Risk factors for suicidal attempts in a sample of outpatients with treatment-resistant depression: an observational study

Introduction

Treatment-resistant depression (TRD) is commonly defined as the failure of at least two trials with antidepressant drugs, given at the right dose and for an appropriate duration. TRD is associated with increased mortality, compared to patients with a simple major depressive episode. This increased rate was mainly attributed to death from external causes, including suicide and accidents. The aim of our study is to identify socio-demographic and psychopathological variables associated with suicidal attempts in a sample of outpatients with TRD.

Material and methods

We performed a monocentric observational study with a retrospective design including a sample of 63 subjects with TRD referred to an Italian outpatient mental health centre. We collected socio-demographic and psychopathological data from interviews and clinical records.

Results

77.8% of the sample (N=49) were females, the mean age was 49.2 (15.9). 33.3% (N=21) of patients had attempted suicide. 54% (N=34) of patients had a psychiatric comorbidity. Among the collected variables, substance use (p=0.031), psychiatric comorbidities (p=0.049) and high scores of HAM-D (p=0.011) were associated with the occurrence of suicide attempts. In the regression model, substance use (OR 6.779), psychiatric comorbidities (OR 3.788) and HAM-D scores (OR 1.057) were predictive of suicide attempts. When controlling for gender, only substance use (OR 6.114) and HAM-D scores (OR 1.057) maintained association with suicide attempts.

Conclusion

The integrated treatment of comorbidities and substance abuse, which involves different mental health services, is fundamental in achieving the recovery of these patients. Our study supports the importance of performing a careful clinical evaluation of patients with TRD in order to identify factors associated with increased risk of suicide attempts.

Investigating the characteristics of residential end uses of water: A worldwide review

A detailed characterization of residential water consumption is essential for ensuring urban water systems' capability to cope with changing water resources availability and water demands induced by growing population, urbanization, and climate change. Several studies have been conducted in the last decades to investigate the characteristics of residential water consumption with data at a sufficiently fine temporal resolution for grasping individual end uses of water. In this paper, we systematically review 114 studies to provide a comprehensive overview of the state-of-the-art research about water consumption at the end-use level. Specifically, we contribute with: (1) an in-depth discussion of the most relevant findings of each study, highlighting which water end-use characteristics were so far prioritized for investigation in different case studies and water demand modelling and management studies from around the world; and (2) a multi-level analysis to qualitatively and quantitatively compare the most common results available in the literature, i.e. daily per capita end-use water consumption, end-use parameter average values and statistical distributions, end-use daily profiles, end-use determinants, and considerations about efficiency and diffusion of water-saving end uses. Our findings can support water utilities, consumers, and researchers (1) in understanding which key aspects of water end uses were primarily investigated in the last decades; and (2) in exploring their main features considering different geographical, cultural, and socio-economic regions of the world.

[Case report: the psychotic-mystical effects related to an unaware use of Salvia divinorum.]

It's well known that exotoxicosis can originate various psychiatric clinical pictures. The psychic impact of "classic" substances of abuse is well known and easily detectable with the usual methods of examination. In the last years new psychoactive substances (NPS) are spreading worldwide, determining not easily recognizable situations, with a significant clinical and organizational impact on psychiatry. In this case report, we present a clinical picture treated in hospital and outpatient settings in Vigevano (Pavia - Italy) and characterized by a psychotic onset secondary to an unaware use of Salvia divinorum. After the failure of two psychopharmacological treatment, the patient showed an excellent response to brexiprazole, with substantial restitutio ad integrum in the absence of significant side effects.

The lung immuno-oncology prognostic score (LIPS-3): a prognostic classification of patients receiving first-line pembrolizumab for PD-L1 ≥ 50% advanced non-small-cell lung cancer

Background

To stratify the prognosis of patients with programmed cell death-ligand 1 (PD-L1) ≥ 50% advanced non-small-cell lung cancer (aNSCLC) treated with first-line immunotherapy.

