House dust mite subcutaneous immunotherapy has sustained long-term effectiveness on allergic rhinitis and asthma: A 10-year follow-up

BACKGROUND

Maintenance doses for allergen immunotherapy (AIT) have been recommended for at least 3 years but little data on long-term efficacy is available depending on AIT duration. To show sustained efficacy 10 years after completion of treatment with depigmented-polymerized house dust mite (dpg-pol HDM) allergen extract in adults with asthma and/or rhinoconjunctivitis.

METHODS

Patients included in a double-blind placebo-controlled AIT study with dpg-pol HDM allergen extract were reviewed at completion of the perennial treatment and 10-year follow-up (10y-FU). Change in symptom and rescue medication score was the primary objective. Visual analog scale (VAS), asthma control test (ACT), and degree of disease control were the secondary objectives. A comparative analysis between patients who underwent AIT treatment for <3 years and ≥3 years was performed.

RESULTS

Data from 31 patients (mean age 38 years) were available at 10y-FU. All had asthma and 29 had rhinoconjunctivitis at baseline. Twenty-three patients were treated ≥3 years and 8 for <3 years. Seventeen (55%) patients were asymptomatic at completion of AIT, with significant differences for nasal, conjunctival, and bronchial symptoms (p < .0001) compared with baseline only in those patients treated ≥3 years. Nine (52.9%) patients remained completely asymptomatic at 10y-FU, all were treated for ≥3 years. Moreover, significant reduction in the number of patients with rhinitis (p = .0117), conjunctivitis (p < .0001), and bronchial (p = .0005) symptoms was observed at 10y-FU compared with baseline only in the ≥3 years treated. Ten (32.3%) patients did not require any rescue medication at 10y-FU, all had been treated for ≥3 years. ACT at 10y-FU showed a good control of asthma (median 23.5; 95% IC[22.0, 25.0]). No significant differences were observed between VAS at end of treatment compared with VAS at 10y-FU.

CONCLUSIONS

Sustained clinical efficacy is achieved 10 years after completion of depigmented-polymerized HDM, however, these findings were observed only if patients are treated for at least 3 years.

Predictors of rehospitalization in Psychotic Patients after their first hospitalization

Introduction

It is important to determine those clinical factors that imply a greater risk of rehospitalization in psychotic patients

Objectives

To determine the rate and predictors of rehospitalization in psychotic patients after their first hospitalization

Methods

We include all Psychotic patients admitted for first time in their life in our Psychiatric Unit between 2009 and 2019 (N=359) , including all diagnosed according DSM-IV of Schizophrenia or other Psychotic disorders -Multiple clinical, sociodemographic and biological variables of the basal hospitalization were recorded With the SPSS program we compared the variables between patients who needed any hospitalization in the follow-up until 31th December 2019 and those who do not. We use the Chi square ( qualitative variables) and the Student T ( quantitative variables)

Results

109 psychotic inpatients had at least one rehospitalizations (30,4%). The qualitative variables significantly associated with rehospitalization were : cannabis in urine at admission (P<0.03), and treatment with risperidone (P<0.014). Instead treatment with long acting paliperidone was associated with absence of rehospitalization (P<0.005) .The quantitative variables relationed significantly with multiple rehospitalization were : lower age (P<0,015) lower HDL cholesterol levels (P<0.02) and higher years of follow-up after discharge (P<0.000)

Conclusions

1-More of 30% of psychotic patients need rehospitalization after their first hospitalization in a mean of follow up of 5,8 years 2-Lower age, longer follow-up period and treatment with risperidone are significantly associated with rehospitalization , instead treatment with long acting paliperidone are significantly associated with absence of rehospitalization

Disclosure

No significant relationships.

Completed suicide in bipolar i patients after their first hospitalisation

Introduction

Bipolar disorder is a mental disorder that has one of the greatest risk of completed suicide (CS)

Objectives

Determine the rate and the risk factors of CS in a cohort of Bipolar I patients followed after their first hospitalization

Methods

We choose all Bipolar I patients (DSM-IV) who were first time hospitalized in our Psychiatric unit between 1996 and 2016. We reviewed the charts of first hospitalization and recorded multiple baseline variables. In the follow-up we updated the database recording all patients who CS. We compared the different baseline variables between Bipolar patients who CS and the rest.

Results

Of a total of 254 bipolar I patients 9 (3,5%) CS in the mean of 13 years of follow up (rate 40 times higher than General Population). The average age at CS was 41.1 years (range between 26 and 71 years old) so there was a 9 years gap on average between the first psychiatric hospitalization and suicide. CS was characterized by a violent act (8 out of 9 cases, 89 %). When we compared BP patients who CS with the rest, only history of suicide in first-degree relatives was detected as a risk factor significantly associated (P<0.01) with CS. Conversely baseline treatment with anticonvulsants (mainly valproate) was detected as a significantly (P<0.004) protective factor of CS.

Conclusions

1-Bipolar I patients after first hospitalization completed suicide 40 times higher than general population almost always by violent method 2-History of CS in first-degree relatives is predictor of completed suicide

Disclosure

No significant relationships.

Completed suicide in bipolar ii patients after their first hospitalization

Introduction

Bipolar disorder, especially Bipolar II subtype, is a mental disorder that has one of the greatest risk of completed suicide (CS).

Objectives

Determine the rate and the risk factors of CS in a cohort of Bipolar II patients followed after their first hospitalization

Methods

We choose all Bipolar II patients (DSM-IV) who were hospitalized for first time in our Psychiatric unit between 1996 and 2016. We reviewed the charts of first hospitalization and recorded multiple baseline variables. In the follow-up we updated the database recording all patients who CS. We compared the different baseline variables between Bipolar II patients who CS and the rest

Results

Of a total of 59 bipolar II patients 6 (10 %) CS in the mean of 13 years of follow up (rate 120 times higher than General Population). The average age at CS was 45.3 years (range between 33 and 57 years old) so there was a 2 years gap on average between the first psychiatric hospitalization and suicide. CS was characterized by a violent act (5 out of 6 cases, 83 %). When we compared BP II patients who CS with the rest, only history of previous violent suicide attempt was detected as a risk factor significantly associated (P<0.04) with CS.

