Neuroleptic Malignant Syndrome: A case report and a literature review

Introduction

Neuroleptic malignant syndrome (NMS) may be a life-threatening neurologic crisis primarily emerging as an idiosyncratic reaction to antipsychotic agent use, and characterized by a particular clinical syndrome of mental status alter, rigidity, fever and dysautonomia. Mortality results straightforwardly from the dysautonomic manifestations of the disease and from systemic complications.

Objectives

To describe an unusual clinical case in order to determine the management regarding medication and electroconvulsive therapy (ECT), and provide an overview of NMS for the general practitioner with the most up-to-date information on etiology, workup, and management.

Methods

We report a case involving a 55-year-old man with paranoid schizophrenia disorder who presented with hyperthermia, hemodynamic instability, miosis, muscular rigidity, urinary incontinence, catatonic signs and mutism after combining several antipsychotics at the same time: long-acting injectable form of paliperidone, aripiprazol and haloperidol.

Results

Guidelines for specific medical treatments in NMS are based upon case reports and clinical experience. Generally used agents are dantrolene, bromocriptine, and amantadine. A conceivable approach is to start with benzodiazepines along with dantrolene in moderate or severe cases, followed by the addition of bromocriptine or amantadine. ECT is generally reserved for patients not responding to other treatments.

Conclusions

NMS is an uncommon adverse drug reaction, with a multifactor pathophysiology and manifestation. Early diagnosis and interruption of antipsychotic therapy is the first-line treatment, followed by supportive care and pharmacotherapy. ECT is an effective treatment when supportive treatment together with pharmacotherapy fails. It could be considered first line in severe life-threatening situations. It is advisable to consider maintenance ECT due to the high risk of relapse.

Disclosure

No significant relationships.

Role of MAOI drugs as triggers of manic episodes in bipolar disorders: A case report and a narrative review

Introduction

Use of Monoamine Oxidase Inhibitors (MAOIs) has experimented an important reduction in recent years, being replaced by other antidepressant drugs (ADs) associated with a better safety profile. Its use has been restricted to instructed professionals treating resistant and atypical depression. Thus, treatment-emergent affective switch (TEAS) induced by MAOIs is a rare event nowadays.

Objectives

To describe a manic episode associated to a one-year-long treatment with phenelzine, a MAOI agent.

Methods

We present the case of a 47-year-old man hospitalized in our acute psychiatric unit after presenting compatible clinical symptoms with a manic episode. He showed severe irritability, decreased need for sleep, pressured speech, increased energy and goal-directed activities. The patient had started phenelzine a year ago for the treatment of major depressive episode resistant to previous pharmacological essayed treatments. No previous history of TEAS was reported, although he had already taken other ADs and mood-stabilizer treatments in the past.

Results

Several studies reported the effectiveness of MAOIs for the treatment of monopolar depressive episodes resistant to other ADs, especially when atypical symptoms were observed. Data on the use of MAOIs for the treatment of drug-resistant bipolar depressive episodes is scarce. Few studies have described a good response without showing and increased risk of TEAS.

Conclusions

As MAOIs have fallen out of favour with modern psychiatry, there is scarce evidence on the prevalence of TEAS in patients undergoing treatment with these drugs. Further research is needed in order to accurately define these complex relationships.

Disclosure

No significant relationships.

Pseudobulbar affect as an early manifestation of HIV-related toxoplasmosis

Introduction

Pseudobulbar affect (PBA) is an emotional disorder characterized by uncontrollable outbursts of laughing and/or crying. It is caused by lesions that damage pathways in the frontal lobe and descending to the brain stem, basis pontis and cerebellum. The main causes are neurodegenerative diseases.

Objectives

To present a case of PBA secondary to cerebral toxoplasmosis.

Methods

The present study is a case report of a patient admitted for HIV-related toxoplasmosis to our hospital. We also researched previous case reports of PBA secondary to CNS infection using a pubmed query.

Results

Mr. JA is a 38-year-old male, with no prior psychiatric or medical history. He reported having had same-sex sexual encounters previously. He was admitted for ataxia and dysarthria in a medical unit, and diagnosed of HIV infection, with a CD4 count of 19 cells/μL. The MRI showed a lesion of 22x19x18mm with ring enhancement predominantly in basis pontis, compatible with toxoplasmosis(Image1). Treatment with sulfadiazine, pyrimethamine and dexamethasone was initiated. After five days of hospitalization he was referred to Consultation-Liaison Psychiatry for involuntary and uncontrollable outbursts of laughing and crying, insomnia, but no other psychopathological symptoms. Therefore, citalopram 20mg per day was started, with reduction on the frequency of outbursts.

Conclusions

The clinical presentation suggested the diagnosis of PBA due to cerebral toxoplasmosis. Although we found no previous reports of PBA related to HIV infection or toxoplasmosis, the location of the toxoplasmosis lesion is congruent with the typical damaged pathways in PBA. To our knowledge, this is the first report about PBA secondary to HIV-related toxoplasmosis.

Disclosure

No significant relationships.

Atrial fibrillation debut following first electroconvulsive therapy combined with venlafaxine: a case report and a literature review

Introduction

Cardiovascular events (CVE) are infrequent adverse effects in patients receiving electroconvulsive therapy (ECT). Nonetheless, it constitutes a threat for patient’s life and may compromise continuing ECT.

Objectives

To describe a case of acute-onset atrial fibrillation under combined therapy with ECT and venlafaxine.

