Efficacy and Safety of Subcutaneous Esketamine in the Treatment of Suicidality in Major Depressive Disorder and Bipolar Depression

BACKGROUND AND OBJECTIVE

Affective disorders account for most cases of suicide. The pharmacological arsenal to treat suicidality is limited and available agents take too long to take effect. A large body of evidence shows optimal results of ketamine for treating depression, but the evidence concerning suicidality has not been fully described. We report the first real-world study of severely depressed patients presenting with suicide ideation who were treated with repeated administration of subcutaneous esketamine.

METHODS

We analyzed data from 70 acutely depressed subjects diagnosed with resistant major depressive disorder or bipolar depression. Subjects were administered subcutaneous esketamine once a week for 6 weeks. The primary efficacy endpoint, the change from baseline to 24-h post-administration 6 in the item 10 Montgomery-Åsberg Depression Rating Scale score, was analyzed using a mixed-effects repeated-measures model.

RESULTS

There were significant effects for time on item 10 Montgomery-Åsberg Depression Rating Scale scores (p < 0.0001) but not for a time × diagnosis interaction (p = 0.164) from baseline to the end of the study. Efficacy of esketamine did not differ between groups (major depressive disorder vs bipolar depression) at any timepoint. Statistical significance on suicidality scores was observed from 24 h after the first administration (p < 0.001), and a further reduction was observed with repeated administrations. Esketamine was safe and well tolerated. Mean heart rate remained stable during the administrations and the blood pressure increase was self-limited.

CONCLUSIONS

Repeated subcutaneous esketamine administration had significant anti-suicidality effects in both major depressive disorder and bipolar groups, with a rapid onset of action and a good tolerability profile. Large randomized controlled trials are warranted to confirm these preliminary findings.

The probability of response after each subcutaneous injection of esketamine in treatment-resistant depression

INTRODUCTION

The administration of multiple esketamine doses has shown efficacy for unipolar and bipolar treatment-resistant depression (TRD). Nevertheless, the probability of responding or not after each dose in the real-world remains unknown. This study aimed to estimate it throughout four doses of esketamine, administrated via subcutaneous (SC).

MATERIAL AND METHODS

We conducted a retrospective analysis of a case series of 70 patients with TRD who received treatment from the esketamine assistance program at Federal University of Sao Paulo, between April 2017 and December 2018. The SC injections were administrated weekly at a dose of 0.5-1.0mg/kg, in conjunction with patients' psychotropic drugs. Response was defined as a decrease of at least 50% in the Montgomery-Åsberg Depression Rating Scale between baseline and 24h after dose. We used hidden Markov modeling in order to estimate de probability of response after each esketamine injection.

RESULTS

The probability of a patient that was a "non-responder" to become a "responder" following a SC injection of esketamine was 17.30% and the probability that this patient remains a "non-responder" was 82.70%. The probability of a patient that was a "responder" to remain as a "responder" was 95%.

CONCLUSIONS

Patients with TRD who had not responded after the first dose of esketamine, still had a chance of responding after the subsequent dose administrated via SC.

Comparative effectiveness of esketamine in the treatment of anhedonia in bipolar and unipolar depression

BACKGROUND

Anhedonia is a symptom associated with poorer outcomes in depression treatment, including resistance to treatment, higher functional impact and suicidality. Few drugs are known to adequately treat anhedonia in both unipolar and bipolar depression. The NMDA antagonist ketamine has been demonstrated to be effective in rapidly ameliorating anhedonia in depressive episodes. The main aim of present study is to evaluate the anti-anhedonic effect of esketamine, the S-enantiomer of ketamine recently approved for treatment-resistant depression, in unipolar and bipolar depression.

METHODS

70 patients with unipolar or bipolar depression were treated with 6 weekly subcutaneous esketamine infusions (0.5-1mg/kg). Anhedonia was measured through MADRS item 8 before and 24h after each infusion.

RESULTS

A significant reduction in anhedonia severity was observed (p<0.0001) after 6 infusions. The effect was statistically significant 24h after the first infusion (p<0.001) in both unipolar and bipolar groups and increased with repeated infusions. Anti-anhedonic effect of esketamine did not differ between groups.

LIMITATIONS

This is an open-label, real-world study. Lack of blinding and of a placebo arm may limit the interpretation of findings.

