PRESTOapp for health workers with mental health symptoms related to the COVID-19 pandemic

Introduction

The COVID-19 pandemic has caused a significant impact on the mental health of health workers that has brought many hospitals to launch immediate preventive mental health programs.

Objectives

(1) To adapt and enhance a smartphone app (PRESTOapp) for health workers with mental health symptoms related to the COVID-19, and (2) to demonstrate its potential effectiveness in significantly reducing anxiety-depressive and PTSD symptoms in this population. We aim to incorporate Natural Language Processing (NLP)-based techniques in a chatbot user-interface that will enable a more personalized and accurate monitoring and intervention.

Methods

An 18-months study with a 6-months preliminary phase to adapt PRESTOapp to health workers, enhance it with NLP-based techniques and chatbot user-interface, and evaluate its feasibility, and effectiveness in 12-months.

Results

PRESTOapp has the potential to provide a prompt, personalized and integral response to the mental health demand due to the COVID-19. It will help by providing an innovative digital platform, that will allow remote monitoring of the symptoms course, provide brief psychotherapeutic interventions, and detect urgent situations. If the preliminary results of this study point to a potential effectiveness of the intervention, PRESTOapp may be easily adapted to the general population.

Conclusions

PRESTOapp may be one of the key digital platforms that may help preventing and treating potentially severe mental health consequences. Considering the unresolved problem of burnout in health workers even before the COVID-19, this project will develop the necessary technology for implementing cost-effective mental health solutions, not only during the pandemic.

Disclosure

No significant relationships.

Suicide-related thoughts and behavior and suicide death trends during the COVID-19 in the general population of Catalonia, Spain

The COVID-19 pandemic is expected to increase suicidal behavior. However, data available to date are inconsistent. This study examines suicidal thoughts and behaviors and suicide trends in 2020 relative to 2019 as an approximation to the impact of the pandemic on suicidal behavior and death in the general population of Catalonia, Spain. Data on suicide-related thoughts and behaviors (STBs) and suicidal mortality were obtained from the Catalonia Suicide Risk Code (CSRC) register and the regional police, respectively. We compared the monthly crude incidence of STBs and suicide mortality rates of 2020 with those of 2019. Joinpoint regression analysis was used to assess changes in trends over time during the studied period. In 2020, 4,263 consultations for STBs and 555 suicide deaths were registered in Catalonia (approx. 7.5 million inhabitants). Compared to 2019, in 2020 STBs rates decreased an average of 6.3% (incidence rate ratio, IRR=0.94, 95% CI 0,90-0,98) and overall suicide death rates increased 1.2% (IRR=1.01, 95% CI 0.90-1.13). Joinpoint regression results showed a substantial decrease in STBs rates with a monthly percent change (MPC) of -22.1 (95% CI: -41.1, 2.9) from January-April 2020, followed by a similar increase from April-July 2020 (MPC=24.7, 95% CI: -5.9, 65.2). The most restrictive measures implemented in response to the COVID-19 pandemic reduced consultations for STBs, suggesting that the "stay at home" message may have discouraged people from contacting mental health services. STBs and mortality should continue to be monitored in 2021 and beyond to understand better the mid-to-long term impact of COVID-19 on suicide trends.

[The effect of age and sex on factors associated with dementia]

INTRODUCTION

There is currently no cure for dementia and its prevention is considered to be crucial. The aim is to analyse the association between risk factors and dementia, and how this varies according to age and sex.

PATIENTS AND METHODS

This cross-sectional study includes 1,048,956 people aged 65 and over. Data were obtained from the SIDIAP pseudonymised clinical database. The response variable was dementia and cases were identified using a validated algorithm. Exposure to the following risk factors was assessed: smoking, coronary heart disease, cerebrovascular disease, heart failure, peripheral arterial disease, alcoholism, high blood pressure, hyperlipidaemia, diabetes, hyperthyroidism, Parkinson's disease, depressive disorder and rurality. Logistic regression models were estimated to assess the association between risk factors and dementia, and they were stratified by age, sex and both jointly.

RESULTS

The association between a medical history of cerebrovascular disease, Parkinson, depressive disorder or hyperthyroidism and dementia was more pronounced in men. The inverse association between coronary heart disease, heart failure or smoking and dementia was significant only in women. A stronger association was observed in younger age groups for most risk factors, but hypertension, coronary heart disease, heart failure or smoking were negatively associated among the older age groups.

CONCLUSION

Sex and age both condition the association between risk factors and dementia. We recommend promoting effective control of cardiovascular risk factors in order to prevent dementia.

A cost-utility analysis of increasing percutaneous coronary intervention use in elderly patients with acute coronary syndromes in six European countries

AIMS

Percutaneous coronary intervention reduces mortality in acute coronary syndrome patients but the cost-utility of increasing its use in elderly acute coronary syndrome patients is unknown.