Conclusions

Bipolar II patients CS early after their first hospitalization and at very high rate (120 times than GP) almost always by violent method. History of previous violent suicide attempt is predictor of completed suicide

Disclosure

No significant relationships.

Cortisol-binding globulin levels in bipolar disorder

Cortisol-binding globulin (CBG) is an alpha-1-glycoprotein with high affinity for cortiso that could be a potential biological marker of chronic stress, according to several previous studies. In order to examine CBG concentrations in bipolar disorder, we determined serum CBG levels by radioimmunoassay with monoclonal antibodies in a sample of 39 RDC bipolar I patients in remission and 21 healthy age-, sex- and weight-matched control subjects. Only lithium treatment was permitted. Plasma cortisol and serum lithium levels were also determined. Bipolar males showed statistically significant lower serum CBG levels than controls, whereas women showed very similar values. No correlation was found between CBG levels and cortisol or lithium concentrations. It is concluded that CBG levels are affected by chronic affective illness, even during remission periods, at least in bipolar males.

Asenapine prescribing patterns in the treatment of manic in- and outpatients: Results from the MANACOR study

Background:

Asenapine is the most recent compound that has been FDA- and EMA-approved for treatment of mania. Its efficacy and safety have been assessed in placebo-controlled trials, but little is known about its performance in routine clinical conditions. In this study, we compared features of patients treated with adjunctive asenapine or other adjunctive antipsychotics and the costs of the treatment.

Methods:

A combined prospective and retrospective data collection and analysis was conducted from January 2011 to December 2013 following a clinical interview and assessment of manic and depressive symptoms (YMRS, HDRS-17), clinical state (CGI-BP-M), psychosocial functioning (FAST), sexual dysfunction (PRSexDQ) and health resource costs associated with treatment with adjunctive asenapine versus other adjunctive antipsychotics.

Results:

Hundred and fifty-two patients from different university hospitals were included. Fifty-three patients received adjunctive asenapine and 99 received other adjunctive antipsychotics concomitantly to mood stabilizers. Considering inpatients, those treated with adjunctive asenapine presented a significantly less severe manic episode (P = 0.001), less psychotic symptoms (P = 0.030) and more comorbid personality disorder (P = 0.002). Regarding outpatients, those treated with adjunctive asenapine showed significantly less severe manic episode (P = 0.046), more previous mixed episodes (P = 0.013) and more sexual dysfunction at baseline (P = 0.036). No significant differences were found in mean total costs per day.

Conclusion:

Clinicians tended to use adjunctive asenapine in patients with less severe manic symptoms but more complex clinical profile, including more mixed episodes in the past, concomitant personality disorder, and sexual problems. Treatment with adjunctive asenapine was not associated with higher costs when compared to other options.

Association between completed suicide and bipolar disorder: A systematic review of the literature

BACKGROUND

Completed suicide is a major cause of death in bipolar disorder (BD) patients.

OBJECTIVE

The aim of this paper is to provide an overall review of the existing literature of completed suicide in BD patients, including clinical and genetic data DATA SOURCES: We performed a systematic review of English and non-English articles published on MEDLINE/PubMed, PsycInfo and Cochrane database (1970-2017). Additional studies were identified by contacting clinical experts, searching bibliographies, major textbooks and website of World Health Organization. Initially we did a broad search for the association of bipolar disorder and suicide and we were narrowing the search in terms included "bipolar disorder" and "completed suicide".

STUDY SELECTION

Inclusion criteria were articles about completed suicide in patients with BD. Articles exclusively focusing on suicide attempts and suicidal behaviour have been excluded. We used PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) consensus for drafting this systematic review.

RESULTS

The initial search generated 2806 articles and a total of 61 meeting our inclusion criteria. We reviewed epidemiological data, genetic factors, risk factors and treatment of completed suicide in BD. Suicide rates in BD vary between studies but our analyses show that they are approximately 20-30-fold greater than in general population. The highest risk of successful suicide was observed in BD-II subjects. The heritability of completed suicide is about 40% and some genes related to major neurotransmitter systems have been associated with suicide. Lithium is the only treatment that has shown anti-suicide potential.

LIMITATIONS

The most important limitation of the present review is the limited existing literature on completed suicide in BD.

CONCLUSIONS

BD patients are at high risk for suicide. It is possible to identify some factors related to completed suicide, such as early onset, family history of suicide among first-degree relatives, previous attempted suicides, comorbidities and treatment. However it is necessary to promote research on this serious health problem.

Treatment with Risperidone vs. Olanzapine in Naturalistic Study of Bipolar Manic Inpatients

Introduction

There are very few comparative controlled trials of risperidone versus olanzapine in manic patients. No previous naturalistic study has compared the efficacy of these two antipsychotics in the natural environment of manic inpatients.

Objective

The aim of this retrospective and naturalistic study was to evaluate the efficacy of acute treatment with risperidone vs. olanzapine in Bipolar I manic inpatients.

Methods

(1) Patients: the study includes all the inpatients diagnosed with bipolar I manic episode (DSM-IV) who were admitted during the years 2009 to 2014. Patients treated with risperidone and olanzapine concomitantly (n = 6) and patients not treated with risperidone or olanzapine (n = 129) were excluded.

The patients finally included (n = 183) were separated in two groups:

– treated with risperidone (n = 89);

– treated with olanzapine (n = 94).

(2) The Student-T test was used to compare, between the groups, the mean of scores in YMRS and CGI-S scales and the mean of length of stay.