CONCLUSION

Although preliminary, present findings suggest that repeated subcutaneous esketamine infusions are effective for the treatment of anhedonia in both unipolar and bipolar depressed patients. These results need to be confirmed through replication in larger double-blinded controlled trials.

The probability of response after each subcutaneous injection of esketamine in treatment-resistant depression

INTRODUCTION

The administration of multiple esketamine doses has shown efficacy for unipolar and bipolar treatment-resistant depression (TRD). Nevertheless, the probability of responding or not after each dose in the real-world remains unknown. This study aimed to estimate it throughout four doses of esketamine, administrated via subcutaneous (SC).

MATERIAL AND METHODS

We conducted a retrospective analysis of a case series of 70 patients with TRD who received treatment from the esketamine assistance program at Federal University of Sao Paulo, between April 2017 and December 2018. The SC injections were administrated weekly at a dose of 0.5-1.0mg/kg, in conjunction with patients' psychotropic drugs. Response was defined as a decrease of at least 50% in the Montgomery-Åsberg Depression Rating Scale between baseline and 24h after dose. We used hidden Markov modeling in order to estimate de probability of response after each esketamine injection.

RESULTS

The probability of a patient that was a "non-responder" to become a "responder" following a SC injection of esketamine was 17.30% and the probability that this patient remains a "non-responder" was 82.70%. The probability of a patient that was a "responder" to remain as a "responder" was 95%.

CONCLUSIONS

Patients with TRD who had not responded after the first dose of esketamine, still had a chance of responding after the subsequent dose administrated via SC.

Portuguese consensus document for the management of alpha-1-antitrypsin deficiency

Alpha-1-antitrypsin deficiency (AATD) is a genetic autosomal codominant disorder caused by mutations in SERPINA1 gene. It is one of the most prevalent genetic disorders, although it remains underdiagnosed. Whereas at international level there are several areas of consensus on this disorder, in Portugal, inter-hospital heterogeneity in clinical practice and resources available have been adding difficulties in reaching a diagnosis and in making therapeutic decisions in this group of patients. This raised a need to draft a document expressing a national consensus for AATD. To this end, a group of experts in this field was created within the Portuguese Pulmonology Society - Study group on AATD, in order to elaborate the current manuscript. The authors reviewed the existing literature and provide here general guidance and extensive recommendations for the diagnosis and management of AATD that can be adopted by Portuguese clinicians from different areas of Medicine. This article is part of a supplement entitled "Portuguese consensus document for the management of alpha-1-antitrypsin deficiency" which is sponsored by Sociedade Portuguesa de Pneumologia.

Clinical predictors of antidepressant response to ketamine in unipolar treatment-resistant depression

Introduction

The non-competitive N-methyl-d-aspartate glutamate receptor antagonist ketamine has been shown to have rapid antidepressant effects in treatment-resistant depression (TRD). However, only a few studies have investigated which clinical characteristics predict a response to ketamine.

Objectives

To assess sociodemographic variables and clinical markers that predict response to ketamine in unipolar TRD patients.

Methods

Searches of Pubmed, NCBI and Google Scholar were conducted for clinical trials and systematic reviews, through October 2016, using the keywords:

ketamine, N-methyl-d-aspartate receptor antagonist, rapid-acting antidepressant, depression, treatment-resistant depression, clinical predictors.

Results

Findings support the following clinical predictors:

– sociodemographic variables: positive family history of alcohol abuse disorder in first-degree relative (increased antidepressant response and fewer depressive symptoms for up to 4 weeks post-infusions), higher BMI (improvement in depression severity at 230 minutes and one day post-infusion), negative history of suicide attempt (greater improvement at day 7);

– infusion-associated events: greater dissociation during infusion (better antidepressant response at 230 minutes and one week post-infusion); rapid response to first infusion (sustained response to subsequent infusions in one-third responders for up to 83 days);

– symptomatology: anxious depression (fewer depression symptoms at day one up to 25 associated with longer time to relapse); neurocognitive performance (lower attention) predicts change in severity of depressive symptoms over six infusions.

