An integrated precision medicine approach in major depressive disorder: a study protocol to create a new algorithm for the prediction of treatment response

Major depressive disorder (MDD) is the most common psychiatric disease worldwide with a huge socio-economic impact. Pharmacotherapy represents the most common option among the first-line treatment choice; however, only about one third of patients respond to the first trial and about 30% are classified as treatment-resistant depression (TRD). TRD is associated with specific clinical features and genetic/gene expression signatures. To date, single sets of markers have shown limited power in response prediction. Here we describe the methodology of the PROMPT project that aims at the development of a precision medicine algorithm that would help early detection of non-responder patients, who might be more prone to later develop TRD. To address this, the project will be organized in 2 phases. Phase 1 will involve 300 patients with MDD already recruited, comprising 150 TRD and 150 responders, considered as extremes phenotypes of response. A deep clinical stratification will be performed for all patients; moreover, a genomic, transcriptomic and miRNomic profiling will be conducted. The data generated will be exploited to develop an innovative algorithm integrating clinical, omics and sex-related data, in order to predict treatment response and TRD development. In phase 2, a new naturalistic cohort of 300 MDD patients will be recruited to assess, under real-world conditions, the capability of the algorithm to correctly predict the treatment outcomes. Moreover, in this phase we will investigate shared decision making (SDM) in the context of pharmacogenetic testing and evaluate various needs and perspectives of different stakeholders toward the use of predictive tools for MDD treatment to foster active participation and patients' empowerment. This project represents a proof-of-concept study. The obtained results will provide information about the feasibility and usefulness of the proposed approach, with the perspective of designing future clinical trials in which algorithms could be tested as a predictive tool to drive decision making by clinicians, enabling a better prevention and management of MDD resistance.

A genome-wide association study of antidepressant-induced mania

Antidepressant-induced mania (AIM) is a side effect of antidepressant treatment that is characterized by mania or hypomania after the start of medication. It is likely polygenic, but its genetic component remains largely unexplored. We aim to conduct the first genome-wide association study of AIM in 814 bipolar disorder patients of European ancestry. We report no significant findings from our single-marker or gene-based analyses. Our polygenic risk score analyses also did not yield significant results with bipolar disorder, antidepressant response, or lithium response. Our suggestive findings on the hypothalamic-pituitary-adrenal axis and the opioid system in AIM require independent replications.

Early sexual or physical abuse in female and male mood disorder patients

Early abuse has been associated with psychiatric morbidity but comparisons of bipolar (BD) and major depressive (MDD) disorder subjects with versus without early sexual or physical abuse are rare. Patients (n = 684) diagnosed with a DSM-5-TR major mood disorder were evaluated and followed for several years at mood disorder centers to compare details of history and clinical status in participants with versus without early sexual or physical abuse. Early history of sexual (16.2%) or physical abuse (11.9%) was prevalent; 5.15% reported both. Both types of abuse were much more prevalent with BD than MDD. Sexual abuse was associated with younger illness-onset and somewhat younger menarche in females; both abuse-types were associated with familial mood disorders, especially BD. Prospective, long-term illness episode-frequency, depressions or [hypo]manias/year and %-time [hypo]manic all were greater following sexual abuse but morbidity measures did not differ following physical abuse. Prevalence of suicidal behavior ranked: double (48.5%) > physical (32.1%) > sexual (30.3%) abuse, and with BD > MDD (OR = 2.31). Recall bias and not using psychometric instruments to define abuse severity or type may limit interpretation of findings. Early sexual (more than physical) abuse, led to greater morbidity and both abuses were strongly associated with familial mood disorders and greater suicidal risk, especially with double-abuse and BD diagnosis. We support a bilateral relationship between abuse and diagnosis of BD: abuse may facilitate early appearance of BD but also may result from the actions of abusive BD family members.

Suicidal risk and protective factors in major affective disorders: A prospective cohort study of 4307 participants

BACKGROUND

Suicidal behavior is strongly associated with major affective disorders, but there is a need to quantify and compare specific risk and protective factors in bipolar disorder (BD) and major depressive disorder (MDD).

METHODS

In 4307 extensively evaluated major affective-disorder participants with BD (n = 1425) or MDD (n = 2882) diagnosed by current international criteria, we compared characteristics among those with versus without suicidal acts from illness-onset through 8.24 years of follow-up.

RESULTS

Suicidal acts were identified in 11.4 % of participants; 25.9 % were violent and 6.92 % (0.79 % of all participants) were fatal. Associated risk factors included: diagnosis (BD > MDD), manic/psychotic features in first-episodes, family history of suicide or BD, separation/divorce, early abuse, young at illness-onset, female sex with BD, substance abuse, higher irritable, cyclothymic or dysthymic temperament ratings, greater long-term morbidity, and lower intake functional ratings. Protective factors included marriage, co-occurring anxiety disorder, higher ratings of hyperthymic temperament and depressive first episodes. Based on multivariable logistic regression, five factors remained significantly and independently associated with suicidal acts: BD diagnosis, more time depressed during prospective follow-up, younger at onset, lower functional status at intake, and women > men with BD.

LIMITATIONS

Reported findings may or may not apply consistently in other cultures and locations.

CONCLUSIONS

Suicidal acts including violent acts and suicides were more prevalent with BD than MDD. Of identified risk (n = 31) and protective factors (n = 4), several differed with diagnosis. Their clinical recognition should contribute to improved prediction and prevention of suicide in major affective disorders.

Exploratory study of ultraviolet B (UVB) radiation and age of onset of bipolar disorder

BACKGROUND

Sunlight contains ultraviolet B (UVB) radiation that triggers the production of vitamin D by skin. Vitamin D has widespread effects on brain function in both developing and adult brains. However, many people live at latitudes (about > 40 N or S) that do not receive enough UVB in winter to produce vitamin D. This exploratory study investigated the association between the age of onset of bipolar I disorder and the threshold for UVB sufficient for vitamin D production in a large global sample.

METHODS

Data for 6972 patients with bipolar I disorder were obtained at 75 collection sites in 41 countries in both hemispheres. The best model to assess the relation between the threshold for UVB sufficient for vitamin D production and age of onset included 1 or more months below the threshold, family history of mood disorders, and birth cohort. All coefficients estimated at P ≤ 0.001.

RESULTS

The 6972 patients had an onset in 582 locations in 70 countries, with a mean age of onset of 25.6 years. Of the onset locations, 34.0% had at least 1 month below the threshold for UVB sufficient for vitamin D production. The age of onset at locations with 1 or more months of less than or equal to the threshold for UVB was 1.66 years younger.

CONCLUSION

UVB and vitamin D may have an important influence on the development of bipolar disorder. Study limitations included a lack of data on patient vitamin D levels, lifestyles, or supplement use. More study of the impacts of UVB and vitamin D in bipolar disorder is needed to evaluate this supposition.

Characteristics of rapid cycling in 1261 bipolar disorder patients

BACKGROUND

Rapid-cycling (RC; ≥ 4 episodes/year) in bipolar disorder (BD) has been recognized since the 1970s and associated with inferior treatment response. However, associations of single years of RC with overall cycling rate, long-term morbidity, and diagnostic subtypes are not clear.

RESULTS

We compared descriptive and clinical characteristics in 1261 BD patients with/without RC, based on history and prospective follow-up for several years. RC in any previous year was identified in 9.36% of BD subjects (3.74% in BD1, 15.2% BD2), and somewhat more among women than men. RC-BD subjects had 3.21-fold greater average prospective annual rates of recurrence but not hospitalizations, had less difference in %-time-ill, received more mood-stabilizing treatments, and had greater suicidal risk, lacked familial psychiatric illnesses, had more cyclothymic temperament, were more likely to be married, had more siblings and children, experienced early sexual abuse, but were less likely to abuse drugs (not alcohol) or smoke. In multivariable regression modeling, older age, mood-switching with antidepressants, and BD2 > BD1 diagnosis, as well as more episodes/year were independently associated with RC. Notably, prospective mean recurrence rates were below 4/year in 79.5% of previously RC patients, and below 2/year in 48.1%.