Results

Baseline characteristics were similar between the groups. The majority of patients were also treated with mood stabilizers (46% with lithium and 45% with valproate).

The mean decrease in CGI-S scores from baseline to the day of discharge was significantly (P < 0.003) higher in the risperidone group (−2.81 vs. −2.36). The length of stay was significantly (P < 0.004) lower in the olanzapine group (mean of 23.03 days vs. mean of 30.3).

Conclusions

(1) The CGI-S scores in manic patients treated with risperidone decreased more than in patients treated with olanzapine during admission. (2) The length of stay was significantly lower in patients treated with olanzapine.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Retinoids as a potential treatment for experimental puromycin-induced nephrosis

1 Puromycin aminonucleoside (PAN)-induced nephrosis is a model of human minimal change disease. In rats, PAN induces nephrotic-range proteinuria, renal epithelial cell (podocyte) damage, infiltration of mononuclear leukocytes, and apoptosis of several renal cell types. 2 Retinoic acid (RA) modulates a wide range of biological processes, such as inflammation and apoptosis. Since renal damage by PAN is characterized by inflammatory infiltration and epithelial cell death, the effect of treatment with all-trans RA (tRA) was examined in the PAN nephrosis model and in the cultured differentiated podocyte. 3 Treatment with tRA 4 days after PAN injection did not inhibit the proteinuria peak but reversed it significantly. However, treatment with tRA both before and 2 days after the injection of PAN protected the glomerular epithelial cells, diminishing the cellular edema and diffuseness of the foot process effacement. Preservation of the podocyte architecture correlated with the inhibition of proteinuria. The anti-inflammatory effect of tRA was evidenced by the inhibition of PAN-induced interstitial mononuclear cell infiltration and the decreased renal expression of two molecules involved in monocyte infiltration: fibronectin and monocyte chemoattractant protein-1. TUNEL assays showed that tRA inhibited the PAN-induced apoptosis of cultured differentiated mouse podocytes. 4 We conclude that tRA treatment may prevent proteinuria by protecting the podocytes from injury and diminishing the interstitial mononuclear infiltrate in the model of PAN nephrosis. Retinoids are a potential new treatment for kidney diseases characterized by proteinuria and mononuclear cell infiltration.

Effect of dexamethasone and pentoxifylline in combination with amoxicillin in the treatment of penicillin-insensitive pneumococcal pneumonia in guinea pigs

A fatal guinea pig model of pneumococcal pneumonia was developed in order to evaluate the efficacy of amoxicillin combined with either pentoxifylline or dexamethasone. Parameters assessed were survival time and lung changes (alterations, bacterial colony counts, inducible nitric oxide synthase [iNOS] and cyclooxygenase-2 [COX-2] protein expression). Animals receiving pentoxifylline (50 mg/kg) showed higher survival rates than controls (p < 0.05). Animals which received amoxicillin (50 mg/kg), alone or combined, showed significantly higher survival rates than controls (p < 0.05). Animals dying in spite of receiving amoxicillin alone or combined had lung colony counts significantly lower than those that did not receive the antibiotic (p < 0.001), but their lungs showed identical changes. The correlation between COX-2 protein expression and mortality was rather high (r = 0.75). The addition of either dexamethasone or pentoxifylline to amoxicillin improved neither survival rates nor lung pathology when compared with the antibiotic alone.

Effects of single oral doses of gemifloxacin (320 milligrams) versus trovafloxacin (200 milligrams) on fecal flora in healthy volunteers

Gemifloxacin and trovafloxacin were administered to 12 volunteers in a randomized crossover trial with a 2-week washout period. Stool samples were collected predose and 1, 2, and 3 days postdose. Both quinolones reduced the number of organisms of the family Enterobacteriaceae and aerobic gram-positive organisms. Escherichia coli reduction was greater with gemifloxacin than with trovafloxacin, with postdose isolation of quinolone-resistant strains for which MICs of trovafloxacin were higher than those of gemifloxacin.

Thrombin formation and fibrinolytic activity in patients with acute myocardial infarction or unstable angina: in-hospital course and relationship with recurrent angina at rest

OBJECTIVES

The goal of this study was to investigate possible differences in thrombin generation or fibrinolytic capacity in patients with unstable angina (UA) or acute myocardial infarction (AMI) with or without recurrent angina at rest.

BACKGROUND

Angina at rest in patients with AMI or UA is generally produced by a reduction in coronary flow, but it is unclear whether patients with or without this event differ in their thrombin generation or in their fibrinolytic capacities, which might influence the course of the culprit lesion.

METHODS

Thrombin-antithrombin complex (TAT), D-dimer, fibrinogen and plasminogen activator inhibitor (PAI-1) antigen plasma levels were determined in 40 patients with AMI and in 23 with UA on admission, at 10 days and at three months.

RESULTS

First day values for TAT, fibrinogen and D-dimer were comparable in patients with AMI and in those with UA. At 10 days they increased significantly in each group, and at 3 months they decreased to a similar extent. First day PAI-1 levels, however, were highest in both groups and declined in AMI patients at 10 days and at three months, whereas they also decreased at 10 days in UA patients but not any further at three months. Ten patients with AMI (25%) and 12 with UA (52%) developed in-hospital angina at rest. First day values for TAT, fibrinogen and D-dimer were similar in patients with or without angina, but PAI-1 levels were higher in the former subset (p < 0.008). At 10 days, however, TAT (p < 0.013) and D-dimer (p < 0.013) were higher in patients who developed angina than in those who did not.

CONCLUSIONS

The higher inhibition of fibrinolytic activity in the first day in patients with AMI or UA who will develop recurrent angina suggests that maintenance of a prothrombotic status may contribute to its mechanisms, perhaps by preventing passivation of the culprit thrombus/plaque. This is consistent with greater thrombin generation and greater levels of fibrynolitic products at 10 days observed in these patients compared with those who attain early stability.