Conclusions

Findings suggest that specific clinical characteristics are predictors of ketamine response in TRD. Future studies confirming reliable predictors will assist clinicians to implement efficacious and individualized treatment for TRD patients.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A new technique in double-bundle anterior cruciate ligament reconstruction with implant-free tibial fixation

PURPOSE

This case-series outcome study presents a surgical technique for anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with 4-tunnel using two interference screws. There was a 2-year minimum follow-up.

METHODS

From January to December 2009, an ACL 4-tunnel, anatomic, double-bundle reconstruction was performed on 27 patients. Double-strand hamstring tendon grafts were used in each femoral tunnel as well as two interference screws. Tibial fixation was insured through manual tension, by tying non-absorbable sutures on the bone bridge between the two tunnels at 20° of knee flexion. Clinical assessments included the International Knee Documentation Committee (IKDC) and Lysholm knee scores, range of motion (ROM), pivot-shift test, single-leg hop, and quadriceps-hamstrings strength tests using a hand-held dynamometer. Anterior knee laxity was also assessed using a rolimeter. A single examiner performed all testing pre-operatively at 6 months and during the 2-year follow-up.

RESULTS

All patients were assessed during the 2-year follow-up. At that time, 92 % of the patients presented normal anterior laxity (average, 1.3 ± 0.5 mm) and rotational knee stability. No statistical side-to-side difference was found for ROM, muscle strength, single-leg hop, and function (n.s.). All patients presented a normal knee function according to the IKDC and the Lysholm score. In addition, no infection, graft failure, or pain were observed at the harvesting site.

CONCLUSION

The study shows that satisfactory results in relation to knee laxity, function, and strength can be achieved with the implant-free tibial fixation in the ACL double-bundle reconstruction with two interference screws.

LEVEL OF EVIDENCE

Therapeutic case series, Level IV.

Oxidative stress and mitochondrial dysfunction play a role in myelodysplastic syndrome development, diagnosis, and prognosis: A pilot study

The imbalance between reactive oxygen species (ROS) production and their elimination by antioxidants leads to oxidative stress. Depending on their concentration, ROS can trigger apoptosis or stimulate cell proliferation. We hypothesized that oxidative stress and mitochondrial dysfunction may participate not only in apoptosis detected in some myelodysplastic syndrome (MDS) patients, but also in increasing proliferation in other patients. We investigated the involvement of oxidative stress and mitochondrial dysfunction in MDS pathogenesis, as well as assessed their diagnostic and prognostic values. Intracellular peroxides, superoxide, superoxide/peroxides ratio, reduced glutathione (GSH), and mitochondrial membrane potential (Δψ(mit)) levels were analyzed in bone marrow cells from 27 MDS patients and 12 controls, by flow cytometry. We observed that all bone marrow cell types from MDS patients had increased intracellular peroxide levels and decreased GSH content, compared with control cells. Moreover, oxidative stress levels were MDS subtype- and risk group-dependent. Low-risk patients had the highest ROS levels, which can be related with their high apoptosis; and intermediate-2-risk patients had high Δψ(mit) that may be associated with their proliferative potential. GSH levels were negatively correlated with transfusion dependency, and peroxide levels were positively correlated with serum ferritin level. GSH content proved to be an accurate parameter to discriminate patients from controls. Finally, patients with high ROS or low GSH levels, as well as high superoxide/peroxides ratio had lower overall survival. Our results suggest that oxidative stress and mitochondrial dysfunction are involved in MDS development, and that oxidative stress parameters may constitute novel diagnosis and/or prognosis biomarkers for MDS.

Comparison of isometric ankle strength between females with and without patellofemoral pain syndrome

INTRODUCTION

Proximal and distal influences on the knee may be related as etiological factors of patellofemoral pain syndrome (PFPS). The distal factors include subtalar excessive pronation as well as medial tibia rotation, but no study has investigated whether ankle weakness could lead to alterations that influence the patellofemoral joint. Thus, the purpose of this study was to compare the ankle dorsiflexor and invertor muscles strength, as well as rearfoot eversion and the Navicular Drop Test (NDT) in females with PFPS to a control group of females of similar demographics without PFPS.

METHODS

Forty females, between 20 and 40 years of age (control group: n=20; PFPS group: n=20) participated. Rearfoot eversion range of motion and the NDT were assessed for both groups. The Numeric Pain Rating Scale and the Anterior Knee Pain Scale were used to evaluate the level of pain and the functional capacity of the knee during activities, respectively. Isometric ankle dorsiflexor and invertor strength was measured using a handheld dynamometer as the dependent variable.

