Costs of disorders of the brain in Europe

A simple mathematical tool to forecast COVID-19 cumulative case numbers

Objective

Mathematical models are known to help determine potential intervention strategies by providing an approximate idea of the transmission dynamics of infectious diseases. To develop proper responses, not only are more accurate disease spread models needed, but also those that are easy to use.

Materials and methods

As of July 1, 2020, we selected the 20 countries with the highest numbers of COVID-19 cases in the world. Using the Verhulst–Pearl logistic function formula, we calculated estimates for the total number of cases for each country. We compared these estimates to the actual figures given by the WHO on the same dates. Finally, the formula was tested for longer-term reliability at t = 18 and t = 40 weeks.

Results

The Verhulst–Pearl logistic function formula estimated the actual numbers precisely, with only a 0.5% discrepancy on average for the first month. For all countries in the study and the world at large, the estimates for the 40th week were usually overestimated, although the estimates for some countries were still relatively close to the actual numbers in the forecasting long term. The estimated number for the world in general was about 8 times that actually observed for the long term.

Conclusions

The Verhulst–Pearl equation has the advantage of being very straightforward and applicable in clinical use for predicting the demand on hospitals in the short term of 4–6 weeks, which is usually enough time to reschedule elective procedures and free beds for new waves of the pandemic patients.

Shaping therapeutic trajectories in mental health: Instructive vs. permissive causality

We are currently facing the challenge of improving treatments for psychiatric disorders such as major depression. Notably, antidepressants have an incomplete efficacy, mostly due to our limited knowledge of their action. Here we present a theoretical framework that considers the distinction between instructive and permissive causality, which allows formalizing and disentangling the effects exerted by different therapeutic strategies commonly used in psychiatry. Instructive causality implies that an action determines a specific effect while permissive causality allows an action to take effect or not. We posit that therapeutic strategies able to improve the quality of the living environment or the ability to face it, including changes in lifestyle and psychotherapeutic interventions, rely mainly on instructive causality and thus shape the individual's ability to face the psychopathology and build resilience. By contrast, pharmacological treatments, such as selective serotonin reuptake inhibitors, act primarily through a permissive causality: they boost neural plasticity, i.e. the ability of the brain to change itself, and therefore allow for instructive interventions to produce beneficial effects or not. The combination of an instructive and a permissive action represents the most promising approach since the quality of the living environment can shape the path leading to mental health while drug treatment can increase the likelihood of achieving such a goal.

Fluoxetine effects on molecular, cellular and behavioral endophenotypes of depression are driven by the living environment

Selective serotonin reuptake inhibitors (SSRIs) represent the most common treatment for major depression. However, their efficacy is variable and incomplete. In order to elucidate the cause of such incomplete efficacy, we explored the hypothesis positing that SSRIs may not affect mood per se but, by enhancing neural plasticity, render the individual more susceptible to the influence of the environment. Consequently, SSRI administration in a favorable environment promotes a reduction of symptoms, whereas in a stressful environment leads to a worse prognosis. To test such hypothesis, we exposed C57BL/6 mice to chronic stress in order to induce a depression-like phenotype and, subsequently, to fluoxetine treatment (21 days), while being exposed to either an enriched or a stressful condition. We measured the most commonly investigated molecular, cellular and behavioral endophenotypes of depression and SSRI outcome, including depression-like behavior, neurogenesis, brain-derived neurotrophic factor levels, hypothalamic-pituitary-adrenal axis activity and long-term potentiation. Results showed that, in line with our hypothesis, the endophenotypes investigated were affected by the treatment according to the quality of the living environment. In particular, mice treated with fluoxetine in an enriched condition overall improved their depression-like phenotype compared with controls, whereas those treated in a stressful condition showed a distinct worsening. Our findings suggest that the effects of SSRI on the depression- like phenotype is not determined by the drug per se but is induced by the drug and driven by the environment. These findings may be helpful to explain variable effects of SSRI found in clinical practice and to device strategies aimed at enhancing their efficacy by means of controlling environmental conditions.

Implementing Case Management in Portuguese Mental Health Services: Conceptual Background

Case management implementation processes are one of the best examples on how an evidence-based practice can influence health services organisation. This practice helped shaping mental health teams, increasing their multidisciplinarity and interdisciplinary work in the last decades. Examples from several countries show how effectiveness research blends into health policy development to meet different needs in each health system, thus influencing case management inception and improvement of care. Portugal followed its own path in case management implementation, determined mostly by mental health services organisation and closely linked with the capacity to implement a national mental health policy in the last years.