CONCLUSIONS

Lifetime risk of RC in BD was 9.36%, more likely in women, with older age, and in BD2 > BD1. With RC, recurrence rates were much higher, especially for depression with less effect on %-time ill, suggesting shorter episodes. Variable associations with unfavorable outcomes and prospective recurrence rates well below 4/year in most previously RC patients indicate that RC was not a sustained characteristic and probably was associated with use of antidepressants.

Affective temperaments mediate aggressive dimensions in bipolar disorders: A cluster analysis from a large, cross-sectional, international study

BACKGROUND

Affective temperaments show potential for aggressive behavior (AB) preventive strategies in bipolar disorder (BD). We aim to define intra-diagnostic subgroups of patients with BD based on homogeneous behaviors related to AB. Subsequently, to assess whether affective temperament dimensions may contribute to the presence and severity of AB.

METHODS

Patients with BD were recruited. AB was evaluated through the modified overt aggression scale (MOAS); affective temperaments were assessed with the TEMPS-A. A cluster analysis was conducted based on TEMPS-A and MOAS scores. Stepwise backward logistic regression models were used to identify the predictive factors of cluster membership.

RESULTS

799 patients with BD were enrolled. Three clusters were determined: non-aggressive (55.5 %), self-aggressive (18 %), and hetero-aggressive (26.5 %). Depressive, irritable, and anxious temperament scores significantly increased from the non-aggressive (lower) to the self-aggressive (intermediate) and the hetero-aggressive group (highest). A positive history of a suicide attempt (B = 5.131; OR = 169.2, 95 % CI 75.9; 377) and rapid cycling (B = -0.97; OR = 0.40, 95 % CI 0.17; 0.95) predicted self-aggressive cluster membership. Atypical antipsychotics (B = 1.19; OR = 3.28, 95 % CI 2.13; 5.06) or SNRI treatment (B = 1.09; OR = 3, 95 % CI 1.57; 5.71), psychotic symptoms (B = 0.73; OR = 2.09, 95 % CI 1.34; 3.26), and history of a suicide attempt (B = -1.56; OR = 0.20, 95 % CI 0.11; 0.38) predicted hetero-aggressive cluster membership.

LIMITATIONS

Recall bias might have affected the recollection of AB.

CONCLUSIONS

Clinical factors orientate the prevention of different ABs in BD. Affective temperaments might play a role in preventing AB since patients with more pronounced affective temperaments might have an increased risk of showing AB, in particular hetero-AB.

Comparison of bipolar disorder type II and major depressive disorder

OBJECTIVE

Compare patients diagnosed as DSM-5 type II bipolar disorder (BD2) vs. major depressive disorder (MDD).

METHODS

We compared characteristics of 3246 closely and repeatedly evaluated, consenting, adult patient-subjects (n = 706 BD2, 2540 MDD) at a specialty clinic using bivariate methods and multivariable modeling.

RESULTS

Factors more associated with BD2 than MDD included: [a] descriptors (more familial psychiatric, mood and bipolar disorders and suicide; younger at onset, diagnosis and first-treatment; more education; more unemployment; fewer marriages and children; higher cyclothymic, hyperthymic and irritable temperament ratings, lower anxious); [b] morbidity (more hypomanic, mixed or panic first episodes; more co-occurring general medical diagnoses, more Cluster B personality disorder diagnoses and ADHD; more alcohol and drug abuse and smoking; shorter depressive episodes and interepisode periods; lower intake ratings of depression and anxiety, higher for hypomania; far more mood-switching with antidepressants; lower %-time depressed; DMI > MDI course-pattern in BD2; more suicide attempts and violent suicidal behavior); [c] item-scores with intake HDRS₂₁ higher for suicidality, paranoia, anhedonia, guilt, and circadian variation; lower somatic anxiety, depressed mood, insight, hypochondriasis, agitation, and insomnia; and [d] treatment (more lithium, mood-stabilizing anticonvulsants and antipsychotics, less antidepressants and benzodiazepines).

CONCLUSIONS

BD2 and MDD subjects differed greatly in many descriptive, psychopathological and treatment measures, notably including more familial risk, earlier onset, more frequent recurrences and greater suicidal risk with BD2. Such differences can contribute to improving differentiation of the disorders and planning for their treatment.

Risk factors for early recurrence after discontinuing lithium in bipolar disorder

BACKGROUND

Time to a new episode of bipolar disorder (BD) is shorter after discontinuing lithium rapidly. We now address this and other factors associated with the risk of early illness after discontinuing lithium.

METHODS

We compared factors for association with recurrences of BD within 12 months of discontinuing long-term lithium treatment, using bivariate and multivariable analyses, as well as survival analysis to evaluate latency to new episodes versus rate of lithium-discontinuation and prior treatment duration.

RESULTS

Among 227 BD subjects who received lithium for 4.47 [CI: 3.89-5.04] years and then discontinued, rapid treatment-discontinuation, and stopping for medical reasons were strongly associated with new illness-episodes within 12 months, as were diagnosis (BD-I > BD-II), greater morbidity during lithium-treatment, and less education, but neither longer treatment nor serum lithium concentrations. Discontinuation rate was strongly associated with shorter median latency to a new episode (rapid: 3.50; gradual [≥2 weeks]: 10.6 months), even with very early recurrences excluded to avoid potential contributions of emerging illness to treatment-discontinuation. Early recurrence was not associated with treatment-duration of ≥2 or ≥5 years or less. In multivariable logistic regression, rapid discontinuation, stopping for medical reasons, and BD-I diagnosis remained significantly, independently associated with early illness after lithium-discontinuation, with no effect of treatment duration.

CONCLUSIONS

Early recurrence risk was again much greater after rapid discontinuation of lithium and discontinuing for medical reasons, somewhat greater with BD-I than BD-II, and following greater morbidity during lithium-treatment, but not related to dose or duration of preceding treatment exposure.

Association between polarity of first episode and solar insolation in bipolar I disorder

OBJECTIVE

Circadian rhythm disruption is commonly observed in bipolar disorder (BD). Daylight is the most powerful signal to entrain the human circadian clock system. This exploratory study investigated if solar insolation at the onset location was associated with the polarity of the first episode of BD I. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area of the Earth.

METHODS

Data from 7488 patients with BD I were collected at 75 sites in 42 countries. The first episode occurred at 591 onset locations in 67 countries at a wide range of latitudes in both hemispheres. Solar insolation values were obtained for every onset location, and the ratio of the minimum mean monthly insolation to the maximum mean monthly insolation was calculated. This ratio is largest near the equator (with little change in solar insolation over the year), and smallest near the poles (where winter insolation is very small compared to summer insolation). This ratio also applies to tropical locations which may have a cloudy wet and clear dry season, rather than winter and summer.

RESULTS

The larger the change in solar insolation throughout the year (smaller the ratio between the minimum monthly and maximum monthly values), the greater the likelihood the first episode polarity was depression. Other associated variables were being female and increasing percentage of gross domestic product spent on country health expenditures. (All coefficients: P ≤ 0.001).

CONCLUSION

Increased awareness and research into circadian dysfunction throughout the course of BD is warranted.

