Inter-relationships among psychopathology, cognition, and real-life functioning in early and late phase schizophrenia: A network analysis approach

Many illness-related factors contribute to the reduction of the real-life functioning observed in people with schizophrenia (SZ). These include the psychopathological dimensions of the disorder such as positive, negative, disorganization, and depressive symptoms as well as impairment in neurocognition, social cognition, and metacognition. The associations between some of these variables change with the duration of illness (DOI), but this aspect was not explored with a network approach. This study aimed at describing and comparing the inter-relationships between psychopathological, cognitive, and functioning variables in early (DOI ≤ 5 years) and late (DOI > 5 years) phase SZ with network analyses and at assessing which variables were more strictly and directly associated with the real-life functioning. A network representation of the relationships between variables and the calculation of centrality indices were performed within each group. The two groups were compared with a network comparison test. Seventy-five patients with early and ninety-two with late phase SZ were included. No differences in the global network structure and strength were found between the two groups. In both groups, visual learning and disorganization exhibited high centrality indices and disorganization, negative symptoms, and metacognition were directly and strongly associated with real-life functioning. In conclusion, regardless of the DOI, a rehabilitation aimed at improving visual learning and disorganization (i.e., the most central variables) might reduce the strength of the associations that compose the network and therefore indirectly facilitate functional recovery. Simultaneously, therapeutic interventions targeting disorganization and metacognition might directly improve real-life functioning.

Influenza vaccine effectiveness studies in Europe: SWOT analysis of DRIVE collaborating sites

Background

DRIVE is a European public-private partnership that aims at creating a network that works on high quality, brand-specific effectiveness estimates for all influenza vaccines used in the EU each season. The SWOT analysis aims at assessing the quality and feasibility of DRIVE operational model after its implementation, i.e. the operations of the study site network as applied in DRIVE.

Methods

The SWOT analysis was conducted through two meetings held among 2 of 14 partners participating in the DRIVE studies in the first season, with clinicians, nurses, data managers and lab technicians from the sites in the network. We collected data on two identified axes (1.organizational and 2.logistical, practical, and laboratory aspects), containing more than one SWOT objective. For each item classified under Strength (S), Weakness (W), Opportunity (O) or Threat (T), experts assigned a 1-5 score, meant to reflect the impact of each listed item on reaching the objectives.

Results

The most common topics, reported by both Italian and Finnish sites collaborators, were the opportunities related to the training and development of the network; funding concerns; opportunities and challenges in training the personnel; management issues due to the project practical organization (e.g. for lack of dedicated personnel, including administrative and for data entry). The scores attributed to the single items appeared skewed to the top, showing how the researchers perceived the majority of the topics as relevant for their day-to-day work.

Conclusions

The SWOT exercise was welcomed as a useful means to compare issues and practices among local study sites, but also as a chance for exchange with both peers and project lead. The results highlight the great value of communication and discussion between study groups, albeit the geographical distance. Such exercise should be included as a routine opportunity for discussion aiming at improving both collaboration and governance model in large projects.

Key messages

One of the main challenges of large public-private consortiums is building a shared governance model; opportunities for collective sharing and collaboration should be promoted in this setting. This SWOT analysis was a useful exercise that should inform the prosecution of the programming of DRIVE operational model, allowing a comparison of issues and practices among local study sites.

Efficacy and tolerability of duloxetine in the treatment of patients with borderline personality disorder: a pilot study

Guidelines of the American Psychiatric Association for borderline personality disorder (BPD) indicate selective serotonin reuptake inhibitors and the serotonin and noradrenaline reuptake inhibitor (SNRI) venlafaxine for treating affective dysregulation and impulsive behavioural dyscontrol symptoms. The SNRI duloxetine has been studied in patients with major depression, generalized anxiety disorder and fibromyalgia, showing particular efficacy on somatic complaints. This study investigates duloxetine in the treatment of patients with BPD. Eighteen outpatients with a DSM-IV-TR diagnosis of BPD were treated with open-label duloxetine, 60 mg/day, for 12 weeks. Patients were assessed at baseline, week 4 and 12 with the CGI Severity item, the BPRS, the HAM-D, the HAM-A, the SOFAS, the BPD Severity Index (BPDSI) and the HSCL-90-Somatization Subscale (HSCL-90 SOM). Adverse effects were evaluated using the Dosage Record Treatment Emergent Symptom Scale. Statistics were performed with the analysis of variance. Significant P values were <or=0.05. Fourteen patients completed the study. Four patients (22.2%) discontinued treatment in the first 4 weeks because of non-compliance. A significant change was found for: BPRS, HAM-D, SOFAS, BPDSI total score and items 'impulsivity', 'outbursts of anger' and 'affective instability' and HSCL-90 SOM. Adverse effects were mild headache and nausea. Initial results suggest that duloxetine is an effective and well-tolerated treatment for BPD, with positive effects on somatic symptoms.