Adjunctive gabapentin treatment of bipolar disorder

INTRODUCTION

The aim of this study was to analyze the effectiveness of gabapentin administration to bipolar patients who had an incomplete response to other mood stabilizers.

SUBJECTS AND METHODS

Twenty-two RDC bipolar 1 and II patients were assessed by means of the SADS and entered if they gave their consent to participate. All them had suffered from frequent relapses, subsyndromal features (mostly depressive) and incomplete response to other drugs. They all received open-label increasing doses of gabapentin until clinical response. The patients were assessed through the CGI-BP and a specific questionnaire at baseline and at 12 weeks of follow-up.

RESULTS

Six out of the 22 patients dropped out for various reasons (four because of relapse, one because of side effects and one more because of poor compliance). Eight of the 16 patients that completed the 12-week follow-up showed at least two stages of improvement in the CGI. Using the last observation-carried forward analysis, the improvement was statistically significant for the depression subscale, and apparently related to social functioning, irritability and anxiety. Only one patient dropped out because of intolerance (mild rash). The mean dose of gabapentin was 1,310 mg/day.

CONCLUSION

Gabapentin may be a useful drug for the add-on treatment of bipolar patients with poor response to other mood stabilizers. Gabapentin may improve depressive residual symptoms such as irritability, social withdrawal or anxiety. These results should be confirmed in randomized clinical trials.

Biochemical, antimicrobial susceptibility and genotyping studies on Corynebacterium urealyticum isolates from diverse sources

Thirty-two isolates of Corynebacterium urealyticum, isolated between 1991 and 1995, were studied by biochemical tests, phospholipid content, analysis of fatty and mycolic acids, ribotyping, whole-cell protein patterns and antimicrobial susceptibility to six antibiotics. Nineteen isolates were from human and human-related sources (HHRS); the remainder were from animal and animal-related sources (AARS). Most C. urealyticum isolates were similar in their biochemical and whole-cell protein profiles, although most HHRS isolates were alkaline phosphatase-positive (84%) and produced almost identical protein patterns, whereas AARS isolates were quite diverse. The qualitative composition of cellular fatty acids was identical for all isolates examined. Twelve different ribotypes were obtained with HindIII producing four-to-seven bands. Ribotypes 8, 9 and 10 were predominant in isolates from HHRS, whereas in isolates from AARS, ribotypes 5 and 6 predominated. AARS isolates were significantly less antibiotic-resistant, in comparison with HHRS isolates. Ribotyping appeared to be the most useful tool for strain characterisation.

Alpha-1-acid glycoprotein in major depressive disorder. Relationships to severity, response to treatment and imipramine plasma levels

BACKGROUND

Increased plasma levels of alpha-1-acid glycoprotein (AGP) were reported in major depressive disorder. However, the relationship between AGP levels, severity of depression, treatment response and antidepressant levels are still unclear.

METHODS

Plasma AGP levels were measured in 36 subjects with major depressive disorder before and after a 6-week treatment with imipramine and in 30 controls. Free imipramine plasma levels of depressed patients were measured at 6 weeks. Comparative analysis between depressed patients and controls, between non-responders (N = 12) and responders (N = 24), and between severely depressed patients (N = 14) and moderately depressed patients (N = 22) were made.

RESULTS

Depressed patients had significantly higher mean values of AGP than control subjects. Imipramine non-responders and specially severely depressed patients had significantly greater increases of AGP levels during treatment than other depressed subgroups. There was no correlation between baseline AGP levels and severity of depression or free imipramine levels.

LIMITATIONS

The most significant limitations of this study are the small sample size and the fact that all the subjects were out-patients. Results should not be generalized to in-patient populations.

CONCLUSIONS

Depressed patients showed high baseline concentrations of AGP. AGP levels did not predict either free imipramine plasma levels or differential response after 6 weeks of treatment with imipramine. A greater increase of AGP during treatment was associated with severity of depression and treatment non-response.

CLINICAL IMPLICATIONS

The relationship between high plasma levels of AGP, severity of depression and lack of treatment response is clarified. The influence of imipramine levels is minimized.

Role of Streptococcus pneumoniae and Haemophilus influenzae in the development of acute otitis media and otitis media with effusion in a gerbil model

The efficacy of amoxicillin/clavulanate and cefuroxime was determined in a gerbil model of otitis media with a mixed Streptococcus pneumoniae plus Haemophilus influenzae middle ear (ME) infection. Results were compared with those obtained in a previous single H. influenzae model. All untreated animals inoculated with the mixed inoculum developed acute otitis media (AOM), whereas 86.7% of those inoculated with H. influenzae developed otitis media with effusion (OME). Antibiotics eradicated H. influenzae from the ME more efficiently in AOM than in OME, and this difference was highly significant (P</=.001) after administration of 5 mg/kg of either drug (amoxicillin/clavulanate, 100% vs. 10%; cefuroxime, 73.3% vs. 10%). Efficacy was predicted by the relation of in vitro susceptibility and ME antibiotic concentration, which was 2.7 times higher in AOM than in OME. In the mixed otitis model, the most efficacious antibiotic was able to prevent AOM, but >80% of animals developed culture-negative OME.

