Diagnosis and treatment of Tropheryma whipplei infection in patients with inflammatory rheumatic disease: Data from the French Tw-IRD registry

OBJECTIVES

Tropheryma whipplei infection can manifest as inflammatory joint symptoms, which can lead to misdiagnosis of inflammatory rheumatic disease and the use of disease-modifying antirheumatic drugs. We investigated the impact of diagnosis and treatment of Tropheryma whipplei infection in patients with inflammatory rheumatic disease.

METHODS

We initiated a registry including patients with disease-modifying antirheumatic drugs-treated inflammatory rheumatic disease who were subsequently diagnosed with Tropheryma whipplei infection. We collected clinical, biological, treatment data of the inflammatory rheumatic disease, of Tropheryma whipplei infection, and impact of antibiotics on the evolution of inflammatory rheumatic disease.

RESULTS

Among 73 inflammatory rheumatic disease patients, disease-modifying antirheumatic drugs initiation triggered extra-articular manifestations in 27% and resulted in stabilisation (51%), worsening (34%), or improvement (15%) of inflammatory rheumatic disease. At the diagnosis of Tropheryma whipplei infection, all patients had rheumatological symptoms (mean age 58 years, median inflammatory rheumatic disease duration 79 months), 84% had extra-rheumatological manifestations, 93% had elevated C-reactive protein, and 86% had hypoalbuminemia. Treatment of Tropheryma whipplei infection consisted mainly of doxycycline plus hydroxychloroquine, leading to remission of Tropheryma whipplei infection in 79% of cases. Antibiotic treatment of Tropheryma whipplei infection was associated with remission of inflammatory rheumatic disease in 93% of cases and enabled disease-modifying antirheumatic drugs and glucocorticoid discontinuation in most cases.

CONCLUSIONS

Tropheryma whipplei infection should be considered in inflammatory rheumatic disease patients with extra-articular manifestations, elevated C-reactive protein, and/or hypoalbuminemia before disease-modifying antirheumatic drugs initiation or in inflammatory rheumatic disease patients with an inadequate response to one or more disease-modifying antirheumatic drugs. Positive results of screening and diagnostic tests for Tropheryma whipplei infection involve antibiotic treatment, which is associated with complete recovery of Tropheryma whipplei infection and rapid remission of inflammatory rheumatic disease, allowing disease-modifying antirheumatic drugs and glucocorticoid discontinuation.

Linking emotional valence and anxiety in a mouse insula-amygdala circuit

Responses of the insular cortex (IC) and amygdala to stimuli of positive and negative valence are altered in patients with anxiety disorders. However, neural coding of both anxiety and valence by IC neurons remains unknown. Using fiber photometry recordings in mice, we uncover a selective increase of activity in IC projection neurons of the anterior (aIC), but not posterior (pIC) section, when animals are exploring anxiogenic spaces, and this activity is proportional to the level of anxiety of mice. Neurons in aIC also respond to stimuli of positive and negative valence, and the strength of response to strong negative stimuli is proportional to mice levels of anxiety. Using ex vivo electrophysiology, we characterized the IC connection to the basolateral amygdala (BLA), and employed projection-specific optogenetics to reveal anxiogenic properties of aIC-BLA neurons. Finally, we identified that aIC-BLA neurons are activated in anxiogenic spaces, as well as in response to aversive stimuli, and that both activities are positively correlated. Altogether, we identified a common neurobiological substrate linking negative valence with anxiety-related information and behaviors, which provides a starting point to understand how alterations of these neural populations contribute to psychiatric disorders.

Psychotropics and COVID-19: An analysis of safety and prophylaxis

The use of psychotropics during the COVID-19 pandemic has raised two questions, in order of importance: first, what changes should be made to pharmacological treatments prescribed to mental health patients? Secondly, are there any positive side effects of these substances against SARS-CoV-2? Our aim was to analyze usage safety of psychotropics during COVID-19; therefore, herein, we have studied: (i) the risk of symptomatic complications of COVID-19 associated with the use of these drugs, notably central nervous system activity depression, QTc interval enlargement and infectious and thromboembolic complications; (ii) the risk of mistaking the iatrogenic impact of psychotropics with COVID-19 symptoms, causing diagnostic error. Moreover, we provided a summary of the different information available today for these risks, categorized by mental health disorder, for the following: schizophrenia, bipolar disorder, anxiety disorder, ADHD, sleep disorders and suicidal risk. The matter of psychoactive substance use during the pandemic is also analyzed in this paper, and guideline websites and publications for psychotropic treatments in the context of COVID-19 are referenced during the text, so that changes on those guidelines and eventual interaction between psychotropics and COVID-19 treatment medication can be reported and studied. Finally, we also provide a literature review of the latest known antiviral properties of psychotropics against SARS-CoV-2 as complementary information.

