Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Benzodiazepine use during cariprazine treatment in acute schizophrenia

Introduction

Although antipsychotics are first-line treatments for schizophrenia, benzodiazepines (BZDs) are often used as concomitant medications in acutely exacerbated patients due to their anxiolytic and sedative effects. Cariprazine (CAR), a D3-preferring dopamine D2/D3 partial agonist antipsychotic, has been examined in many clinical studies for the treatment of acute schizophrenia, with and without benzodiazepines.

Objectives

To delineate the effects of benzodiazepine-use during cariprazine treatment in acute schizophrenia.

Methods

Pooled data of cariprazine-treated (1.5-6mg/day) and placebo-treated patients from four short-term, randomised, double-blind trials (NCT00404573, NCT01104766, NCT01104779, NCT00694707) were analysed. Baseline characteristics (age, duration of illness) and efficacy outcome parameters (Total and Hostility Factor Score of the Positive and Negative Syndrome Scale [PANSS]) were compared in patients receiving benzodiazepines (for more ≥3 consecutive days) and not receiving benzodiazepines (<3 consecutive days).

Results

Altogether, 36.7% and 40.7% of the CAR-treated and PBO-treated patients required BZDs. BZD-taking was associated with a higher age in both the CAR-treated (p=0.0002) and PBO-treated (p<0.0001) patients, and with longer illness-duration in both treatment groups (p<0.0001). PANSS Total Score at baseline was similar for BZD users and non-users (CAR: LS Mean=96.36 and 96.27; PBO: LS Mean=95.55 and 96.66). Change from baseline in the PANSS Total Score was greater for patients who did not use BZD vs those who did (CAR: LS Mean= -23.8 vs LS Mean 17.2, p<0.0001; PBO: LS Mean= -14.0 vs LS Mean 12.9, p=0.5776).

Conclusions

These findings may suggest that requiring benzodiazepines is a potential indicator of longer illness duration and poorer response in acute schizophrenia.

Disclosure

I am an employee of Gedeon Richter Plc.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Efficacy and tolerability of lurasidone in schizophrenia: A systematic review and meta-analysis of short-term, randomized, placebo controlled trials

Introduction

Lurasidone is an atypical antipsychotic approved for the treatment of patients with schizophrenia. We report on a meta-analysis focusing on both the efficacy and safety/tolerability of lurasidone in the treatment of patients with schizophrenia.

Objectives

To obtain pooled estimates from placebo-controlled clinical trials on the efficacy and safety/tolerability of lurasidone in schizophrenia.

Methods

We selected acute, randomized placebo-controlled trials of lurasidone for schizophrenia. Primary outcome for efficacy was the Positive and Negative Syndrome Scale (PANSS) change and for “acceptability” was all-cause discontinuation. Secondary outcomes included specific adverse events, body weight change, ≥7% weight gain, and glucose and lipid parameter change.

Results

Across 10 RCTs (n=3,963, age=40.5±2.3 years, males=64.7 %, trial duration=6.0 weeks), lurasidone outperformed placebo regarding the PANSS total score (N=10, n=3,354, SMD=-0.34, 95% CI: -0.47−-0.21, p<0.001). Stratifying the analysis by dose, lurasidone significantly outperformed placebo at doses 40-160 mg/day. Lurasidone was associated with significantly lower all-cause discontinuation than placebo (N=10, n=3,410, RR=0.87, 95% CI: 0.78−0.97, p=0.014). Lurasidone had significantly higher body weight change compared with placebo (N=10, n=3,359, SMD=0.17, 95% CI: 0.09−0.24, p<0.001), but without significant differences regarding ≥7% body weight gain (N=9, n=3,186, p=0.112). Lurasidone did not differ from placebo in total cholesterol (N=10, n=3,140, p=0.439), LDL-cholesterol (N=7, n=2,414, p=0.849), triglycerides (N=10, n=3,140, p=0.238), and fasting glucose change (N=10, n=3,112, p=0.633).

Conclusions

In short-term trials, lurasidone was efficacious, acceptable and safe, having minimal effect on body weight gain and glucose and lipid metabolism.