Methods

Baseline clinical prognostic factors, the neutrophil-to-lymphocyte ratio (NLR), PD-L1 tumour cell expression level, lactate dehydrogenase (LDH) and their combination were investigated by a retrospective analysis of 784 patients divided between statistically powered training (n = 201) and validation (n = 583) cohorts. Cut-offs were explored by receiver operating characteristic (ROC) curves and a risk model built with validated independent factors by multivariate analysis.

Results

NLR < 4 was a significant prognostic factor in both cohorts (P < 0.001). It represented 53% of patients in the validation cohort, with 1-year overall survival (OS) of 76.6% versus 44.8% with NLR > 4, in the validation series. The addition of PD-L1 ≥ 80% (21% of patients) or LDH < 252 U/l (25%) to NLR < 4 did not result in better 1-year OS (of 72.6% and 74.1%, respectively, in the validation cohort). Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 2 [P < 0.001, hazard ratio (HR) 2.04], pretreatment steroids (P < 0.001, HR 1.67) and NLR < 4 (P < 0.001, HR 2.29) resulted in independent prognostic factors. A risk model with these three factors, namely, the lung immuno-oncology prognostic score (LIPS)-3, accurately stratified three OS risk-validated categories of patients: favourable (0 risk factors, 40%, 1-year OS of 78.2% in the whole series), intermediate (1 or 2 risk factors, 54%, 1-year OS 53.8%) and poor (>2 risk factors, 5%, 1-year OS 10.7%) prognosis.

Conclusions

We advocate the use of LIPS-3 as an easy-to-assess and inexpensive adjuvant prognostic tool for patients with PD-L1 ≥ 50% aNSCLC.

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Immunotherapy/chemoimmunotherapy combinations are currently not superior to immunotherapy alone for high PD-L1 aNSCLC.

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NLR with a cut-off of 4 was validated as an independent prognostic factor for immunotherapy in high PD-L1 aNSCLC.

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The addition of either PD-L1 ≥ 80% or LDH < 252 U/l to NLR < 4 did not result in better prognostic stratification.

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The LIPS-3 is a validated 3-class prognostic classification based on the NLR, ECOG PS and pretreatment steroids.

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The LIPS-3 is a routinely assessable adjuvant prognostic tool for high PD-L1 aNSCLC patients.

Primary resistance to osimertinib due to SCLC transformation: Issue of T790M determination on liquid re-biopsy

OBJECTIVES

EGFR T790M mutation is the most common mechanism of resistance to first-/second-generation EGFR tyrosine kinase inhibitors (TKIs) in non-small cell lung cancer (NSCLC) and could be overcome by third-generation EGFR-TKIs, such as osimertinib. Liquid biopsy, a non-invasive technique used to test the presence of the resistant mutation, may help avoiding tissue re-biopsy. However, analysing only circulating-free DNA, information about other less frequent and coexisting resistance mechanisms may remain unrevealed.

MATERIALS AND METHODS

All patients reported in this series participated in the ASTRIS trial, a real world treatment study testing the efficacy of osimertinib (80mg os die) in advanced T790M-positive NSCLC progressed to prior EGFR-TKI. Patients were considered eligible to osimertinib if T790M positive on tissue or plasma samples. In our patients, EGFR molecular testing on blood sample was conducted with digital droplet PCR (ddPCR).

RESULTS

We report our experience of five patients treated with osimertinib after T790M detection on liquid biopsy that presented a disease progression at first tumor assessment mediated by SCLC transformation, as evidenced at tissue re-biopsies. All patients showed low ratio T790M/activating mutation in the blood before osimertinib (lower than 0.03). For three patients, EGFR mutational analysis was T790M-negative when re-assessed by using a less sensitive method (therascreen^®) on the same liquid biopsy sample analysed by ddPCR before osimertinib therapy.

CONCLUSION

Although liquid biopsy is a relevant tool to diagnose T790M presence in NSCLC patients resistant to EGFR-TKI, in case of a low ratio T790M/activating mutation, tissue biopsy should be considered to exclude the presence of SCLC transformation and/or other concomitant resistance mechanisms.