Antiproteinuric effect of calcium antagonists on puromycin-induced experimental nephrosis

Calcium antagonists have a potential for beneficial effects on kidney function unrelated to their antihypertensive action. In this study we have investigated the efficacy of calcium antagonists compounds (verapamil, nifedipine and diltiazem) on reversible acute renal insufficiency, proteinuria and interstitial nephritis induced by the puromycin ammonucleoside (PAN). An increase in blood pressure (BP) was detected on day 14, with no statistical differences in the response to calcium antagonists. Serum creatinine concentration increased to 1.2 mg/dL on day 7 after PAN and decreased to 0.7 mg/dL at 14 days, calcium antagonists shortened the time required to reach baseline or control levels. Calcium antagonists also reduced proteinuria in the PAN-treated animals, in both day 7 and day 14. Differential effects of the antagonists were observed. Verapamil caused a greater reduction (p < 0.01) in proteinuria than nifedipine or diltiazem in day 7. Moreover, verapamil (p < 0.01) and nifedipine (p < 0.01) reduced the total number of interstitial infiltrating leukocytes from 690 to 120 and 425 positive cells/20 high power fields (x63) respectively, by contrast, diltiazem had no effect. We conclude that in this model of PAN nephropathy verapamil is more effective in reducing both proteinuria and the severity of acute interstitial nephritis than either nifedipine or diltiazem. The possible clinical implications of these results remain to be elucidated.

Microbiological characterization and clinical significance of Corynebacterium amycolatum strains

The laboratory records of patients with bacillus isolates identified as Corynebacterium xerosis were reviewed in an attempt to establish the clinical significance of the isolates, and the isolated strains were reidentified. Of the 22 strains available for reidentification, four were identified as Corynebacterium striatum and 18 as Corynebacterium amycolatum. Forty-one patients were considered to have Corynebacterium amycolatum isolates, and in 13 (31.7%) of these patients a genuine clinical infection occurred, comprising catheter-related infection in seven cases, surgical wound infection in five cases, and pilonidal cyst infection in one case. Most patients were treated with antimicrobial agents (vancomycin in seven cases and amoxicillin/clavulanic acid in four cases). All patients were cured. Corynebacterium amycolatum can cause genuine infection, usually hospital-acquired, and the clinical significance of isolates must be determined to ensure proper management of patients.

Antimicrobial treatment of an experimental otitis media caused by a beta-lactamase positive isolate of Haemophilus influenzae

A gerbil model of otitis media induced by a beta-lactamase producing and non-serotypeable isolate of Haemophilus influenzae was used to assess the in-vivo efficacy of co-amoxiclav and cefuroxime at low (5 mg/kg) and high (20 mg/kg) doses. The MIC of the antibiotics tested against the pathogen was 1 mg/L (1/0.5 mg/L for co-amoxiclav). The organism was inoculated (+/-10(6) cfu) by transbullar challenge directly in the middle ear and antibiotic treatment was commenced 2 h post-inoculation and continued at 8 h intervals for three doses. Only high dose co-amoxiclav significantly reduced the number of culture-positive specimens as compared with untreated animals or with other treatment groups (91.7% as compared with 36.7% for high dose cefuroxime). The results obtained in any treatment group were related to middle ear antibiotic level/MIC. Antibiotic concentrations in the middle ear 90 min after administration were about 10% of serum levels at 15 min, probably related to a slight inflammatory response. Only after high dose co-amoxiclav did the concentration in the middle ear exceed the MIC by a factor of four. In otitis media with effusion, if indicated, antibiotics active in vitro should be administered in high doses and, to avoid side effects, probably in short courses.

Recurrent brief depression successfully treated with lithium

BACKGROUND

The diagnostic criteria for RBD requires the presence of at least five out of nine depressive symptoms analogous to the symptoms of major depression, yet a duration of less than two weeks, a recurrence of at least 12 times a year, and the evidence of impairment in occupational or other important areas of functioning. The lack of a successful treatment represents one of the main challenges of this disorder. The therapeutic value of lithium in RBD has been suggested by Montgomery, but the specific efficacy of this agent has not been tested yet in the case of patients with recurrent brief depressive disorder.

METHODS

We report on a 38-year-old man who presented a 10-month history of sudden depressive episodes, with monthly recurrences lasting 2-4 days, prior to our first assessment.

RESULTS

The patient was treated with clomipramine, with complete remission of the depressive episode after three days. Nevertheless, in spite of maintaining the treatment, he presented a new episode one month later and two episodes the month after. Since then, lithium therapy was added and during the last 13 months he has remained euthymic, without any recurrence of depressive symptoms. Lithium treatment has been maintained and clomipramine treatment was gradually tapered because of the complaints of impotence, dry mouth, and dizziness.

CONCLUSIONS

The absence of recurrences since lithium treatment was started (during the last 13 months, and especially during the last 10 months, where lithium has been the only treatment), suggests a prophylactic effect of this agent on RBD. Lithium's mechanism of action in preventing depressive recurrences might play a major role in the therapeutic approach of RBD, especially since recurrence (but not the duration of the symptoms) is the main feature that defines the severity of this disorder.

In vivo efficacies of amoxicillin and cefuroxime against penicillin-resistant Streptococcus pneumoniae in a gerbil model of acute otitis media

The comparative efficacies of amoxicillin and cefuroxime against acute otitis media caused by a penicillin-resistant (MIC, 2 micrograms/ml) Streptococcus pneumoniae strain were assessed in a gerbil model by challenging each ear with 10(7) bacteria through transbullar instillation. Each antibiotic was tested at two doses (5 and 20 mg/kg of body weight) administered at 2, 10, and 18 h postinoculation. Samples were obtained from the middle ear (ME) on days 3 and 7 postinoculation for determination of bacterial counts. Only amoxicillin, at both doses, was able to significantly halt the weight loss in animals, reducing both the number of culture-positive animals and the bacterial concentration in ME samples versus the values for untreated animals. Comparison of the efficacies between the antibiotics, determined by their ability to achieve culture-negative ME specimens, showed that amoxicillin at 5 mg/kg was significantly more active than cefuroxime at the same dose. The use of higher doses of either amoxicillin or cefuroxime did not produce significantly better results than those obtained with the lower dose but caused a greater inflammatory response. The more favorable results obtained with amoxicillin compared with those obtained with cefuroxime could be related to the antimicrobial susceptibility of the pneumococcal strain (MICs and minimum bactericidal concentrations of 1 and 1 microgram/ml and 4 and 4 micrograms/ml for amoxicillin and cefuroxime, respectively) as well as to the better pharmacokinetic parameters obtained with amoxicillin.