Parallel conduction of the phase I preventive and therapeutic trials based on the Tat vaccine candidate

The native HIV-1 Tat protein was chosen as vaccine candidate for phase I clinical trials in both uninfected (ClinicalTrials.gov identifier: NCT00529698) and infected volunteers (ClinicalTrials.gov identifier: NCT00505401). The rationale was based on the role of Tat in the natural infection and AIDS pathogenesis, on the association of Tat-specific immune responses with the asymptomatic stage and slow-progression rate as well as on its sequence conservation among HIV clades (http://www.hiv1tat-vaccines.info/). The parallel conduction in the same clinical centers of randomized, double blind, placebo-controlled phase I studies both in healthy, immunologically competent adults and in HIV-infected, clinically asymptomatic, individuals represents a unique occasion to compare the vaccine-induced immune response in both the preventive and therapeutic setting. In both studies, the same lot of the native Tat protein was administered 5 times, every four weeks, subcute (SC) with alum adjuvant or intradermic (ID), in the absence of adjuvant, at 7.5 microg, 15 microg or 30 microg doses, respectively. The primary and secondary endpoints of these studies were the safety and immunogenicity of the vaccine candidate, respectively. The study lasted 52 weeks and monitoring was conducted for on additional 3 years. The results of both studies indicated that the Tat vaccine is safe and well tolerated both locally and systemically and it is highly immunogenic at all the dosages and by both routes of administration. Vaccination with Tat induced a balanced immune response in uninfected and infected individuals. In particular, therapeutic immunization induced functional antibodies and partially reverted the marked Th1 polarization of anti-Tat immunity seen in natural infection, and elicited a more balanced Th1/Th2 immune response. Further, the number of CD4 T cells correlated positively with anti-Tat antibody titers. Based on these results, a phase II study is ongoing in infected drug-treated individuals (http://www.hiv1tat-vaccines.info/).

Psychometric comparison of students in medicine and other faculties: social factors and psychologic symptoms

Few studies have investigated personality and psychopathological profiles associated to the choice of university education. Our study examined students from four faculties of Turin University, in Turin, Italy (Medicine, Engineering, Education, Law), comparing sociodemographic features, personality characteristics and psychiatric symptoms. A heterogeneous group of 1,323 students were assessed using a semistructured interview, the Personality Diagnostic Questionnaire-Revised (PDQ-R), and the Symptoms Checklist 90 (SCL-90). Statistical analysis included four logistic regression models, each fitted for one faculty, considering the other three as a control group. Associations were found in Medical and Engineering students concerning type of high school, school final score, and father?s socioeducational level. Factors associated with students of Law and Education included socioeducational characteristics, but stronger correlations were seen with PDQ-R personality scales and SCL-90 symptom clusters. In conclusion, four different profiles were identified. Medicine was not significantly related to personality and psychiatric factors. Engineering was related to male gender, choice of technical high school and father?s social level. Law was related to female gender and narcissistic personality profile. These data may be useful for counseling activities addressed to high school and university students.

Renal tolerability of three commonly employed non-steroidal anti-inflammatory drugs in elderly patients with osteoarthritis

OBJECTIVE

The primary endpoint of this study was to compare the renal tolerability of amtolmetin guacyl (AMG), diclofenac and rofecoxib in elderly patients with symptomatic osteoarthritis (OA). The assessment of efficacy was the secondary endpoint.

METHODS

90 patients who satisfied the American College of Rheumatology classification criteria for hand, hip or knee OA were randomly assigned to 3 treatment groups receiving either: AMG 1,200 mg over thefirst 3 days and and 600 mg/day thereafter; diclofenac 150 mg/day; or rofecoxib 25 mg/day for 2 weeks. At baseline and after therapy patients were clinically assessed by the same examiner who was unaware of the treatment arm assignement. Serum and urinary parameters of renal function and the outcome measures of efficacy were evaluated before (t(0)) and after therapy (t(1)).