AB0469 PROTON PUMP INHIBITORS MAY IMPAIR RESPONSE TO TNF-INHIBITORS IN SPONDYLOARTHRITIS PATIENTS

Background:

Considering the potential role of the gut microbiota in the pathophysiology of spondyloarthritis (SpA) as in the therapeutic response to biologics (1), we evaluated the hypothesis that co-medications known to interfere with the gut microbiota could impair the therapeutic response to TNF-inhibitors (TNF-i) in SpA patients. This was first suggested by the results of a retrospective cohort showing that a co-medication with proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs) or antibiotics was significantly associated with a decreased chance to respond to a first TNF-I, independently of each other (2).

Objectives:

To validate in a replication cohort the potential negative association between therapeutic response to TNF-i and co-medication with commonly used drugs.

Methods:

Demographic information and disease characteristics were retrospectively collected. Patients were classified as responder (R) or non-responder (NR) according to the BASDAI (< 40/100) value at month 6 or to the clinician judgment (when BASDAI was not available). We collected all drugs known to interfere with the gut microbiota that were administered 1 month before and during the first 3 months of the TNF-i treatment. We only considered drugs given to more than 5% of patients. Univariate and multivariate analyses were performed to evaluate the relationship between co-medications, predictors of response known from literature and TNF-i response. All analyses were computed on STATA 13.1 with a statistically significant threshold of 0.05.

Results:

We included from 4 different centres 185 patients having axial SpA with radiographic or magnetic sacroiliitis in 75% and 73% of cases, respectively. One third of them had peripheral involvement. 73% were B27 positive. TNF-i administrated were infliximab (8%), etanercept (22%), adalimumab (44%) golimumab (19%), certolizumab (7%). 127 patients (69%) were considered as R. 59.4% of patients who received NSAIDs were R, compared to 81% not treated with NSAIDs (p< 0.0001). 43,3% of patients receiving PPIs were R compared to 83% of patients PPI free (p< 0.0001). Differences were not significant for antibiotics, methotrexate (MTX), psychotic drugs and corticosteroids. Considering known predictors of response, a magnetic sacroiliitis and the age at TNF-i initiation were significantly associated with a higher proportion of R patients (p=0.048 and 0.018 respectively). In multivariate analysis, PPIs intake remained associated with a poorer response to a first TNF-i (p<0.001), even though 88% of patients exposed to PPIs received also NSAIDs.

Univariate analysisMultivariate analysisOdd Ratio (95% Confidence Interval)Gender1.43 (0.76; 2.72)Disease duration1.02 (0.99; 1.06)Age at TNF-I initiation0.97 (0.95; 0.995) 0.97 (0.94; 0.999)Magnetic sacroiliitis0.46 (0.21; 0.99)0.63 (0.26; 1.52)Baseline BASDAI1.02 (0.99;1.04)Baseline CRP0.99 (0.98; 1.02)Positive B270.81 (0.4;1.68)Peripheral involvement0.79 (0.4; 1.56)NSAIDs2.91 (1.47; 5.77)1.08 (0.41; 2.79)PPIs6.4 (3.25; 12.7)6.9 (2.8;17)Antibiotics1.87 (0.84; 4.16)Psychotics1.94 (0.75; 4.97)Corticosteroids1.11 (0.39; 3.11)Methotrexate2.29 (0.97; 5.38)

Conclusion:

Co-medication with PPIs was considered as an independent factor associated with TNF-i failure. The hypothesis that this effect is due to their interference with the gut microbiota is only speculative but, regardless of the reason for this interaction, clinicians should be aware of the potential negative effect on TNF-i response.

References:

[1]Bazin, T., Hooks, K.B., Barnetche, T. et al. Microbiota Composition May Predict Anti-Tnf Alpha Response in Spondyloarthritis Patients: an Exploratory Study. Sci Rep8, 5446 (2018). https://doi.org/10.1038/s41598-018-23571-4

[2]Masson M, Kostine M, Barnetche T, Truchetet ME, Richez C, Schaeverbeke T. Ab0661 Co-Medications May Alter the Response to Tnf-Inhibitors in Spondyloarthritis Patients: A Pharmacomicrobiomic Effect? Annals of the Rheumatic Diseases. 1 juin 2020;79(Suppl 1):1625–6.

Disclosure of Interests:

None declared.

Impact of COVID-19 on surgical emergencies: nationwide analysis

Background

The COVID-19 pandemic has had a major impact on healthcare in many countries. This study assessed the effect of a nationwide lockdown in France on admissions for acute surgical conditions and the subsequent impact on postoperative mortality.

