EBAR together with 46 BA patients who underwent LTx without prior registration at EBAR were evaluated with a median follow-up of 39 months (range: 25-85 months). 29 hospitals performed a total of 159 Kasai procedures, but only 7 centers treated 5 or more patients (116 patients, range: 5-68), and 22 hospitals performed less than 5 KP (43 patients, range: 1-4). Primary LTx was performed in 21 patients (11.5%) and 3 patients died without surgical intervention. 16 patients were lost to follow-up (8.7%). Overall survival after 2 years was 83.3% (139 patients), including 105 patients (63%) who had undergone LTx and 34 patients (20.3%) with native liver. 28 patients died (16.7%), 8 after LTx (5.8%). The experience of the center was the only factor with a significant predictive value for jaundice-free survival with native liver (p=0.001).

CONCLUSION

25% of all German BA patients were not registered at EBAR, and 29 clinics were involved in the surgical management of BA patients. Therefore a new approach consisting of an internet-based decentralized registry for rare neonatal liver diseases is outlined which could improve the future management of patients with BA. The centralization of such patients at experienced centers with higher caseloads is necessary in Germany and would improve the outcome of patients with biliary atresia.

The helps toolkit - a tool to promote the physical health of residents in psychiatric facilities across Europe

Introduction

People with a mental disorder are at increased risk for physical illness and therefore their risk of premature death is raised. An unhealthy lifestyle, living conditions, medication side-effects and a lack of physical health monitoring are regarded as the main causes of high somatic morbidity. But up to now only little research has addressed the physical co-morbidity in mentally ill. At present, there are no specific policies to improve the health status of residents in mental health care facilities.

Objectives / methods

Against this background a multi-disciplinary network of experts from 15 European countries was set up. Working together with researchers, stakeholders, professionals, networks, practitioners, and relevant organizations, the HELPS network developed a “physical health promotion toolkit” for routine application in a wide range of mental health care facilities across Europe. The HELPS toolkit intends to empower patients and staff to identify the most relevant risk factors in their specific context and subsequently select the most appropriate action out of a range of defined health promoting interventions. In doing so, the toolkit takes into account the heterogeneity of mental disorders, the high number of somatic problems, aspects of lifestyle, environment, medical care system, personal goals of patients and their motivation for health behavior.

Results / conclusions

The poster presents the HELPS toolkit. It illustrates the individual components of the tool and the processes of its implementation and evaluation. First results of the pilot study concerning the feasibility of the toolkit will be presented and discussed.

[Current developments in liver transplantation in Germany: MELD-based organ allocation and incentives for transplant centres]

Liver transplantation represents a successful and well-established therapeutic concept for patients with advanced liver diseases. Organ donor shortage continues to pose a significant problem. To ensure fair and transparent allocation of too few post-mortem grafts, the model of end-stage liver disease (MELD)-based allocation was implemented in December 2006. This has decreased waiting list mortality from 20 to 10 % but at the same time has reduced post OLT survival (1-year survival from almost 90% to below 80%), which is largely due to patients with a labMELD score > 30. Following MELD introduction the regular allocation threshold has increased from a matchMELD of initially 25 to meanwhile 34. At the same time the quality of donor organs has seen a continuous deterioration over the last 10 - 15 years: 63% of organs are "suboptimal" with a donor risk index of > 1.5. Moreover, the numbers of living-related liver transplantations have decreased. In Germany incentives for transplant centres are inappropriate: patients with decompensated cirrhosis, high MELD scores and high post-transplant mortality as well as marginal liver grafts are accepted for transplantation without the necessary consideration of outcomes, and against a background of the still absent publication and transparency of outcome results. The outlined development calls for measures for improvement: (i) the increase of donor grafts (e. g., living donation, opt-out solutions, non-heart beating donors), (ii) the elimination of inappropriate incentives for transplant centres, (iii) changes of allocation guidelines, that take the current situation and suboptimal donor grafts into account, and (iv) the systematic and complete collection of transplant-related data in order to allow for the development of improved prognostic scores.