Evaluation of a new selective medium for the isolation of Corynebacterium urealyticum

A new selective medium (CBU agar) was compared with blood agar (BA) medium for primary isolation of Corynebacterium urealyticum from urine and skin samples of hospitalised patients. Overall, the CBU agar detected C. urealyticum in 14 (4.6%) of 302 urine samples and the BA medium detected the organism in four (1.3%), but most cultures which were positive only on CBU agar had < 10(4) cfu/ml. Six strains of C. urealyticum were isolated from 60 skin samples with CBU agar, whereas none was detected with BA. Although most skin samples had heavy inocula, the selective agar facilitated the recognition of low colony counts (< or = 10 cfu/plate) of C. urealyticum by reducing the growth of competing flora. Challenge of the selective medium with reference and clinical strains showed that CBU agar was inhibitory for gram-negative bacteria and reduced the gram-positive flora, allowing the growth of C. urealyticum strains. The new selective medium appears to be a useful epidemiological tool to study urinary and skin colonisation by C. urealyticum.

Prevalence and associated factors for gallstone disease: results of a population survey in Spain

We conducted a cross-sectional survey to determine the prevalence of gallstone disease (gallstone or cholecystectomy) in a random sample of the adult population of Guadalajara, Spain. The sample stratified by age and sex was drawn from the municipal census. Stratum sample sizes were proportional to population sizes and to the expected prevalence rates calculated through a meta-analysis of the European literature. The screening protocol included a gallbladder ultrasonography, a questionnaire on personal and family history, a physical examination, and a blood sample for biochemical determinations. The response rate was 61.2%. The overall prevalence of gallstone disease was 9.7% (95% CI, 7.3-12.0). Prevalence was higher (but not statistically significant) in women (11.5%; 95% CI, 8.2-14.7) than in men (7.8%; 95% CI, 4.6-11.1). After controlling for confounding by multiple logistic regression, increasing age, body mass index, dyspeptic symptoms, smoking habit, and use of hypolipidemic drugs were positively associated with gallstone disease. Total serum cholesterol and alcohol consumption were negatively associated.

[Bipolar II disorder: course and suicidal behavior]

INTRODUCTION

Bipolar II disorder seems to be more than a mild form of classic manic-depressive illness. Differences with bipolar I concern genetic, biological, clinical and pharmacological aspects. Nevertheless, studies on suicidal behavior in both groups have resulted in inconsistent results

PATIENTS AND METHOD

Twenty-two patients fulfilling Research Diagnostic Criteria for the diagnosis of bipolar II disorder and 38 bipolar I were evaluated with the Schedule for Affective Disorders and Schizophrenia by two independent interviewers, and compared.

RESULTS

Bipolar II patients had significantly more previous episodes (p = 0.001), including both depressive (p = 0.003) and hypomanic switches (p = 0.006), but had been hospitalized (p = 0.001) and presented psychotic symptoms (p < 0.001) less frequently.

CONCLUSIONS

There were no significant differences between both groups regarding suicidal behavior variables. These results suggest that bipolar II disorder is less severe than bipolar I regarding symptoms intensity, but more severe with respect to episodes frequency, and that suicide attempts rates are not useful to discriminate between both groups.

Differential features between bipolar I and bipolar II disorder

Although bipolar II disorder is generally viewed as a mild form of classic manic-depressive illness, recent investigations suggest that it could be a valid diagnostic category different from bipolar I in genetic, biological, clinical, and pharmacological aspects. Twenty-two patients fulfilling Research Diagnostic Criteria for the diagnosis of bipolar II disorder and 38 bipolar I patients were evaluated with the Schedule for Affective Disorders and Schizophrenia by two independent interviewers and compared. Bipolar II patients had significantly more previous episodes (P = .001), including both depressive (P = .003) and hypomanic (P = .006) switches, but had been hospitalized (P = .001) and presented psychotic symptoms (P < .001) less frequently. These results suggest that bipolar II disorder is less severe than bipolar I with regard to symptom intensity, but is more severe with respect to episode frequency.

Prediction of depressive relapse in remitted bipolar patients using corticotrophin-releasing hormone challenge test

Abnormalities in corticotrophin (ACTH) and cortisol levels before and after corticotrophin-releasing hormone (CRH) stimulation have been reported in depressed bipolar patients. The ACTH and free cortisol response to the injection of 100 micrograms of synthetic human CRH and plasma cortisol-binding globulin (CBG) levels were measured in 42 lithium-treated patients suffering from RDC bipolar-I disorder in remission, and in 21 age- and sex-matched control subjects. A 1-year follow-up was conducted in order to assess any possible relationship between outcome and the hormonal response. Bipolar patients showed higher baseline and peak ACTH concentrations than controls. A lower net area under the ACTH concentration curve after CRH stimulation predicted depressive relapse within 6 months by multiple regression analysis. The CRH challenge test could be a potentially good predictor of depressive relapse in remitted bipolar patients.