METHODS

We assessed the efficiency of increased percutaneous coronary intervention use compared to current practice in patients aged ≥75 years admitted for acute coronary syndrome in France, Germany, Greece, Italy, Portugal and Spain with a semi-Markov state transition model. In-hospital mortality reduction estimates by percutaneous coronary intervention use and costs were derived from the EUROpean Treatment & Reduction of Acute Coronary Syndromes cost analysis EU project (n = 28,600). Risk of recurrence and out-of-hospital all-cause mortality were obtained from the Information System for the Development of Research in Primary Care (SIDIAP) database from North-Eastern Spain (n = 55,564). In-hospital mortality was modelled using stratified propensity score analysis. The 8-year acute coronary syndrome recurrence risk and out-of-hospital mortality were estimated with a multistate survival model. The scenarios analysed were to increase percutaneous coronary intervention use among patients with the highest, moderate and lowest probability of receiving percutaneous coronary intervention based on the propensity score analysis.

RESULTS

France, Greece and Portugal showed similar total costs/1000 individuals (7.29-11.05 m €); while in Germany, Italy and Spain, costs were higher (13.53-22.57 m €). Incremental cost-utility ratios of providing percutaneous coronary intervention to all patients ranged from 2262.8 €/quality adjusted life year gained for German males to 6324.3 €/quality adjusted life year gained for Italian females. Increasing percutaneous coronary intervention use was cost-effective at a willingness-to-pay threshold of 10,000 €/quality adjusted life year gained for all scenarios in the six countries, in males and females.

CONCLUSION

Compared to current clinical practice, broadening percutaneous coronary intervention use in elderly acute coronary syndrome patients would be cost-effective across different healthcare systems in Europe, regardless of the selected strategy.

THU0462 CHARACTERIZATION OF PATIENTS WITH FIBROMYALGIA AFFECTS WITH OR WITHOUT JOINT HYPERLAXITY SYNDROME

Background:

The prevalence of joint hypermobility (JH) and Joint Hypermobility Syndrome (JHS) in patients with fibromyalgia (FM) is considerable and is much more than can be explained at random(1). Some authors propose that FM and JHS share a common pathophysiological mechanism is some patients. Currently it is accepted that Ehlers-Danlos Syndrome Hypermobility subtype (EDSh) and JHS are the same entity. We regard the subgroup of FM patients with JHS a different subtype of FM, even phenotypically similar to EDSh.

Objectives:

Determine the possible differences between both groups according to their body composition, bone metabolism and clinical findings.

Methods:

Our study is observational, descriptive, transverse cohort study in which we included 86 women with fibromyalgia recruited at the Fibromyalgia and Chronic Fatigue Unit at Parc Salut-Mar in Barcelona, Spain. The patients were grouped according to the presence or absence of JHS, following the Brighton Criteria. Diverse clinical data was collected: Pain Visual Analogue Scale (PVAS), time from pain onset, time from diagnosis, somatic symptoms, state of mind, presence of a FM trigger, concurrent medication, anxiety, quality of life, disease impact, anthropometric data, Bioelectrical Impedance Analysis (BIA), bone density test (BMD) and bone metabolism data in blood samples.

Results:

51 patients were included in the FM group and 35 patients in the FM-JHS group. We did not find differences between groups PVAS; time from pain onset; somatic symptoms using the Psychiatric Disorder and Somatic Pathology Scale (TOPYPS); nor Fibromyalgia Impact Questionnaire (FIQ). Both groups scored similarly on SF-36 Health Questionnaire. The use of opioids was more common in the FM group (p<0,001). Anxiety disorder (AnD) was present in a greater proportion of FM-JHS (p<0,001). We found the Body Mass Index and Muscle Mass (MM) to be less in the FM-JHS group (p=0.001 and p=0.008, respectively). Obesity and fat mass (FatM) were more frequent in the FM group. The FatM and less MM correlated with less quality of life on the SF-36 scale. There was less bone mass (BM) in the FM-JHS group (p=0.005). We found an inverse correlation between the Beighton score and the MM and BM in the FM-JHS group. The FM-JHS group also had less bone mineral density (BMD) at total hip DXA, with significant differences p=0.038. The BM by Bioelectrical Impedance Analysis (BIA) had a positive correlation on the BMD by DXA. The optimum point, capable of distinguishing between normal DXA and osteopenia/osteoporosis was 2,325kg with a specificity of 86% and sensibility of 52%. Vitamin D deficiency/insufficiency was found in 62/84 (73,8%) without significant differences between groups (p>0,05)

Conclusion:

Our work revealed that FM patients with JHS are different from FM without JHS, by manifesting differences in certain clinical, anthropometric, and bone metabolism features.