Disclosure

K. Hagi is a full time employee of Sumitomo Dainippon Phrma Co., Ltd.

Standardized training in the rating of the six-item positive and negative syndrome scale (PANSS-6)

Introduction

The six-item Positive And Negative Syndrome Scale (PANSS-6) is short psychometric valid scale quantifying the severity of core schizophrenia symptoms. Using PANSS-6 to guide treatment decision-making requires that staff members’ ratings are valid and reliable.

Objectives

The objective of the study was to evaluate whether such valid and reliable PANSS-6 ratings can be obtained through a video-based training program.

Methods

One-hundred-and-four staff members from Aarhus University Hospital - Psychiatry, Denmark participated in the training. Participants conducted baseline PANSS-6 ratings based on a video of a patient being interviewed using the Simplified Positive And Negative Symptoms interview (SNAPSI). Subsequently, a theoretical introduction video was displayed followed by five SNAPSI patient interviews. After each SNAPSI video, individual ratings were performed before a video providing the gold standard scores was displayed. The validity of ratings was estimated by calculating the proportion of participants not deviating from the gold standard scores with >2 points on individual items or >6 points on the PANSS-6 total score. Reliability was evaluated after each step in the training by means of Gwet’s Agreement Coefficient (Gwet).

Results

By the end of the training, 72% of the participants rated within the acceptable deviations of the gold standard, ranging from 60% (nurses) to 91% (medical doctors/psychologists). The reliability improved (Gwet baseline vs. endpoint) for all PANSS-6 items, except for Blunted affect.

Conclusions

The majority of the staff members conducted valid PANSS-6 ratings after a brief standardized training program, supporting the implementation of PANSS-6 in clinical settings to facilitate measurement-based care.

Conflict of interest

Dr. Opler is a full-time employee of MedAvante-ProPhase Inc. Dr. Correll has been a consultant and/or advisor to or have received honoraria from: Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, Gerson Lehrman Group, Indivior, IntraCellular T

The Efficacy of Lurasidone on PANSS Subscales in Adolescent Patients with Schizophrenia: Results from a 6-week, Double-blind, Placebo-controlled, Multicenter Study

Introduction

Lurasidone is an atypical antipsychotic that demonstrated efficacy in the treatment of adults with schizophrenia in the dose range of 37–148 mg/day.

Objective/Aims

The objective of this analysis was to evaluate the efficacy of lurasidone in adolescent patients with schizophrenia.

Methods

Adolescents (13–17 years old) diagnosed with schizophrenia were randomly assigned to six weeks of double-blind treatment with lurasidone 37 mg/day, 74 mg/day or placebo. Changes from baseline to week 6 in PANSS total and subscale (positive, negative, general psychopathology, excitability) scores were evaluated using mixed-model repeated-measures analysis.

Results

A total of 326 patients (mean age, 15.4 years) were randomized and received lurasidone 37 mg/day (n = 108), 74 mg/day (n = 106), or placebo (n = 112). The PANSS total score at week 6 demonstrated a placebo-adjusted, least-squares (LS) mean improvement of –8.0 (P < 0.001; effect size [ES], 0.51) for the 37 mg/day group and –7.7 (P < 0.001; ES = 0.48) for the 74 mg/day group. Placebo-adjusted LS mean change for lurasidone 37 mg/day and 74 mg/day, respectively, was –3.2 (P < 0.001; ES = 0.62) and –3.2 (P < 0.001; ES = 0.60) on the PANSS positive subscale, –1.7 (P = 0.011; ES = 0.41) and –1.6 (P = 0.022; ES = 0.35) on the PANSS negative subscale, –2.8 (P = 0.012; ES = 0.38) and –2.8 (P = 0.011; ES = 0.37) on the PANSS general psychopathology subscale, and –1.1 (P = 0.016; ES = 0.36) and –1.8 (P < 0.001; ES = 0.53) on the PANSS excitability subscale.

Conclusions

In adolescent patients with schizophrenia, lurasidone (37 mg/day and 74 mg/day) demonstrated statistically significant efficacy and clinically meaningful improvement across a wide spectrum of symptoms associated with schizophrenia. Sponsored by Sunovion Pharmaceuticals Inc. ClinicalTrials.gov identifier: NCT01911429.