Cost-Utility Analysis of Pharmacogenetic Testing Based on CYP2C19 or CYP2D6 in Major Depressive Disorder: Assessing the Drivers of Different Cost-Effectiveness Levels from an Italian Societal Perspective

Background and Objectives

Major depressive disorder (MDD) is a common and severe psychiatric disorder that has enormous economical and societal costs. As pharmacogenetics is one of the key tools of precision psychiatry, we analyze the cost–utility of test screening of CYP2C19 and CYP2D6 for patients suffering from major depressive disorder (MDD) and try to understand the main drivers that influence the cost–utility.

Methods

We developed two pharmacoeconomic nonhomogeneous Markov models to test the cost–utility, from an Italian societal perspective, of pharmacogenetic testing genetic to characterize the metabolizing profiles of cytochrome P450 (CYP) 2C19 and CYP2D6 in a hypothetical case study of patients suffering from major depressive disorder (MDD). The model considers different scenarios of adjustment of antidepressant treatment according to the patient’s metabolizing profile or treatment over a period of 18 weeks. The uncertainty of model parameters is tested through both a probabilistic sensitivity analysis and a one-way deterministic sensitivity analysis, and these results are used in a post-hoc analysis to understand the main drivers of three alternative cost-effectiveness levels (“poor,” “standard,” and “high”). These drivers are first evaluated from an exploratory multidimensional perspective and next from a predictive perspective as the probability that a patient belongs to a specific cost-effectiveness level is estimated on the basis of a restricted set of parameters used in the original pharmacoeconomic model.

Results

The models for CYP2C19 and CYP2D6 indicate that screening has an incremental cost-effectiveness ratio of 60,000€ and 47,000€ per quality-adjusted life year (QALY), respectively. The probabilistic sensitivity analysis shows that the treatments are cost-effective for a 75,000€ willingness to pay (WTP) threshold in 58% and 63% of the Monte Carlo replications, respectively. The post-hoc analysis highlights the factors that allow us to clearly discriminates poor cost-effectiveness from high cost-effectiveness scenarios and demonstrates that it is possible to predict with reasonable accuracy the cost-effectiveness of a genetic test and the associated therapeutic pattern.

Conclusions

Our findings suggest that screenings for both CYP2C19 and CYP2D6 enzymes for patients with MDD are cost-effective for a WTP threshold of 75,000€ per QALY, and provide relevant suggestions about the most important aspects to be further explored in clinical studies aimed at addressing the cost-effectiveness of genetic testing for patients diagnosed with MDD.

Differences between bipolar disorder types 1 and 2 support the DSM two-syndrome concept

Objective

To compare characteristics of bipolar disorder patients diagnosed as DSM-5 types I (BD-1) vs. II (BD-2).

Methods

We compared descriptive, psychopathological, and treatment characteristics in a sample of 1377 consenting, closely and repeatedly evaluated adult BD patient-subjects from a specialty clinic, using bivariate methods and logistic multivariable modeling.

Results

Factors found more among BD-2 > BD-1 cases included: [a] descriptors (more familial affective disorder, older at onset, diagnosis and first-treatment, more education, employment and higher socioeconomic status, more marriage and children, and less obesity); [b] morbidity (more general medical diagnoses, less drug abuse and smoking, more initial depression and less [hypo]mania or psychosis, longer episodes, higher intake depression and anxiety ratings, less mood-switching with antidepressants, less seasonal mood-change, greater %-time depressed and less [hypo]manic, fewer hospitalizations, more depression-predominant polarity, DMI > MDI course-pattern, and less violent suicidal behavior); [c] specific item-scores with initial HDRS₂₁ (higher scores for depression, guilt, suicidality, insomnia, anxiety, agitation, gastrointestinal symptoms, hypochondriasis and weight-loss, with less psychomotor retardation, depersonalization, or paranoia); and [d] treatment (less use of lithium or antipsychotics, more antidepressant and benzodiazepine treatment).

Conclusions

BD-2 was characterized by more prominent and longer depressions with some hypomania and mixed-features but not mania and rarely psychosis. BD-2 subjects had higher socioeconomic and functional status but also high levels of long-term morbidity and suicidal risk. Accordingly, BD-2 is dissimilar to, but not necessarily less severe than BD-1, consistent with being distinct syndromes.

P-212 Impact of post-thaw blastocyst culture time prior to transfer on live birth rate in frozen-thawed embryo transfer cycles: a retrospective observational study

Study question

Does post-thaw blastocyst culture time prior to transfer influence the live birth rate in frozen-thawed embryo transfer cycles?

Summary answer

Our study revealed that different culture times of frozen-thawed blastocysts prior to transfer does not influence live birth rate.

What is known already

Several studies demonstrated a significantly increased clinical pregnancy rate after a frozen-thawed embryo transfer (FET) compared to a fresh embryo transfer (ET). FET reduces the risk of ovarian hyperstimulation syndrome without facing adverse effects of supraphysiological hormonal levels over endometrial receptivity. However, little is known on the effect of post-thaw embryo culture duration prior to transfer on live birth rate in FET cycles. Recent findings described an improved blastocyst morphological grade after a 20-22h post-thaw culture. Of note, the overnight culture of non-ideal morphology thawed blastocysts prior to transfer resulted in an enhanced live birth rate.

Study design, size, duration

We compared the live birth rate of patients undergoing FET after a short blastocyst culture time (2-4h) prior to transfer to that of patients in whom thawed blastocysts were transferred after a long embryo culture time (20-22h). Frozen-thawed transfers of blastocysts vitrified at Day 5 and subsequently thawed were evaluated. Only transfers of single blastocyst were included.

Participants/materials, setting, methods

The study was conducted at the Infertility Center – Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan. We included couples with indications for IVF cycles who underwent frozen-thawed blastocyst transfer procedure on the following natural cycles for freeze-all strategy or to transfer supernumerary embryos from 2014-2021. Data were analyzed using SPSS Statistics software. We evaluated statistically significant differences using various tests including Fisher's test, chi-squared test and Wilcoxon's test.

Main results and the role of chance

A total of 2012 frozen-thawed cycles were included in the analysis; in 977 of them, blastocysts were transferred after a 2-4h post-thaw period and in 1035, blastocysts were transferred after a 20-22h post thaw culture period. The age of the women was comparable (35.4 ± 4.2 and 35.3 ± 4.1; p = 0.5, respectively in the short and long culture period). According to statistical analysis, no significant difference in pregnancy outcomes was found between the two groups. Live birth rate was respectively 40% and 42% ( p = 0.2) in the short and long post-thaw blastocyst culture period prior to transfer.

Limitations, reasons for caution

Our study was limited by the retrospective nature and was performed in a single fertility center. Moreover, only blastocysts vitrified on day 5 were evaluated and findings might not be generalized to day 6 and 7 blastocysts.

Wider implications of the findings

These findings might be useful in the context of the organization of the laboratory workflow. Indeed, the possibility to thaw blastocysts on the day before transfer may represent an advantage in order to avoid an overload of the laboratory procedures during very busy days.

Trial registration number

28_2022

P-300 Evaluation of CYP19A1 gene expression in luteinized granulosa cells of women affected by endometriosis undergoing assisted reproductive technology (ART) treatments

Study question

Does endometriosis affect the expression of the aromatase gene CYP19A1 in the cumulus oophorous (COCs) and mural lutein-granulosa cells (GCs) influencing ART procedures?

Summary answer

Endometriosis does not impair CYP19A1 gene expression. However, the correlation between the aromatase expression and the number of oocytes retrieved is lost in endometriosis patients.