Methods

This was an observational analytical study, evaluating data from a national discharge database that collected all discharge reports from any hospital in France. All adult patients admitted through the emergency department and requiring a surgical treatment between 17 March and 11 May 2020, and the equivalent period in 2019 were included. The primary outcome was the change in number of hospital admissions for acute surgical conditions. Mortality was assessed in the matched population, and stratified by region.

Results

During the lockdown period, 57 589 consecutive patients were admitted for acute surgical conditions, representing a decrease of 20.9 per cent compared with the 2019 cohort. Significant differences between regions were observed: the decrease was 15.6, 17.2, and 26.8 per cent for low-, intermediate- and high-prevalence regions respectively. The mortality rate was 1.92 per cent during the lockdown period and 1.81 per cent in 2019. In high-prevalence zones, mortality was significantly increased (odds ratio 1.22, 95 per cent c.i. 1.06 to 1.40).

Conclusion

A marked decrease in hospital admissions for surgical emergencies was observed during the lockdown period, with increased mortality in regions with a higher prevalence of COVID-19 infection. Health authorities should use these findings to preserve quality of care and deliver appropriate messages to the population.

Prevalence and impact of patient suicide in psychiatrists: Results from a national French web-based survey

BACKGROUND

Patient suicide (PS) is known to be a frequent and challenging occupational hazard for mental health professionals. No study previously explored the prevalence and impact of PS in a large sample of French psychiatrists.

METHOD

A national web-based survey was performed between September and December 2019 to assess (a) the prevalence of the exposure to PS, (b) the emotional, traumatic and professional impacts of PS, and (c) the perceived support in the aftermath of PS in French psychiatrists. Participants were contacted through email to answer the online 62-item questionnaire, including a measure of traumatic impact through the Impact of Event Scale-Revised. Emotional and professional impacts and perceived support were assessed through dedicated items.

RESULTS

A total of 764 psychiatrists fully completed the survey. Of them, 87.3% reported an exposure to PS and 13.7% reported PTSD symptoms afterward. Guilt, sadness and shock were the most frequent emotions. Among the exposed psychiatrists, 15.1% have temporarily considered changing their career path. The most emotionally distressing PS occurred during their ten first years of practice or during residency. A total of 37.1% of respondents felt unsupported and 50.4% reported that no team meeting had been organized in the aftermath. The feeling of responsibility for the death was strongly associated with negative impacts.

CONCLUSION

Our results entail considerations to prevent negative mental health outcomes in psychiatrists after PS. Notably, our results advocate for the implementation of educational programs during psychiatric residency and postvention programs in healthcare settings to effectively help psychiatrists in dealing with PS.

The Covid-19 infection: An opportunity to develop systematic vitamin D supplementation in psychiatry

Psychiatric patients are at risk of hypovitaminosis D and Covid-19-related mortality. In addition to the mental health benefits, vitamin D supplementation may be potentially effective in preventing severe forms of Covid-19 infections. Vitamin D supplementation is not necessary and is not reimbursed in France for this indication. A monthly supplementation of 50,000 IU may be sufficient in most cases. Double the dose is recommended for obese patients. The risk of renal lithiasis is not increased at these doses, even when supplemented in a patient without vitamin D deficiency. The Covid-19 crisis is an opportunity to disseminate vitamin D supplementation in psychiatric patients, as it has been shown to be effective in other respiratory diseases such as mild upper respiratory tract infections and influenza.

[Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review]

OBJECTIVE

The lack of ressources and coordination to face the epidemic of coronavirus raises concerns for the health of patients with mental disorders in a country where we keep in memory the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims at proposing guidance to ensure mental health care during the SARS-CoV epidemy in France.

METHODS

Authors performed a narrative review identifying relevant results in the scientific and medical literature and local initiatives in France.

RESULTS

We identified four types of major vulnerabilities in patients suffering from mental disorders during this pandemic: (1) medical comorbidities that are more frequently found in patients suffering from mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which represent risk factors for severe infections with Covid-19; (2) age (the elderly constituting the population most vulnerable to coronavirus); (3) cognitive and behavioral troubles which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability due to stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly adapted to psychiatric establishments in a context of major shortage of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds are closed, wards have a high density of patients, mental health community facilities are closed, medical teams are understaffed and poorly trained to face infectious diseases. We could also face major issues in referring patients with acute mental disorders to intensive care units. To maintain continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of Covid+ units. These units are under the dual supervision of a psychiatrist and of an internist/infectious disease specialist; all new entrants should be placed in quarantine for 14 days; the nurse staff should benefit from specific training, from daily medical check-ups and from close psychological support. Family visits would be prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management should be organized with the possibility of home visits, in order to support them when they get back home and to help them to cope with the experience of confinement, which is at risk to induce recurrences of mental disorders. The total or partial closure of mental health community facilities is particularly disturbing for patients but a regular follow-up is possible with telemedicine and should include the monitoring of the suicide risk and psychoeducation strategies; developing support platforms could also be very helpful in this context. Private psychiatrists have also a crucial role of information with their patients on confinement and barrier measures, but also on measures to prevent the psychological risks inherent to confinement: maintenance of sleep regularity, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic.