Disclosure of interest

Dr Correll reports being a consultant and/or advisor for Alkermes, Forum Pharmaceuticals Inc., Gerson Lehrman Group, IntraCellular Therapies, Janssen/J&J, Lundbeck, Medavante, Medscape, Otsuka, Pfizer Inc, ProPhase, Sunovion Pharmaceuticals Inc., Supernus, Takeda, and Teva providing expert testimony for Bristol-Myers Squibb Company, Janssen, and Otsuka serving on a Data Safety Monitoring Board for Lundbeck and Pfizer Inc and receiving grant support from Takeda. Drs Goldman, Cucchiaro, Deng and Loebel are employees of Sunovion Pharmaceuticals Inc.

Pharmacotherapy in Children and Adolescents at Clinical-High Risk for Psychosis and Bipolar Disorder

This review aims to describe the importance of i) detecting individuals at clinical high-risk for psychosis (schizophrenia) or bipolar disorder, especially in children and adolescents, in order to enable early intervention, and ii) evaluating different intervention strategies, especially pharmacotherapy, during the subsyndromal or "prodromal" stages of these severe and often debilitating disorders. The different approaches regarding the psychotic and bipolar clinical high-risk state are discussed, including reasons and evidence for early (pharmacological) intervention and risks of treatment vs. non-treatment. Only 10 prospective studies of antipsychotics (randomized=4) and 6 prospective studies of non-antipsychotic pharmacologic agents (randomized=3, i. e., omega-3 fatty acids=2, glycine=1) for the psychotic clinical high-risk state and only 4 prospective studies of mood stabilizing medications for the bipolar clinical high-risk state (randomized=2, i. e., lithium=1, valproate=1) were detected. Based on the minimal efficacy data, adverse effect risks, especially in pediatric populations, nonspecific psychopathology, and unknown true risk for the development of either psychosis or bipolar disorder or of chronically disabling symptoms and disability, medication treatment currently remains second choice after psychosocial intervention. Additional research in this area is clearly needed in order to shed more light on the relevance and predictive value of potentially prodromal symptoms, their identification and most appropriate management options.

Mega-review of meta-analyses investigating the short-term efficacy of pharmacologic augmentation strategies of antipsychotics in patients with schizophrenia

Antipsychotics are the cornerstone of treatment for schizophrenia, but they have limited effectiveness, as most patients require subsequent strategies at some point of their treatment. Despite being widely used, the efficacy of pharmacologic augmentation of antipsychotics is controversial and no combination treatment has been approved for schizophrenia. We conducted a systematic review in PubMed and PsycInfo on June 1st 2015 and a random effects meta-analysis of meta-analyses of short-term, placebo-controlled studies of pharmacological augmentation strategies of antipsychotics in schizophrenia. Methodological quality of meta-analyses was measured using the AMSTAR, plus 6 additional items developed to rate the content quality of the meta-analyzed trials. Out of 3062 publications, we identified 36 eligible augmenting strategies. For total symptom reduction, 25 strategies augmenting antipsychotics and 5 strategies augmenting clozapine were eligible and examined. Eleven strategies were more efficacious than placebo, none of them augmenting clozapine. Significant effect sizes ranged between SMD −1.03 and −0.23. Efficacy was not correlated with the quality of the meta-analyses. Only the meta-analysis for NSAIDs augmentation had a score greater than half of the possible points for content quality. Only antipsychotics, azapirones, antidepressants and lithium were less discontinued than placebo. Serotonin-3-receptor antagonists, lamotrigine, mirtazapine/mianserine, minocycline and estrogens had large effect sizes augmenting antipsychotics. However the quality of the content of most meta-analyses was low. The NSAIDs augmentation meta-analysis had the best content quality, yet with a low effect size for efficacy. The evidence for short-term augmentation strategies of antipsychotics in schizophrenia is inconclusive, due to the limited quality of the available trials.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Mental health of children, adolescents and young adults--part 2: burden of illness, deficits of the German health care system and efficacy and effectiveness of early intervention services]

Numerous birth-control studies, epidemiological studies, and observational studies investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use of children, adolescents and young adults is low, even lower than in adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the border of child and adolescent and adult psychiatry. Emerging studies show that these health care structures are effective and efficient. Part 2 of the present review focuses on illness burden including disability and costs, deficits of the present health care system in Germany, and efficacy and efficiency of early intervention services.