Fractalkine receptor deficiency impairs microglial and neuronal responsiveness to chronic stress

Chronic stress is one of the most relevant triggering factors for major depression. Microglial cells are highly sensitive to stress and, more generally, to environmental challenges. However, the role of these brain immune cells in mediating the effects of stress is still unclear. Fractalkine signaling - which comprises the chemokine CX3CL1, mainly expressed by neurons, and its receptor CX3CR1, almost exclusively present on microglia in the healthy brain - has been reported to critically regulate microglial activity. Here, we investigated whether interfering with microglial function by deleting the Cx3cr1 gene affects the brain's response to chronic stress. To this purpose, we housed Cx3cr1 knockout and wild-type adult mice in either control or stressful environments for 2weeks, and investigated the consequences on microglial phenotype and interactions with synapses, synaptic transmission, behavioral response and corticosterone levels. Our results show that hampering neuron-microglia communication via the CX3CR1-CX3CL1 pathway prevents the effects of chronic unpredictable stress on microglial function, short- and long-term neuronal plasticity and depressive-like behavior. Overall, the present findings suggest that microglia-regulated mechanisms may underlie the differential susceptibility to stress and consequently the vulnerability to diseases triggered by the experience of stressful events, such as major depression.

Holmes tremor: Clinical description, lesion localization, and treatment in a series of 29 cases

OBJECTIVE

To describe the clinical features, etiology, findings from neuroimaging, and treatment results in a series of 29 patients with Holmes tremor (HT).

METHODS

A retrospective study was performed based on review of medical records and videos of patients with HT diagnosis.

RESULTS

A total of 16 women and 13 men were included. The mean age at the moment of CNS insult was 33.9 ± 20.1 years (range 8-76 years). The most common causes were vascular (48.3%), ischemic, or hemorrhagic. Traumatic brain injury only represented 17.24%; other causes represented 34.5%. The median latency from lesion to tremor onset was 2 months (range 7 days-228 months). The most common symptoms/signs associated with HT were hemiparesis (62%), ataxia (51.7%), hypoesthesia (27.58%), dystonia (24.1%), cranial nerve involvement (24.1%), and dysarthria (24.1%). Other symptoms/signs were vertical gaze disorders (6.8%), bradykinesia/rigidity (6.8%), myoclonus (3.4%), and seizures (3.4%). Most of the patients had lesions involving more than one area. MRI showed lesions in thalamus or midbrain or cerebellum in 82.7% of the patients. Levodopa treatment was effective in 13 out of 24 treated patients (54.16%) and in 3 patients unilateral thalamotomy provided excellent results.

CONCLUSIONS

The most common causes of HT in our series were vascular lesions. The most common lesion topography was mesencephalic, thalamic, or both. Treatment with levodopa and thalamic stereotactic lesional surgery seems to be effective.

Understanding the direct and indirect costs of patients with schizophrenia

BACKGROUND

Schizophrenia is a disabling mental disorder with high prevalence and that usually  requires long-term follow-up and expensive lifelong treatment. The cost of schizophrenia treatment consumes a significant amount of the health services' budget in western countries.

OBJECTIVE

The aim of the study was to find out about the costs related to schizophrenia across different european countries and compare them.

RESULTS

Schizophrenia treatment costs an estimated 18 billion euros annually worldwide. The direct costs associated with medical help are only part of the total expenditure. The indirect costs are an equally (or even more)important part of the total cost. These expenses are related to the lack of productivity of schizophrenic patients and the cost that relatives have to bear as a result of taking care of their affected relatives.

CONCLUSIONS

Although data on the cost of schizophrenia may vary slightly between different european countries, the general conclusion that can be drawn is that schizophrenia is a very costly disorder. Not only because of direct costs related to medical procedures, but also due to the non-medical (indirect) costs. Together this suggests the need to investigate cost-efficient strategies that could provide a better outcome for schizophrenic patients, as well as the people who care for them.