Methods

We present a 76-year-old man diagnosed of delusional disorder and without any previous CVE, who was hospitalized in our acute psychiatric unit by major depressive episode with psychotic symptoms resistant to pharmacological treatment (valproic-acid 100mg/d, haloperidol 6mg/d, venlafaxine 300mg/d). ECT was initiated presenting atrial fibrillation after first session of ECT, requiring amiodarone and anticoagulant treatment for stabilization. Second session of ECT was delayed for three-weeks, worsening the psychiatric symptoms. Haloperidol was discontinued initiating lurasidone with better cardiovascular profile.

Results

CVE occur in 2% of the patients receiving ECT, being acute arrhythmia the most frequent one. Among them, few cases of atrial fibrillation (AF) under ECT have been reported. It has been hypothesised that initial vagal response followed by catecholamine surge secondary to ECT could facilitate the development of AF. In addition venlafaxine, an antidepressant drug, may also predispose to arrhythmia in high-risk individuals. High doses of venlafaxine (>300mg/d) combined with ECT have been related with an increment of CVE.

Conclusions

Although clinically effective for the treatment of major depression disorder, combined therapy of ECT and venlafaxine could precipitate the start of a CVE in genetically susceptible individuals. Therefore, identify and clarify potential risk factors other than previous history of CVE is critical to reduce morbidity and mortality in these patients.

Disclosure

No significant relationships.

Parkinson’s Disease and Bipolar Disorder: a case report and narrative review

Introduction

Bipolar disorder (BD) is considered a risk factor for developing Parkinson’s Disease (PD) because of an altered dopamine activity in both entities. Comorbidity may delay diagnosis and difficult therapeutic management.

Objectives

To describe the case of a patient with both BD and PD and to determine the appropriate diagnostic and therapeutic approach for patients presenting both entities.

Methods

We present the case of a 58-year-old woman attended in our neurology unit due to the initial presence of visual hallucinations as a core symptom.

Results

Psychotic symptoms as hallucinations and off-times, frequently observed in PD, may be misdiagnosed with a worsening of depressive polarity of BD. Thus, overlap between symptoms may lead to a challenging differential diagnosis. Moreover, there is no consensus about the therapeutic management of the comorbidity, due to the bidirectional worsening of symptoms when treatment is adjusted. In our case, a diagnosis of dopaminergic psychosis was made so antipsychotic treatment with quetiapine 50 mg/d was initiated. A worsening of symptoms was observed, presenting the patient a stuporous status, mutism and generalized rigidity. Neuroimaging and lumbar puncture were performed showing no alterations; electroencephalogram showed diffuse slowing. Final diagnosis was an off-episode of PD and a multifactorial encephalopathy resulting in visual hallucinations.

Conclusions

Coexistence of PD and BD may lead to a diagnostic and therapeutic delay and therefore a worse prognosis. Although these diseases are well-known, it is still challenging to manage patients presenting both entities. Further research is needed to clarify the proper diagnostic and therapeutic approach for these patients.

Disclosure

No significant relationships.

Cariprazine as a useful treatment for patients with schizophrenia and antipsychotic-induced extrapyramidal symptoms: a case report and literature review

Introduction

The discovery of second-generation antipsychotics represented an authentic breakthrough for the management of psychotic disorders. Nevertheless, they still don’t adequately manage some aspects of these disorders, such as negative symptoms (NS), cognitive impairment, or extra-pyramidal symptoms (EPS). New-generation antipsychotics present different pharmacological mechanisms and have been reported to ameliorate these aspects. Among them, cariprazine acts as a D2/D3 partial agonist with variable affinity with serotoninergic receptors, and many studies show its efficacy for preventing and treating positive symptoms as well as for the management of NS and EPS.

Objectives

To report a case of a patient diagnosed with schizophrenia with highly invalidating antipsychotic-induced EPS that remitted after switching to cariprazine, while maintaining clinical stability. To review literature about cariprazine and its relationship with NS and EPS.

Methods

We describe the case of a 66-year-old woman diagnosed with schizophrenia and under treatment with three-month injectable paliperidone 175mg. During her follow-up at outpatient clinic, she presented a progressively highly invalidating non-trembling parkinsonian syndrome attributable to medication. Paliperidone plasmatic levels were within therapeutic range. An antipsychotic switch was agreed, and cariprazine was started.

Results

The switch from a second-generation antipsychotic to cariprazine entailed the remission of a highly invalidating EPS while improving some of the NS and maintaining psychopathological stability.

Conclusions

Assessing and differentiating NS and EPS is of an utmost importance during the follow-up of patients under antipsychotic treatment. Cariprazine is an interesting alternative when treating patients diagnosed with psychotic disorders that present mostly NS and antipsychotic-induced EPS.

Disclosure

No significant relationships.

Lurasidone-induced mania: A case report

Introduction

Lurasidone is an atypical antipsychotic agent with potential antidepressant effects through its antagonist activity at the 5-HT7 receptor. Although treatment-emergent affective switch (TEAS) induced by second-generation antipsychotics are not frequent, several cases have been reported. To our knowledge, there is no evidence of lurasidone-induced TEAS.

Objectives

To describe a case of lurasidone-induced mania.

Methods

We describe a clinical case of a patient admitted to our psychiatric outpatient unit who developed a manic episode, presumably induced by the introduction of lurasidone. We also conduct a review of the literature on this subject.

Results

A 37-year-old man diagnosed with obsessive-compulsive disorder (OCD) and an alcohol use disorder was hospitalized due to OCD decompensation with depressive symptomatology and suicidal thoughts, and for alcohol detoxification process. Since he had a previous history of clomipramine-induced TEAS, he was started on lurasidone up to 111mg to avoid the use of antidepressants, showing a progressive improvement of depressive symptoms. Thus, the patient was discharged when alcohol detoxification process was completed. Eight days after discharge, the patient began to show manic symptoms, so he had to be readmitted. Lurasidone was discontinued and valproic acid up to 1000mg/day as mood stabilizer was added, presenting a positive remission of manic symptoms.