[Mental health of children, adolescents and young adults--part 1: prevalence, illness persistence, adversities, service use, treatment delay and consequences]

Numerous birth-control studies, epidemiological studies, and observational studies have investigated mental health and health care in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, treatment delay and course of illness. Moreover, the impact of the burden of illness, of deficits of present health care systems, and the efficacy and effectiveness of early intervention services on mental health were evaluated. According to these data, most mental disorders start during childhood, adolescence and early adulthood. Many children, adolescents and young adults are exposed to single or multiple adversities, which increase the risk for (early) manifestations of mental diseases as well as for their chronicity. Early-onset mental disorders often persist into adulthood. Service use by children, adolescents and young adults is low, even lower than for adult patients. Moreover, there is often a long delay between onset of illness and first adequate treatment with a variety of linked consequences for a poorer psychosocial prognosis. This leads to a large burden of illness with respect to disability and costs. As a consequence several countries have implemented so-called "early intervention services" at the interface of child and adolescent and adult psychiatry. Emerging studies show that these health-care structures are effective and efficient. Part 1 of the present review summarises the current state of mental health in childhood, adolescence and early adulthood, including prevalence, age at onset, adversities, illness persistence, service use, and treatment delay with consequences.

Prevalence of the metabolic syndrome in patients with borderline personality disorders - results of a cross-sectional study

Introduction

The metabolic syndrome (MetS) is an important risk factor for the development of type-2 diabetes and coronary artery disease. However, little is known about the prevalence of the MetS in patients with borderline personality disorder (BPD).

Objectives, aims

We aimed to compare the MetS prevalence in patients with borderline personality disorder (BPD) with control subjects followed in primary care from a similar region.

Methods

One-hundred thirty five BPD patients according to DSM-IV diagnostic criteria were compared to 1009 subjects from primary care. We used the American Heart Association/National Heart, Lung and Blood Institute (AHA/NHBLI) criteria to determine the rate of MetS and of each individual MetS criterion. For comparison purposes we calculated age-standardized rates of the MetS and their 95%-confidence intervals (CI).

Results

The age-standardized prevalence of MetS was more than double in patients with BPD compared to control subjects (23.3% vs. 10.6%, p < 0.05).

Within BPD patients, an increased rate of MetS was associated with higher BMI (Wald = 10.2; p = 0.004), age (Wald = 4.7; p = 0.03), treatment with second generation antipsychotics (quetiapine, olanzapine and clozapine) (Wald = 4.6; p = 0.032), dysthymia (Wald = 4.6; p = 0.031), panic disorder (Wald = 4.6; p = 0.032), benzodiazepine dependency (Wald = 5.9; p = 0.015), and binge-eating disorder (Wald = 5.4; p = 0.02).

Conclusions

Our results demonstrate an increased MetS rate, dysregulated glucose and lipid metabolism in patients with BPD. Independent predictors of MetS in BPD patients require further study to inform targeted prevention efforts in this population. Cardiometabolic monitoring and careful screening for physical health conditions among people with BPD is warranted.

A systematic evaluation and comparison of the guidelines for screening and monitoring of cardiometabolic risk in people with schizophrenia

Metabolic and cardiovascular health problems have become a major focus for clinical care and research in schizophrenia. To evaluate the content and quality of screening guidelines for cardiovascular risk in schizophrenia we performed a systematic review and quality assessment of guidelines/recommendations published between 2000–2010, using the Appraisal of Guidelines for Research and Evaluation (AGREE). AGREE domain scores varied between 18 identified guidelines. Most guidelines scored best on the domains ‘Scope and Purpose’ and ‘Clarity of Presentation’. The domain ‘Rigour of Development’ was problematic in most guidelines, while the domains ‘Stakeholder Involvement’ and ‘Editorial Independence’ scored the lowest. The following parameters were recommended, in order of frequency: fasting glucose, BMI, fasting triglycerides, fasting cholesterol, waist, HDL/LDL, blood pressure, symptoms of diabetes. In terms of interventions most guidelines recommended advise on physical activity, advise on diet psycho-education of the patent, treatment of lipid abnormalities, treatment of diabetes, referral for advise and treatment, psycho-education of family and smoking cessation advice. Compared across all domains and content, 4 European guidelines could be recommended. Four of the evaluated guidelines are of good quality and should guide clinicians’ screening and monitoring practices. Future guideline development could be improved by increasing its rigour and assuring user and patient involvement. Although good guidelines are available research shows that the implementation in daily clinical practice remains poor.