DISCUSSION

French mental healthcare is now in a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the containment of the general population.

Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review

OBJECTIVE

The lack of resources and coordination to face the coronavirus epidemic raises concerns for the health of patients with mental disorders in a country where we still have memories of the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims to propose guidance to ensure mental health care during the SARS-CoV epidemic in France.

METHODS

The authors performed a narrative review identifying relevant results in the scientific and medical literature and in local initiatives in France.

RESULTS

We identified four types of major vulnerabilities among patients with mental disorders during this pandemic: (1) medical comorbidities that are more frequently found among patients with mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which are risk factors for severe covid-19 infection; (2) age (the elderly form the population most vulnerable to the coronavirus); (3) cognitive and behavioural disorders, which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability as a result of stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly suited to psychiatric establishments in a context of major shortages of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds have been closed, wards have high densities of patients, mental health community facilities are closed, and medical teams are understaffed and poorly trained to face infectious diseases. There are also major issues when referring patients with acute mental disorders to intensive care units. To maintain the continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of "COVID+ units". These units are under the dual supervision of a psychiatrist and an internist/infectious disease specialist; all new entrants are placed in quarantine for 14 days; the nursing staff receives specific training, daily medical check-ups and close psychological support. Family visits are prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management are organized with the possibility of home visits, in order to support patients when they get back home and to help them cope with the experience of confinement, which is liable to induce recurrences of mental disorders. The total or partial closure of community mental health facilities is particularly disturbing for patients, but a regular follow-up is possible with telemedicine and should include the monitoring of suicide risk and psycho-education strategies; developing support platforms could also be very helpful in this context. Private practice psychiatrists also have a crucial role of information towards their patients on confinement and barrier measures, and also on measures to prevent the psychological risks inherent in confinement: maintenance of regular sleep r, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic.

DISCUSSION

French mental healthcare is now facing a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the confinement of the general population.

AB0661 CO-MEDICATIONS MAY ALTER THE RESPONSE TO TNF-INHIBITORS IN SPONDYLOARTHRITIS PATIENTS: A PHARMACOMICROBIOMIC EFFECT?

Background:

The reason why some spondyloarthritis (SA) patients fail to respond to TNF inhibitors (TNF-i) remains unclear. Recently, it has been shown in cancer immunotherapy that the therapeutic response may be strongly altered by co-medication with drugs interfering with the gut microbiota, such as antibiotics, proton pump inhibitors (PPI), non-steroidal anti-inflammatory drugs (NSAIDs), psychotropic or antidiabetic drugs.

Objectives:

Considering the potential role of the gut microbiota in the pathophysiology of SA as in the therapeutic response, the aim was to study the influence of co-medications known to interfere with the microbiota with the therapeutic response to TNF-i in SA patients.

Methods:

We retrospectively reviewed the charts of all patients treated in our department with a first TNF-i from 2009 to 2018. Data collected were demographic information, HLA-B27 status, disease characteristics… Patients were classified as responder (R) or non-responder (NR) according to the BASDAI (< 40/100) value at M6 or to the clinician judgment (when BASDAI was not available). Regarding co-medications, we collected all drugs known to interfere with the gut microbiota that were administered 1 month before and during the first 3 months of the TNF-i treatment. We only considered drugs given to more than 5% of patients. Quantitative data were expressed as mean ± standard deviation, and qualitative variables as percentages. Univariate and multivariate analyses were performed to evaluate the relationship between co-medications and TNF-i. All analyses were computed on STATA 13.1 software with a statistically significant threshold of 0.05.