Conclusions

According to our experience, lurasidone may have induced an affective switch in this patient. Based on our findings, patients and psychiatrists should monitor possible lurasidone-induced mood switching. However, further research is needed in order to back-up this one case report findings.

Disclosure

No significant relationships.

Radiofrequency-assisted transection of the pancreas vs stapler in distal pancreatectomy: a propensity score matched cohort analysis

To demonstrate the efficacy of radiofrequency for pancreatic stump closure in reducing the incidence of postoperative pancreatic fistula (POPF) in distal pancreatectomy (DP) compared with mechanical transection methods. Despite all the different techniques of pancreatic stump closure proposed for DP, best practice for avoiding POPF remains an unresolved issue, with an incidence of up to 30% regardless of center volume or surgical expertise. DP was performed in a cohort of patients by applying radiofrequency to stump closure (RF Group) and compared with mechanical closure (Control Group). A propensity score (PS) matched cohort study was carried out to minimize bias from nonrandomized treatment assignment. Cohorts were matched by PS accounting for factors significantly associated with either undergoing RF transection or mechanical closure through logistic regression analysis. The primary end-point was the incidence of clinically relevant POPF (CR-POPF). Of 89 patients included in the whole cohort, 13 case patients from the RF-Group were 1:1 matched to 13 control patients. In both the first independent analysis of unmatched data and subsequent adjustment to the overall propensity score-matched cohort, a higher rate of CR-POPF in the Control Group compared with the RF-Group was detected (25.4% vs 5.3%, p = 0.049 and 53.8% vs 0%; p = 0.016 respectively). The RF Group showed better outcomes in terms of readmission rate (46.2% vs 0%, p = 0.031). No significant differences were observed in terms of mortality, major complications (30.8% vs 0%, p = 0.063) or length of hospital stay (5.7 vs 5.2 days, p = 0.89). Findings suggest that the RF-assisted technique is more efficacious in reducing CR-POPF than mechanical pancreatic stump closure.

Chronic pancreatitis for the clinician. Complications and special forms of the disease. Interdisciplinary position paper of the Catalan Society of Digestology (SCD) and the Catalan Pancreatic Society (SCPanc)

Chronic pancreatitis tends to develop a number of complications that may constitute the form of presentation of the disease. Some societies have issued guidelines for diagnosis and treatment of chronic pancreatitis complications, but the level of evidence for any topic is usually low and recommendations tend to be weak. We aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The goal was to propose defined terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 14 sections related to complications and special forms of chronic pancreatitis (early chronic, groove and autoimmune pancreatitis) were reviewed by 21 specialists from 6 different fields to generate 32 statements. Featured statements assert common bile duct stenosis does not require invasive treatment (endoscopic or surgical) unless cholestasis, cholangitis, lithiasis or other symptoms develop. Pancreatic duct strictures and calculi should be approached (after ruling out malignancy) if causing pain, pancreatitis, pseudocysts or other complications. Treatment of symptomatic pseudocysts must be individualized, considering associated main duct stenosis, vascular and pericystic complications. Higher risk conditions for pancreatic cancer are advance age, smoking, genetic background, recent diagnosis of chronic pancreatitis or diabetes, and appearance of new symptoms. Groove pancreatitis can initially be treated with conservative measures. Both prednisolone or rituximab can induce remission and maintenance of autoimmune pancreatitis. Internal fistula, vascular complications, bacterial overgrowth, osteoporosis and renal lithiasis require specific therapeutic approaches.

Pleuropulmonary pathologies in the early phase of acute pancreatitis correlate with disease severity

Background

Respiratory failure worsens the outcome of acute pancreatitis (AP) and underlying factors might be early detectable.

Aims

To evaluate the prevalence and prognostic relevance of early pleuropulmonary pathologies and pre-existing chronic lung diseases (CLD) in AP patients.

Methods

Multicentre retrospective cohort study. Caudal sections of the thorax derived from abdominal contrast enhanced computed tomography (CECT) performed in the early phase of AP were assessed. Independent predictors of severe AP were identified by binary logistic regression analysis. A one-year survival analysis using Kaplan-Meier curves and log rank test was performed.

Results

358 patients were analysed, finding pleuropulmonary pathologies in 81%. CECTs were performed with a median of 2 days (IQR 1–3) after admission. Multivariable analysis identified moderate to severe or bilateral pleural effusions (PEs) (OR = 4.16, 95%CI 2.05–8.45, p<0.001) and pre-existing CLD (OR = 2.93, 95%CI 1.17–7.32, p = 0.022) as independent predictors of severe AP. Log rank test showed a significantly worse one-year survival in patients with bilateral compared to unilateral PEs in a subgroup.

Conclusions

Increasing awareness of the prognostic impact of large and bilateral PEs and pre-existing CLD could facilitate the identification of patients at high risk for severe AP in the early phase and thus improve their prognosis.

Gallbladder disease and pancreatic cancer risk: a multicentric case-control European study

BACKGROUND AND AIMS

The overall evidence on the association between gallbladder conditions (GBC: gallstones and cholecystectomy) and pancreatic cancer (PC) is inconsistent. To our knowledge, no previous investigations considered the role of tumour characteristics on this association. Thus, we aimed to assess the association between self-reported GBC and PC risk, by focussing on timing to PC diagnosis and tumour features (stage, location, and resection).

METHODS

Data derived from a European case-control study conducted between 2009 and 2014 including 1431 PC cases and 1090 controls. We used unconditional logistic regression models to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs) adjusted for recognized confounders.