Development of experimental pneumonia by infection with penicillin-insensitive Streptococcus pneumoniae in guinea pigs and their treatment with amoxicillin, cefotaxime, and meropenem

Acute respiratory infection with penicillin-insensitive Streptococcus pneumoniae (MIC and MBC, 1 and 2 micrograms/ml, respectively) was established in guinea pigs. Intratracheal instillation of 0.5 ml of an overnight culture of S. pneumoniae concentrated 25 times (approximately 3 x 10(9) CFU) induced a bacteremic and fatal pneumonia in > 85% of untreated animals within 46 h, with a mean +/- standard deviation bacterial count of 8.83 +/- 1.11 log10 CFU in lung homogenates. This model was used to evaluate the efficacies of two doses each of amoxicillin, cefotaxime, and meropenem given 1 h after bacterial inoculation. The antibiotics were given at 8-h intervals for up to a total of four injections. The dose of 50 mg of any antibiotic per kg of body weight gave 66.6% survival, compared with 5.05% survival for untreated control animals (P < 0.001). A dose of 200 mg/kg gave a survival rate of 77.8% for meropenem and 83.3% for amoxicillin and cefotaxime, while survival for untreated controls was 11.1% (P < 0.001). Although antibiotic treatment decreased mortality compared with that in untreated controls, the antibiotics contributed to a high early (less than 9 h after bacterial inoculation) mortality, being 53.5% compared with only 6.06% for the untreated controls (P < 0.001). Quantitative cultures of the lungs of animals that died during the 46-h observation period or that were killed after this time showed a significant reduction in the numbers of organisms among treated animals compared with numbers among the control animals (P < 0.001). The described model is an appropriate system for evaluating antibiotic efficacy in invasive pulmonary infection caused by penicillin-insensitive S. pneumoniae.

Correlation of in-vitro activity and pharmacokinetic parameters with in-vivo effect of amoxycillin, co-amoxiclav and cefotaxime in a murine model of pneumococcal pneumonia

In an attempt to determine the susceptibility breakpoints for amoxycillin, co-amoxiclav and cefotaxime in pneumococcal pneumonia, a neutropenic mouse model was established and tested with two strains having different susceptibility to penicillins and cefotaxime. With a penicillin-sensitive strain (MIC/MBC = 0.01/0.01 mg/L) the minimum dosage tested achieving significant cure was 2 mg/kg for amoxycillin, co-amoxiclav and cefotaxime. For the penicillin-insensitive strain (MIC/MBC = 1/2 mg/L), the minimum dosage tested giving significant cure was 50 mg/kg for amoxycillin and co-amoxiclav but 100 mg/kg for cefotaxime. Our results support the belief that MICs of amoxycillin, co-amoxiclav and cefotaxime for pneumococcal strains of < or = 0.5 or < or = 1 mg/L can be considered as clinically relevant susceptibility breakpoints.

Antimicrobial susceptibilities of Corynebacterium species and other non-spore-forming gram-positive bacilli to 18 antimicrobial agents

The susceptibilities of 265 strains of Corynebacterium species and other non-spore-forming gram-positive bacilli to 18 antimicrobial agents were tested. Most strains were susceptible to vancomycin, doxycycline, and fusidic acid. Corynebacterium jeikeium and Corynebacterium urealyticum were the most resistant organisms tested. Resistance to beta-lactams, clindamycin, erythromycin, azythromycin, ciprofloxacin and gentamicin was common among strains of Corynebacterium xerosis and Corynebacterium minutissimum. Ampicillin resistance among Listeria monocytogenes was more prevalent than previously reported. Optochin, fosfomycin, and nitrofurantoin showed very little activity against most organisms tested, but the use of nitrofurantoin as a selective agent in culture medium may prevent the recovery of some isolates. Except for the unvarying activity of vancomycin against Corynebacterium species, the antimicrobial susceptibilities of the latter to other antibiotics are usually unpredictable, such that susceptibility tests are necessary for selecting the best antimicrobial treatment.

Problems in minimum inhibitory concentration determinations in coryneform organisms. Comparison of an agar dilution and the Etest

The antimicrobial susceptibility of 159 coryneform organisms was determined by an agar dilution and Etest methods. Overall, the correlation between minimum inhibitory concentrations obtained by both techniques was good (> or = 0.09) for most antibiotics and organisms although the essential agreement ranged from 59% to 88.3%. Most organisms were equally categorized (sensitive, intermediate, or resistant) by both methods with only 0.2%, 0.4%, and 3.5% of very major, major or minor discrepancies, respectively. Such percentages dropped significantly when discrepant strains were retested. The correlation was specially good for Corynebacterium jeikeium and Corynebacterium urealyticum.

Identification of bloodmeal sources of Lutzomyia spp. in Peru

Bloodmeal sources of Lutzomyia spp. were determined, using the bloodmeal analysis precipitin test, in Chaute, Lima, Peru, an area endemic for cutaneous leishmaniasis (uta). From April 1990 to May 1991, sandflies were sampled in and around the village houses, with CDC light traps and a Shannon trap with protected human bait, respectively. Overall, 1424 sandflies were collected engorged. In indoor collections, human blood (N = 275) was the most frequent bloodmeal found, followed by cow (171) and cat (152). The most frequent bloodmeals of the flies caught in the Shannon trap collections were from cow (31), man (23) and cat (23). Of the two predominant sandfly species in the area, Lutzomyia peruensis was more anthropophilic than Lu. verrucarum (chi 2 = 14.13, P < 0.001). The sandflies from Chaute appear to be opportunistic feeders; 16 different hosts were identified. There was evidence of bloodmeals from more than one host in each of 151 sandflies, including bloodmeals containing blood from an animal only present within the houses mixed with blood from animals only present in the corrals near the house. Some sandflies must therefore have flown from the corrals to the houses (or vice versa) to take the last bloodmeals before their capture.

Natural Leishmania infection of Lutzomyia spp. in Peru

Natural infection of Lutzomyia spp. with Leishmania was studied with the aid of the polymerase chain reaction (PCR) in Chaute, Lima, Perú, a locality endemic for Andean cutaneous leishmaniasis (uta). The PCR, with primers specific for the L. braziliensis complex, was applied to sandfly pools. Sandflies were sampled from April 1990 to May 1991 with CDC light traps in homes, and from near homes with a Shannon trap using protected human bait. Lu. verrucarum (4 pools) and Lu. peruenis (2 pools) from the anthropophilic collections, and Lu. verrucarum (2 pools) from indoors were found to be infected with Leishmania. The majority of infected sandflies were recorded mainly in April 1991 (4 pools), coinciding with the highest sandfly densities and the maximum number of new cases of uta (7). Non-infected sandflies were found from May to October 1990 and January to March 1991. Thus, these 2 sandfly species play a role in the spread of leishmaniasis among humans and other animals in Chaute.