Results:

We included 188 patients suffering from ankylosing spondylitis (n=89) or peripheral SA (n=99). They were 68 women and 120 men, mean aged 46.6 ± 13; 53% were B27 positive. TNF-i were infliximab (19%), etanercept (44%), adalimumab (34%) golimumab (2%), certolizumab (1%), combined with MTX in 51 patients. 135 patients (72%) were R and 53 (28%) NR. In univariate analysis, 59.1% of patients who received NSAIDs were R, compared to 88.2% of patients not treated with NSAIDs (p< 0.0001); 42.2% of patients receiving PPIs were R compared to 86.3% of patients PPI free (p< 0.0001); 55.8% of patients who were given antibiotics were R, compared to 75.7% of patients who did not (p=0,02); 27.8% of patients treated with psychotropic drugs were R, compared to 75.9% of patients not receiving such treatment (p< 0.0001) (Figure 1). Differences were not statistically significant for corticosteroids, MTX, angiotensin-converting enzyme inhibitors and statins. Although 91% of patients taken PPIs were also given NSAIDs, NSAIDs, PPIs and antibiotics intake were considered as independent factors associated with TNF-i failure in multivariate analysis.

Conclusion:

Co-medication with NSAIDs, PPIs, antibiotics and psychotropic drugs were significantly associated with a decreased chance to respond to TNF-i. The hypothesis that this effect is due to their interference with the gut microbiota is only speculative but, regardless the reason of this interaction, clinician should be aware of the potential negative effect of these co-medication on TNF-i.

Figure 1.

Disclosure of Interests:

Maéva Masson: None declared, Marie Kostine: None declared, Thomas Barnetche: None declared, Marie-Elise Truchetet: None declared, Christophe Richez Consultant of: Abbvie, Amgen, Mylan, Pfizer, Sandoz and UCB., Thierry Schaeverbeke: None declared

[Informations on psychotropics and their adaptations for patients suffering from mental disorders in France during the SARS-CoV-2 epidemic]

The 2019-20 coronavirus pandemic (SARS-CoV-2; severe acute respiratory syndrome coronavirus 2) has dramatic consequences on populations in terms of morbidity and mortality and in social terms, the general confinement of almost half of the world's population being a situation unprecedented in history, which is difficult today to measure the impact at the individual and collective levels. More specifically, it affects people with various risk factors, which are more frequent in patients suffering from psychiatric disorders. Psychiatrists need to know: (i) how to identify, the risks associated with the prescription of psychotropic drugs and which can prove to be counterproductive in their association with COVID-19 (coronavirus disease 2019), (ii) how to assess in terms of benefit/risk ratio, the implication of any hasty and brutal modification on psychotropic drugs that can induce confusion for a differential diagnosis with the evolution of COVID-19. We carried out a review of the literature aimed at assessing the specific benefit/risk ratio of psychotropic treatments in patients suffering from COVID-19. Clinically, symptoms suggestive of COVID-19 (fever, cough, dyspnea, digestive signs) can be caused by various psychotropic drugs and require vigilance to avoid false negatives and false positives. In infected patients, psychotropic drugs should be used with caution, especially in the elderly, considering the pulmonary risk. Lithium and Clozapine, which are the reference drugs in bipolar disorder and resistant schizophrenia, warrant specific attention. For these two treatments the possibility of a reduction in the dosage - in case of minimal infectious signs and in a situation, which does not allow rapid control - should ideally be considered taking into account the clinical response (even biological; plasma concentrations) observed in the face of previous dose reductions. Tobacco is well identified for its effects as an inducer of CYP1A2 enzyme. In a COVID+ patient, the consequences of an abrupt cessation of smoking, particularly related with the appearance of respiratory symptoms (cough, dyspnea), must therefore be anticipated for patients receiving psychotropics metabolized by CYP1A2. Plasma concentrations of these drugs are expected to decrease and can be related to an increase risk of relapse. The symptomatic treatments used in COVID-19 have frequent interactions with the most used psychotropics. If there is no curative treatment for infection to SARS-CoV-2, the interactions of the various molecules currently tested with several classes of psychotropic drugs (antidepressants, antipsychotics) are important to consider because of the risk of changes in cardiac conduction. Specific knowledge on COVID-19 remains poor today, but we must recommend rigor in this context in the use of psychotropic drugs, to avoid adding, in patients suffering from psychiatric disorders, potentially vulnerable in the epidemic context, an iatrogenic risk or loss of efficiency.

Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: A cross-sectional multicenter study

OBJECTIVE

Although lithium is widely used in current practice to treat bipolar disorder (BD) and treatment-resistant major depressive disorder (MDD) among older adults, little is known about its efficacy and tolerability in this population, which is generally excluded from randomized clinical trials. The objective of this study was to evaluate the efficacy and tolerability of long-term use of lithium among older adults with BD and MDD.