What is known already

Endometriosis-related infertility could be associated with a dysregulation of oocytes development. Indeed, endometriosis seems to have a negative effect on the intrafollicular environment, hindering oocyte maturation. A dysregulated synthesis of steroid hormones by GCs in the ovaries of affected women may be at the basis of an inadequate folliculogenesis. In line, some studies have investigated the expression levels of aromatase p450 ( CYP19A1 ) -the key enzyme involved in 17β-estradiol (E2) synthesis - in GCs and COCs collected from endometriosis women, reporting controversial results.

Study design, size, duration

In order to identify novel prognostic factors of ART outcomes in affected women, we set the evaluation of CYP19A1 expression in GCs samples isolated from endometriosis patients undergoing ART in comparison to control women. In a subgroup of patients, COCs were also collected. CYP19A1, StAR and 3βHSD gene expression was evaluated in both cell types. Finally, we evaluated the association between the expression of the analyzed genes and E2 levels with the clinical ART outcomes

Participants/materials, setting, methods

GCs were isolated from follicular fluids(FF) of n = 68 women with stage III-IV endometriosis and of n = 69 control patients. CYP19A1 gene expression was quantified by qPCR. 17β-estradiol levels in FF were assessed using an ELISA kit. In addition to CYP19A1 gene expression, mRNA levels of StAR and 3βHSD both in GCs and COCs (n = 20 endometriosis;n=21 controls) were evaluated in both cell types using qPCR. Differences between the two patients’ groups were estimated using linear regression models.

Main results and the role of chance

qPCR results showed no differences in mRNA expression of CYP19A1, StAR and 3βHSD in both GCs and COCs between the two groups of ART patients. These results were supported by the presence of the same concentration of E2 in the FF of controls (median: 877.7 ng/mL) and endometriosis patients (median: 878.3 ng/mL) (p-value=0.87). Linear regression model including as input variables gene expression values and ART outcomes showed that the blastulation rate was the only ART outcome associated with the expression levels of CYP19A1  (p-value=0.043, 95% CI: 0.001-0.061). In particular, a decrease of aromatase levels was associated with an increase in blastulation rate. After stratification of the population based on the presence of the disease, it emerged that, in the control group, the CYP19A1 expression correlated with the number of oocytes retrieved [β:-1.214;95%CI: -2.085 - (-0.343); p-value=0.007], while in the group of patients with endometriosis this association was no more present [β:-0.003;95%CI:-0.468 - 0.461; p-value=0.988)]. These results do not support data from the literature indicating that aromatase expression is reduced in GCs of affected women, but they highlight a potential disease-related mechanism affecting the ovulation process in these women

Limitations, reasons for caution

These findings need to be validated in a different cohort of samples. An RNA-seq approach is needed in order to validate our results and to obtain the overall transcriptome profiles of GCs and COCs in endometriosis patients.

Wider implications of the findings

Our data do not confirm previous evidence supporting a reduced expression/activity of aromatase in GCs in endometriosis. However, they suggest that aromatase may have a complex and sophisticated regulation of its expression in this cell type, which is not maintained in presence of endometriosis.

Trial registration number

not applicable

Nanoparticle anisotropy induces sphere-to-cylinder phase transition in block copolymer melts

Block copolymer nanocomposites including anisotropic nanoparticles have been previously found to co-assemble into complex structures with nanoparticle alignment. Anisotropic nanoparticles with large aspect ratios are found to modify the morphology of block copolymers at modest concentrations, inducing a sphere-to-cylinder phase transition by breaking the local symmetry in the vicinity of a solid particle. This transition takes place over a wide range of NP lengths comparable with the BCP spacing. Controlling the orientation of uniaxial nanoparticles provides additional control over the global orientation of the block copolymer, as previously reported by experiments.

How to Clean and Safely Remove HF from Acid Digestion Solutions for Ultra-Trace Analysis: A Microwave-Assisted Vessel-Inside-Vessel Protocol

The complete dissolution of silicate-containing materials, often necessary for elemental determination, is generally performed by microwave-assisted digestion involving the forced use of hydrofluoric acid (HF). Although highly efficient in dissolving silicates, this acid exhibits many detrimental effects (e.g., formation of precipitates, corrosiveness to glassware) that make its removal after digestion essential. The displacement of HF is normally achieved by evaporation in open-vessel systems: atmospheric contamination or loss of analytes can occur when fuming-off HF owing to the non-ultraclean conditions necessarily adopted for safety reasons. This aspect strongly hinders determination at the ultra-trace level. To overcome this issue, we propose a clean and safe microwave-assisted procedure to induce the evaporative migration of HF inside a sealed “vessel-inside-vessel” system: up to 99.9% of HF can be removed by performing two additional microwave cycles after sample dissolution. HF migrates from the digestion solution to a scavenger (ultrapure H₂O) via a simple physical mechanism, and then, it can be safely dismissed/recycled. The procedure was validated by a soil reference material (NIST 2710), and no external or cross-contamination was observed for the 27 trace elements studied. The results demonstrate the suitability of this protocol for ultra-trace analysis when the utilization of HF is mandatory.

Overweight in mood disorders: Effects on morbidity and treatment response

OBJECTIVE

As it is not clear how body-mass index (BMI) may relate to diagnosis, symptom-severity, illness-course, and treatment-response among psychiatric patients, we related BMI to psychiatric diagnosis and to selected clinical and demographic factors in major affective disorder subjects.

METHODS

We analyzed mean BMI levels vs. diagnosis, and evaluated selected risk factors for association with overweight and obesity among subjects with DSM-5 major affective disorders.

RESULTS

In 1884 subjects, BMI ranged from 23.4 kg/m² with anxiety disorders to 27.6 with psychotic disorders, and averaged 24.1 among 1469 affective disorder subjects. Mood-disorder subjects with BMI ≥ 25 (overweight/obese) were more likely: men, older, married, with more children and siblings, less education, lower socioeconomic status, engaged less in physical exercise, smoked more, and lived in less densely populated areas. They also were more likely to have: BD than MDD, familial mood disorders, no co-occurring ADHD, higher serum triglyceride levels, more time depressed and less improvement in depression ratings with treatment.

CONCLUSIONS

Risk of being overweight or obese was greatest with psychoses, least with anxiety, personality, and minor depressive disorders, and intermediate with major mood disorders. Several plausible risk factors for high BMI were identified in mood disorder subjects, including male sex and with BD > MDD. Striking were selectively greater prospective morbidity and decreased treatment-response for depression vs. mania with BMI ≥ 25.

Suicidal risks in rural versus urban populations in Sardinia

OBJECTIVE

Rural locations have been associated with suicidal risk; low population density may be a relevant factor. Accordingly, we investigated hypothesized associations between suicidal ideation and behavior with selected geographic and population-related measures and other factors.

METHODS

Consenting adult patients at a mood disorder center in Cagliari, Sardinia, were assessed for the presence of suicidal ideation and acts and their association with selected demographic and clinical factors as well as indicators of urbanicity and rurality, including distance from the region's main metropolitan area, population density, altitude, and population growth trends.

RESULTS

Of 5,668 subjects, 27% had an indication of lifetime suicidal behavior or ideation; 8.6% had at least one suicidal act. Low population density, higher altitude and their interaction, distance from the metropolitan center of the main city (Cagliari), and population decline were associated with greater risk of suicidal ideation or behavior. In addition, and as expected, alcohol or substance abuse, diagnosis of mood disorders, higher depression ratings at intake, being younger at illness-onset, family history of suicide or other psychiatric disorder, being female, unmarried, separated or divorced, currently smoking cigarettes, being unemployed, and having experienced sexual abuse all were more likely in subjects with suicidal ideation or behavior.

CONCLUSION

Suicidal ideation and behavior were associated with indicators of social isolation as well as with previously reported clinical and demographic risk factors.