[Pneumonia in patients undergoing heart surgery]

OBJECTIVE

We performed a follow-up study of 104 consecutive patients who underwent cardiac surgery to ascertain the following: 1) the incidence of nosocomial pneumonia (NP) in this patient population; 2) the differences in the incidence of NP between patients who underwent coronary artery bypass grafting (CABG) vs. valvular replacement (VR), and 3) the identification of risk factors which predispose patients to the development of NP.

RESULTS

The study included 104 patients of which 49 underwent VR, 43 CABG and 12 who had both procedures performed simultaneously. Six of the 104 patients developed NP (5.7%). Five of these patients had undergone VR where as opposed to only one in the CABG group. Pulmonary hypertension preoperatively was a risk factor for the development of NP. Of the 49 patients in the VR group, 46 had pulmonary artery pressures (PAP) recorded, and from their 23 (50%) had pulmonary hypertension. However, 4 of the 5 (80%) patients who developed NP had elevated PAP. The mortality among patients with NP was high. Sixty six percent of patients (4/6) with NP died in comparison to the 10 deaths (10.2%) among 92 patients without NP (p = 0.002).

CONCLUSIONS

A trend in the development of NP was observed in patients who underwent valve replacement as opposed to CABG. Because of the small number of patients who developed pneumonia in the study population statistical significance cannot be reached. Pulmonary hypertension in the post operative period is a risk factor for the development of NP. Mortality among patients who develop NP is significantly high (p = 0.002).

Suicide attempts of high medical seriousness in schizophrenic patients

A retrospective study was conducted that included all patients who in the previous 6 years had required admission to our hospital for medical reasons following attempted suicide (N = 253). Those diagnosed as schizophrenic (n = 43) in accordance with DSM-III-R criteria were compared with the other nonschizophrenic suicide attempters. Schizophrenic patients were significantly different in that they were younger and generally unmarried, usually used violent methods, made more attempts while in a psychiatric center, and presented a lower incidence of concurrent organic illness than the nonschizophrenics; almost all of them were chronic. A large majority (80%) showed delusional and hallucinatory symptoms at the time of the attempt. In contrast, depressive symptoms were noted in an appreciably lower percentage of subjects than that in other studies of suicidal behavior in schizophrenics.

[Suicide attempts in patients with organic disease]

BACKGROUND

The aim of the present was to study the relation between organic disease and suicidal behavior.

METHODS

The characteristics of 257 patients hospitalized for medical or surgical causes following attempted suicide were studied between June 1984 and June 1990 with 45 cases previously having had physical disease being compared with 212 that had not.

RESULTS

Ninety-seven percent of the attempted suicides with organic disease fulfilled the DSM-III-R criteria for some psychiatric diagnosis with affective disorders predominating (64%). Suicides with organic illness tended to be older (p less than 0.0001), present a larger number of widowed patients (p less than 0.0001), have affective disorders (p less than 0.0001), non violent modes of suicidal behavior (p less than 0.008), and have a preference for non psychotropic drugs and barbiturates (p less than 0.007).

CONCLUSIONS

Patients with organic disease who make serious attempts to commit suicide are characterized by high psychiatric morbidity (97%) with a predominance in the diagnosis of severe depression.

Serious suicide attempts in affective patients

A retrospective study was carried out including all patients who in the previous 6 years had required admission to our hospital for medical or surgical reasons following attempted suicide (n = 257). Those diagnosed as having affective disorder (n = 96), according to DSM-IIIR criteria, were compared with the other non-affective suicide attempters (n = 161). Affective patients were significantly different in that they were older, more often women, married or widowed, usually used non-violent methods, made more serious attempts and presented a higher incidence of concomitant physical illness. Affective patients with a history of previous attempts were more likely to be recurrent unipolar depressives or first episode unipolars with a concurrent diagnosis of personality disorder. Most of the depressed patients made the attempt within the first 12 months of the episode. Patients who attempted suicide in the first 12 months of the depression were more likely to use non-violent methods and to receive a diagnosis of bipolar or unipolar recurrent disorder.

Serious suicide attempts in the elderly

A retrospective study was carried out including all those patients who, over the last 6 years (n = 257), required admission to our hospital for medical or surgical reasons following attempted suicide. The authors examined a series of clinical and demographic variables. Thirty-eight patients over 65 years of age were compared with 120 patients aged between 30 and 64 years and 99 aged under 30 years. When compared with the other two groups, a significantly higher proportion of elderly patients were widowed and showed affective disorders and concurrent physical illness.

[Psychiatric morbidity in elderly patients admitted to a general hospital. A day-prevalence study]

BACKGROUND

The most common psychiatric diseases in the geriatric population are depression, the acute confusional state or delirium and dementia.

METHODS

A prevalence-day study of psychopathology was carried out in the elderly population admitted to the hospital for several medical and surgical conditions. The semistructured psychiatric interview (CIS), cognoscitive miniexamination (MEC) and Zung's depression scale (SDS) were administered. When appropriate, a diagnosis was established following the DSM-III-R criteria. 15% of the overall number of elderly patients were excluded because of severe medical disease or surgical operation on the study day.

RESULTS

A 43% prevalence of psychiatric disorders was found. 21% of them had depression and 18% a mental organic disorder with cognitive deficit in the form of dementia (6%), delirium (10%), or both (2%). The depression symptoms were more marked with greater cognitive deterioration, and both were greater with increasing age. In only 10% of the patients considered as psychiatric cases the cooperation of the psychiatric interconsultation team had been requested.

CONCLUSIONS

The diagnosis of these diseases (depression, delirium and dementia) is very important because in the elderly population with these disorders a higher morbidity and mortality due to medical causes is found.