RESULTS

Overall, 298 (20.8%) cases and 127 (11.6%) controls reported to have had GBC, corresponding to an OR of 1.70 (95% CI 1.33-2.16). The ORs were 4.84 (95% CI 2.96-7.89) for GBC diagnosed <3 years before PC and 1.06 (95% CI 0.79-1.41) for ≥3 years. The risk was slightly higher for stage I/II (OR = 1.71, 95% CI 1.15-2.55) vs. stage III/IV tumours (OR = 1.23, 95% CI 0.87-1.76); for tumours sited in the head of the pancreas (OR = 1.59, 95% CI 1.13-2.24) vs. tumours located at the body/tail (OR = 1.02, 95% CI 0.62-1.68); and for tumours surgically resected (OR = 1.69, 95% CI 1.14-2.51) vs. non-resected tumours (OR = 1.25, 95% CI 0.88-1.78). The corresponding ORs for GBC diagnosed ≥3 years prior PC were close to unity.

CONCLUSION

Our study supports the association between GBC and PC. Given the time-risk pattern observed, however, this relationship may be non-causal and, partly or largely, due to diagnostic attention and/or reverse causation.

Chronic pancreatitis for the clinician. Part 2: Treatment and follow-up. Interdisciplinary Position Paper of the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees

Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis.

Psychiatric clinical profiles and pharmacological interactions in COVID-19 inpatients referred to a consultation liaison psychiatry unit

Introduction

The Coronavirus Disease 2019 (COVID-19) can affect mental health in different ways. There is little research about psychiatric complications in hospitalized patients with COVID-19.

Objectives

The aim of the study was to describe the psychiatric clinical profile and pharmacological interactions in COVID-19 inpatients referred to a Consultation-Liaison Psychiatry (CLP) unit.

Methods

This is a cross-sectional retrospective study, carried out at a tertiary hospital in Spain, in inpatients admitted because of COVID-19 and referred to our CLP Unit from March 17,2020 to April 28,2020. Clinical data were extracted from electronic medical records. The patients were divided in three groups depending on psychiatric diagnosis: delirium, severe mental illness (SMI) and non-severe mental illness (NSMI).

Results

Of 71 patients included (median [ICR] age 64 [54-73] years; 70.4% male), 35.2% had a delirium, 18.3% had a SMI, and 46.5% had a NSMI. Compared to patients with delirium and NSMI, patients with SMI were younger, more likely to be institutionalized and were administered less anti-COVID19 drugs. Mortality was higher among patients with delirium (21.7%) than those with SMI (0%) or NSMI (9.45%). The rate of side effects due to interactions between anti-COVID19 and psychiatric drugs was low, mainly drowsiness (4.3%) and borderline QTc prolongation (1.5%).

Conclusions

Patients affected by SMI were more often undertreated for COVID-19. However, the rate of interactions was very low, and avoidable with a proper evaluation and drug-dose adjustment. Half of the patients with SMI were institutionalized, suggesting that living conditions in residential facilities could make them more vulnerable to infection.

Disclosure

No significant relationships.

Dhat syndrome: A case report on a culture-bound challenge

Introduction

Dhat Syndrome is a culture-bound entity frequent in the Indian subcontinent. It is characterized by somatic symptoms, together with depressive and anxiety features, specifically focused on the belief of losing semen through urine¹.

Objectives

To describe an atypical Dhat Syndrome case in European cultural context,and to determine the appropriate diagnostic frame and subsequent therapeutic approach.

Methods

We present the case of a 37-year-old Indian man attended in our psychiatric outpatient unit mainly due to somatic complaints (gastrointestinal, sexual dysfunction, weakness, and dizziness). He interpreted his problem as possibly due to diabetes and hypothyroidism, and specifically from sugar loss in urine. Organic diseases were excluded.

Results

Although considered as culture-bound, Dhat syndrome has been classified as a subtype of depression, anxiety disorder, somatoform disorder^2,3,4, and even a prodromal phase of schizophrenia⁵. Antidepressants and benzodiazepines are the most recommended pharmacological treatments¹. Antipsychotic agents have been used when clear psychotic symptoms were present (auditory hallucinations,delusions)⁵. Nonetheless, paliperidone 6mg/d was initiated at baseline, with good response and partial remission of the symptoms at two weeks, despite the absence of clear psychotic features. Culturally-informed cognitive-behavioural therapy, as well as sexual education could be beneficial were planned and initiated¹.

Conclusions

Data on Dhat Syndrome is scarce, yet agreement exist in considering the cultural context of the patient to avoid diagnostic delays. The adequate treatment remains uncertain. Antipsychotics may be a potential treatment. Further research is necessary to clarify the nature of this syndrome but European clinicians must be aware of culturally-mediated psychiatric manifestations which are increasingly prevalent due to globalization.

Disclosure

No significant relationships.

A multilayered post-GWAS assessment on genetic susceptibility to pancreatic cancer

BACKGROUND

Pancreatic cancer (PC) is a complex disease in which both non-genetic and genetic factors interplay. To date, 40 GWAS hits have been associated with PC risk in individuals of European descent, explaining 4.1% of the phenotypic variance.

METHODS

We complemented a new conventional PC GWAS (1D) with genome spatial autocorrelation analysis (2D) permitting to prioritize low frequency variants not detected by GWAS. These were further expanded via Hi-C map (3D) interactions to gain additional insight into the inherited basis of PC. In silico functional analysis of public genomic information allowed prioritization of potentially relevant candidate variants.