Schizoaffective disorder--an ongoing challenge for psychiatric nosology

OBJECTIVE

Schizoaffective disorder is a common diagnosis in mental health services. The present article aims to provide an overview of diagnostic reliability, symptomatology, outcome, neurobiology and treatment of schizoaffective disorder.

METHOD

Literature was identified by searches in "Medline" and "Cochrane Library".

RESULTS

The diagnosis of schizoaffective disorder has a low reliability. There are marked differences between the current diagnostic systems. With respect to psychopathological symptoms, no clear boundaries were found between schizophrenia, schizoaffective disorder and affective disorders. Common neurobiological factors were found across the traditional diagnostic categories. Schizoaffective disorder according to ICD-10 criteria, but not to DSM-IV criteria, shows a more favorable outcome than schizophrenia. With regard to treatment, only a small and heterogeneous database exists.

CONCLUSION

Due to the low reliability and questionable validity there is a substantial need for revision and unification of the current diagnostic concepts of schizoaffective disorder. If future diagnostic systems return to Kraepelin's dichotomous classification of non-organic psychosis or adopt a dimensional diagnostic approach, schizoaffective disorder will disappear from the psychiatric nomenclature. A nosological model with multiple diagnostic entities, however, would be compatible with retaining the diagnostic category of schizoaffective disorder.

[The "Aktion T4". In remembrance of victims of the healing and nursing institution in Günzburg]

OBJECTIVE

The aim of this article was to achieve a commemoration of patients of the Healing and Nursing Institute in Günzburg who were victims of "Aktion T4".

METHODS

On the basis of pre-defined criteria several individual patient documents were selected for this study and analyzed historically. Most items of information concerning patient histories and diagnoses were obtained from the stock R 179 of the branch office of the federal archives in Berlin Lichterfelde. Further supplementary information was extracted from administrative documents and patient charts of the archives of the psychiatric department at the regional hospital Günzburg.

RESULTS

The historical reconstruction of three individual life histories contributes to a literary memorial for the victims.

CONCLUSIONS

It is a historical responsibility to remember the victims of the "Aktion T4" by contributing to a reconstruction of their life histories.

Sotrastaurin, a novel small molecule inhibiting protein kinase C: first clinical results in renal-transplant recipients

Sotrastaurin, a novel protein-kinase-C inhibitor, blocks early T-cell activation. In this 12-month, Phase II study, de novo renal-transplant patients were randomized to sotrastaurin (200 mg b.i.d.) + standard-exposure tacrolimus (SET) or reduced-exposure tacrolimus (RET) (SET: n = 76; RET: n = 66), or control (SET + mycophenolic acid [MPA, 720 mg b.i.d.]; n = 74). In both sotrastaurin groups, patients were converted from tacrolimus to MPA after Month 3, achieving calcineurin inhibitor-free immunosuppression. The primary endpoint was composite efficacy failure (treated biopsy-proven acute rejection, graft loss, death or loss to follow-up). The key secondary endpoint was glomerular filtration rate (GFR). Composite efficacy failure rates were: 4.1%, 5.4% and 1.5% at Month 3 (preconversion) and 7.8%, 44.8% and 34.1% at study end in the control, sotrastaurin + SET and sotrastaurin + RET groups, respectively; these results led to premature study discontinuation. Median GFR at Month 6 was: 57.0, 53.0 and 60.0 mL/min/1.73 m(2), respectively. Study-drug discontinuations due to adverse events occurred in 16.2%, 18.4% and 12.1%, respectively. Leukopenia and neutropenia occurred more frequently preconversion in control versus sotrastaurin groups: 13.7%, 5.6%, and 4.6%; and 11.1%, 4.3% and 3.1%, respectively. The initial sotrastaurin + tacrolimus regimen was efficacious and well tolerated but the postconversion sotrastaurin + MPA regimen showed inadequate efficacy. Longer-term evaluation of sotrastaurin + tacrolimus is warranted.