References:

[1]Lai S, Goldman JA, Child AH, Engel A, Lamm SH. Fibromyalgia, hypermobility, and breast implants. J Rheumatol. 2000;27(9):2237-41.

[2]Malfait, F., Francomano, C., Byers, P., Belmont, J., Berglund, B., Black, J., ... & Castori, M. (2017, March). The 2017 international classification of the Ehlers–Danlos syndromes. InAmerican Journal of Medical Genetics Part C: Seminars in Medical Genetics(Vol. 175, No. 1, pp. 8-26).

Disclosure of Interests: :

None declared

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.

Brain structural changes in schizoaffective disorder compared to schizophrenia and bipolar disorder

OBJECTIVE

Brain structural changes in schizoaffective disorder, and how far they resemble those seen in schizophrenia and bipolar disorder, have only been studied to a limited extent.

METHOD

Forty-five patients meeting DSM-IV and RDC criteria for schizoaffective disorder, groups of patients with 45 matched schizophrenia and bipolar disorder, and 45 matched healthy controls were examined using voxel-based morphometry (VBM).

RESULTS

Analyses comparing each patient group with the healthy control subjects found that the patients with schizoaffective disorder and the patients with schizophrenia showed widespread and overlapping areas of significant volume reduction, but the patients with bipolar disorder did not. A subsequent analysis compared the combined group of patients with the controls followed by extraction of clusters. In regions where the patients differed significantly from the controls, no significant differences in mean volume between patients with schizoaffective disorder and patients with schizophrenia in any of five regions of volume reduction were found, but mean volumes in the patients with bipolar disorder were significantly smaller in three of five.

CONCLUSION

The findings provide evidence that, in terms of structural gray matter brain abnormality, schizoaffective disorder resembles schizophrenia more than bipolar disorder.

Failure of deactivation in the default mode network: a trait marker for schizophrenia?

BACKGROUND

Functional imaging studies in relatives of schizophrenic patients have had inconsistent findings, particularly with respect to altered dorsolateral prefrontal cortex activation. Some recent studies have also suggested that failure of deactivation may be seen.

METHOD

A total of 28 patients with schizophrenia, 28 of their siblings and 56 healthy controls underwent functional magnetic resonance imaging during performance of the n-back working memory task. An analysis of variance was fitted to individual whole-brain maps from each set of patient-relative-matched pair of controls. Clusters of significant difference among the groups were then used as regions of interest to compare mean activations and deactivations among the groups.

RESULTS

In all, five clusters of significant differences were found. The schizophrenic patients, but not the relatives, showed reduced activation compared with the controls in the lateral frontal cortex bilaterally, the left basal ganglia and the cerebellum. In contrast, both the patients and the relatives showed significant failure of deactivation compared with the healthy controls in the medial frontal cortex, with the relatives also showing less failure than the patients. Failure of deactivation was not associated with schizotypy scores or presence of psychotic-like experiences in the relatives.

CONCLUSIONS

Both schizophrenic patients and their relatives show altered task-related deactivation in the medial frontal cortex. This in turn suggests that default mode network dysfunction may function as a trait marker for schizophrenia.

Association of formal thought disorder in schizophrenia with structural brain abnormalities in language-related cortical regions

BACKGROUND

Formal thought disorder (FTD) in schizophrenia has been found to be associated with volume reductions in the left superior temporal cortex. However, there have been negative findings and some studies have also found associations in other cortical regions.

METHOD

Fifty-one schizophrenic patients were evaluated for presence of FTD with the Thought, Language and Communication (TLC) scale and underwent whole-brain structural MRI using optimized voxel-based morphometry (VBM). Fifty-nine matched healthy controls were also scanned.

RESULTS

Compared to 31 patients without FTD (global TLC rating 0 or 1), 20 patients with FTD (global TLC rating 2-5) showed clusters of volume reduction in the medial frontal and orbitofrontal cortex bilaterally, and in two left-sided areas approximating to Broca's and Wernicke's areas. The pattern of FTD-associated volume reductions was largely different from that found in a comparison between the healthy controls and the patients without FTD. Analysis of correlations within regions-of-interest based on the above clusters indicated that the 'fluent disorganization' component of FTD was correlated with volume reductions in both Broca's and Wernicke's areas, whereas poverty of content of speech was correlated with reductions in the medial frontal/orbitofrontal cortex.

CONCLUSIONS

The findings point to a relationship between FTD in schizophrenia and structural brain pathology in brain areas involved in language and executive function.

Cumulative risk of cancer detection in breast cancer screening by protocol strategy

BACKGROUND

There is little information on the individual risk of screen-detected cancer in women over successive participations. This study aimed to estimate the 10-year cumulative breast cancer detection risk (ductal carcinoma in situ and invasive carcinoma) in a population-based breast cancer screening program according to distinct protocol strategies. A further aim was to determine which strategies maximized the cancer detection risk and how this risk was affected by the radiologic protocol variables.