Relationships of affective temperament ratings to diagnosis and morbidity measures in major affective disorders

BACKGROUND

Ratings of affective temperament types show promise in helping to differentiate diagnostic groups among major affective disorders as well as to predict associations with important aspects of morbidity including suicidal risk.

METHODS

The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego auto-rating (TEMPS-A) questionnaire was completed by 858 unselected, consecutive, consenting adults diagnosed with a DSM-5 major affective disorder (173 bipolar-1 [BD-1]), 250 BD-2, 435 major depressive disorder [MDD]) to score for anxious (anx), cyclothymic (cyc), dysthymic (dys), hyperthymic (hyp), and irritable (irr) affective temperaments. We tested their associations with diagnosis and selected clinical factors, including diagnosis, depression scores, suicidal ideation or acts, substance abuse, episodes/year, and %-time ill.

RESULTS

Scores for cyc ranked: BD-2 > BD-1 > MDD; anx ranked: MDD > BD-2 > BD-1; irr was greater in BD than MDD; dys was greater in MDD than BD; hyp did not differ by diagnosis. We confirmed associations of suicidal risk with higher scores of all temperament types except lower hyp scores. Higher cyc and irr scores and lower anx scores were associated with substance abuse. Several scores were higher with measures of greater affective morbidity: cyc with current depression, episodes/year, and %-time ill; irr with more episodes and depressions/year and greater %-time manic. Some of these associations were selective for BD or MDD.

CONCLUSIONS

The findings indicate that TEMPS-A ratings of affective temperament types can contribute to differential diagnoses and predict types and amounts of affective morbidity, as well as detecting suicidal risks.

Protocol for a pharmacogenetic study of antidepressants: characterization of drug-metabolizing profiles of cytochromes CYP2D6 and CYP2C19 in a Sardinian population of patients with major depressive disorder

The effectiveness of antidepressants shows high interindividual variability ranging from full symptomatologic remission to treatment-resistant depression. Many factors can determine the variation in the clinical response, but a fundamental role is played by genetic variation within the genes encoding for the enzymes most involved in the metabolism of antidepressant drugs: the CYP2D6 and CYP2C19 isoforms of the cytochrome P450 system. This study is poised to clarify whether the different metabolizing phenotypes related to CYP2D6 and CYP2C19 could have an impact on the clinical efficacy of antidepressants and whether the frequency of these phenotypes of metabolization shows differences in the population of Sardinian patients compared to other Caucasian populations. The sample is being recruited from patients followed-up and treated at the Psychiatric Unit of the Department of Medical Science and Public Health, University of Cagliari and the University Hospital Agency of Cagliari (Italy). The study design includes three approaches: (1) a pharmacogenetic analysis of 80 patients diagnosed with MDD resistant to antidepressant treatment compared to 80 clinically responsive or remitted patients; (2) a prospective arm (N = 30) of the study where we will test the impact of genetic variation within the CYP2D6 and CYP2C19 genes on clinical response to antidepressants and on their serum levels and (3) the assessment of the socio-economic impact of antidepressant therapies, and estimation of the cost-effectiveness of the pharmacogenetic test based on CYP genes.

Variations in seasonal solar insolation are associated with a history of suicide attempts in bipolar I disorder

Background

Bipolar disorder is associated with circadian disruption and a high risk of suicidal behavior. In a previous exploratory study of patients with bipolar I disorder, we found that a history of suicide attempts was associated with differences between winter and summer levels of solar insolation. The purpose of this study was to confirm this finding using international data from 42% more collection sites and 25% more countries.

Methods

Data analyzed were from 71 prior and new collection sites in 40 countries at a wide range of latitudes. The analysis included 4876 patients with bipolar I disorder, 45% more data than previously analyzed. Of the patients, 1496 (30.7%) had a history of suicide attempt. Solar insolation data, the amount of the sun’s electromagnetic energy striking the surface of the earth, was obtained for each onset location (479 locations in 64 countries).

Results

This analysis confirmed the results of the exploratory study with the same best model and slightly better statistical significance. There was a significant inverse association between a history of suicide attempts and the ratio of mean winter insolation to mean summer insolation (mean winter insolation/mean summer insolation). This ratio is largest near the equator which has little change in solar insolation over the year, and smallest near the poles where the winter insolation is very small compared to the summer insolation. Other variables in the model associated with an increased risk of suicide attempts were a history of alcohol or substance abuse, female gender, and younger birth cohort. The winter/summer insolation ratio was also replaced with the ratio of minimum mean monthly insolation to the maximum mean monthly insolation to accommodate insolation patterns in the tropics, and nearly identical results were found. All estimated coefficients were significant at p < 0.01.

Conclusion

A large change in solar insolation, both between winter and summer and between the minimum and maximum monthly values, may increase the risk of suicide attempts in bipolar I disorder. With frequent circadian rhythm dysfunction and suicidal behavior in bipolar disorder, greater understanding of the optimal roles of daylight and electric lighting in circadian entrainment is needed.

Clinical response and metabolic effects of lithium in 323 mood disorder patients

BACKGROUND

Lithium is the mainstay for the maintenance treatment of mood disorders (MD), but its efficacy needs to be weighed against its side effects profile. Here, we assessed retrospectively the clinical response to long-term lithium treatment, as well as the rate of associated metabolic side effects.

METHODS

Clinical data were collected from patients treated with lithium for at least 12 months at the Lucio Bini Center for Mood Disorders in Cagliari, Italy. Clinical response was determined as the difference in number of mood episodes and percent of illness time before and during lithium treatment. Symptomatic values of metabolic parameters (plasma levels of glucose, cholesterol, urea nitrogen [BUN], creatinine, TSH, white blood cells [WBC]), and Body Mass Index (BMI) were determined.

RESULTS

We studied 323 MD patients (60.2% women). The percent of illness time was significantly reduced for both depressive (F = 4.94, p<0.0001), and manic (F = 3.95, p < 0.0001) episodes, whereas the rates of episodes/year were significantly reduced for mania (F = 2.01, p = 0.02), but not for depression (F = 1.54, p = 0.06). Rates of MD patients with symptomatic values of metabolic parameters were 14.3% for WBC ≥10,000/µl, 26.9% for glucose levels ≥100 mg/dl, 54.2% for cholesterol levels ≥200 mg/dl, 7.5% for BUN ≥50 mg/dl, 21.9% for creatinine levels ≥1.2 mg/dl, and 20.9% for TSH levels ≥3.50 mU/l.

CONCLUSIONS

Long-term lithium treatment was clinically effective, but the rates of metabolic effects were substantial although some of them were also associated with older age. Lithium-treated patients should receive accurate clinical monitoring to decrease the impact of long-term side effects.

Prediction of lithium response using clinical data

OBJECTIVE

Promptly establishing maintenance therapy could reduce morbidity and mortality in patients with bipolar disorder. Using a machine learning approach, we sought to evaluate whether lithium responsiveness (LR) is predictable using clinical markers.

METHOD

Our data are the largest existing sample of direct interview-based clinical data from lithium-treated patients (n = 1266, 34.7% responders), collected across seven sites, internationally. We trained a random forest model to classify LR-as defined by the previously validated Alda scale-against 180 clinical predictors.

RESULTS

Under appropriate cross-validation procedures, LR was predictable in the pooled sample with an area under the receiver operating characteristic curve of 0.80 (95% CI 0.78-0.82) and a Cohen kappa of 0.46 (0.4-0.51). The model demonstrated a particularly low false-positive rate (specificity 0.91 [0.88-0.92]). Features related to clinical course and the absence of rapid cycling appeared consistently informative.