RESULTS

We identified several new variants located in genes for which there is experimental evidence of their implication in the biology and function of pancreatic acinar cells. Among them is a novel independent variant in NR5A2 (rs3790840) with a meta-analysis p value = 5.91E-06 in 1D approach and a Local Moran's Index (LMI) = 7.76 in 2D approach. We also identified a multi-hit region in CASC8-a lncRNA associated with pancreatic carcinogenesis-with a lowest p value = 6.91E-05. Importantly, two new PC loci were identified both by 2D and 3D approaches: SIAH3 (LMI = 18.24), CTRB2/BCAR1 (LMI = 6.03), in addition to a chromatin interacting region in XBP1-a major regulator of the ER stress and unfolded protein responses in acinar cells-identified by 3D; all of them with a strong in silico functional support.

CONCLUSIONS

This multi-step strategy, combined with an in-depth in silico functional analysis, offers a comprehensive approach to advance the study of PC genetic susceptibility and could be applied to other diseases.

Deciphering the complex interplay between pancreatic cancer, diabetes mellitus subtypes and obesity/BMI through causal inference and mediation analyses

OBJECTIVES

To characterise the association between type 2 diabetes mellitus (T2DM) subtypes (new-onset T2DM (NODM) or long-standing T2DM (LSDM)) and pancreatic cancer (PC) risk, to explore the direction of causation through Mendelian randomisation (MR) analysis and to assess the mediation role of body mass index (BMI).

DESIGN

Information about T2DM and related factors was collected from 2018 PC cases and 1540 controls from the PanGenEU (European Study into Digestive Illnesses and Genetics) study. A subset of PC cases and controls had glycated haemoglobin, C-peptide and genotype data. Multivariate logistic regression models were applied to derive ORs and 95% CIs. T2DM and PC-related single nucleotide polymorphism (SNP) were used as instrumental variables (IVs) in bidirectional MR analysis to test for two-way causal associations between PC, NODM and LSDM. Indirect and direct effects of the BMI-T2DM-PC association were further explored using mediation analysis.

RESULTS

T2DM was associated with an increased PC risk when compared with non-T2DM (OR=2.50; 95% CI: 2.05 to 3.05), the risk being greater for NODM (OR=6.39; 95% CI: 4.18 to 9.78) and insulin users (OR=3.69; 95% CI: 2.80 to 4.86). The causal association between T2DM (57-SNP IV) and PC was not statistically significant (OR_LSDM=1.08, 95% CI: 0.86 to 1.29, OR_NODM=1.06, 95% CI: 0.95 to 1.17). In contrast, there was a causal association between PC (40-SNP IV) and NODM (OR=2.85; 95% CI: 2.04 to 3.98), although genetic pleiotropy was present (MR-Egger: p value=0.03). Potential mediating effects of BMI (125-SNPs as IV), particularly in terms of weight loss, were evidenced on the NODM-PC association (indirect effect for BMI in previous years=0.55).

CONCLUSION

Findings of this study do not support a causal effect of LSDM on PC, but suggest that PC causes NODM. The interplay between obesity, PC and T2DM is complex.

Pancreatic Cancer Risk in Relation to Lifetime Smoking Patterns, Tobacco Type, and Dose-Response Relationships

BACKGROUND

Despite smoking being a well-established risk factor for pancreatic cancer, there is a need to further characterize pancreatic cancer risk according to lifespan smoking patterns and other smoking features, such as tobacco type. Our aim was to deeply investigate them within a large European case-control study.

METHODS

Tobacco smoking habits and other relevant information were obtained from 2,009 cases and 1,532 controls recruited in the PanGenEU study using standardized tools. Multivariate logistic regression analysis was performed to evaluate pancreatic cancer risk by smoking characteristics and interactions with other pancreatic cancer risk factors. Fractional polynomials and restricted cubic splines were used to test for nonlinearity of the dose-response relationships and to analyze their shape.

RESULTS

Relative to never-smokers, current smokers [OR = 1.72; 95% confidence interval (95% CI), 1.39-2.12], those inhaling into the throat (OR = 1.48; 95% CI, 1.11-1.99) or chest (OR = 1.33; 95% CI, 1.12-1.58), and those using nonfiltered cigarettes (OR = 1.69; 95% CI, 1.10-2.61), were all at an increased pancreatic cancer risk. Pancreatic cancer risk was highest in current black tobacco smokers (OR = 2.09; 95% CI, 1.31-3.41), followed by blond tobacco smokers (OR = 1.43; 95% CI, 1.01-2.04). Childhood exposure to tobacco smoke relative to parental smoking was also associated with increased pancreatic cancer risk (OR = 1.24; 95% CI, 1.03-1.49). Dose-response relationships for smoking duration, intensity, cumulative dose, and smoking cessation were nonlinear and showed different shapes by tobacco type. Effect modification by family history of pancreatic cancer and diabetes was likely.

CONCLUSIONS

This study reveals differences in pancreatic cancer risk by tobacco type and other habit characteristics, as well as nonlinear risk associations.

IMPACT

This characterization of smoking-related pancreatic cancer risk profiles may help in defining pancreatic cancer high-risk populations.

Mean muscle attenuation correlates with severe acute pancreatitis unlike visceral adipose tissue and subcutaneous adipose tissue

Background

Acute pancreatitis (AP) is a frequent disorder with considerable morbidity and mortality. Obesity has previously been reported to influence disease severity.

Objective

The aim of this study was to investigate the association of adipose and muscle parameters with the severity grade of AP.

Methods

In total 454 patients were recruited. The first contrast-enhanced computed tomography of each patient was reviewed for adipose and muscle tissue parameters at L3 level. Associations with disease severity were analysed through logistic regression analysis. The predictive capacity of the parameters was investigated using receiver operating characteristic (ROC) curves.