METHOD

Data from the Cohort of individuals with Schizophrenia and mood disorders Aged 55 years or more (CSA) were used. Two groups of patients with BD and MDD were compared: those who were currently receiving lithium versus those who were not. The effects of lithium on psychiatric (i.e., depressive symptoms severity, perceived clinical severity, rates of psychiatric admissions in the past-year), geriatric (overall and cognitive functioning) and physical outcomes (i.e., rates of non-psychiatric medical comorbidities and general hospital admissions in the past-year) were evaluated. All analyses were adjusted for age, sex, duration of disorder, diagnosis, smoking status, alcohol use, and use of antipsychotics, antiepileptics or antidepressants.

RESULTS

Among the 281 older participants with BD or MDD, 15.7% were taking lithium for a mean duration of 12.5(SD = 11.6) years. Lithium use was associated with lower intensity of depressive symptoms, reduced perceived clinical global severity and lower benzodiazepine use (all p < 0.05), without being linked to greater rates of medical comorbidities, except for hypothyroidism.

LIMITATIONS

Data were cross-sectional and data on lifetime history of psychotropic medications was not assessed.

CONCLUSION

Our results suggest that long-term lithium use may be efficient and relatively well-tolerated in older adults with BD or treatment-resistant MDD.

Salivary dysbiosis and the clinical spectrum in anti-Ro positive mothers of children with neonatal lupus

Mothers giving birth to children with manifestations of neonatal lupus (NL) represent a unique population at risk for the development of clinically evident pathologic autoimmunity since many are asymptomatic and only become aware of anti-SSA/Ro positivity (anti-Ro+) based on heart block in their fetus. Accordingly, we hypothesized that the microbiome in saliva is associated with the development of autoreactivity and in some cases the progression in health status from benign to overt clinical disease including Sjögren's syndrome (SS) and systemic lupus erythematosus (SLE). The study comprised a clinical spectrum of anti-Ro+ mothers, all of whom gave birth to a child with NL: 9 were asymptomatic or had an undifferentiated autoimmune disease (Asym/UAS) and 16 fulfilled criteria for SS and/or SLE. Microbial diversity was reduced across all levels from kingdom to species for the anti-Ro+ mothers vs healthy controls; however, there were no significant differences between Asym/UAS and SS/SLE mothers. Relative abundance of Proteobacteria and more specifically class Betaproteobacteria decreased with clinical severity (healthy controls < Asym/UAS < SS/SLE). These ordered differences were maintained through the taxonomic hierarchy to three genera (Lautropia, Comamonas, and Neisseria) and species within these genera (L. mirabilis, N. flavescens and N. oralis). Biometric analysis comparing von Willebrand Factor domains present in human Ro60 with L. mirabilis proteins support the hypothesis of molecular mimicry. These data position the microbiome in the development of anti-Ro reactivity and subsequent clinical spectrum of disease.

Sampling of suspended particulate matter using particle traps in the Rhône River: Relevance and representativeness for the monitoring of contaminants

Monitoring hydrophobic contaminants in surface freshwaters requires measuring contaminant concentrations in the particulate fraction (sediment or suspended particulate matter, SPM) of the water column. Particle traps (PTs) have been recently developed to sample SPM as cost-efficient, easy to operate and time-integrative tools. But the representativeness of SPM collected with PTs is not fully understood, notably in terms of grain size distribution and particulate organic carbon (POC) content, which could both skew particulate contaminant concentrations. The aim of this study was to evaluate the representativeness of SPM characteristics (i.e. grain size distribution and POC content) and associated contaminants (i.e. polychlorinated biphenyls, PCBs; mercury, Hg) in samples collected in a large river using PTs for differing hydrological conditions. Samples collected using PTs (n = 74) were compared with samples collected during the same time period by continuous flow centrifugation (CFC). The grain size distribution of PT samples shifted with increasing water discharge: the proportion of very fine silts (2-6 μm) decreased while that of coarse silts (27-74 μm) increased. Regardless of water discharge, POC contents were different likely due to integration by PT of high POC-content phytoplankton blooms or low POC-content flood events. Differences in PCBs and Hg concentrations were usually within the range of analytical uncertainties and could not be related to grain size or POC content shifts. Occasional Hg-enriched inputs may have led to higher Hg concentrations in a few PT samples (n = 4) which highlights the time-integrative capacity of the PTs. The differences of annual Hg and PCB fluxes calculated either from PT samples or CFC samples were generally below 20%. Despite some inherent limitations (e.g. grain size distribution bias), our findings suggest that PT sampling is a valuable technique to assess reliable spatial and temporal trends of particulate contaminants such as PCBs and Hg within a river monitoring network.