Understanding the direct and indirect costs of patients with schizophrenia

Background : Schizophrenia is a disabling mental disorder with high prevalence and that usually  requires long-term follow-up and expensive lifelong treatment. The cost of schizophrenia treatment consumes a significant amount of the health services' budget in western countries. Objective : The aim of the study was to find out about the costs related to schizophrenia across different european countries and compare them. Results : Schizophrenia treatment costs an estimated 18 billion euros annually worldwide. The direct costs associated with medical help are only part of the total expenditure. The indirect costs are an equally (or even more)important part of the total cost. These expenses are related to the lack of productivity of schizophrenic patients and the cost that relatives have to bear as a result of taking care of their affected relatives. Conclusions : Although data on the cost of schizophrenia may vary slightly between different european countries, the general conclusion that can be drawn is that schizophrenia is a very costly disorder. Not only because of direct costs related to medical procedures, but also due to the non-medical (indirect) costs. Together this suggests the need to investigate cost-efficient strategies that could provide a better outcome for schizophrenic patients, as well as the people who care for them.

Agmatine induces Nrf2 and protects against corticosterone effects in hippocampal neuronal cell line

Hyperactivation of the hypothalamic-pituitary-adrenal axis is a common finding in major depression; this may lead to increased levels of cortisol, which are known to cause oxidative stress imbalance and apoptotic neuronal cell death, particularly in the hippocampus, a key region implicated in mood regulation. Agmatine, an endogenous metabolite of L-arginine, has been proposed for the treatment of major depression. Corticosterone induced apoptotic cell death and increased ROS production in cultured hippocampal neuronal cells, effects that were abolished in a concentration- and time-dependent manner by agmatine. Interestingly, the combination of sub-effective concentrations of agmatine with fluoxetine or imipramine afforded synergic protection. The neuroprotective effect of agmatine was abolished by yohimbine (α2-adrenoceptor antagonist), ketanserin (5-HT2A receptor antagonist), LY294002 (PI3K inhibitor), PD98059 (MEK1/2 inhibitor), SnPP (HO-1 inhibitor), and cycloheximide (protein synthesis inhibitor). Agmatine increased Akt and ERK phosphorylation and induced the transcription factor Nrf2 and the proteins HO-1 and GCLc; induction of these proteins was prevented by yohimbine, ketanserin, LY294002, and PD98059. In conclusion, agmatine affords neuroprotection against corticosterone effects by a mechanism that implicates Nrf2 induction via α2-adrenergic and 5-HT2A receptors, Akt and ERK pathways, and HO-1 and GCLc expression.

Antidepressant treatment outcome depends on the quality of the living environment: a pre-clinical investigation in mice

Antidepressants represent the standard treatment for major depression. However, their efficacy is variable and incomplete. A growing number of studies suggest that the environment plays a major role in determining the efficacy of these drugs, specifically of selective serotonin reuptake inhibitors (SSRI). A recent hypothesis posits that the increase in serotonin levels induced by SSRI may not affect mood per se, but enhances neural plasticity and, consequently, renders the individual more susceptible to the influence of the environment. Thus, SSRI administration in a favorable environment would lead to a reduction of symptoms, while in a stressful environment might lead to a worse prognosis. To test this hypothesis, we treated C57BL/6 adult male mice with chronic fluoxetine while exposing them to either (i) an enriched environment, after exposure to a chronic stress period aimed at inducing a depression-like phenotype, or (ii) a stressful environment. Anhedonia, brain BDNF and circulating corticosterone levels, considered endophenotypes of depression, were investigated. Mice treated with fluoxetine in an enriched condition improved their depression-like phenotype compared to controls, displaying higher saccharin preference, higher brain BDNF levels and reduced corticosterone levels. By contrast, when chronic fluoxetine administration occurred in a stressful condition, mice showed a more distinct worsening of the depression-like profile, displaying a faster decrease of saccharin preference, lower brain BDNF levels and increased corticosterone levels. Our findings suggest that the effect of SSRI on depression-like phenotypes in mice is not determined by the drug per se but is induced by the drug and driven by the environment. These findings may be helpful to explain variable effects of SSRI found in clinical practice and to device strategies aimed at enhancing their efficacy by means of controlling environmental conditions.

Evaluation of admission characteristics, hospital length of stay and costs for cerebral infarction in a medium-sized city in China

BACKGROUND AND PURPOSE

Stroke is a heavy economic and health burden for the patients and society. This study aimed to evaluate hospital length of stay (LOS) by admission characteristics and costs correlated with medical insurance status for cerebral infarction in a medium-sized city in China.

METHODS

A total of 557 consecutive patients with principal diagnosis of cerebral infarction were enrolled. Admission characteristics, LOS, and costs were retrospectively analyzed.