Phase II trial of single-agent oral vinorelbine in elderly (> or =70 years) patients with advanced non-small-cell lung cancer and poor performance status

BACKGROUND

Elderly patients with advanced non-small-cell lung cancer (NSCLC) with poor performance status (PS) are a special population requiring particular attention. Single-agent oral vinorelbine could be an attractive option.

PATIENTS AND METHODS

A total of 43 patients with stage IIIB-IV NSCLC and Eastern Cooperative Oncology Group (ECOG) PS of two or more with good functional status were prospectively recruited. Oral vinorelbine was administered at the dose of 60 mg/m(2) on days 1-8 every 3 weeks. Primary end points were response rate and safety.

RESULTS

Overall response rate was 18.6% with 8 partial responses; 18 of 43 (41.8%) experienced stable disease lasting >12 weeks and 17 of 43 (39.6%) disease progression for an overall clinical benefit of 60.4%. Median time to progression was 4.0 (range 2-22) months and median overall survival 8.0 (range 3-35) months. Treatment was well tolerated. Of 187 cycles, we did not observe any grade 3/4 toxicity with the exception of a single not-febrile G3 neutropenia. Regardless of severity, main toxic effects observed were nausea in 48.1% and vomiting in 22.9% of patients, anemia in 43.2%, fatigue in 32.6% and leukopenia in 23.2%.

CONCLUSION

Single-agent oral vinorelbine is extremely safe in elderly patients with advanced NSCLC and ECOG PS of two or more and may represent a valid option in this very special population.

Weekly paclitaxel plus capecitabine in advanced breast cancer patients: dose-finding trial of GOIRC and GOL

BACKGROUND

Paclitaxel and capecitabine have demonstrated a synergic effect and significant antitumor activity in patients with advanced breast cancer. A weekly schedule of paclitaxel obtained a response rate of 50-68% in advanced breast cancer and less serious side-effects.

PATIENTS AND METHODS

Thirty-two patients with advanced breast cancer pretreated with chemotherapy were enrolled in a dose-finding trial to determine the maximum tolerated dose (MTD) and the dose-limiting toxicity (DLT) of paclitaxel given on days 1, 8 and 15 of each cycle combined with capecitabine given twice daily from day 1 through day 14, every 21 days. Three patients were recruited at one of six dose levels (paclitaxel 70-100 mg/m2, capecitabine 1650-2500 mg/m2).

RESULTS

Thirty-two patients were accrued and 31 were evaluated for toxicity. One DLT has been experienced at level VI as diarrhea grade 3. We determined dose level V as the MTD, but we recommend dose level IV for phase II studies (capecitabine 1250 mg/m2 orally twice daily plus paclitaxel 80 mg/m2 intravenously weekly), owing to cumulative toxicity at level V. The objective response rate was 43%.

CONCLUSIONS

Weekly paclitaxel plus capecitabine is a safety and active chemotherapy in previously treated metastatic breast cancer.

Multicentric phase II trial of gemcitabine plus epirubicin plus paclitaxel as first-line chemotherapy in metastatic breast cancer

In this phase II, multicentre trial, patients with metastatic breast cancer (MBC) were treated with a combination of gemcitabine, epirubicin and paclitaxel (GET). The primary objective of this study was to determine the tolerability and activity in terms of complete responce (CR) and overall response rate of the GET combination in this patient population. Patients with no prior treatment for MBC, and at least one bidimensionally measurable lesion received gemcitabine 1000 mg m⁻² intravenously (i.v.) over 30 min on days 1 and 4, followed by epirubicin i.v. at 90 mg m⁻² on day 1, and paclitaxel 175 mg m⁻² over 3 h on day 1, every 21 days, up to eight courses. From May 1999 to June 2000, 48 patients were enrolled from seven Italian institutions. A total of 297 chemotherapy courses were administered with a median of six cycles patient⁻¹ (range 1–8). Seven patients (15%) obtained CR and 27 patients (56%) had partial responce, for an overall response rate of 71% (95% CI: 58.3–83.7). After a median follow-up of 23.7 months (range 7.0–34.4), median progression-free survival was 10.5 months (95% CI: 9.2–11.7), and median overall survival 25.9 months. The main haematological toxicity consisted of grade 3 or 4 neutropenia that occurred in 62% of cycles (22% grade 4 and 40% grade 3). The GET combination is active and well tolerated as first-line chemotherapy for MBC.