METHODS

Data were drawn from a retrospective cohort of women from nine population-based screening programs in Spain from 1990 to 2006. We used logistic regression with discrete intervals to estimate the cumulative detection risk at 10 years of follow-up according to radiologic variables and protocol strategies.

RESULTS

In women starting screening at the age of 45-59 years, the cumulative risk of screen-detected cancer at 10 years ranged from 11.11 to 16.71 per 1,000 participants according to the protocol strategy. The cumulative detection risk for overall cancer and invasive cancer was the highest with strategies using digital mammography, double reading, and two projections (16.71 and 12.07 ‰, respectively). For ductal carcinoma in situ, cumulative detection risk was the highest with strategies using screen-film, double reading, and two projections (2.32 ‰). The risk was the lowest with strategies using screen-film mammography, single reading, and two projections.

CONCLUSIONS

This study found that at least eleven cancers are detected per 1,000 women screened in the first 10 years of follow-up. Enhanced knowledge of the variability in cumulative risk of screen-detected cancer could improve protocol strategies.

Breast cancer detection risk in screening mammography after a false-positive result

BACKGROUND

False-positives are a major concern in breast cancer screening. However, false-positives have been little evaluated as a prognostic factor for cancer detection. Our aim was to evaluate the association of false-positive results with the cancer detection risk in subsequent screening participations over a 17-year period.

METHODS

This is a retrospective cohort study of 762,506 women aged 45-69 years, with at least two screening participations, who underwent 2,594,146 screening mammograms from 1990 to 2006. Multilevel discrete-time hazard models were used to estimate the adjusted odds ratios (OR) of breast cancer detection in subsequent screening participations in women with false-positive results.

RESULTS

False-positives involving a fine-needle aspiration cytology or a biopsy had a higher cancer detection risk than those involving additional imaging procedures alone (OR = 2.69; 95%CI: 2.28-3.16 and OR = 1.81; 95%CI: 1.70-1.94, respectively). The risk of cancer detection increased substantially if women with cytology or biopsy had a familial history of breast cancer (OR = 4.64; 95%CI: 3.23-6.66). Other factors associated with an increased cancer detection risk were age 65-69 years (OR = 1.84; 95%CI: 1.67-2.03), non-attendance at the previous screening invitation (OR = 1.26; 95%CI: 1.11-1.43), and having undergone a previous benign biopsy outside the screening program (OR = 1.24; 95%CI: 1.13-1.35).

CONCLUSION

Women with a false-positive test have an increased risk of cancer detection in subsequent screening participations, especially those with a false-positive result involving cytology or biopsy. Understanding the factors behind this association could provide valuable information to increase the effectiveness of breast cancer screening.

First-episode psychosis is characterized by failure of deactivation but not by hypo- or hyperfrontality

BACKGROUND

It is not known whether first-episode psychosis is characterized by the same prefrontal cortex functional imaging abnormalities as chronic schizophrenia.

METHOD

Thirty patients with a first episode of non-affective functional psychosis and 28 healthy controls underwent functional magnetic resonance imaging (fMRI) during performance of the n-back working memory task. Voxel-based analyses of brain activations and deactivations were carried out and compared between groups. The connectivity of regions of significant difference between the patients and controls was also examined.

RESULTS

The first-episode patients did not show significant prefrontal hypo- or hyperactivation compared to controls. However, they showed failure of deactivation in the medial frontal cortex. This area showed high levels of connectivity with the posterior cingulate gyrus/precuneus and parts of the parietal cortex bilaterally. Failure of deactivation was significantly greater in first-episode patients who had or went on to acquire a DSM-IV diagnosis of schizophrenia than in those who did not, and in those who met RDC criteria for schizophrenia compared to those who did not.

CONCLUSIONS

First-episode psychosis is not characterized by hypo- or hyperfrontality but instead by a failure of deactivation in the medial frontal cortex. The location and connectivity of this area suggest that it is part of the default mode network. The failure of deactivation seems to be particularly marked in first-episode patients who have, or progress to, schizophrenia.

Polymorphisms in the interleukin-6 receptor gene are associated with bone mineral density and body mass index in Spanish postmenopausal women

OBJECTIVE

Osteoporosis and obesity are complex diseases with a strong genetic component. Bone mineral density (BMD) and body mass index (BMI) linkage studies identified a locus at 1q21-23, where the interleukin-6 receptor (IL6R) gene is located. The IL6R and the gp130 receptors are the mediators of IL6 action. Serum levels of IL6 and sIL6R (the soluble form of IL6R) are higher in several diseases such as osteoporosis or obesity. Variants at IL6R have been associated with BMI and obesity. However, IL6R is an as-yet-unexplored osteoporosis candidate gene.