Results

No distinct variation was found between the AP severity groups in either adipose tissue parameters (visceral adipose tissue and subcutaneous adipose tissue) or visceral muscle ratio. However, muscle mass and mean muscle attenuation differed significantly with p-values of 0.037 and 0.003 respectively. In multivariate analysis, low muscle attenuation was associated with severe AP with an odds ratio of 4.09 (95% confidence intervals: 1.61-10.36, p-value 0.003). No body parameter presented sufficient predictive capability in ROC-curve analysis.

Conclusions

Our results demonstrate that a low muscle attenuation level is associated with an increased risk of severe AP. Future prospective studies will help identify the underlying mechanisms and characterise the influence of body composition parameters on AP.

Pancreatic cancer and autoimmune diseases: An association sustained by computational and epidemiological case-control approaches

Deciphering the underlying genetic basis behind pancreatic cancer (PC) and its associated multimorbidities will enhance our knowledge toward PC control. The study investigated the common genetic background of PC and different morbidities through a computational approach and further evaluated the less explored association between PC and autoimmune diseases (AIDs) through an epidemiological analysis. Gene-disease associations (GDAs) of 26 morbidities of interest and PC were obtained using the DisGeNET public discovery platform. The association between AIDs and PC pointed by the computational analysis was confirmed through multivariable logistic regression models in the PanGen European case-control study population of 1,705 PC cases and 1,084 controls. Fifteen morbidities shared at least one gene with PC in the DisGeNET database. Based on common genes, several AIDs were genetically associated with PC pointing to a potential link between them. An epidemiologic analysis confirmed that having any of the nine AIDs studied was significantly associated with a reduced risk of PC (Odds Ratio (OR) = 0.74, 95% confidence interval (CI) 0.58-0.93) which decreased in subjects having ≥2 AIDs (OR = 0.39, 95%CI 0.21-0.73). In independent analyses, polymyalgia rheumatica, and rheumatoid arthritis were significantly associated with low PC risk (OR = 0.40, 95%CI 0.19-0.89, and OR = 0.73, 95%CI 0.53-1.00, respectively). Several inflammatory-related morbidities shared a common genetic component with PC based on public databases. These molecular links could shed light into the molecular mechanisms underlying PC development and simultaneously generate novel hypotheses. In our study, we report sound findings pointing to an association between AIDs and a reduced risk of PC.

PET/TC imaging with somatostatin analogues for assessment of neuroendocrine tumors, initial experience

PET with somatostatin analogues (SSA PET/CT) enables the detection of cells with overexpression of somatostatin receptors, especially subtypes 2 and 5; this detection is variable depending on the type of molecule used. This is the basis for its use in the study of neuroendocrine tumours (NETs), which are characterized by an overexpression of these receptors in more than 80% of the subtypes. This PET is now being used in our country supported by the good results published by other groups, that were superior to those of other imaging techniques. We present two of the first cases of SSA-PET/CT with ⁶⁸Ga-edotreotide (SomaKit TOC®) performed in our centre. SSA-PET/CT was the test that finally determined the clinical management of both patients.

Risk of pancreatic cancer associated with family history of cancer and other medical conditions by accounting for smoking among relatives

Background

Family history (FH) of pancreatic cancer (PC) has been associated with an increased risk of PC, but little is known regarding the role of inherited/environmental factors or that of FH of other comorbidities in PC risk. We aimed to address these issues using multiple methodological approaches.

Methods

Case-control study including 1431 PC cases and 1090 controls and a reconstructed-cohort study (N = 16 747) made up of their first-degree relatives (FDR). Logistic regression was used to evaluate PC risk associated with FH of cancer, diabetes, allergies, asthma, cystic fibrosis and chronic pancreatitis by relative type and number of affected relatives, by smoking status and other potential effect modifiers, and by tumour stage and location. Familial aggregation of cancer was assessed within the cohort using Cox proportional hazard regression.

Results

FH of PC was associated with an increased PC risk [odds ratio (OR) = 2.68; 95% confidence interval (CI): 2.27-4.06] when compared with cancer-free FH, the risk being greater when ≥ 2 FDRs suffered PC (OR = 3.88; 95% CI: 2.96-9.73) and among current smokers (OR = 3.16; 95% CI: 2.56-5.78, interaction FHPC*smoking P-value = 0.04). PC cumulative risk by age 75 was 2.2% among FDRs of cases and 0.7% in those of controls [hazard ratio (HR) = 2.42; 95% CI: 2.16-2.71]. PC risk was significantly associated with FH of cancer (OR = 1.30; 95% CI: 1.13-1.54) and diabetes (OR = 1.24; 95% CI: 1.01-1.52), but not with FH of other diseases.

Conclusions

The concordant findings using both approaches strengthen the notion that FH of cancer, PC or diabetes confers a higher PC risk. Smoking notably increases PC risk associated with FH of PC. Further evaluation of these associations should be undertaken to guide PC prevention strategies.

Minimally invasive surgery in the era of step-up approach for treatment of severe acute pancreatitis

OBJECTIVES

To assess the minimally invasive surgery into the step-up approach procedures as a standard treatment for severe acute pancreatitis and comparing its results with those obtained by classical management.

METHODS

Retrospective cohort study comparative with two groups treated over two consecutive, equal periods of time were defined: group A, classic management with open necrosectomy from January 2006 to June 2010; and group B, management with the step-up approach with minimally invasive surgery from July 2010 to December 2014.