RESULTS

The mean LOS was 18.5 days (median, 16 days). Our analysis demonstrated that medical insurance status, stroke severity (National Institutes of Health Stroke Scale score, Functional Independence Measure cognitive and motor score, Glasgow coma scale), Oxfordshire Community Stroke Project (OCSP) classification, some comorbidities (coronary heart disease, chronic obstructive pulmonary disease, and hyperlipemia), and raised leukocytes were the main explanatory factors for LOS by stepwise multiple regression model. The mean per patient costs were US $983.0, and mean daily costs US $67.0. Drugs were the most expensive cost subtype, all subtypes costs except non-medical care were significantly higher in patients with state medicine than in those with new cooperative medical scheme (NCMS) (P < 0.001).

CONCLUSION

Stroke severity, OCSP classification, raised leukocytes on admission, some comorbidities, and medical insurance status may help to predict LOS for patients with cerebral infarction. Healthcare expenditures were heavy burdens to inhabitants. State medicine patients could shorten unnecessary LOS to improve the resources allocation and cost-efficiency.

The double edged sword of neural plasticity: increasing serotonin levels leads to both greater vulnerability to depression and improved capacity to recover

Major depression is a chronic, recurring and potentially life-threatening illness that affects up to 10% of the population worldwide. Pharmacological and genetic studies highlight the serotonergic system as being a key player in the disorder. However, despite drugs designed to boost serotonin transmission represent the first line of therapy for depression, the role of this system still remains elusive. Here, I propose a new theoretical framework, the undirected susceptibility to change model, potentially accounting for the experimental and clinical results concerning the role of this neurotransmitter in depression. Since the capacity of the individual to change its physiology and behavior according to the environment is dependent on neural plasticity which, in turn, is controlled by serotonin, I assume that changes in the levels of serotonin affect the sensitivity to the environment. Consequently, the undirected susceptibility to change model predicts that an increase of serotonin levels, for instance induced through selective serotonin reuptake inhibitor (SSRI) administration, does not affect mood per se, but--acting as a catalyzer--enhances neural plasticity and, thus, the effects of the environment on mood. However, since the environment can be either supportive or adverse, its effects can be beneficial or detrimental. Therefore enhancing the serotonin system can increase the likelihood both of developing the psychopathology and recovering from it. This model, on the one hand, suggests an explanation for the limited SSRI efficacy described in clinical studies and allows apparently contradictory data to be reconciled; on the other, it describes neural plasticity as a double edged sword that, according to the quality of the environment, may have either positive or negative consequences.

Estrogen receptor beta activation prevents glucocorticoid receptor-dependent effects of the central nucleus of the amygdala on behavior and neuroendocrine function

Neuropsychiatric disorders such as anxiety and depression have formidable economic and societal impacts. A dysregulation of the hypothalamo-pituitary-adrenal (HPA) axis leading to elevated endogenous glucocorticoid levels is often associated with such disorders. Chronically high glucocorticoid levels may act upon the central nucleus of the amygdala (CeA) to alter normally adaptive responses into those that are maladaptive and detrimental. In addition to glucocorticoids, other steroid hormones such as estradiol and androgens can also modify hormonal and behavioral responses to threatening stimuli. In particular, estrogen receptor beta (ERbeta) agonists have been shown to be anxiolytic. Consequently, these experiments addressed the hypothesis that the selective stimulation of glucocorticoid receptor (GR) in the CeA would increase anxiety-like behaviors and HPA axis reactivity to stress, and further, that an ERbeta agonist could modulate these effects. Young adult female Sprague-Dawley rats were ovariectomized and bilaterally implanted via stereotaxic surgery with a wax pellet containing the selective GR agonist RU28362 or a blank pellet, to a region just dorsal to the CeA. Four days later, animals were administered the ERbeta agonist S-DPN or vehicle (with four daily sc injections). Anxiety-type behaviors were measured using the elevated plus maze (EPM). Central RU28362 implants caused significantly higher anxiety-type behaviors in the EPM and greater plasma CORT levels than controls given a blank central implant. Moreover, S-DPN treated animals, regardless of type of central implant, displayed significantly lower anxiety-type behaviors and post-EPM plasma CORT levels than vehicle treated controls or vehicle treated animals implanted with RU28362. These results indicate that selective activation of GR within the CeA is anxiogenic, and peripheral administration of an ERbeta agonist can overcome this effect. These data suggest that estradiol signaling via ERbeta prevents glucocorticoid-dependent effects of the CeA on behavior and neuroendocrine function.