Sudden death in psychiatric patients

Introduction

Studies using death certificates have indicated an excess of sudden cardiac deaths among users of antipsychotic drugs compared to the general population, but may have underestimated the presence of other known causes of sudden and unexpected death.

Objectives

To assess the cause and risk factors for sudden death discovered by contemporaneous investigation of all deaths occurring over a 26-year period (1984–2009) in adult patients registered for care in one large psychiatric hospital in New York.

Methods

Circumstances of death, psychiatric diagnoses, psychotropic drugs and past medical history were extracted from the root cause analyses of sudden unexpected deaths. After the exclusion of suicides, homicides and drug overdoses, explained and unexplained cases were compared regarding clinical variables and the utilization of antipsychotics.

Results

One hundred cases of sudden death were identified among of 119, 500 patient-years. The death remained unexplained in 52 cases. The incidence of unexplained sudden death was 125/100,000 (95% CI 88.9–175.1/100,000) patient-years in 2005–2009, 53/100,000 (95% CI 31.7–88.5/100,000) patient-years in 1999–2004 and 7/100,000 (95% CI 3.7–19.4/100,000) patient-years in 1984–1998. Explained and unexplained cases were similar regarding psychiatric diagnoses and treatment with any psychotropic class, including first- and second-generation antipsychotics. Dyslipidemia (p = 0.012), diabetes (p = 0.055) and co-morbid dyslipidemia and diabetes (p = 0.008) were more common in the unexplained than in the explained cases.

Conclusions

In a consecutive cohort of psychiatric patients, the unexplained sudden deaths were associated with known risk factors for coronary artery disease, but not with higher utilization of first- or second-generation antipsychotics.

Psychotropic drug presentation in medical and lay press journals

OBJECTIVE

Media coverage of psychotropic medications affects public views and patients' and therapists' compliance. This study is aimed to identify characteristics of and differences between medical and lay press presentations of psychotropic drugs.

METHODS

Two leading German medical and three lay press journals were analyzed in seven annual sets, ranging from 1963 to 1996.

RESULTS

There is a clear difference in the reporting on psychotropic drugs between the different types of journals. Lay press journals primarily focus on minor tranquilizers and hypnotics which are indiscriminately presented as one group with other psychotropics, have a rather critical view on these drugs and underrepresent the needs for treatment of major mental illnesses. There were no marked trends over time in the attitude towards psychotropics. On comparing the publications before and after 1984, when benzodiazepines were put under schedule IV by WHO, differences in reports on dependency problems can only be found for the daily newspaper.

CONCLUSION

It is the responsibility of psychiatrists to enter the public discussion on how psychiatric disorders should be treated and to run public "awareness programmes".

Prognostic value of lower limb motor evoked potentials for motor impairment and disability after 8 weeks of stroke rehabilitation--a prospective investigation of 100 patients

We investigated 100 patients with a one-sided, functionally relevant hemiparesis after stroke. Motor evoked potentials (MEPs) were obtained from the anterior tibial muscle four or more weeks after the insult as well as after an eight week period of inpatient rehabilitation. The MEP results were correlated with motor deficit, walking ability, and activities of daily living (ADLs). Patients with loss of MEP had lower scores on the Motricity Index (MI) both at the beginning and at the end of the rehabilitative treatment (p < 0.001) and also gained fewer points on the MI than patients with preserved MEP. This was the case even when analyzing the lower limb scores alone (p < 0.001 before treatment, p = 0.003 after eight week rehabilitation). When the MEP was preserved, patients were more likely to regain independence in walking (specificity 0.67, positive predictive value 0.96) and stair climbing (specificity 1.0, positive predictive value 1.0). Patients with preserved MEP also scored higher on global outcome scales such as Barthel Index (BI), Functional Independence Measure (FIM) and Glasgow Outcome Scale (GOS). However, these differences did not reach statistical significance (p > 0.05). According to our results, MEPs of the lower extremity are of predictive value for the rehabilitative treatment of patients in the postacute phase after stroke. This is especially true for the extent of the motor impairment and walking ability. The utilization of MEPs for prediction of future levels of disability and handicap is limited and only useful taking into consideration other clinical and diagnostic findings as well as the patients' cognitive, emotional and social state.