Ethical considerations in bipolar disorders

The implications of biomedical ethics principles extend to both medical care and biomedical research. They are particularly relevant for psychiatry in which pathologies are often chronic and disabling. Bipolar disorders impact the ability to make judgements and to take decisions during mood episodes and remain a stigmatised condition. Early interventions, even those in the prodromal phase, pose ethical questions for both clinicians and researchers. The degree of patients' autonomy in their clinical care must also now be considered from a biomedical ethics perspective.

[Switching from antipsychotics to aripiprazole and risk of agitation]

The exact modalities of switching between two antipsychotics are rarely studied despite the high frequency of this issue in clinical practice. In this context, description of clinical cases may be enlightening. We report on three new cases of agitation after replacing a dopaminergic antagonist with aripiprazole. A literature review indicated no other predictive clinical feature associated with a higher risk of agitation than therapeutic history. In fact, patients who previously received a greater dose of antipsychotic are more at risk to present paradoxical agitation when switching to aripiprazole. This has led to the hypothesis of dopaminergic hypersensitivity: dopaminergic antagonists could increase the number of receptors to be activated by a partial agonist-like aripiprazole. In one of the cases described here, the patient had received aripiprazole two years previously without any particular side effects. The reintroduction of aripiprazole after a treatment by risperidone was followed by agitation. Other pharmacological hypotheses to explain this agitation involve cholinergic and histaminergic rebounds as well. The frequency of these paradoxical reactions is probably underreported, and psychiatrists should be more attentive to them. During the replacement, aripiprazole should be prescribed at the maximal posology from the start, and the previous antipsychotic should be maintained and slowly decreased in no fewer than four weeks.

Keep calm and carry on: Mental disorder is not more "organic" than any other medical condition

Psychiatry as a discipline should no longer be grounded in the dualistic opposition between organic and mental disorders. This non-dualistic position refusing the partition along functional versus organic lines is in line with Jean Delay, and with Robert Spitzer who wanted to include in the definition of mental disorder discussed by the DSM-III task force the statement that "mental disorders are a subset of medical disorders". However, it is interesting to note that Spitzer and colleagues ingeniously introduced the definition of "mental disorder" in the DSM-III in the following statement: "there is no satisfactory definition that specifies precise boundaries for the concept "mental disorder" (also true for such concepts as physical disorder and mental and physical health)". Indeed, as for "mental disorders", it is as difficult to define what they are as it is to define what constitutes a "physical disorder". The problem is not the words "mental" or "organic" but the word "disorder". In this line, Wakefield has proposed a useful "harmful dysfunction" analysis of mental disorder. They raise the issue of the dualistic opposition between organic and mental disorders, and situate the debate rather between the biological/physiological and the social. The paper provides a brief analysis of this shift on the question of what is a mental disorder, and demonstrates that a mental disorder is not more "organic" than any other medical condition. While establishing a dichotomy between organic and psychiatry is no longer intellectually tenable, the solution is not to reduce psychiatric and non-psychiatric disorders to the level of "organic disorders" but rather to continue to adopt both a critical and clinically pertinent approach to what constitutes a "disorder" in medicine.

Identifying the ideal profile of French yogurts for different clusters of consumers

Identifying the sensory properties that affect consumer preferences for food products is an important feature of product development. Different methods, such as external preference mapping or partial least squares regression, are used to establish relationships between sensory data and consumer preferences and to identify sensory attributes that drive consumer preferences, by highlighting optimum products. Plain French yogurts were evaluated by a sensory profiling method performed by 12 trained judges. In parallel, 180 consumers were asked to score their overall liking and complete a cognitive restraint questionnaire. After hierarchical cluster analysis on the liking scores, preference mapping using a quadratic regression model was performed. Five clusters of consumers were identified as a function of different preference patterns. Contrary to our expectations, fat levels were not discriminating. For each cluster, the results of preference mapping enabled the identification of optimum products. A comparison of the 5 sensory profiles revealed numerous differences between key sensory attributes. For example, one consumer cluster had a strong preference for products perceived as very thick, grainy, but with a less flowing texture, less sticky, whey presence and color, in contrast to other clusters. In addition, each segment of consumers was characterized according to the results of the cognitive restraint questionnaire.

Direct comparison of current cell-based and cell-free approaches towards the repair of craniofacial bone defects - A preclinical study

For craniofacial bone defect repair, several alternatives to bone graft (BG) exist, including the combination of biphasic calcium phosphate (BCP) biomaterials with total bone marrow (TBM) and bone marrow-derived mesenchymal stromal cells (MSCs), or the use of growth factors like recombinant human bone morphogenic protein-2 (RhBMP-2) and various scaffolds. Therefore, clinicians might be unsure as to which approach will offer their patients the most benefit. Here, we aimed to compare different clinically relevant bone tissue engineering methods in an "all-in-one" study in rat calvarial defects. TBM, and MSCs committed or not, and cultured in two- or three-dimensions were mixed with BCP and implanted in bilateral parietal bone defects in rats. RhBMP-2 and BG were used as positive controls. After 7 weeks, significant de novo bone formation was observed in rhBMP-2 and BG groups, and in a lesser amount, when BCP biomaterials were mixed with TBM or committed MSCs cultured in three-dimensions. Due to the efficacy and safety of the TBM/BCP combination approach, we recommend this one-step procedure for further clinical investigation.