RESULTS

Diclofenac produced a significant reduction in creatinine clearance (t(0) = 88.93 +/- 11.59; t(1) = 75.90 +/- 16.32; p: < 0.001) and in the daily urine volume (t(0) = 1,337.93 +/- 202.07; t(1) = 1,027.59 +/- 249.14; p: < 0.001). In the same treatment group a significant increase in serum creatinine, blood urea nitrogen, uric acid and potassium were observed. Rofecoxib treated patients showed a significant increase in body weight (t(0) = 75.31 +/- 4.26; t(1) = 76.54 +/- 4.84; p: < 0.001), systolic blood pressure (t(0) = 144 +/- 10.86; t(1) = 154 +/- 11.8; p < 0.001), diastolic blood pressure (t(0) = 80 +/- 6.05; t(1) = 89 +/- 7.66; p < 0.001) and serum sodium (t(0) = 138.73 +/- 1.28; t(1) = 140.12 +/- 1.80; p < 0.005) associated with a significant decrease in the daily urine volume (t(0) = 1294.64 +/- 205.21; t, = 1,115.48 +/- 238.47; p < 0.001) and creatinine clearance (t(0)= 86.73 +/- 8.14; t(1) = 83.15 +/- 7.96; p < 0.01). No significant changes in the clinical and humoral parameters were recorded in AMG treated patients. Diclofenac was more efficacious than the other 2 drugs (p < 0.001). No differences were observed between AMG and rofecoxib. Side effects related to altered kidney function were significantly higher in the rofecoxib group (p < 0.005).

CONCLUSION

Diclofenac mainly impaired blood renal flow and the glomerularfiltration rate, while rofecoxib negatively influenced the renal sodium-water exchange. AMG demonstrated a renal sparing effect, although the eract mechanism is unclear

Clinical features of dysthymia and age: a clinical investigation

A few authors have described the clinical picture of dysthymia in groups of elderly patients and pointed out differences from literature reports of dysthymia in younger adults. The present study, an attempt to analyze age effects on clinical characteristics of dysthymia throughout a lifetime, was performed in a sample of 106 patients, all aged > or =18 years, who were diagnosed according to DSM-IV. The patients were evaluated using: (1) a semistructured interview to assess clinical features, family history and previous treatments; (2) the Hamilton Depression Rating Scale; (3) the Interview for Recent Life Events; and (4) the Structured Clinical Interview for DSM-IV Disorders. Statistical analysis with stepwise logistic regression revealed that age was positively related to concomitant medical illnesses and to the total score of recent life events, but negatively related to the presence of avoidant or dependent personality disorders. The data suggested different etiologic pathways in older and younger patients. Dysthymia appeared to be associated in younger adults with abnormalities of personality; in the elderly, with a history of health problems and life losses.

Olanzapine augmentation of fluvoxamine-refractory obsessive-compulsive disorder (OCD): a 12-week open trial

A few studies have tried antipsychotic augmentation in obsessive-compulsive disorder (OCD) patients who are non-responders to selective serotonin reuptake inhibitors. The aim of this study was to investigate the efficacy and tolerability of olanzapine addition to fluvoxamine-refractory OCD patients and to assess if a comorbid chronic tic disorder or a concomitant schizotypal personality disorder was associated with response. Twenty-three OCD non-responders to a 6-month, open-label trial with fluvoxamine (300 mg/day) entered a 3-month open-label trial of augmentation with olanzapine (5 mg/day). OC symptom change was measured with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Clinical Global Impression (CGI) scale. Differences between responders and non-responders were assessed with regard to age, sex, duration of illness, baseline Y-BOCS score, and comorbidity with chronic tic disorders or schizotypal personality disorder. A significant decrease of mean Y-BOCS score between pre- and post-treatment (26. 8+/-3.0 vs. 18.9+/-5.9) was found at endpoint. Ten patients (43.5%) were rated as responders. The most common side effects were mild to moderate weight gain and sedation. In our sample, three patients (13. 04%) had a chronic motor tic disorder, and four (17.39%) had a codiagnosis of schizotypal personality disorder. Concomitant schizotypal personality disorder was the only factor significantly associated with response. It appears that augmentation of olanzapine in fluvoxamine-refractory OCD may be effective in a large number of patients, including those with comorbid schizotypal personality disorder.

Nosocomial candidemia in non-neutropenic patients at an Italian tertiary care hospital

In a retrospective study conducted in an Italian tertiary care hospital, the incidence of nosocomial candidemia was evaluated together with causative pathogens, treatment, and risk factors for death. Over a 6-year period (1992-1997), a total of 189 episodes of candidemia occurred in 189 patients (mean age 58+/-19 years), accounting for an average incidence of 1.14 episodes per 10,000 patient-days per year. The most common reasons for hospitalization were solid neoplasia (21%), trauma (17%), abdominal diseases requiring surgery (13%), and cardiovascular diseases (13%). No patient was neutropenic within 3 weeks prior to the onset of candidemia. One hundred thirty patients were hospitalized in intensive care units, 47 patients in surgical wards, and 12 patients in medical wards. Candida albicans was the most frequently isolated pathogen, accounting for 54% of fungal isolates, followed by Candida parapsilosis (23%), Candida glabrata (7%), Candida tropicalis (5%), Candida pelliculosa (4%), Candida lusitaniae (1%), Candida humicula (1%), and other non-albicans Candida spp. (5%). Seventy-six (41%) patients received adequate antifungal therapy. Seventy-one (58%) of the 123 evaluable patients with central venous catheters underwent line removal; 51 of them had catheter-related candidemia. The 30-day crude mortality rate was 45%. Older age, hospitalization in an intensive care unit, a longer duration of candidemia, retention of central lines, and inadequate antifungal therapy were significantly associated with poor outcome. In the present study, nosocomial candidemia was a frequent and relatively underestimated illness. Adequate antifungal therapy and central line removal independently reduced the high mortality of the disease.