CONCLUSION

Clinical data can inform out-of-sample LR prediction to a potentially clinically relevant degree. Despite the relevance of clinical course and the absence of rapid cycling, there was substantial between-site heterogeneity with respect to feature importance. Future work must focus on improving classification of true positives, better characterizing between- and within-site heterogeneity, and further testing such models on new external datasets.

Large scale three dimensional simulations of hybrid block copolymer/nanoparticle systems

Block copolymer melts self-assemble in the bulk into a variety of nanostructures, making them perfect candidates to template the position of nanoparticles. The morphological changes of block copolymers are studied in the presence of a considerable filling fraction of colloids. Furthermore, colloids can be found to assemble into ordered hexagonally close-packed structures in a defined number of layers when softly confined within the phase-separated block copolymer. A high concentration of interface-compatible nanoparticles leads to complex long-lived block copolymer morphologies depending on the polymeric composition. Macrophase separation between the colloids and the block copolymer can be induced if colloids are unsolvable within the matrix. This leads to the formation of ellipsoid-shaped polymer-rich domains elongated along the direction perpendicular to the interface between block copolymer domains.

Co-assembly of Janus nanoparticles in block copolymer systems

Block copolymer are ideal matrices to control the localisation of colloids. Furthermore, anisotropic nanoparticles such as Janus nanoparticles possess an additional orientational degree of freedom that can play a crucial role in the formation of highly ordered materials made of block copolymers. This work presents a mesoscopic simulation method to assert the co-assembly of Janus nanoparticles in a block copolymer mixture, finding numerous instances of aggregation and formation of ordered configurations. Comparison with chemically homogeneous neutral nanoparticles shows that Janus nanoparticles are less prone to induce bridging along lamellar domains, thus being a less destructive way to segregate nanoparticles at interfaces. The combination of asymmetric block copolymer and asymmetric Janus nanoparticles can result in assembly of colloids with an even number of layers within the minority domain.

Suicidal risk factors in major affective disorders

BACKGROUND

Rates and risk factors for suicidal behaviour require updating and comparisons among mood disorders.AimsTo identify factors associated with suicidal risk in major mood disorders.

METHOD

We considered risk factors before, during and after intake assessments of 3284 adults with/without suicidal acts, overall and with bipolar disorder (BD) versus major depressive disorder (MDD), using bivariate comparisons, multivariable regression modelling and receiver operating characteristic (ROC) analysis.

RESULTS

Suicidal prevalence was greater in BD versus MDD: ideation, 29.2 versus 17.3%; attempts, 18.8 versus 4.78%; suicide, 1.73 versus 0.48%; attempts/suicide ratio indicated similar lethality, 10.9 versus 9.96. Suicidal acts were associated with familial BD or suicide, being divorced/unmarried, fewer children, early abuse/trauma, unemployment, younger onset, longer illness, more dysthymic or cyclothymic temperament, attention-deficit hyperactivity disorder (ADHD), substance misuse, mixed features, hospital admission, percentage time unwell, less antidepressants and more antipsychotics and mood stabilisers. Logistic regression found five independent factors: hospital admission, more depression at intake, BD diagnosis, onset age ≤25 years and mixed features. These factors were more associated with suicidal acts in BD than MDD: percentage time depressed/ill, alcohol misuse, >4 pre-intake depressions, more dysthymic/cyclothymic temperament and prior abuse/trauma. ADHD and total years ill were similar in BD and MDD; other factors were more associated with MDD. By ROC analysis, area under the curve was 71.3%, with optimal sensitivity (76%) and specificity (55%) with any two factors.

CONCLUSIONS

Suicidal risks were high in mood disorders: ideation was highest with BD type II, attempts and suicides (especially violent) with BD type I. Several risk factors for suicidal acts differed between BD versus MDD patients.Declaration of interestNo author or immediate family member has financial relationships with commercial entities that might appear to represent potential conflicts of interest with the information presented.

Association between solar insolation and a history of suicide attempts in bipolar I disorder

In many international studies, rates of completed suicide and suicide attempts have a seasonal pattern that peaks in spring or summer. This exploratory study investigated the association between solar insolation and a history of suicide attempt in patients with bipolar I disorder. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area on Earth. Data were collected previously from 5536 patients with bipolar I disorder at 50 collection sites in 32 countries at a wide range of latitudes in both hemispheres. Suicide related data were available for 3365 patients from 310 onset locations in 51 countries. 1047 (31.1%) had a history of suicide attempt. There was a significant inverse association between a history of suicide attempt and the ratio of mean winter solar insolation/mean summer solar insolation. This ratio is smallest near the poles where the winter insolation is very small compared to the summer insolation. This ratio is largest near the equator where there is relatively little variation in the insolation over the year. Other variables in the model that were positively associated with suicide attempt were being female, a history of alcohol or substance abuse, and being in a younger birth cohort. Living in a country with a state-sponsored religion decreased the association. (All estimated coefficients p < 0.01). In summary, living in locations with large changes in solar insolation between winter and summer may be associated with increased suicide attempts in patients with bipolar disorder. Further investigation of the impacts of solar insolation on the course of bipolar disorder is needed.

Characteristics of depressive and bipolar disorder patients with mixed features

OBJECTIVE

To assess differences between subjects with vs. without mixed features in major affective disorders.

METHODS

In 3099 out-patient subjects with DSM-5 major depressive disorder (MDD, n = 1921) or bipolar disorders (BD, n = 1178), we compared those with (Mx) vs. without (Non-Mx) mixed features (agitated-irritable depression or dysphoric [hypo]mania) in an index episode.

RESULTS

Prevalence of Mx averaged 21.9% [CI: 20.5-23.4] overall, ranking: BD-II > BD-I > MDD, and in BD depression ≥ [hypo]mania > MDD. Mx subjects were significantly more likely than Non-Mx cases to (i) have other mixed episodes, (ii) have higher irritable and agitated ratings, (iii) have more substance abuse, (iv) switch into mixed episodes, (v) have more suicide attempts and higher suicidal ratings, (vi) change diagnosis from depression to BD, (vii) have higher hypomania scores when depressed or depression scores when [hypo]manic, (viii) be unmarried or separated with fewer children and siblings, (ix) be diagnosed more with BD than MDD, (x) be unemployed, (xi) have BD, suicide and divorce among first-degree relatives, (xii) be female, (xiii) be younger at illness-onset. Both BD and MDD Mx subjects also received antidepressants less, but antipsychotics and mood-stabilizers more, alone and in combination with antidepressants.

CONCLUSIONS

Mood disorder subjects with agitated-irritable depression or dysphoric [hypo]mania differed from those without such mixed features, including having a less favorable clinical course and repeated mixed episodes. They may represent a distinct and prevalent, syndromal clinical subtype with prognostic and therapeutic significance.

Isolation of a Trypanosome Related to Trypanosoma theileri (Kinetoplastea: Trypanosomatidae) from Phlebotomus perfiliewi (Diptera: Psychodidae)

The Trypanosoma theileri group includes several trypanosome species hardly distinguishable due to the lack of discriminating morphological characters. Trypanosomes belonging to this group have been isolated from different bovine, ovine, and cervids in Europe, Africa, Asia, and Americas. The principal vectors of the T. theileri group are considered tabanid flies; however, T. melophagium is transmitted exclusively by sheep keds. In 2016, 128 sand flies out of 2,728 trapped in Valsamoggia municipality, Italy, were individually dissected and an unknown trypanosome strain, named TrPhp1, was isolated from a female of the sand fly Phlebotomus perfiliewi. Sequence analysis placed this trypanosome in the T. theileri group with very high homology to other trypanosomes detected in European cervids. This is the first report of the T. theileri group isolation from a sand fly, and the possible role of this insect group in the trypanosome transmission cycle is discussed. Within the T. theileri group, the phylogenetic analysis distinguished several lineages, which, unfortunately, do not correspond with their host specificity and their taxonomic status remains ambiguous.