Fulminant hepatic failure due to chemotherapy-induced hepatitis B reactivation: role of rituximab

Hepatitis B virus reactivation during immunosuppressive therapies can lead to liver failure with very limited treatment options available. We report here on two cases of severe hepatitis B reactivation during chemotherapy including rituximab for B cell lymphoma which were treated with liver or liver-cell transplantation. Liver function was normal and HBV infection was unknown in both patients before chemotherapy was started. Impaired liver function became apparent after 4 and 6 courses of chemotherapy, respectively, and both patients experienced fulminant hepatic failure despite antiviral treatment with lamivudine or entecavir. Patient A underwent liver transplantation after documentation of complete remission of the lymphoma and survived without any evidence for hepatitis B recurrence. Patient B received 4 courses of hepatocyte transplantation but did not survive. These cases underline the importance of anti-HBc screening in patients receiving immunosuppressive treatments in particular when rituximab is given. Pre-emptive antiviral treatments should be administered since delayed antiviral treatment is frequently unable to prevent liver failure.

Treatment of schizoaffective disorder - a challenge for evidence-based psychiatry

OBJECTIVE

Schizoaffective disorder is a common diagnosis in mental health services. The aim of the present article was to review treatment studies for schizoaffective disorder and draw conclusions for clinical decision making.

METHOD

We searched MEDLINE and Cochrane Library for relevant clinical trials and review articles up to the year 2008.

RESULTS

Thirty-three studies using standardized diagnostic criteria, 14 of which were randomized controlled trials, could be identified. The comparability of studies is limited by the use of different diagnostic criteria. The studies reviewed do not permit consistent recommendations as to whether schizoaffective disorder should be treated primarily with antipsychotics, mood stabilizers or combinations of these drugs. The relevance of diverse subtypes of schizoaffective disorder for treatment recommendations is unclear.

CONCLUSION

The pertinent empirical database is small and heterogeneous. The lack of conclusive recommendations is related to issues of nosological status, plurality of diagnostic criteria and validity of the concept of schizoaffective disorder.

The TRAF1/C5 locus confers risk for familial and severe alopecia areata

BACKGROUND

Alopecia areata (AA) is a common hair loss disorder with a complex mode of inheritance. Autoimmune mechanisms are presumed to be crucial aetiologically. It is plausible that a number of autoimmune disorders may share a common genetic background. This phenomenon has been demonstrated in previous studies, which have shown an overlap of susceptibility alleles between AA and other autoimmune disorders. Recent studies have shown that genetic variants on the TRAF1/C5 (tumor necrosis factor receptor-associated factor 1, complement component 5) locus confer susceptibility to rheumatoid arthritis (RA).

OBJECTIVES

To examine the role of the TRAF1/C5 locus in the development of AA using a large sample of 1,195 patients with AA and 1280 controls.

METHODS

We genotyped the two most significant single nucleotide polymorphisms (SNPs) (rs10818488, rs2416808) from a former RA candidate gene study. After having obtained evidence for association, we performed a fine-mapping study and genotyped the locus with an additional 27 SNPs.

RESULTS

While no significant result was obtained for the overall sample, rs2416808 showed significant associations in the analysis of the subgroups with severe AA and with a positive family history. The most significant P-value for rs2416808 was in familial cases (P = 0.004, P(corr) = 0.026). The fine mapping revealed significant associations for four additional SNPs in the analysis of subgroups, with rs2416808 remaining the most significant marker.

CONCLUSIONS

Our results point to the involvement of the TRAF1/C5 locus in the aetiology of familial and severe AA, and provide further support for a shared aetiology between AA and other autoimmune disorders.

Outcome management in in-patient psychiatric care

OBJECTIVE

To delineate methods and to describe patient appraisal as well as effect of outcome management in in-patient psychiatric care.

METHOD

Two hundred and ninety-four adults with mental illness receiving in-patient treatment at a psychiatric hospital in rural Bavaria gave informed consent to participate in this cluster-randomised trial. Participants were asked to provide information on treatment outcome via weekly computerised standardised assessments. Patients and clinicians in the intervention group received continuous feedback of outcome.

RESULTS

Patients were willing and able to regularly provide outcome data and valued feedback. However, use of feedback in conversations between patient and clinician was rare. Outcome management failed to impact on patient-rated outcome during in-patient treatment.

CONCLUSION

Outcome management is feasible in people receiving in-patient psychiatric care, but failed to show an overall short-term effect. Strategies need to be developed to improve active use of routinely collected treatment outcome data in mental health care.