Virological analysis of shellfish for food safety and control

The present study was performed in order to obtain reliable and applicable techniques of viral detection in shellfish for use in ensuring food safety. This research was developed in two steps: (a) different techniques to recover viruses from artificially contaminated shellfish were tested and (b) the best technique was applied to analyse shellfish collected from sites along the coast of Salento.

Virological control of groundwater quality using biomolecular tests

Deep groundwater, even if generally protected, could be contaminated by surface or rain water infiltration through soil fractures, septic tanks, cesspits, land irrigation, disposal of wastewater and disposal of muds from depuration systems. The sanitary importance of such possible contamination is related to the different uses of the water and it is at the maximum level when it is intended for human use. Routine microbiological analyses do not consider viruses, only bacterial parameters, as contamination indicators. However, it is known that enteric viruses can survive a long time in deep aquifers and that they may not always be associated with bacterial indicators. The virological analysis of waters intended for drinking use is provided only as an occasional control exercised at the discretion of the sanitary authority. Technological difficulties with obtaining data about groundwater viral contamination led to a study to devise rapid and efficient methods for their detection and the application of these methods to samples from different sources. Four acid nucleic extraction techniques have been tested (classic proteinase K- phenol/chloroform, QIAamp Viral RNA Kit (Qiagen), SV Total RNA Isolation System (Promega) and NucleoSpin Virus L (Macherey-Nagel). Sensitivity and specificity of RT-PCR protocols for entero- (EV), hepatitis A (HAV) and small round structured (SRSV) viruses have been verified. Deep groundwater samples (100 L) were concentrated (2-step tangential flow ultrafiltration) and the concentrate contaminated with serial 10-fold dilutions of a known titre of poliovirus type 3. Extracted RNA was concentrated (microcon-100) and analysed by RT-PCR using specific EV primers and visualising amplification products by agarose gel electrophoresis. In addition, two different methods of RT-PCR for non-cultivable viruses have been tested: (a) RT-PCR and nested RT-PCR for HAV and (b) RT-PCR with generic primers and RT-PCR with specific primers for SRSV. Different specificity tests have been carried out in the presence of some of the commoner microorganisms. The most efficient, sensitive and specific protocols were used to test 35 x 100L deep groundwater samples. Sample concentrates were split with one part treated with chloroform and analysed by cell culture (BGM and Frp/3, derived from FrHK/4, cells) and the other tested by RT-PCR for HAV, EV and SRSV. Results demonstrated the high efficiency of the classic and QIAamp methods. Microcon-100 did not increase the sensitivity of the technique used. The highest sensitivity was observed for RT-PCR with specific primers for SRSV and for nested RT-PCR for HAV. One sample showed a cytopathic effect, not confirmed at the third subculture, while the RT-PCR allowed the detection of echovirus 7. Cell culture did not allow detection of the majority of the enteric viruses while PCR gave sensitive, specific and rapid detection of a range of agents in the same samples. Even if it was impossible to fix a virological quality standard, it would be necessary to find a viral indicator in order to achieve a complete preventive check which would be particularly useful in some cases (e.g. water never used before, after pollution accidents, for seasonal checking).

Detection and potential indicators of the presence of hepatitis C virus on surfaces in hospital settings

AIMS

The risk of hepatitis C virus infection in hospital environments can be assessed not only by studying epidemiological data and work practices, but also by the detection of these viruses (or indicators thereof) in health-care settings, on instruments etc.

METHODS

Since standardized techniques specific to this end do not exist, this study was undertaken to apply methods currently used on clinical samples to the assessment of environmental HCV risk, either through direct detection of the virus (RT-PCR), or by probing for haemoglobin as a potential indicator of blood contamination. The tested techniques were applied in a trial environmental monitoring programme undertaken in various hospital laboratories and clinics, during which total bacterial count determinations were performed in parallel with haemoglobin and hepatitis C virus detection.