DESIGN

In the present study we analysed two polymorphisms in the IL6R promoter, -1435 C/T (rs3887104) and -208 G/A (rs4845617), and the Asp358Ala polymorphism (rs8192284), in relation to both BMD and BMI in a cohort of 559 postmenopausal Spanish women.

RESULTS

The promoter polymorphisms, -1435 C/T and -208 G/A were associated with femoral neck (FN) BMD (P=0.011 and P=0.025 respectively). The C-A and T-G promoter haplotypes were also associated with FN BMD. Additionally, the Asp358Ala variant was associated with lumbar spine BMD (P=0.038). Finally, the -208 G/A polymorphism and the C-G and C-A haplotypes were associated with BMI and obesity, where GG was the risk genotype (P=0.033 for BMI; P=0.010 for obesity).

CONCLUSION

These data suggest that variants in the IL6R gene are not only involved in the determination of BMI but also relevant for the determination of BMD. The IL6R gene may belong to the growing list of genes known to be involved in both phenotypes.

Patient-rated emotional and physical functioning among hematologic cancer patients during hospitalization for stem-cell transplantation

In this 3-year prospective inpatient study, 220 patients received stem-cell transplantation (SCT) for hematologic cancer at a single institution. The objective of the study is to provide data on patient-rated emotional (depression and anxiety) and physical (overall physical status, energy level, and systemic symptomatology) functioning during hospitalization for SCT and to compare whether these differ between autologous and allogeneic SCT. Patients were assessed at hospital admission (T1), day of SCT (T2), and 7 days (T3) and 14 days (T4) after SCT, yielding a total of 852 evaluations. For the overall sample, anxiety was highest at T1 and decreased afterwards; a marked worsening in physical health status variables corresponded with a sharp increase in depression from T1 to T3, and was followed by an improvement in physical health and a reduction of depression. Compared to allogeneic SCT, a better physical outcome for autologous SCT was demonstrated by the significant group effect for systemic symptomatology and by the significant group x time interaction for overall physical status and energy level; there were no significant differences in depression or anxiety between SCT groups. These findings have implications for treatment decision making, coping with the transplantation process, and improving prevention and treatment strategies.

A validation study of the hospital anxiety and depression scale (HADS) in a Spanish population

The present study aims to validate the Spanish version of the Hospital Anxiety and Depression Scale (HADS) and to determine the use of this tool for screening mood and anxiety disorders. Psychometric properties of the HADS were assessed in different groups of general medical outpatients attending the Hospital Clínic in Barcelona (N=385), and psychiatric diagnoses were made using DSM-IV criteria. A two-factor solution corresponding to the original two subscales of the HADS was found. The Spanish version of the HADS had good internal consistency and external validity, with favorable sensitivity and specificity in identifying cases of psychiatric disorder as defined by the Structured Clinical Interview for DSM-IV (SCID-I). The psychometric properties of the HADS and its brevity make it useful for screening for psychiatric disorders in the medically ill.

[Economic evaluation of a new selective COX-2 NSAID, rofecoxib, in a real practice context]

OBJECTIVE

To evaluate the economic and health consequences of the use of a new COX-2 anti-inflammatory drug.

DESIGN

Cost-effectiveness analysis by modelling three options for prescribing non-steroidal anti-inflammatories (NSAIDs) in patients diagnosed with arthrosis and undergoing long-term NSAID treatment. Option 1: NSAID prescription without gastric protection for low-risk patients, and with gastric protection for patients running a medium or high risk of developing complications (current procedure). Option 2: exclusive prescription of rofecoxib (25 mg/day) for all patients (high and low risk). Option 3: single-therapy rofecoxib (25 mg/day) prescription for patients sensitive to combined treatment (NSAIDs and gastric protection) due to the risk of complications. In each case, resources and expected clinical benefits were accounted for by the calculation of the cost of avoidance of each moderate or high gastro-intestinal side-effect (GISE) (symptomatic ulcer or complication) avoided. The direct economic impact on the centre of passing from option 1 to any of the other two options was calculated.

SETTINGS AND PARTICIPANTS

The study, conducted in the Barceloneta Primary Care Centre, included in its modelling the 124 patients diagnosed with arthrosis who received NSAIDs continuously during the year 2000.

RESULTS

Option 2 supposed avoiding 1.5 cases of GISE (0.5 symptomatic ulcers and 0.9 serious complications), to an additional cost of 336 566.78 euros. Each case avoided would cost 24,641.50 euros; and each serious case avoided 38,464.79 euros. Option 3 avoided 0.25 cases of serious complication, at an additional cost of 9,015.18 euros. Avoiding one case would cost 37,262.75 euros.