Association of suicidal risk with ratings of affective temperaments

BACKGROUND

Ratings of particular temperament-types with the TEMPS-A autoquestionnaire have been associated with suicidal risk, and combinations of such ratings may enhance the association. However, the predictive value of scores for individual temperaments and combinations remains to be quantified.

METHOD

We evaluated associations of TEMPS-A ratings for anxious (anx), cyclothymic (cyc), dysthymic (dys), hyperthymic (hyp) and irritable (irr) temperaments, with a history of suicidal acts or reported suicidal ideation in 882 patients with bipolar (BD; n = 509), major depressive (MDD; n = 268) or anxiety (ANX; n = 105) disorders.

RESULTS

With BD, scores for cyc and irr were highest and anx lowest; with MDD, dys scored highest, hyp lowest; anx was highest with ANX and MDD. Women (n = 497) had higher anx and cyc scores than men; scores for irr and hyp decreased with age. Scores for dys, anx, and cyc, were higher, and hyp lower, with greater HDRS₂₁ depression ratings. Among 347 suicidal subjects (112 with attempts), cyc, dys, and irr scores were higher, hyp lower. Pooled score [cyc+ dys+ irr - hyp] best distinguished subjects with suicide attempts versus nonsuicidal subjects, including in Receiver-Operating Characteristic (ROC) analysis (AUC for acts = 70.1% [64.9- 75.3]). Multivariable modeling associated suicidal acts with TEMPS-A [cyc+ dys+ irr - hyp] composite-score, depression severity, BD or MDD diagnosis, and older at illness-onset.

CONCLUSIONS

Subjects with suicidal acts or ideation were best distinguished by composite TEMPS-A score [cyc+ dys+ irr - hyp]. These factors should help to identify those at suicidal risk.

Effect of On-Line Hemodiafiltration with Endogenous Reinfusion (HFR) on the Calcium-Phosphorus Metabolism: Medium-Term Effects

Aim

The purpose of the study was to examine the effect of hemodiafiltration with endogenous reinfusion (HFR) compared to hemodialysis (HD) on 28 uremic patients with secondary hyperparathyroidism (2HPT) but positively selected for good and stable control of phosphatemia in order to evaluate the independent effects of dialysis treatments on bone turnover metabolism. Methods: The study was divided into 3 periods of observation: a) HD for three months; b) HFR for three months; c) HFR for a further 3 months. We analysed the trend of: whole PTH, 1–84 PTH, 7–84 PTH, alkaline phosphatase and its bone isoenzyme, total and ionised calcium, phosphatemia, dose of phosphate binder agents, β2-microglobulin, CRP. All the variations found were evaluated through mean values ± SD, t-tests, multivariate analysis.

Results

We observed a deceleration in bone turnover characterized by a reduction of the total and bone alkaline phosphatase (IU/mL) from 92.3 ± 82.8 and 35.8 ± 49.8 at the end of HD to 63.4 ± 23.9 and 16.0 ± 8.7 at the end of HFR, respectively, and 1–84 PTH from 317.5 ± 264.6 pg/mL at the end of HD to 287.5 ± 258.9 pg/mL at the end of the 3rd month of HFR. β2-microglobulin was reduced from 32.9 ± 16.1 mg/L at the end of HD to 26.4 ± 8.1 mg/L already at the end of the first three months of HFR. CRP was reduced from 2.5 ± 2.6 mg/dL at the beginning of the study to 1.3 ± 1.7 mg/dL at the end of HFR. There were no differences with regard to: dialytic efficiency, nutritional status, calcemia, phosphatemia (maintained in the K-DOQI range for the entire duration of the study), also thanks to more careful use of phosphate chelating agents.

Conclusion

We are of the opinion that HFR - essentially thanks to the use of ultrapure endogenous infusate - induces a deceleration in bone turnover due to 2PHT. In addition, phosphate substraction in HFR is better compared to HD, thanks to the improvement of the anti-inflammatory conditions by removing the cytokines harmful to bone metabolism and excluding a priori the negative effects related to hyperphosphatemia. (Int J Artif Organs 2006; 29: 1042–52)

Solar insolation in springtime influences age of onset of bipolar I disorder

OBJECTIVE

To confirm prior findings that the larger the maximum monthly increase in solar insolation in springtime, the younger the age of onset of bipolar disorder.

METHOD

Data were collected from 5536 patients at 50 sites in 32 countries on six continents. Onset occurred at 456 locations in 57 countries. Variables included solar insolation, birth-cohort, family history, polarity of first episode and country physician density.

RESULTS

There was a significant, inverse association between the maximum monthly increase in solar insolation at the onset location, and the age of onset. This effect was reduced in those without a family history of mood disorders and with a first episode of mania rather than depression. The maximum monthly increase occurred in springtime. The youngest birth-cohort had the youngest age of onset. All prior relationships were confirmed using both the entire sample, and only the youngest birth-cohort (all estimated coefficients P < 0.001).

CONCLUSION

A large increase in springtime solar insolation may impact the onset of bipolar disorder, especially with a family history of mood disorders. Recent societal changes that affect light exposure (LED lighting, mobile devices backlit with LEDs) may influence adaptability to a springtime circadian challenge.

Age at menarche predicts age at onset of major affective and anxiety disorders

BACKGROUND

Menarche age has been associated inconsistently with the occurrence, timing or severity of major depressive disorder (MDD), but rarely studied in women with bipolar (BDs) or anxiety disorders.

METHODS

We investigated women patients at a Sardinian mood disorder center for associations of age at menarche with age at illness onset for major affective or anxiety disorders, year of birth, and other selected factors, using bivariate comparisons and multivariate regression modeling.

RESULTS

Among women (n=1139) with DSM-IV MDD (n=557), BD-I (n=223), BD-II (n=178), or anxiety disorders (n=181), born in 1904-1998, of mean age 42.9 years, menarche age averaged 12.8 [CI: 12.7-12.9] years. Illness onset age averaged 30.9 [30.1-31.8] years, ranking: BD-I, 25.8; anxiety disorders, 28.0; BD-II, 30.3; MDD, 34.1 years. Menarche age declined secularly over birth years, and was associated with younger illness-onset, having no or fewer siblings, more psychiatrically ill first-degree relatives, living in rural environments, being suicidal, substance abuse, and being unemployed. Earlier menarche and earlier illness-onset were significantly associated for onset age groups of ≤ 20, 20-39, and > 40 years. Menarche age versus diagnosis ranked: BD-II<BD-I<anxiety disorders<MDD.

CONCLUSIONS

Age at menarche in Sardinia, as elsewhere, has declined over the past decades. It was strongly associated with age at onset of bipolar and anxiety, as well as major depressive disorders across the age range, suggesting sustained effects of biological maturational factors.

Diving response after a one-week diet and overnight fasting

Background

We hypothesized that overnight fasting after a short dietary period, especially with carbohydrates, could allow performing breath-hold diving with no restraint for diaphragm excursion and blood shift and without any increase of metabolism, and in turn improve the diving response.

Methods

During two separate sessions, 8 divers carried out two trials: (A) a 30-m depth dive, three hours after a normal breakfast and (B) a dive to the same depth, but after following a diet and fasting overnight. Each test consisted of 3 apnea phases: descent, static and ascent whose durations were measured by a standard chronometer. An impedance cardiograph, housed in an underwater torch, provided data on trans-thoracic fluid index (TFI), stroke volume (SV), heart rate (HR) and cardiac output (CO). Mean blood pressure (MBP), arterial O₂ saturation (SaO₂), blood glucose (Glu) and blood lactate (BLa) were also collected.