SIGNIFICANCE AND IMPACT OF THE STUDY

The data indicate that the applied methods are of value in detecting low levels of contamination in a hospital environment.

Interference between enterovirus and reovirus as a limiting factor in environmental virus detection

AIMS

Faecal material from raw sewage or other sources lacking effective treatment sometimes contaminates water for human consumption. The relevant Italian regulations therefore call for testing drinking and recreational water for the presence of enterovirus.

METHODS AND RESULTS

Traditional methods of analysis are based on revealing the typical cytopathic effects of enterovirus on cell cultures. However, the presence in environmental samples of different types of virus may cause interference phenomena that mask such cytopathic effects. The paper reports on an experimental test of this interference hypothesis. Buffalo Green Monkey cell cultures were co-infected via mixed suspensions of the polio type 3 virus and reovirus type 1. Cytopathic effects were then sought and the presence of enterovirus tested for via RT-PCR.

CONCLUSIONS, SIGNIFICANCE AND IMPACT OF THE STUDY

The results obtained indicate that the normally high sensitivity of tests for the detection of enterovirus in samples is considerably decreased by the simultaneous presence of reovirus.

The gemcitabine/epirubicin/paclitaxel trials in advanced breast cancer

Numerous trials have shown that the pharmacokinetic interferences of epirubicin (Ellence)/paclitaxel (Taxol) combinations produce less pharmacodynamic effect than doxorubicin/paclitaxel regimens. Paclitaxel is more easily combined when infused over 3 (as compared to 24) hours; the administration of optimal doses of both agents is important. Based on these findings, a phase II study was performed to evaluate the feasibility and activity of the combination of gemcitabine (Gemzar), epirubicin, and paclitaxel as first-line therapy in advanced breast cancer. Patients received gemcitabine at 1,000 mg/m2 on days 1 and 4, plus epirubicin at 90 mg/m2 on day 1, plus paclitaxel at 175 mg/m2/d on day 1 every 21 days. After six courses, patients less than 60 years old and in complete or partial remission or stable disease were treated with high-dose chemotherapy as consolidation treatment. The overall response rate was 92%, with 31% complete responses; 25 patients received high-dose chemotherapy, achieving a final overall response rate of 97%, with 47% complete responses. At a median follow-up of 25 months, median progression-free survival is 21 months. Grade 4 neutropenia was observed in 64% of patients. Other hematologic toxicities were mild. Mild to moderate peripheral neuropathy was experienced by 39% of patients; grade 2 or 3 mucositis occurred in 25% and 17% of patients, respectively. Based on these results, a multicenter trial has been started in seven Italian centers to confirm the feasibility of this regimen.

Medical treatment of brain metastases from solid tumours

Brain metastases (BrM) are estimated to occur in 20% to 40% of cancer patients, and two-thirds of them become symptomatic during their lifetime. Although every solid tumour may spread to the brain, the risk of developing BrM is higher in lung cancer, breast cancer and melanoma patients. Several findings suggest that the incidence of BrM is rising as a result of advances in imaging procedures and improvements in therapy, which leaves more cancer patients at risk as survival increases. The prognosis of patients with BrM is dependent on the type of the primary tumour. Breast cancer patients have better prognosis than those with BrM from lung, melanoma or colorectal cancer. Patients with BrM from renal cell carcinoma tend to have a poor prognosis. The optimal treatment of patients with BrM continues to evolve. Several factors interfere with the therapeutic strategy, such as histology of primary tumour, patient compliance, localisation, size and number of BrM, and outcome of extracranial disease. Generally, surgery or stereotactic radiotherapy followed by whole brain radiotherapy (WBRT) are indicated in patients with controlled extracranial disease and good performance status presenting an isolated BrM. Adding chemotherapy in this subset of patients is controversial. Supportive care associated with WBRT remains the standard treatment for all patients with multiple symptomatic BrM or with isolated symptomatic BrM in the presence of uncontrolled extracranial disease. For potentially chemosensitive patients with asymptomatic multiple or isolated BrM with disseminated disease, chemotherapy represents the optimal starting therapy.