CONCLUSIONS

The overall health benefits arising from the universal or partial introduction of a selective COX-2 inhibitor NSAID involve a unit cost of 24,040.48 or 36,060.73 euros, depending on the option. The impact on the Centre s pharmaceutical budget would increase by 1.3% under option 2, and by 0.35% under option 3.

Comparative hemodynamic effects of urapidil and labetalol after electroconvulsive therapy

Urapidil, a postsynaptic alpha 1 -adrenergic antagonist, has been reported to improve intraoperative hemodynamic stability, although it has never been used to prevent the hemodynamic response of electroconvulsive therapy (ECT). This study was designed to evaluate the clinical effectiveness of urapidil, as an alternative to labetalol, in preventing the hemodynamic response of ECT. Twenty-seven patients undergoing a series of six consecutive ECT treatments were studied. Each patient received all three pretreatments twice: no drug, labetalol 0.2 mg/kg, or urapidil 25 mg. Systolic, diastolic, and mean blood pressure and heart rate (HR) were recorded during the awake state, after anesthesia induction, and 1, 2, 5, 10 and 30 minutes after electroencephalographic (EEG) seizure ended. The duration of the EEG convulsion was also recorded. After induction, the HR increased for no drug and urapidil pretreatments, whereas it decreased when labetalol was given. Labetalol and urapidil attenuated the peak increase of blood pressure and returned it to earlier baseline values. There were no differences in the duration of EEG convulsion between the three pretreatments. Urapidil seems to be a good alternative to labetalol for attenuating the hypertensive response to ECT in cases where there is a contraindication to beta-antagonists.

Preliminary data of a prospective study on neuropsychiatric side effects after initiation of efavirenz

OBJECTIVE

To assess baseline variables able to predict neuropsychiatric side effects (NPSEs) associated with the initiation of an efavirenz (EFV)-containing regimen in HIV-1-infected patients.

DESIGN

Open-label, prospective, observational study.

METHODS

Consecutive HIV-1-infected outpatients in whom EFV was prescribed underwent a psychiatric interview. At baseline and at 2, 4, and 12 weeks, patients completed the Symptoms Check List-90-Revised (SCL-90-R), the Medical Outcome Study for HIV-positive patients (MOS-HIV), and a standardized questionnaire concerning potential NPSEs.

RESULTS

Preliminary data showed that discontinuation of EFV because of NPSEs occurred in 4 of 31 patients (13%). Patients who completed the follow-up showed a decrease in SCL-90-R total score (p =.004) and in several subscales such as Interpersonal Sensitivity (p =.009), Depression (p =.001), and Anxiety (p =.040), whereas no changes in MOS-HIV were observed. Having fewer years of education (p =.006), having fewer baseline central nervous symptoms (p =.000), reporting better baseline physical status (p =.013), and having higher baseline scores in the Heath Transition subscale of the MOS-HIV (p =.000) and in the Somatization subscale of the SCL-90-R (p =.002) were associated with more NPSEs.

CONCLUSION

Patients maintained on EFV showed a decrease in psychologic distress related to self-image, depression, and anxiety, without any effect on quality of life. Patients with a lower level of education, those who feel physically and psychologically better at baseline than in the past, and those who suffer from more distress as a result of physical complaints may be at greater risk of reporting more NPSEs after EFV initiation.

Risk of lipodystrophy in HIV-1-infected patients treated with protease inhibitors: a prospective cohort study

BACKGROUND

Risk factors for lipodystrophy in patients infected with HIV-1 treated with highly active antiretroviral therapy (HAART) containing HIV-1 protease inhibitors are poorly understood. We aimed to identify the risk factors for lipodystrophy in antiretroviral-naive HIV-1-infected adults on HAART.

METHODS

Moderate or severe body-fat changes were clinically assessed and categorised as subcutaneous lipoatrophy, central obesity, or both, in all consecutive antiretroviral-naïve HIV-1-infected adults who began HAART with two nucleoside reverse transcriptase inhibitors plus at least one protease inhibitor from October, 1996, to September, 1999. A person-years analysis was used to calculate the incidence of types of lipodystrophy, and Cox proportional hazards models were used to describe the univariate and multivariate factors associated with progression to any lipodystrophy.