RESULTS

In group A, 83 patients with severe acute pancreatitis were treated, of whom 19 underwent at least one laparotomy, and in 5 any minimally invasive surgery. In group B, 81 patients were treated: minimally invasive surgery was necessary in 17 cases and laparotomy in 3. Among operated patients, the time from admission to first interventional procedures was significantly longer in group B (9 days vs. 18.5 days; p = 0.042). There were no significant differences in Intensive Care Unit stay or overall stay: 9.5 and 27 days (group A) vs. 8.5 and 21 days (group B). Mortality in operated patients and mortality overall were 50% and 18.1% in group A vs 0% and 6.2% in group B (p < 0.001 and p = 0.030).

CONCLUSIONS

The combination of the step-up approach and minimally invasive surgery algorithm is feasible and could be considered as the standard of treatment for severe acute pancreatitis. The mortality rate deliberately descends when it is used.

Inflammatory Bowel Disease and Eating Disorders: A systematized review of comorbidity

OBJECTIVE

Research has shown that there is an association between Inflammatory Bowel Disease, anxiety and mood disorders, however little is known about their association with Eating Disorders. In this paper we will present a case of a young female with a comorbid diagnosis of Inflammatory Bowel Disease and Eating Disorder, and then discuss the results from a systematic review of the literature, describing published cases of patients with the same condition.

METHODS

A systematized review of the literature was conducted according to MOOSE guidelines. A computerized literature search of MEDLINE, PsycINFO and EMBASE, and a manual search through reference lists of selected original articles were performed to identify all published case-reports, case series and studies of Inflammatory Bowel Disease and Eating Disorders.

RESULTS

Fourteen articles were included, encompassing 219 cases, including ours. The vast majority were females ranging from 10 to 44years old. Anorexia Nervosa (n=156) and Crohn's Disease (n=129) was the most frequent combination (n=90) reported in the literature. These cases present a poor prognosis because of corticoid refusal, medication abandon and/or deliberate exacerbation of IBD symptoms, in the context of trying to lose weight.

CONCLUSION

Recent evidence suggests there is a possible association between Inflammatory Bowel Disease and Eating Disorders, although the mechanisms involved in its ethiopathogenesis are still unknown. To be aware of this association is important because a delayed diagnosis of this comorbidity may lead to worse prognosis. Further research and a multidisciplinary approach could facilitate earlier diagnosis and provide therapeutic interventions.

A systems approach identifies time-dependent associations of multimorbidities with pancreatic cancer risk

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is usually diagnosed in late adulthood; therefore, many patients suffer or have suffered from other diseases. Identifying disease patterns associated with PDAC risk may enable a better characterization of high-risk patients.

METHODS

Multimorbidity patterns (MPs) were assessed from 17 self-reported conditions using hierarchical clustering, principal component, and factor analyses in 1705 PDAC cases and 1084 controls from a European population. Their association with PDAC was evaluated using adjusted logistic regression models. Time since diagnosis of morbidities to PDAC diagnosis/recruitment was stratified into recent (<3 years) and long term (≥3 years). The MPs and PDAC genetic networks were explored with DisGeNET bioinformatics-tool which focuses on gene-diseases associations available in curated databases.

RESULTS

Three MPs were observed: gastric (heartburn, acid regurgitation, Helicobacter pylori infection, and ulcer), metabolic syndrome (obesity, type-2 diabetes, hypercholesterolemia, and hypertension), and atopic (nasal allergies, skin allergies, and asthma). Strong associations with PDAC were observed for ≥2 recently diagnosed gastric conditions [odds ratio (OR), 6.13; 95% confidence interval CI 3.01-12.5)] and for ≥3 recently diagnosed metabolic syndrome conditions (OR, 1.61; 95% CI 1.11-2.35). Atopic conditions were negatively associated with PDAC (high adherence score OR for tertile III, 0.45; 95% CI, 0.36-0.55). Combining type-2 diabetes with gastric MP resulted in higher PDAC risk for recent (OR, 7.89; 95% CI 3.9-16.1) and long-term diagnosed conditions (OR, 1.86; 95% CI 1.29-2.67). A common genetic basis between MPs and PDAC was observed in the bioinformatics analysis.

CONCLUSIONS

Specific multimorbidities aggregate and associate with PDAC in a time-dependent manner. A better characterization of a high-risk population for PDAC may help in the early diagnosis of this cancer. The common genetic basis between MP and PDAC points to a mechanistic link between these conditions.

Reduced risk of pancreatic cancer associated with asthma and nasal allergies

OBJECTIVE

Studies indicate an inverse association between ductal adenocarcinoma of the pancreas (PDAC) and nasal allergies. However, controversial findings are reported for the association with asthma. Understanding PDAC risk factors will help us to implement appropriate strategies to prevent, treat and diagnose this cancer. This study assessed and characterised the association between PDAC and asthma and corroborated existing reports regarding the association between allergies and PDAC risk.

DESIGN

Information about asthma and allergies was collated from 1297 PDAC cases and 1024 controls included in the PanGenEU case-control study. Associations between PDAC and atopic diseases were studied using multilevel logistic regression analysis. Meta-analyses of association studies on these diseases and PDAC risk were performed applying random-effects model.

RESULTS

Asthma was associated with lower risk of PDAC (OR 0.64, 95% CI 0.47 to 0.88), particularly long-standing asthma (>=17 years, OR 0.39, 95% CI 0.24 to 0.65). Meta-analysis of 10 case-control studies sustained our results (metaOR 0.73, 95% CI 0.59 to 0.89). Nasal allergies and related symptoms were associated with lower risk of PDAC (OR 0.66, 95% CI 0.52 to 0.83 and OR 0.59, 95% CI 0.46 to 0.77, respectively). These results were supported by a meta-analysis of nasal allergy studies (metaOR 0.6, 95% CI 0.5 to 0.72). Skin allergies were not associated with PDAC risk.