RESULTS

The isometric strength of the dorsiflexor and invertor muscle groups in females with PFPS was not statistically different (P>0.05) than that of the control group. There was no statistically significant difference between groups for rearfoot eversion and NDT (p>0.05).

DISCUSSION/CONCLUSION

These results suggest that there is no difference between isometric ankle dorsiflexion and inversion strength, the NDT, and rearfoot eversion range of motion in females with and without PFPS.

LEVEL OF EVIDENCE

3-b.

Isometric strength ratios of the hip musculature in females with patellofemoral pain: a comparison to pain-free controls

The purpose of the study was to compare hip agonist-antagonist isometric strength ratios between females with patellofemoral pain (PFP) syndrome and pain-free control group. One hundred and twenty females between 15 and 40 years of age (control group: n = 60; PFP group: n = 60) participated in the study. Hip adductor, abductor, medial rotator, lateral rotator, flexor, and extensor isometric strength were measured using a hand-held dynamometer. Comparisons in the hip adductor/abductor and medial/lateral rotator and flexor/extensor strength ratios were made between groups using independent t-tests. Group comparisons also were made between the anteromedial hip complex (adductor, medial rotator, and flexor musculature) and posterolateral hip complex (abductor, lateral rotator, and extensor musculature). On average, the hip adductor/abductor isometric strength ratio in the PFP group was 23% higher when compared with the control group (p = 0.01). The anteromedial/posterolateral complex ratio also was significantly higher in the PFP group (average 8%; p = 0.04). No significant group differences were found for the medial/lateral rotator ratio and flexor/extensor strength ratios. The results of this study demonstrate that females with PFP have altered hip strength ratios when compared with asymptomatic controls. These strength imbalances may explain the tendency of females with PFP to demonstrate kinematic tendencies that increase loading on the patellofemoral joint (i.e., dynamic knee valgus).

Primary endometrial B-cell lymphoma: case report

The female genital tract is usually involved with lymphoma as part of disseminated disease. Primary lymphoid neoplasms of the female genital tract are rare; the frequency was reported to be 2% among extranodal lymphomas in women. Most of the time, primary female genital tract lymphoma occurs in the ovary and cervix, whereas endometrial lymphoma is extremely rare. The case of an 89-year-old patient that presented with postmenopausal bleeding is reported. An endometrial polypoid formation was found on hysteroscopic examination and the biopsy revealed a diffuse large B-cell lymphoma. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were surgically performed. The histologic diagnosis was primary diffuse large B-cell lymphoma of the endometrium. Adjuvant therapy was not performed. Five months after initial diagnosis, the patient died. Only a few case reports of primary endometrial lymphoma have been published; therefore, information concerning etiologic factors, histologic type, treatment and prognosis is limited.

[The adverse effects of antihypertensive therapy: the perception of patients]

OBJECTIVES

To determine the prevalence of side effects of antihypertensive therapy as patients perceive them, their distribution and association with several sociodemographic and clinical characteristics.

DESIGN

Cross-sectional survey, made by telephone on a randomized sample of national scale, selected from the telephone directories.

PARTICIPANTS

Of a randomized sample of 4480 people contacted, 3374 were interviewed, and 1425 hypertensive patients were identified. Of this group, 1000 (70%) completed the interview, and 425 (30%) refused to participate.

METHODS

Patients were interviewed by telephone by a company of market studies. Epi Info was used for statistical analysis. Associations between the occurrence of side effects and the sociodemographic and clinical variables were analysed by logistic regression.

MAIN RESULTS

44.3% of the patients surveyed (45.6% male and 43.6% female), experienced side effects. These were more common among the youngest (50.4%) and the oldest (45.5%). There was a tendency towards an inverse relationship with social class and a significant association (p = 0.009) with the region of residence, the South showing the lowest rate of side effects (26.3%). The analysis of the associations between side effects and the clinical variables showed that only the regularity of medication was close to statistical significance (p = 0.06). The other clinical variables (time since knowledge of hypertension, substitution of medication, number of drugs and current medication) did not show any association with the perception of side effects.