Results

In condition B, duration of the static phase of the dive was longer than A (37.8 ± 7.4 vs. 27.3 ± 8.4 s respectively, P < 0.05). In static phases, mean ∆ SV value (difference between basal and nadir values) during fasting was lower than breakfast one (−2.6 ± 5.1 vs. 5.7 ± 7.6 ml, P < 0.05). As a consequence, since mean ∆ HR values were equally decreased in both metabolic conditions, mean ∆ CO value during static after fasting was lower than the same phase after breakfast (−0.4 ± 0.5 vs. 0.4 ± 0.5 L · min⁻¹ respectively, P < 0.05). At emersion, despite the greater duration of dives during fasting, SaO₂ was higher than A (92.0 ± 2.7 vs. 89.4 ± 2.9 % respectively, P < 0.05) and BLa was lower in the same comparison (4.2 ± 0.7 vs. 5.3 ± 1.1 mmol∙L⁻¹, P < 0.05).

Conclusions

An adequate balance between metabolic and splancnic status may improve the diving response during a dive at a depth of 30 m, in safe conditions for the athlete’s health.

The effect of amidation on the behaviour of antimicrobial peptides

Aurein 2.6-COOH and aurein 3.1-COOH were studied along with their naturally occurring C-terminally amidated analogues. Circular dichroism (CD) and molecular dynamic (MD) simulations were used to study the effects of amidation on the interaction of antimicrobial peptides (AMPs) with lipid bilayers. CD measurements and MD analysis suggested that both peptide analogues were predominantly random coil and adopted low levels of \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α-helical structure in solution (<30 %) and in the presence of a lipid bilayer the peptides formed a stable \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α-helical structure. In general, amidated analogues have a greater propensity than the non-amidated peptides to form a \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α-helical structure. MD simulations predicted that aurein 2.6-COOH and aurein 3.1-CHOOH destabilised lipid bilayers from 1,2-dimyristoyl-sn-glycero-3-phosphocholine and 1,2-dimyristoyl-sn-glycero-3-phosphoserine via angled bilayer penetration. They also showed that aurein 2.6-CONH\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$_2$$\end{document}2 and aurein 3.1-CONH\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$_2$$\end{document}2 formed a helix horizontal to the plane of an asymmetric interface.

Comparison of psychotic bipolar disorder, schizoaffective disorder, and schizophrenia: an international, multisite study

OBJECTIVE

Nosological distinctions among schizoaffective disorder (SA), bipolar I disorder with psychotic features (BDp), and schizophrenia (SZ) remain unresolved.

METHOD

We compared 2269 subjects with psychotic features in DSM-IV-TR diagnoses (1435 BDp, 463 SZ, 371 SA) from 8 collaborating international sites, by 12 sociodemographic and clinical measures, all between diagnostic pairs.

RESULTS

In bivariate comparisons, SA was consistently intermediate between BDp and SZ for 11/12 features (except onset stressors), and SZ vs. BDp differed in all 12 factors. SA differed from both BDp and SZ in 9/12 factors: SA and BDp were similar in education and suicidal ideation or acts; SA and SZ were similar in education, onset stressors, and substance abuse. Meta-analytic comparisons of diagnostic pairs for 10 categorical factors indicated similar differences of SA from both SZ and BDp. Multivariate modeling indicated significantly independent differences between BDp and SZ (8 factors), SA vs. SZ (5), and BDp vs. SA (3). Measurement variance was similar for all diagnoses.

CONCLUSION

SA was consistently intermediate between BDp and SZ. The three diagnostic groups ranked: BDp > SA > SZ related to lesser morbidity or disability. The findings are not consistent with a dyadic Kraepelinian categorization, although the considerable overlap among the three DSM-IV diagnostic groups indicates uncertain boundaries if they represent distinct disorders.

Human and entomological surveillance of Toscana virus in the Emilia-Romagna region, Italy, 2010 to 2012

Toscana virus (TOSV), transmitted by phlebotomine sandflies, is recognised as one of the most important causes of viral meningitis in summer in Mediterranean countries. A surveillance plan based on both human and entomological surveys was started in 2010 in the Emilia-Romagna region, Italy. Clinical samples from patients with neurological manifestations were collected during 2010 to 2012. The surveillance protocol was improved during these years, allowing the detection of 65 human infections. Most of these infections were recorded in hilly areas, where sandflies reach the highest density. Entomological sampling around the homes of the patients resulted in a low number of captured sandflies, while later sampling in a hilly area with high number of human cases (n=21) resulted in a larger number of captured sandflies. Using this approach, 25,653 sandflies were sampled, of which there were 21,157 females, which were sorted into 287 pools. TOSV RNA was detected by real-time PCR in 33 of the pools. The results highlighted the role of Phlebotomus perfiliewi as the main vector of TOSV and a potential link between vector density and virus circulation. This integrated system shows that an interdisciplinary approach improves the sensitiveness and effectiveness of health surveillance.

Cardiovascular responses during free-diving in the sea

Cardiac output has never been assessed during free-diving diving in the sea. Knowledge of human diving response in this setting is therefore scarce. 3 immersions were performed by 7 divers: at depths of 10 m, 20 m and 30 m. Each test consisted of 3 apnea phases: descent, static and ascent. An impedance cardiograph provided data on stroke volume, heart rate and cardiac output. Mean blood pressure, arterial O2 saturation and blood lactate values were also collected. Starting from a resting value of 4.5±1.6 L∙min(-1), cardiac output at 10 m showed an increase up to 7.1±2.2 L∙min(-1) (p<0.01) during the descent, while conditions during the static and ascent phases remained unchanged. At 20 m cardiac output values were 7.3±2.4 L∙min(-1) and 6.7(±1).2 L∙min(-1) during ascent and descent, respectively (p<0.01), and 4.3±0.9 L∙min(-1) during static phase. At 30 m cardiac output values were 6.5±1.8 L∙min(-1) and 7.5±2 L∙min(-1) during descent and ascent, respectively (p<0.01), and 4.7±2.1 L∙min(-1) during static phase. Arterial O2 saturation decreased with increasing dive depth, reaching 91.1±3.4% (p<0.001 vs. rest) upon emergence from a depth of 30 m. Blood lactate values increased to 4.1±1.2 mmol∙L(-1) at the end of the 30 m dive (p<0.001 vs. rest). Results seem to suggest that simultaneous activation of exercise and diving response could lead to an absence of cardiac output reduction aimed at an oxygen-conserving effect.

Sprint vs. intermittent training in young female basketball players

AIM

This study aimed at comparing the effects of intermittent and repeated sprint ability training on physiological variables.

METHODS

Sixteen young female basketball players were randomly allocated to intermittent training (IT=8) or repeated sprint ability training (RST=8) groups. The following outcomes were measured at baseline and after 6 weeks of training: Yo-Yo intermittent recovery (Yo-Yo) and repeated sprint ability (RSA) tests.

RESULTS

For all the variables investigated the effect of training type showed a different trend respect at current knowledge. In the RSA, best time (BT) was a significant main effect of training time (pre- vs. post-) (P<0.0001), and of the interaction training type/time (P=0.03). The RST showed a decrease in BT of 3.1% (P=0.005) while the IT showed a decrease of 6.2% (P<0.0001). In the IT there was a significant main effect of time for the total distance with an increment of 26.9%, and a significant main effect of time in the final speed with an increment of 1.23%.

CONCLUSION

These findings suggest that the two training methods used in this study can be an effective training strategy for inducing anaerobic and basketball-specific training schedules. Besides, even when IT training is not done at very high speed, it can increase the maximum speed of the RSA.