STATEMENT OF SIGNIFICANCE

For craniofacial repair, total bone marrow (BM) and BM mesenchymal stem cell (MSC)-based regenerative medicine have shown to be promising in alternative to bone grafting (BG). Therefore, clinicians might be unsure as to which approach will offer the most benefit. Here, BM and MSCs committed or not were mixed with calcium phosphate ceramics (CaP) and implanted in bone defects in rats. RhBMP-2 and BG were used as positive controls. After 7 weeks, significant bone formation was observed in rhBMP-2 and BG groups, and when CaP were mixed with BM or committed MSCs. Since the BM-based procedure does not require bone harvest or cell culture, but provides de novo bone formation, we recommend consideration of this strategy for craniofacial applications.

Unusual spinal tuberculosis in an Avar Age skeleton (Csongrád-Felgyő, Ürmös-tanya, Hungary): A morphological and biomolecular study

The paleopathological analysis of a well-preserved young adult female skeleton from the AD 7-8th century (Avar Age) in Hungary revealed multiple lytic lesions in all of the thoracic and lumbar vertebral bodies. The lesions were characterized by smooth marginal zones and space-occupying mass appearance. The considerable loss of spongy bone in the thoracolumbar vertebrae resulted in angular deformity and fusion, characteristic of the healing stage of TB. Osteolytic lesions were also observed on the vertebral processes, ribs and sternum. On the endocranial surface, abnormal blood vessel impressions were revealed, indicating some kind of meningitis. The X-ray and CT analysis of the affected bones detected abnormal structures and cystic zones of destruction. The lesions were however not always bordered by areas of increased density, which is typical in cystic TB. Vertebral remains were also subjected to biomolecular analysis in two different laboratories, which attested the presence of Mycobacterium tuberculosis complex (MTBC) DNA and supported the paleopathological diagnosis of TB. Spoligotyping analysis confirmed the presence of MTBC DNA and more specifically an infection caused by bacteria belonging to the M. tuberculosis lineage. This case study provides new data for the paleoepidemiology of TB in this geographical area and historical period, and draws attention to the great variability of TB lesions in the human skeleton.

Phosphate-dependent stimulation of MGP and OPN expression in osteoblasts via the ERK1/2 pathway is modulated by calcium

Inorganic phosphate (Pi) acts as a signaling molecule in bone-forming cells, affecting cell functions and gene expression. Particularly, Pi stimulates the expression of mineralization-associated genes such as matrix gla protein (MGP) and osteopontin (OPN) through the ERK1/2 pathway. With respect to the presence of elevated extracellular calcium and Pi levels during bone remodeling, we questioned whether calcium might play a role in the Pi-dependent effects in osteoblasts. We first showed by Western blot and real-time PCR that the concomitant presence of 10 mM Pi and 1.8 mM calcium is required to stimulate ERK1/2 phosphorylation and MGP/OPN genes expression. The mechanisms involved in the cellular effects of calcium in the presence of Pi were subsequently examined. Firstly, the use of the calcium-sensing receptor (CaSR) agonist gadolinium and the G-protein inhibitor pertussis toxin enabled us to determine that a CaSR mechanism is not involved in the Pi and calcium mediated cellular effects. By transmission electron microscopy, we next demonstrated that adding 10mM Pi to the culture medium containing 1.8mM calcium led to the formation calcium phosphate precipitates (CaPp). Moreover, treatment of osteoblasts with exogenous pre-synthesized CaPp stimulated ERK1/2 phosphorylation and MGP/OPN genes expression. In spite of high extracellular calcium and Pi concentrations, this stimulation was blunted in the presence of phosphocitrate, an inhibitor of crystal formation. Finally, we showed that despite that CaPp are not endocytosed, their effect on ERK1/2 phosphorylation and MGP/OPN genes expression were dependent on lipid rafts integrity. In summary, we showed that calcium is required for Pi-dependent ERK1/2 phosphorylation and regulation of mineralization-associated genes in osteoblasts and that its effect could originate from extracellular-related effects of CaPp that are dependent on the integrity of lipid rafts.