CONCLUSIONS

This study showed a high prevalence of side effects referred by patients under antihypertensive therapy (44.3%). Among several sociodemographic and clinical characteristics, the only significant statistical association found was with region of residence (the South with the lowest rate). The patients' perception of side effects of antihypertensive therapy is admitted as a potential conditioner of compliance and a cause for deficient blood pressure control to be prevented.

Víbrios não coléricos na rotina enterobacteriológica

De 3.250 fezes diarréicas, recebidas para diagnóstico microbiológico em laboratório clínico particular, no Recife, Brasil, isolaram-se 55 (1,7%) linhagens de Vibrio. O estudo foi realizado entre maio de 1989 e maio de 1991. Para o isolamento de Vibrio, os espécimes fecais foram enriquecidos em água peptonada alcalina suplementada com 2% de NaCl e subcultivados em ágar tiosulfato-citrato-sais biliares-sacarose (TCBS). Das espécies isoladas, V. parahaemolyticus foi a mais freqüente (24 cepas), seguida de V. furnissii (15 cepas), V. cholerae não 01 (6 cepas), V. alginolyticus (4 cepas), V. fluvialis (2 cepas) e Vibrio sp. (1 cepa). Do ponto de vista custo-benefício, a baixa taxa de isolamento de Vibrio levanta dúvidas acerca da utilidade do TCBS na rotina enterobacteriológica dos laboratórios clínicos

[Non-cholera vibrios in enterobacteriologic routine]

Of 3250 diarrheal stools received for microbiologic diagnosis at a private clinical laboratory in Recife, Brazil, strains of Vibrio were isolated from 55 (1.7%). The study was carried out from May 1989 through May 1991. For recovering Vibrio, fecal samples were enriched in alkaline peptone water supplemented with 2% NaCl and subcultured on thiosulfate-citrate-bile salts-sucrose agar (TCBS). Of the recovered species, V. parahaemolyticus was most commonly found (24 strains), followed by V. furnissii (15 strains), V. cholerae non-01 (6 strains), V. alginolyticus (4 strains), V. fluvialis (2 strains), and Vibrio sp. (1 strain). The low isolation rate of Vibrio raises doubts about the cost-effectiveness of the use of TCBS in the routine enterobacteriologic workup of clinical laboratories.

[Human gastroenteritis associated with Vibrio fluvialis in Recife]

Due to the low number of reports about vibrio gastroenteritis in Brazil, it was decided to report one case of human gastroenteritis from who only Vibrio fluvialis has been found in patient stools. The main clinical epidemiological and microbiological aspects related to that microorganism are discussed. Probably, this is the first report of gastroenteritis caused by Vibrio fluvialis in the country.

[Measles: optimum age and number of doses recommended for vaccination in Brazil]

Este estudo foi inicialmente conduzido em população adulta normal, compreendendo doadores de Banco de Sangue, estudantes universitários e parturientes, totalizando 889 indivíduos. Foi observado que cerca de 87% desta população apresentava anticorpos específicos para o sarampo, e que o mesmo porcentual de positividade observado nas gestantes, foi encontrado nos seus respectivos conceptos dada a passagem transplacentária dos anticorpos maternos. Foi verificado o declínio desses anticorpos após o 4.° mês, do recém-nato. Os resultados à vacinação contra o sarampo foi estudada em 1268 crianças divididas em três grupos: I) vacinadas aos 7 meses e revacinadas aos 15 meses; II) vacinadas aos 9 meses e III) vacinadas aos 7 meses e revacinadas aos 9 meses. Os resultados deste estudo indicam que apesar da resposta à vacinação ter sido mais eficiente no grupo de crianças maiores, é importante que se vacine aos 7 meses de idade, embora a porcentagem de soroconversão tenha sido de 50%. Esta medida deve ser levada em consideração, tendo em vista que a mortalidade por sarampo em crianças com menos de 1 ano representa a metade dos óbitos pela doença. Foi verificado que após a aplicação da 2.° dose, não houve diferença quanto à soroconversão, tanto no grupo revacinado 2 meses ou 8 meses após a 1.º dose da vacina. Portanto, a vacinação aos 7 meses é necessária, visando diminuir a mortalidade e a morbidade dentro do 1.º ano de vida, e a revacinação aos 9 meses, a fim de imunizar as crianças não beneficiadas com a 1.ª dose.