CONCLUSIONS

This study shows a consistent inverse association between PDAC and asthma and nasal allergies, supporting the notion that atopic diseases are associated with reduced cancer risk. These results point to the involvement of immune and/or inflammatory factors that may either foster or restrain pancreas carcinogenesis warranting further research to understand the molecular mechanisms driving this association.

Significant inter-observer variation in the diagnosis of extrapancreatic necrosis and type of pancreatic collections in acute pancreatitis - An international multicenter evaluation of the revised Atlanta classification

BACKGROUND

For consistent reporting and better comparison of data in research the revised Atlanta classification (RAC) proposes new computed tomography (CT) criteria to describe the morphology of acute pancreatitis (AP). The aim of this study was to analyse the interobserver agreement among radiologists in evaluating CT morphology by using the new RAC criteria in patients with AP.

METHODS

Patients with a first episode of AP who obtained a CT were identified and consecutively enrolled at six European centres backwards from January 2013 to January 2012. A local radiologist at each center and a central expert radiologist scored the CTs separately using the RAC criteria. Center dependent and independent interobserver agreement was determined using Kappa statistics.

RESULTS

In total, 285 patients with 388 CTs were included. For most CT criteria, interobserver agreement was moderate to substantial. In four categories, the center independent kappa values were fair: extrapancreatic necrosis (EXPN) (0.326), type of pancreatitis (0.370), characteristics of collections (0.408), and appropriate term of collections (0.356). The fair kappa values relate to discrepancies in the identification of extrapancreatic necrotic material. The local radiologists diagnosed EXPN (33% versus 59%, P < 0.0001) and non-homogeneous collections (35% versus 66%, P < 0.0001) significantly less frequent than the central expert. Cases read by the central expert showed superior correlation with clinical outcome.

CONCLUSION

Diagnosis of EXPN and recognition of non-homogeneous collections show only fair agreement potentially resulting in inconsistent reporting of morphologic findings.

Diagnosis, treatment and long-term outcomes of autoimmune pancreatitis in Spain based on the International Consensus Diagnostic Criteria: A multi-centre study

OBJECTIVES

Autoimmune pancreatitis (AIP) is a form of chronic pancreatitis that has been reported worldwide for the last two decades. The aim of this study is to analyse the clinical profile of patients from Spain with AIP, as well as treatments, relapses and long-term outcomes.

METHODS

Data from 59 patients with suspected AIP that had been diagnosed in 15 institutions are retrospectively analysed. Subjects are classified according to the International Consensus Diagnostic Criteria (ICDC). Patients with type 1 AIP (AIP1) and type 2 AIP (AIP2) are compared. Kaplan-Meier methodology is used to estimate the overall survival without relapses.

RESULTS

Fifty-two patients met ICDC, 45 patients were AIP1 (86.5%). Common manifestations included abdominal pain (65.4%) and obstructive jaundice (51.9%). Diffuse enlargement of pancreas was present in 51.0%; other organ involvement was present in 61.5%. Serum IgG4 increased in 76.7% of AIP1 patients vs. 20.0% in AIP2 (p = 0.028). Tissue specimens were obtained in 76.9%. Initial successful treatment with steroids or surgery was achieved in 79.8% and 17.3%, respectively. Maintenance treatment was given in 59.6%. Relapses were present in 40.4% of AIP1, with a median of 483 days. Successful long-term remission was achieved in 86.4%.

CONCLUSIONS

AIP1 is the most frequent form of AIP in Spain in our dataset. Regularly, ICDC allows AIP diagnosis without the need for surgery. Steroid and chirurgic treatments were effective and safe in most patients with AIP, although maintenance was required many times because of their tendency to relapse. Long-term serious consequences were uncommon.

Validation Microsatellite Path Score in a Population-Based Cohort of Patients With Colorectal Cancer

Purpose

Bethesda guidelines are used to recognize patients at risk for Lynch syndrome. However, obtaining personal and familial tumor data can sometimes be difficult. The Microsatellite Path Score (MsPath), a pathological score, based on age, tumor location, and pathologic features, has been developed to effectively predict colorectal cancer with DNA mismatch repair (MMR) deficiencies. However, the MsPath model's performance in an unselected, population-based colorectal cancer (CRC) population is unknown.

Patients and Methods

We analyzed all patients with CRC regardless of age, personal or family history, and tumor characteristics from the EPICOLON study, an independent, prospective, multicenter, population-based cohort (N = 1,222). All patients underwent tumor microsatellite instability (MSI) analysis and immunostaining for MLH1/MSH2, and those with MMR underwent tumor BRAF mutation analysis and MLH1/MSH2 germline testing. All the pathologic features were centralized and evaluated blinded to the MMR status.

Results

MsPath score for prediction of having MSI high, with the recommended MsPath cutoff score ≥1.0, had a sensitivity, specificity, and positive predictive value (PPV) of 92.8% (95% CI, 86.9 to 98.3), 64.1% (95% CI, 61.1 to 66.8), and 15.8% (95% CI, 12.2 to 18.6), respectively. MsPath score had a sensitivity, specificity, and PPV of 81.8% (95% CI, 59.0 to 99.8), 60.6% (95% CI, 57.8 to 63.4), and 1.9% (95% CI, 0.7 to 3.1), respectively, for the identification of MLH1/MSH2 gene carriers. Application of the MsPath score, resulted in two (18%) of 11 mutation carriers being missed, both pathogenic germline MSH2 mutations.

Conclusion

In the general nonselected population, the MsPath score accurately predicted the probability of bearing a MSI high CRC, but it was insufficiently accurate to use for the selection of patients warranting MLH1/MSH2 mutation testing in the setting of Lynch syndrome.