Recognition and treatment of dysthymia in elderly patients

This review focuses on recent literature concerning dysthymia in the elderly population. Epidemiological data and clinical picture, diagnostic and therapeutic issues are evaluated and discussed. Although depressive syndromes are common in older patients, prevalence rates of dysthymia in the elderly are lower than in younger adults. This finding may be the consequence of the diagnostic criteria provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM) which are not specific for older adults. Other factors that complicate making diagnoses of dysthymia in older individuals are comorbid general conditions, cognitive deterioration and disorders, and frequent adverse life events (e.g. bereavement). The effects of these factors should be better defined to clarify whether elderly dysthymia is underestimated and if modified diagnostic criteria should be provided. A few researchers have identified a series of clinical features that are clearly different in the elderly and in young adult patients with dysthymia. These features are particularly related to the late onset and to the peculiar comorbidity of this disorder and suggest that dysthymia is a different disorder in the elderly. Drug treatment of depressive conditions in the elderly is currently based on new antidepressants [selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, norepinephrine (noradrenaline) reuptake inhibitors, benzamides]. These agents have an improved adverse effect profile compared with some of the older agents. Moreover, very few systematic studies have been performed using these drugs in samples of older patients with dysthymia and available data do not allow conclusions on drug choice and dosage. Besides, no specific data are available concerning the psychotherapy of dysthymia in this age group. All these topics need to be further investigated in studies comparing the elderly with control groups of younger patients with dysthymia.

Predictors of drug treatment response in obsessive-compulsive disorder

BACKGROUND

Although a large body of evidence indicates the efficacy of pharmacotherapy in the treatment of obsessive-compulsive disorder (OCD), a considerable percentage of these patients do not respond. Very few studies focus on factors related to treatment response of OCD. The purpose of this study was to investigate which clinical factors are related to drug treatment response in OCD.

METHOD

We examined 53 OCD patients treated with either clomipramine or fluoxetine for a period of 6 months, dividing the sample into "responders" and "nonresponders" to treatment. At admission, patients were evaluated using a semistructured clinical interview, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Hamilton Rating Scale for Depression, and the Hamilton Rating Scale for Anxiety. We then compared acute-phase patient characteristics and response to drug treatment. Response was defined as a decrease of at least 40% in the Y-BOCS total score and a rating of "improved" or "very improved" on the Clinical Global Impressions scale within 16 weeks of treatment and maintained over three consecutive evaluations.

RESULTS

By the sixth month of treatment, 31 patients (58.5%) responded to either clomipramine or fluoxetine. Nonresponders had lower age at onset and longer duration of the disorder; in addition, they showed higher frequency of compulsions, washing rituals, chronic course, concomitant schizotypal personality disorder, and previous hospitalizations. A worse response to drug treatment was predicted in a stepwise multiple regression by (1) concomitant schizotypal personality disorder, (2) presence of compulsions, and (3) longer illness length.

CONCLUSION

Our findings suggest that there are distinct types of OCD with respect to drug treatment response. They provide indirect evidence of treatment specificity by identifying characteristics responsive to different modalities, which may be of value in the selection of patients for alternative treatments.

Type I and type II schizophrenia: relations between tonic electrodermal activity and clinical ratings before and after haloperidol treatment

To test the hypothesis that schizophrenic patients with positive vs. negative symptoms show different tonic electrodermal patterns, 26 patients with Type I schizophrenia and 19 patients with Type II schizophrenia were evaluated before and after 2 weeks of haloperidol treatment (standard daily dose = 4.5 mg). Clinical assessments were made with the Brief Psychiatric Rating Scale, the Scale for the Assessment of Positive Symptoms, and the Scale for the Assessment of Negative Symptoms. Skin conductance level (SCL) and spontaneous fluctuations (SF) frequency were recorded for each patient. Before treatment, Type I patients showed higher SCL and SF compared with Type II patients; after treatment, a significative decrease of clinical and psychophysiological variables was found only in Type I patients.