FINDINGS

After a median follow-up of 18 months, 85 (17%) of the 494 patients developed some type of lipodystrophy. The incidences of any lipodystrophy, lipodystrophy with subcutaneous lipoatrophy, and lipodystrophy with central obesity were 11.7 (95% CI 9.2-14.2), 9.2 (7.0-11.4), and 7.7 (5.7-9.7) per 100 patient-years. An increased risk for any lipodystrophy was found among women as compared with men (relative hazard 1.87 [1.07-3.28]), heterosexuals (2.86 [1.50-5.48]), and homosexuals (2.17 [1.07-4.42]) as compared with intravenous drug users, with increasing age (1.33 per 10 years older [1.08-1.62]), and with the duration of exposure to antiretroviral therapy (1.57 per 6 months extra [1.30-1.88]) but not with any individual antiretroviral agent. The factors associated with an increased risk for lipodystrophy with subcutaneous lipoatrophy or lipodystrophy with central obesity were very similar to those associated with any lipodystrophy. The duration of indinavir use may represent an additional contribution for the development of lipodystrophy with central obesity (1.26 per 6 months extra [0.99-1.60]); p=0.064).

INTERPRETATION

Risk factors associated with development of any lipodystrophy, lipodystrophy with subcutaneous lipoatrophy, and tipodystrophy with central obesity in patients infected with HIV-1 who were receiving HAART containing protease inhibitors are multifactorial and overlapping, and cannot be exclusively ascribed to the duration of exposure to an particular antiretroviral agent.

[Optimization of electroconvulsive therapy. Strategies for an adequate convulsion: role of caffeine]

The Electroconvulsive Therapy is a widely used technique in psychiatry as a treatment for several mental disorders with particular indications. To produce therapeutic effect it's necessary to induce a convulsion which is considered adequate if its duration lasts more than 20 seconds. Considerations that should be taken in to account and possible enhancement strategies when convulsion is not adequate are revised in the present article. Among these strategies we focus on the specific role of caffeine as convulsion enhancer and on aspects related to its use and administration form.

Calcium as a treatment of osteoporosis

The role of calcium in bone metabolism, optimal calcium intake, the use of calcium as monotherapy for osteoporosis or in combination with other drugs and the differences between various calcium salts are reviewed. Calcium is an essential element in bone mineralization and formation. There are sufficient data supporting the use of calcium in the prevention and treatment of osteoporosis and calcium in combination with vitamin D is widely used in the prevention and treatment of osteoporosis mainly in elderly patients, although its indication in postmenopausal osteoporosis is not yet clear. Numerous calcium preparations are available on the market and differ only in regard to their bioavailability. However, this difference has very little clinical significance except in patients with achlorhydria or elderly persons with low gastric secretion, in which cases pidolate and calcium citrate can be used since they are more efficiently absorbed.

[Analysis of experience in an integrated program of hospital rheumatological service and primary care]

BACKGROUND

In order to improve the health quality at the Primary care level, the Catalonian Health Authority (Servei Catala de la Salut) has begun a reform of the medical and surgical specialties. In this reform process the Hospital del Mar, Barcelona, Spain, has taken part in the incorporation of several medical and surgical hospital specialists to primary care within its influence area. In this study, we describe the results of the collaboration between Hospital health care and Primary care on rheumatic complaints during one year.

METHODS

We carried out a descriptive study of some clinical and epidemiological variables of the population visited during one year (1995), at the Primary care level by the Rheumatologist. Our area has a population of 90,612 people, and its located in Barcelona City, Ciutat Vella Variables of study were collected during the period of time between January and December 1995. The following variables were recorded: age, gender, referral cause, rheumatologic diagnosis, intra-articular and peri-articular corticosteroid injections perform, techniques used for the diagnosis of rheumatic disease, follow-up level Data were statistically analyzed.

RESULTS

Visits performed were 2,668 on 1,384 patients. Fifty-two percent were first visits, 48% were follow-up visits (Ratio first visits Nolfow-up visits: 0.57). Fifty-one percent of the patients were > 65 years old. Unspecific polyarthralgias, chronic low back pain, gonalgia and pathology of the shoulder were the most frequent complaints (> 50%). Osteoarthritis and soft-tissue diseases were the most frequent diagnosis with a percentage of 41% and 30.7%, respectively. Connective tissue diseases and spondyloarthropathies had account for 3.8% of global diagnosis. X-ray film has been the commonest technique used for the diagnosis of rheumatic diseases (80.5%). The waiting list for first visit initially has been 5 weeks, and at the end of study it has been 3 weeks. Ten percent of patients had been referred to the Hospital.

CONCLUSIONS

Collaboration between Hospital care rheumatology and Primary care, improves the diagnostic quality, as well as it decreases the waiting list and allows the patients' control at the most appropriate care level.

[Favorable response to corticoid therapy in a patient with transverse myelitis in systemic lupus erythematosus]

Transverse myelitis is one of the most unusual neurologic complications of systemic lupus erythematosus. Its pathogenetic mechanisms are controversial. Several therapeutic regimens have been attempted with contradictory results. Corticotherapy appears to improve prognosis, although some authors question its beneficial effects. The case of a patient with systemic lupus erythematosus and transverse myelitis, who presented a favourable clinical course following early treatment with high-dose corticoids, is reported.

Physical and psychosocial functioning of 117 survivors of bone marrow transplantation

All surviving patients receiving a BMT at our center since 1976 were surveyed. Among 163 eligible patients, 145 were contacted and 117 (81%) responded. Their median follow-up was 55 months (range 6-154). The research instruments consisted of a demographic questionnaire, a current medical status form, a quality of life questionnaire (Nottingham Health Profile), and a screening instrument for psychiatric morbidity (the 28-item version of the General Health Questionnaire). Current functioning varied considerably across patients. They reported a high use of medical services (37%) and varied ongoing medical problems within the last 6 months. Most of them (93%) received Karnofsky ratings of 80 or above. Eight percent had current chronic GVHD. Comparing our patients' quality of life with a British reference population, most important differences were found for physical mobility, work, and sex life. Psychiatric morbidity in BMT survivors was higher than in a Spanish general population. Multivariate analyses revealed that a higher systemic symptomatology score, a lower educational level, an older age at BMT, a shorter time post-BMT, a female gender, and impotence were significant predictors of an impaired overall quality of life. Similarly, a higher systemic symptomatology score, a shorter time post-BMT, a higher number of major infections, and a lower educational level were predictive factors of a higher psychosocial distress. No differences in quality of life or psychosocial status between allogeneic and autologous transplants were found. Quality of life and psychosocial distress improved with the passage of time, specially within the first 3 years.

Pregnancy-associated osteoporosis: report of two cases with long-term bone density follow-up

Pregnancy-associated osteoporosis is a rare and poorly characterized clinical entity. We describe two women, aged 28 and 31 yr, who developed vertebral osteopaenia with non-traumatic compression fractures within a few months after delivery. In both women secondary causes of osteoporosis were excluded and routine laboratory data including indices of calcium metabolism were normal. In one patient (Patient 1) spontaneous secretion of IL-1 by cultured blood monocytes was elevated 6 months after delivery and a bone biopsy revealed histomorphometric indices consistent with accelerated bone remodelling. BMD was measured by quantitative computed tomography (QCT) and/or dual energy X-ray absorptiometry (DXA). In Patient 1, BMD, measured with QCT, 6 months after delivery was 3.32 Z-score units below the predicted value for age and sex-matched subjects. At that time treatment (phosphate followed by sodium etidronate) was instituted, and QCT measurements obtained 24 and 30 months after delivery revealed a BMD of -2.98 and -2.67 Z-score units, respectively. The treatment was discontinued just before she became pregnant again, and 3 months after the second delivery QCT showed a BMD of -3.06 Z-score units. Further BMD assessments were obtained with DXA at 15 and 18 months after the second delivery, and the BMD values were -1.41 and -1.08, respectively. In Patient 2, spine BMD, measured with QCT, 4 and 10 months after delivery were -1.68 and -1.59 Z-score units, respectively. At 10, 16 and 22 months after delivery, BMD was assessed with DXA. The initial measurement with this technique disclosed a BMD of 0.52 Z-score units.(ABSTRACT TRUNCATED AT 250 WORDS)

[Syphilitic arthro-osteitis]

We report a black female with past history of sexual promiscuity who developed arthroosteitis of clavicula and sternoclavicular joint and cranial osteitis during secondary syphilis. Spirochaeta were identified in the material from osteoarticular biopsy. The patient was treated with benzathine penicillin, 2,400,000 U weekly for three weeks. There was a complete clinical recovery. We emphasize the uncommon occurrence of osteoarticular involvement in secondary syphilis and the exceptional character, according to the literature, of the finding of spirochaeta in the biopsy material. We discuss the differential diagnosis and we review the literature on secondary syphilis. We suggest that syphilis should be considered in the differential diagnosis of any acute arthritis or osteitis, particularly when the involved joint is the sternoclavicular and the patient is sexually promiscuous.

Determination of succinyldicholine in different tissue samples from guinea pigs after injection of a single intravenous dose

The distribution and postmortem stability of succinyldicholine in different tissues and urine from guinea-pigs has been studied. Succinyldicholine was extracted from tissue homogenates and urine samples from animals sacrificed by intravenous injections of succinyldicholine hydrochloride (40 mg/kg). The bis-quaternary ammonium compound was demethylated and the tertiary amine was analysed by gas chromatography/mass spectrometry. The concentrations found in muscle, kidney and urine were often low; in muscle below 5 pmol/g, in kidney from 5 to 1500 pmol/g and in urine from 5 to 650 pmol/ml. The eye proved to be the best tissue sample, with a rather high and constant concentration (280 +/- 36 pmol/g) of succinyldicholine. The postmortem stability was studied by storing the bodies at 4 degrees C. After 6 days storage the drug concentrations in the eyes started to decline. Four weeks after death it was not possible to detect any succinyldicholine in this tissue.